Mr John Tuckey. Urologist Auckland Hospital Auckland Spinal Unit Ascot Central

Transcription

1 Mr John Tuckey Urologist Auckland Hospital Auckland Spinal Unit Ascot Central 8:30-9:25 WS #191: What to do When Viagra Does Not Work 9:35-10:30 WS #203: What to do When Viagra Does Not Work (Repeated)

2 Erectile Restoration And What To Do When Viagra Does Not Work JOHN TUCKEY AUCKLAND

3 What we will cover today how common and often is it treated in New Zealand? what to focus on in the history and examination discuss the role of behavioural modification review the options if Viagra does not work hear from Shane Way about his journey with ED time for questions at the end

4 Definition of Erectile Dysfunction inability to attain or maintain an erection adequate for sexual intimacy

5 How common is it? New Zealand Male Sexual Massachusetts Male Aging Study Function Study s 38% of men in their 50 s 50% at 50 years 60% of men in their 60 s 60% at 60 years

6 How common is it? New Zealand Male Sexual Function Study of the 42% of men who reported ED 50% have moderate to severe ED 16% medically diagnosed 23% on treatment 17% PDE5 2% natural remedies 1% injectables 1% vacuum pump, 1% testosterone

7 New Zealand Data 295,000 men have ED 68,000 mild to moderate 39,000 moderate 25,000 severe For some men the decline in sexual activity significantly impacts their QOL

8 Why Should We Be Proactive? erectile dysfunction has a significant impact on a man s health - self esteem - mood, can cause depression, suicidal ideation - relationship with their sexual partner - significant negative effect in their QOL

9 When is the Best Time to Treat it? NOW! improve their QOL early use it or lose it atrophy causes loss of 2-12 cm in length every 14 months!

10 History what is the problem? always ask and explore what their issue is some men use the term ED to describe - low libido - early or late ejaculation they may have more than one issue - Peyronie s disease

11 History any stressors in his relationship, at home or at work? how is the issue affecting his relationship with his partner? how is his partner feeling about it? how is it affecting him personally? self esteem life outlook depression has he tried anything?

12 History Social history smoking alcohol - dose related association between smoking and ED - positive or negative effects - smaller amounts reduce anxiety, improve erections and libido - larger amounts produce CNS depression, reduced libido and transient ED - chronic abuse lowers T, increased E2, neuropathy

13 History Social history Medications - does he exercise? - any linked to the start of his ED? - sometimes reversible - what has he tried? supplements? PMHx - surgery, diabetes, CVD, metabolic syndrome

14 ED and Cardiovascular Disease have the same risk factors - smoking, diabetes, dyslipidaemia endothelial dysfunction underpins both, linked through Nitric Oxide 15-20% of men with ED have asymptomatic CVD men who develop ED have a 50% higher chance of developing CVD severity of ED correlates to the severity of CVD

15 ED and Cardiovascular Disease Why does ED develop first in some men? penile arteries coronary arteries 1-2 mm 3-4 mm men with ED and risk factors should be evaluated for silent CVD

16 Examination hands secondary sexual characteristics penis - nodularity - waist or atrophy

17 Investigation testosterone -8 am - if low therapy can restore erectile function cardiovascular - lipids - glucose - BP - if abnormal and no known CVD suggest a cardiology evaluation

18 Treatment what do you think the problem is? - stressors at work/home? - hypogonadism? - medication? - vascular factors - neural factors

19 Behavioural Modification should be part of any assessment the challenge is any benefit is not immediate evidence exists that diet and exercise can improve erections obesity is a significant independent risk factor for ED - via pro-inflammatory markers or lowering testosterone

20 Behavioural Modification obesity and the metabolic syndrome associated with sexual problems Mediterranean diet and caloric restriction can improve ED - improve sexual performance by 10-20% - diet plus exercise with a dietician vs general advice increases the chance of normalising erectile function from 38% to 56%

21 Behavioural Modification multiple studies show higher levels of exercise are associated with lower levels of chronic disease including CVD inverse relationship between physical activity and ED, intensity and duration increasing physical activity and caloric restriction can improve ED - nutritionist + exercise resulted in 20% improvement in ED - other studies 14-86% improvement - probably 6 months +, 40 mins 4 X per week

22 Psychosexual Counselling relationship issues stress related particularly effective if partner attends 50-70% resolution rate usually 5 + sessions do you have an appropriate therapist in your area?

23 Traditional Treatments Egypt 1600 BC

24 PDE-5 revolution

25 PDE5 Inhibitors effective in up to 80% block the off switch - so erections stronger and last longer require intact nerves and stimulation take mins before activity contraindications nitrates systemic dilatation/hypotension

26 PDE5 Inhibitors well tolerated side effects - pounding headache commonest - indigestion funding - insurance no but ACC fund 1-2 tablets/week

27 What if it doesn t work? discussing how they use it this can salvage around 30% what doses have they tried? are they waiting 30 +mins? are they using stimulation? are they taking Viagra with fatty food?

28 What if it doesn t work? data suggests the chance of success increases with time up to 6 tabs try a different medication less effective in those wit neural injury post-surgery or diabetics

29 not available in pharmacies intranasal sublingual Other Delivery Systems sourcing overseas - cheap - but what is in them?

