ASSESSMENT OF PREMATURE EJACULATION AND ERECTILE DYSFUNCTION

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2 ASSESSMENT OF PREMATURE EJACULATION AND ERECTILE DYSFUNCTION Dr Michael Gillman St Andrews Hospital Wickham Terrace Spring Hill Mater Private Clinic, South Brisbane Shore St West Medical Centre, Cleveland 2

3 Disclosure Slide Advisor Lilly Australia Cialis Advisor Pfizer Australia Viagra / Caverject Advisor Bayer Levitra Advisor Andrology Australia Erectile Dysfunction Board Advisor Janssen Cilag Priligy Advisor Sanofi Adventis Xatral Advisor CSL / Astellis Flomaxtra 3

4 Premature Ejaculation A common sexual disorder Usually affects younger couples May accommodate problem with second attempt while still young enough to have a short refractory period Higher levels of intercourse related anxiety Greater patient and partner impairment in intercourse satisfaction Greater impairment in relationship satisfaction 4

5 Premature Ejaculation (PE) ISSM definition of PE: intravaginal ejaculatory latency time (IELT) <1 min inability to delay ejaculation- lack of control negative impact on man and partner- distress either lifelong or acquired (often associated with erectile dysfunction) psychological and physiological components

6 Diagnof Premature Ejaculation Time to ejaculation Inability to delay ejaculation Negative personal + + consequences McMahon et al, 2008

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8 Number of men Prevalence of PE 20 30% of men report PE at some point in their lives IELT range 0 to 44 mins 1 IELT in unselected population of 500 heterosexual males IELT 1 min Median IELT=5.4 mins Mean intravaginal ejaculatory latency time (mins) 1 Waldinger et al, 2005; McMahon et al, 2008.

9 Premature Ejaculation Management Patient presents with suspected PE establish PE diagnosis (ISSM definition) sexual, medical and psychological history physical examination Is PE secondary to ED or other condition? NO YES Manage primary cause first LIFELONG PE Pharmacotherapy behavioural therapy and relationship counselling Patient preference ACQUIRED PE Behavioural therapy and relationship counselling pharmacotherapy Adapted from McMahon et al, 2004.

10 1. Donatucci, Giuliano & Clement, Dapoxetine Product Information. Janssen-Cilag: PE pharmacotherapy: serotonin and 5-HT receptors are involved in ejaculation 1,2

11 Mean ELT (seconds) Effect of SSRIs on Ejaculation Placebo Fluvoxamine 100mg Fluoxetine 20mg Paroxetine 20mg Sertraline 50mg Weeks 1. Waldinger MD, Hengeveld MW, Zwinderman, AH: J.Clin.Pssychopharmacol.1998;18:

12 Effective, Safe, Well Tolerated Effective Daily paroxetine fold increase in IELT On demand clomipramine 4.6 fold increase Safe Usually well tolerated Minor, self limiting adverse effects of SSRIs... Fatigue, yawning, mild nausea, loose stools or perspiration

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14 PE management plan and follow-up Management plan Involve patient and partner partner may influence choice of management Consider SSRI treatment in combination with behavioural therapy Follow up 4 weeks or 6 doses after starting therapy; check efficacy dose titration side effects 1. Dapoxetine Product Information. Janssen-Cilag: 2009.

15 Summary Premature Ejaculation (PE) PE is common and distressing Behavioural therapies are effective in some cases If lifelong PE requires pharmacological treatment Combined medical and psychological treatment is most effective strategy for PE

16 ASSESSMENT OF ERECTILE DYSFUNCTION Dr Michael Gillman St Andrews Hospital Wickham Terrace Spring Hill Mater Private Clinic, South Brisbane Shore St West Medical Centre, Cleveland 16

17 IMPOTENCE Impotence is the inability to achieve or sustain an erection sufficient for the sexual needs of the man or his partner 17

18 ERECTILE DIFFICULTIES 40% at age 40 50% at age 50 60% at age 60 70% at age 70 18

19 Do Men Really Care??? How many of your male patients book appointments to discuss erection problems

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23 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 23

24 Erectile Dysfunction History Main Points >70% have an organic component Assume that most men have both Organic and Psychogenic 24

25 Psychogenic Mainly Performance anxiety Relationship Difficulties Financial Difficulties etc 25

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29 The Deadly Quartet Diabetes Obesity Hypertension Dyslipidemia

30 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 Adapted from Montorsi et al. Am J Cardiol 2005; 96: 19M 23M

31 Examination Examination BP Height Weight and waist circumference Penile shaft for fibrosis Testicles Vascular system AAA, peripheral pulses? Prostate with informed consent 31

32 Investigations E/LFTs HDL/LDL Testosterone ( LH and PRL if low ) TSH Urine WTU?PSA 32

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34 Testosterone and ED?? 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 34

35 TREATMENT 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 Testosterone Vascular Surgery ( Selected Cases Only ) 35

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37 VACUUM DEVICES

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40 INTRACAVERNOSAL INJECTIONS

41 SELF INJECTION THERAPY (cont) Side effects scarring priapism bruising pain Follow up at one month, then every six months as appropriate 41

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44 PRIAPISM 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 44

45 INTRACAVERNOSAL IMPLANTS

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47 Three Piece Inflatable Penile Implant Simple to use Totally concealed within body Acts and feels like a natural erection Provides fullness and girth expansion 47 Softer and more flaccid when deflated

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49 PDE5 s ARE DISCOVERED!!!!!!

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53 Oral Agents Needs sexual stimulation to work Allow time On demand or daily dosing Tailor management to individual couple Cost Convenience Efficacy Side effects 53

54 The Role of PDE5 Inhibitors in Achieving and Maintaining Erection Sexual Stimulation Cavernous nerve Endothelial cell Smooth muscle cell Nitric oxide Guanylate cyclase cgmp cgmp-specific protein kinase Decreased Ca 2+ GT P PDE5 PDE5 Inhibitors 5'GMP K + Ca 2+ Smooth muscle relaxation & erection

55 CHANCE OF A CURE????

56 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 56

57 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 57

58 Main Points 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 58

59 59 They do grow on trees!

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