Sexual problems in the ageing male: ED

Transcription

1 Sexual problems in the ageing male: ED Prism IV September Bruges, Belgium Dr. HHJ Leliefeld and Prof. FMJ Debruyne, urologists The Netherlands

2 Erectile disfunction Definition & Prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction

3 Erectile disfunction Erectile disfunction is the persistent failure to develop and maintain erections of sufficient rigidity for penetrative sexual intercourse. Impotence means something else, something more: lack of desire, disturbance of orgasm, disturbance of ejaculation, etc.

4 Sexual problems in men Decrease of sexual desire Excitement disfunction/erectile disfunction (ED) Orgasm-disfunction/ejaculationdisturbance Pain during sex

5 Sexual history What is the problem? How is the sexual response cycle? How is the relation? Time as a Child:Life-events? What does the patient want?

6 Age and erectile disfunction " men survey, Cologne" 60 57,3 40 erectile disfunction 34 % ,1 19, age

7 Age and erectile disfunction

8 Erectile disfunction Prevalence of erectile disfunction in men with DM lies between 35% and 70% The amount of bother decreases with age: 64 % (40-49 y) 27 % (70-79 y) Carson CC et al. Urology 2002: 60(suppl 2B):12-27 Meuleman EJH et al. NTvG2001; 145(12):

9 Erectile disfunction Definition and prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction

10 The Erectile mechanism Hippocrates (5de-4de eeuw BC) De aëre aquis et locis Aristoteles ( BC) Pneuma as physiologic concept Leonardo da Vinci ( ) Increase of bloodflow

11 Leon ar do da V i n ci ±± 1500 t he copu lat i on

12 Willibrord Weijmar Schultz UMCG (BMJ 1999)

13 Regnier de Graaf , Inventor of the syringe

14 The Lériche-syndrome ( )

15 Psychische Impotenz Freud

16 Physiology of Erections: Vascular Circulation Flaccid Penis Erect Penis Patel U, Lees WR. In: Textbook of Erectile Dysfunction. 1st ed. Oxford, UK: Isis Medical Media Ltd; 1999:

17 A. Flaccid penis B. Penis in erection EM

18 GMP Mechanism of Erection 5 Erection Stimulation 1 Neural Stimulation 2 Relaxation smooth muscles 4 Ca ++ 3 cgmp Cellular Activation Phosphodiesterase (PDE)

19 Mechanism of the erection Visual stimulation Tactile stimulation Olfactory stimulation: feromones Neural stimulation Hormonal stimulation Lead to a vasculair reaction

20 Erectile disfunction Definition & prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction

21 Diseases associated with ED MS and other neurological diseases Lumbar lesion Type 1 en 2 diabetes Vascular diseases Intoxications Cancer surgery in the pelvis Depression

22 Erectile disfunction as first symptom of latent comorbidities Diabetes mellitus Cardiac diseases Hyperlipidaemia Depression Sadovsky R et al. Int J Clin Pract 2001; 55(2):

23 Not everything is organic!!!

24 Psychological causes Depression Fear Excessive stress Relation problems Distress,sorrow Lack of problemsolving capacity

25 Erectile disfunction Definition & prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction

26 ED: physical examination Bloodpressure? Gynecomastia? Vascular problems? Penile disorders? Hypotrofy of the testicle? Abdominal hairdistribution: rhomboid or terminal?

27 Examination ED

28 Frenulum breve

29 Trauma due to false penetration during intercourse: penile fracture

30 Paraphimosis

31 Peyronie s disease

32 Francois de la Peyronie ( )

33 Correction after Nesbit-procedure

34 Erectile disfunction Definition and prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction

35 ED as a sign of other serious diseases Hypertension 68% of men with hypertension has ED Hyperlipidaemia 60% of men with ED has dyslipidemia Coronary heart disease 56% of men with ED has a positive stress test 40% of men with ED has significant stenosis of coronary arteries Burchardt M et al. J Urol 2000; 164: Billups K, Friedrich S. Presented at AUA, May 2000; Atlanta, Ga Pritzker MR. Circulation 1999; 100 (18): I-711. Levine L, Kloner R. Am J Cardiol 2000;86:

