ERECTILE DYSFUNCTION DIAGNOSIS

Transcription

1 ERECTILE DYSFUNCTION DIAGNOSIS Head of Andrology and Sexual Medicine Dep.of Urology and Nefrology Hospital Virgen del Rocío ANDROMEDI. Sexual Medicine SEVILLA. SPAIN General Secretary ESSM Natalio Cruz Urologist Sevilla. Spain

2 Classification: Erectile Dysfunction (ED)

3 Organic Causes of ED Vascular Organic Neurogenic Hormonal Penile injury/disease Medications Lue TF. N Engl J Med. 2000;342: Miller TA. Am Fam Phys. 2001;61: NIH Consensus Development Panel on Impotence. JAMA. 1993;270:83 90.

4 Psychogenic Causes of ED Depression Performance anxiety Relationship problems Psychosocial problems Psychological distress Psychogenic Aizenberg D et al. J Clin Psych. 1995;56: Araujo AB et al. Am J Epidemiol. 2000;152: Lue TF. N Engl J Med. 2000;342: Shabsigh R et al. Urology. 1998;52: Tiefer L, Schuetz Mueller D. Urol Clin North Am. 1995;22: Usta MF et al. Urology. 2001;57:

5 Etiology of ED: Psychogenic and Organic ED commonly involves a combination of psychogenic and organic factors Organic Psychogenic and Organic Psychogenic Tiefer L, Schuetz Mueller D. Urol Clin North Am. 1995;22:

6 Why is Diagnosing ED Important? ED screening may signal underlying disease: Diabetes Hypertension Dyslipidemia and coronary artery disease (CAD) Depression ED can result in: Anxiety Decreased self esteem Reduced quality of life (QOL) Negative effect on relationships Goldstein I. Am J Cardiol. 2000;86(suppl):41F-45F. Goldstein I. Int J Impot Res. 2000;12(suppl 4):S147-S151.

7 ED Is Associated With Other Serious Treatable Disorders 68% of men with hypertension have ED 60% of men with ED have dyslipidemia 56% of men with ED have a positive stress test 40% of men with ED have significant coronary occlusions 20% of men with ED have diabetes mellitus 11% of men with ED have depression Billups K, Friedrich S. J Urol. 2000;163(4) Abstract 655. Braun M et al. Int J Impot Res. 2000;12: Burchardt M et al. J Urol. 2000;164: Levine L, Kloner R. Am J Cardiol. 2000;86: Pritzker MR. Circulation. 1999;100(suppl I):I-711. Abstract Seftel A. J Urol. 2004;171:

8 The Prevalence of Comorbid Conditions Increases With ED Severity ED Severity Comorbidity Mild to None Mild Moderate Moderate Severe High Blood Pressure 24% 25% 32% 42% 39% High Cholesterol 20% 25% 27% 35% 38% Enlarged Prostate 10% 16% 16% 23% 26% Heart Trouble 3% 7% 10% 16% 34% Anxiety 13% 15% 18% 19% 18% Diabetes 11% 8% 11% 16% 24% Depression 8% 8% 12% 12% 12% Heart Attack/Surgery 4% 7% 8% 13% 29% Hardening of Arteries 3% 6% 7% 10% 13% Spinal Cord Injury 3% 5% 5% 3% 5% Prostate Cancer 0 1% 1% 1% 0 Shabsigh R et al. J Urol. 2005;174:

9 A First Sign of Cardiovascular (CV) Disease? In a study of 30 men with ED (International Index of Erectile Dysfunction Erectile Function domain [IIEF EF] =13.7±1.2, mean age, 46.2 years) and 27 age matched normal men (IIEF EF domain=21.3±1.2; mean age, 46.6 years) with no history of CV disease or CV risk factors Compared with normal men, men with ED had: Objective evidence of clinical and penile vascular disease (mean penile peak systolic velocity=28±3 m/s) Reduced brachial artery flow mediated vasodilation (p=0.014) Impaired maximal response to nitrates, 13±1.4% vs. 17.8±1.4% (p=0.02) Improved ED with phosphodiesterase type 5 (PDE5) inhibitor treatment, mean change in IIEF EF domain score=3 Kaiser DR et al. JACC. 2004;43:

10 Major Risk Factors for ED Aging Progressive decline in function Psychological issues Chronic diseases Hypertension Diabetes Depression CV disease Medications Antihypertensives Thiazide diuretics Beta blockers Antidepressants Serotonin re uptake inhibitors Unhealthy lifestyle Stress Alcohol abuse Smoking Feldman HA et al. J Urol. 1994;151:54 61.