30

31 Herbal Ignite Horny Goat Weed - Epimedium - active agent Icariin - PDE5-like effects and may increase testosterone Tribulus Terrestis - fruit producing Mediterranean plant - limited evidence for use Avena Sativa - oats

32 Supplements Ginseng Arginine Ginko Biloba - promotion of nitric oxide - precursor of nitric oxide - purported to increase circulation - no evidence for use

33 Low-Intensity Shock Wave Lithotripsy investigational in ED but verified in musculoskeletal disorders mechanism of action unknown? angiogenesis? tissue regeneration? stem cells change in IIEF is only 2-3 /25? clinical significance randomised studies required

34 Vacuum Pump

35 Vacuum Pump create a vacuum produce a venous erection can be tricky to use shave around the penis for a good seal hinge effect

36 Vacuum Pump mostly used by those in a stable relationship around $600 only a small number continue to use it

37 Intracavernosal Injections

38 Intracavernosal Injections stimulates increased blood flow into the corpora high oxygen content blood nourishes the corporal tissues more effective than PDE5 inhibitor or vacuum devices particularly useful in penile rehabilitation after surgery

39 Intracavernosal Injections different agents exist - Prostaglandin E1 - Papaverine - Regitine - combinations Bimix, Trimix

40 Intracavernosal Injections easy to learn teach patient to self inject 10 or 2 o clock start with a low dose 5mcg Alprostadil erection produced in 5 minutes titrate the dose until the desired effect is achieved

41 Intracavernosal Injections auto injectors can be helpful for the anxious side effects - pain - scarring - using too high doses / double dosing - priapism - cold shower, pseudoephedrine - drainage

42 Intracavernosal Injections commercial preparation Caverject more expensive two strengths 10 or 20 mcg Alprostadil you can make up syringes or vials can add in Papaverine and Regitine if required best for penile rehab post surgery

43 Intracavernosal Injections drawbacks - spoil the spontaneity - inconsistency of effect - do not always work i.e venous leak - need to keep in the fridge, last 3 months - have to take them with you

44 Penile Prostheses

45 Penile Prostheses solves the issues with other treatments efficacy spontaneity

46 Advantages produces a very rigid natural-looking erection works the same every time - reduces anxiety - increases confidence - restores self esteem you always have it with you takes seconds to inflate, reintroduces spontaneity

47 malleable rod Types of Prostheses

48 2 piece inflatable (hydraulic) Types of Prostheses Ambicor (AMS)

49 3 piece inflatable (hydraulic) Types of Prostheses AMS and Coloplast

50 Erection Satisfaction excellent/satisfactory total patient 48%/50% 98% partner 17%/66% 83% Montorsi et al

51 Sexual Activity Satisfaction excellent/satisfactory total patient 70%/22% 92% partner 28%/68% 96% Montorsi et al

52 Satisfaction Other series satisfaction partner 75-91% patient 79-96%

53 Who is suitable? men who fail or dislike other treatments - diabetic - pelvic surgery Peyronie s disease who fail injections Erectile dysfunction after priapism try simple options first funded by insurers

54 Pre-operative Counseling very important to set expectations penile length unchanged man s memory! glans does not engorge complications uncommon - infection - erosion

55 Post-operative 1 night hospital stay 2 week recovery time inflate at clinic 4-6 weeks later

56 Patient Presentation How long have you had ED for? How did it impact your life? What other treatments did you try? How did you find out about implant treatment? Were you nervous about getting an implant? How was your recovery? How easy is it to use? How has it changed your life? What does your wife think of the implant? What suggestions do you have for other men with ED?

57

58 Summary ED is common in New Zealand and largely untreated ED is at least a marker for CVD behavioural modification can be effective but takes time and effort a range of options exist if Viagra does not work penile prostheses are very effective

59 Questions

60

61 3-Piece implant

62

63 Major Advances have been with Complications

64 Complications Infection - usually within 6 months - body reaction -> capsule - relatively avascular, protected cavity

65 Complications Infection - Staphylococcus epidermidis - biofilm - rate % - can this rate be reduced?

66 Infection In vitro studies with antibiotic treated device material and susceptible strains of S. epidermidis and S. aureus shows a microbial zone of inhibition around the test material. Test auger plate inoculated with S.aureus, incubated at 37 Celsius shown at one day in vitro.

67 Infection InhibiZone infection rate pre-inhibizone 1.59% post-inhibizone 0.28% Carson J Urol 2004

68 Inhibizone - Proprietary combination of rifampin and minocycline Low dose of drugs act directly on & around IPP Drug elution strongest when risk of infection greatest immediately after implantation

69 Mentor Titan prosthesis hydrophilic coating absorbs antibiotics infection rate 1.06% vs 2.07% for uncoated

70 Colonisation common 148 patients undergoing revision surgery - non-infectious - swab of fluid around pump or biofilm, - culture capsule - 66% of swabs positive - 43% cultures positive - 25% culture positive after washout Henry et al J Urol 2008

71 Infection Revision surgery Washouts reduced the infection rate from 10%-3% possibly due to - the removal of biofilm load - reactivation of bacteria - Inhibizone less effective Wilson et al J Urol reduction in bacterial

72 Complications Mechanical failure Reliability good Survival 2 piece 93% 3-5 yrs 3 piece 86-96% 5 yrs Mentor 93-96% 5 yrs

73 Complications Mechanical failure - advances Mentor pump reinforcement 65.3% ->88.6% AMS CX Paralyne coating %->97.9%

74 Complications Mechanical - advances AMS CX Tactile pump Momentary squeeze Autoinflation lockout

75 Complications Mechanical failure - usually after 4 years - fluid leakage, autoinflation - lower with newer models

76 Viagra

77 Complications Erosion - remove prosthesis - 3-8%

78 Conclusions perfect treatment does not exist important part of armamentarium expectations important satisfaction rates high

79 Conclusions major advances with infections - postoperative care - mechanical reliability - reduction in

80

81 Patient Satisfaction Montorsi - 59 month follow-up - AMS % using prosthesis times per week Euro Urol 2000;37:50-55