36 ED: stenosis of the coronary arteries Men with ED (n=50) significant stenosis in coronary arteries (40%) no stenosis (60%) ED as a first sign of latent insufficiency of the coronary arteries Pritzker, AHA Meeting report 1999

37 Diameter of arteries of the body

38 Substances that can lead to ED Alcohol Estrogens Antiandrogens H2-receptor blockers Anticholinergics Ketoconazole Antidepressants Marijuana Antihypertensives Narcotics -blockers Psychotropics Cigarettes Cocaine Spironolactone Lipid-lowering agents NSAIDs Cytotoxic drugs Diuretics Benet AE, Melman A. Urol Clin North Am. 1995;22:

39 Lifestyle factors that can lead to ED Smoking Drugs Alcohol abuse Overweight Lack of physical activities ( use it or lose it ) Richtlijnen diagnostiek en behandeling van erectiele disfunctie, Nederlandse Vereniging voor Urologie 2001

40 STOP smoking! Smoking doubles the chance of moderate to serious ED

41 Erectile disfunction Definition & prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction

42 Treatment In ageing male:organic factors, In young men: psychogenic factors Aim : satisfying sexual activities and adequate erections Optimal information to the patient and partner Evaluation

43 Treatment modalities Sexuological treatment Oral substances Vacuum Devices Prosthesis Injections Testosteron

44 Consultation

45 Bear in mind: Men are more focused on Sex Genitals Penetration Women are more focused on The relation Contact` Intimity Orgasm

46 Media Hype 1998

47 Drug therapy / oral medication Sildenafil (Viagra) Tadalafil (Cialis) H 3 Vardenafil (Levitra)

48 Why PDE5 inhibitors enable erections sexual stimulation corpus cavernosum guanylate cyclase cell membrane Erection NO GTP cgmp Smooth muscle relaxation Adapted from Sadovsky R, et al. Int J Clin Pract. 2001;55: GMP phosphodiesterase 5 PDE5 inhibitors PDE5 inhibitors are competitive inhibitors that resemble cgmp (the substrate) and bind to the active site of PDE5

49 Time of onset and duration Tadalafil = minutes 36 hour Cialis R Sildenafil = minutes 4 5 hour Viagra R Vardenafil = minutes 4 5 hour Levitra R

50 Side-effects Placebo Cialis Side-effects (N = 308) (N = 804) Headache 6% 14% Dyspepsia 2% 10% Backpain 5% 6% Nasal congestion 4% 5% Muscle pain 2% 5% Flushed face 2% 4% Brock et al J Urol :1332-6

51 Contra-indications Use of nitrates Within 6 months after MI or CVA Retinitis pigmentosa IB tekst Cialis

52 Oral medication Watch out! Combination with an alfablocker Combination with CYP3A4 inhibitors as HIV-proteaseinhibitors, certain macrolids/ antibiotics, some SSRI s, cimetidine and

53 Vacuum devices Problems: Insufficient rigidity Haematoma Painful ejaculation Painful scrotum inside the cylinder

54 A Pilot Study to Determine Penile Oxygen Saturation Before and After Vacuum Therapy in Patients with Erectile Dysfunction After Radical Prostatectomy. Welliver RC, et al, Springfield Illinois,USA 55% Increase of corporal oxygenation The Journal of Sexual Medicine 10 FEB 2014 DOI: /jsm

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57 Testosterone therapy In non-responders of PDE 5-I s: if T < 12 nmol/l: a short trial of TRT: salvage therapy

58 ED: Self-injections ANDROSKAT=PAPAVERINE/PHENTOLAMINE

59 Complications self-injections Priapism Haematoma Fibrosis Non-cooperative partner Prerequisite: Adequate instruction 24-hours availability Exclusion of..

60 Prosthesis models

61 Satisfaction percentage must be (!) greater than 80 %

62 Why are patients reluctant to discuss their EDproblems with the doctor? 71% thinks their physician won t see the ED as a medical problem. 68% is afraid he will embarrass his doctor. 44% of men with erectionproblems,visiting a urologist, don t discuss it because of a sense of shame Drugs (14)

63 Summing Up: ED is a disease / symptom, with a high prevalence, especially in risk patients ED has a great impact on quality of life Doctors should approach ED patients normally ED can be treated effective Prescribing a pill is only the beginning, evaluating the treatment is essential