11 ED Diagnosis: Step Based procedure

12 Diagnosis of ED Comprehensive history: medical, drug, sexual, psychosocial Focused physical examination Lab. Tests: Testosterone, lipids, fasting glucose or glycosylated hemoglobin (HbA1C), prostate specific antigen (PSA) Thyroids Specialized testing As appropriate( when there is evidence of significant, endocrine, psychogenic, or vascular disease) Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction. Plymouth, UK: Health Publication, Ltd; 2000:

13 Diagnosis of ED Comprehensive history: medical, drug, sexual, psychosocial Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction. Plymouth, UK: Health Publication, Ltd; 2000:

14 Causes of Erectile Dysfunction

15 The Comprehensive Sexual and Medical History Medical history Rule out comorbid conditions Atherosclerotic risk factors and vascular disease Use of medications/ recreational drugs or smoking History of surgeries or pelvic/perineal trauma Depressive symptoms Sexual history Patient or partner sexual desire Ejaculation Orgasm Partner sexual function Genital pain Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction. Plymouth, UK: Health Publication, Ltd; 2000: The Process of Care Consensus Panel. Int J Impot Res. 1999;11:59 70.

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21 Diagnosis of ED Specialized testing As appropriate (when there is evidence of significant, endocrine, psychogenic, or vascular disease): Nocturnal Penile Tumescence Vascular (hemodynamic) tests Neurologic Investigations Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A et al, eds. Erectile Dysfunction. Plymouth, UK: Health Publication, Ltd; 2000:

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23 The recordings must be performed for at least 2 consecutive nights. The proof of fully rigid erections lasting at least 10 minutes during NPT recordings, indicates an intact veno occlusive mechanism

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25 t does not necessarily rule out other organic causes such as arteriogenic ED. wadays NPT measurements do not play a role in the routine diagnosis of ED

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32 Penile Selective Angiography

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37 avernosometry and Cavernosography

38 vernosometry / Cavernosography and Penile Selective Angiography nly in very rare cases where vascular surgery may be an option such s after trauma etc. may be considered, AND ALSO provided an xperienced surgeon in this field is available.

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40 J Sex Med 2011;8: ernocomputed tomography (CT) ltidetector computed tomography (MDCT) ernography ee dimensional volume rendering technique VRT) under IC pharmacological stimulation

41 J Sex Med 2011;8:

42 Management of ED World Health Organization Guidelines l Agents (unless contraindicated), ual Counseling Education ED Unresolved lter odifiable isk Factors ED resolved. Patient satisfied. ED Unresolved Local Therapies Intracavernosal injections Intraurethral prostaglandin E1 Vacuum device Surgical ED Unresolved

43 tment Diagnosis Summary Diagnostic strategy based on the Therapeutic Option Standard CIS Diagnostic Test Duplex ultrasonography Cavernosometr ycavernosography Angiography drugs uum? 1 sthesis *? ous ery rial ery

44 Diagnosis Summary ost men with ED are not diagnosed or treated t is important to discuss the sexual health of patients ED screening may detect underlying comorbid conditions 1,2 mprovement in erectile function in men with ED ay result in Better Quality of Life (QoL) 3 Increased patient satisfaction 1 Reduced symptoms of clinical depression in patients with ED and depression 3

45 Conclusions The depth diagnostic assessment in DE depends on the age, patient expectations and treatment goals. General hemodynamic basic diagnostic tests have lost prominence (Still useful) : IIC, Doppler Special diagnostic tests and cavernosometry or angiography are reserved for cases with possible surgical treatment We need to adjust our diagnostic algorithm to advances in the understanding of the physiology of erection, the pathophysiology of ED

46 THANK YOU FOR YOUR ATTENTION ad of Andrology and Sexual Medicine Dep.of Urology and Nefrology Hospital Virgen del Rocío Natalio Cruz Urologist Sevilla. Spain