Disclosure Slide. Dr Michael Gillman IMPOTENCE ERECTILE DIFFICULTIES. Do Men Really Care??? 15/10/2014 ASSESSMENT OF ERECTILE DYSFUNCTION

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1 ASSESSMENT OF ERECTILE DYSFUNCTION Dr Michael Gillman St Andrews Hospital North St Specialist Suites Mater Hospital 3 rd Floor Mater Private Clinic Wesley Hospital Suite 5 Level 9 Evan Thomson Bld Cleveland- Shore Street West Medical Centre Disclosure Slide Advisor Lilly Australia Cialis and Axiron Advisor Pfizer Australia Viagra / Caverject Advisor Bayer Levitra Advisor Andrology Australia Erectile Dysfunction Board Advisor Menarini Priligy Advisor Sanofi Adventis Xatral Advisor CSL Flomaxtra IMPOTENCE ERECTILE DIFFICULTIES Impotence is the inability to achieve or sustain an erection sufficient for the sexual needs of the man or his partner 40% at age 40 50% at age 50 60% at age 60 70% at age 70 Do Men Really Care??? How many of your male patients book appointments to discuss erection problems? 1

2 Erectile Dysfunction History Main Points Duration of onset of problem. Quality of all erections ( Spontaneous and sexual ) Relationship issues Previous Treatments including Newspaper Commercial Clinics Erectile Dysfunction History Main Points >70% have an organic component Assume that most men have both Organic and Psychogenic Psychogenic Mainly Performance anxiety Relationship Difficulties Financial Difficulties etc 2

3 The Deadly Quartet Why does ED occur earlier than cardiovascular disease? The arterial size hypothesis Artery Diameter (mm) Critical events Penile 1 2 Erectile dysfunction Coronary 3 4 Angina / MI Carotid 5 7 TIA / Stroke Diabetes Obesity Hypertension Dyslipidemia Adapted from Montorsi et al. Am J Cardiol 2005; 96: 19M 23M Examination Investigations Examination BP Height Weight and waist circumference Penile shaft for fibrosis Testicles Vascular system AAA, peripheral pulses? Prostate with informed consent Renal and Liver Function Tests HDL/LDL Testosterone ( LH and PRL if low ) TSH Urine WTU?PSA 3

4 Testosterone and ED?? TREATMENT Low testosterone is an uncommon cause of ED However PDE 5 inhibitors do not work as well in the presence of low testosterone Free Androgen Index, Bioavailable Index and Free Testosterone are unreliable and generally not used best of a bad bunch is two morning sample serum testosterone levels Counselling Viagra Cialis, Levitra, Uprima ( Not Yet Available ) Intracavernosal Injections ( Caverject and Combinations) Trans-urethral Agents (MUSE) ( Not currently available) Topiglans ( Not yet available ) Vacuum Devices Penile implants Low intensity Extracorporeal shockwave device Testosterone Vascular Surgery ( Selected Cases Only ) VACUUM DEVICES 4

5 SELF INJECTION THERAPY (cont) INTRACAVERNOSAL INJECTIONS Side effects Scarring?? No real evidence of this is injection performed correctly priapism bruising pain Follow up at one month, then every six months as appropriate 5

6 PRIAPISM The only real side-effect of injections Prolonged erection not associated with sexual stimulation After 24 hours may have irreversible cavernosal damage resulting in permanent erectile dysfunction Must have action plan Not usual with PDE5 inhibitors alone INTRACAVERNOSAL IMPLANTS Three Piece Inflatable Penile Implant Simple to use Totally concealed within body Acts and feels like a natural erection Provides fullness and girth expansion Softer and more flaccid when deflated Disadvantages Requires some manual dexterity Possibility of malfunction Possibility of leakage Shockwave Therapy 6

7 Extracorporeal Shockwave Therapy Extracorporeal Shockwave Therapy Electrical energy is converted into acoustic shockwaves. When shockwaves come into contact with the endothelial wall there is the creation of cavitation forced, sheer stress and tissue radical formation. This has been shown to improve perfusion (1) Also shown to increase NO production (2) 1. Aicher et al Shockwave Therapy Recruits Systematically Infused Endothelial Progenitor Cells Presented at AHA convention Nov Mariotto et al Extracorporeal shockwaves: from Lithotripsy to anti-inflammatory action by NO production 12(2):89-96 Mar 2005 Extracorporeal Shockwave Therapy Assumed that ECSWT may provide a rehabilitative or curative effect for ED Studies are underway at many centres and preliminary results show an improvement in IIEF of around 7 at 6 months ECSWT is applied at various points along the penile shaft and on the penile crura. Each treatment last around 20 mins and usual number of treatments is 12 May have a role in men with vascular aetiology who are poor responders to PDE5 inhibitors PDE5 s ARE DISCOVERED!!!!!! 7

8 Oral Agents Needs sexual stimulation to work Allow time On demand or daily dosing Tailor management to individual couple Cost Convenience Efficacy Side effects The Role of PDE5 Inhibitors in Achieving and Maintaining Erection Sexual Stimulation Cavernous nerve Nitric oxide GT P Guanylate cyclase Endothelial cell cgmp PDE5 PDE5 Inhibitors cgmp-specific protein kinase 5'GMP Smooth muscle cell K + Ca 2+ Decreased Ca 2+ Smooth muscle relaxation & erection CHANCE OF A CURE???? CAVERNOSAL HYPOXIA Aging effects on the corporal vasculature supply (hyperlipidaemia, hyperglycaemia etc.) cause hypoxic changes Transforming Growth Factor TGF-B(1) is inhibited by prostaglandin PGE(1&2) suppress collagen synthesis in human fibroblast cultures CAVERNOSAL HYPOXIA (cont) An imbalance between PGE and TGF-B(1) in the corpora due to hypoxia, may cause increased extracellular matrix deposition, inhibition of smooth muscle growth, and eventually fibrosis PGE may have a role in the management of cavernosal fibrosis 8

9 Main Points They do grow on trees! Take a good history Ask at risk patients about sexual function Offer patients a range of options Discuss pros and cons of each Ensure they use product effectively 9

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