Erectile Dysfunction An overview Lorraine Montgomery Specialist Nurse Practitioner Urology BAUN Essential Urology Study Day Centre for life: Newcastle. 20/9/2017
What is erectile dysfunction? The persistent or recurring inability to achieve or maintain an erection sufficient for satisfactory sexual activity This includes an inconsistent ability to gain an erection or the ability to achieve only brief short - lasting erections, and premature ejaculation L.Montgomery 2
CONTENTS OF THE SESSION Incidence of ED Basic anatomy and physiology of erections Possible effect of ED on man and their partners. Assessment of ED Restrictions to prescribing Treatment options Any questions.
More common than you will imagine. Incidence of ED Estimated that half of the men between the ages of 40 and 70 will have it to some degree and incidence increases as we get older. Chronic ED affects about 4% of men in their 50s 17% of men in their 60 s and 47% of men over 75 Transient ED and inadequate erection affect as many as 50% of men between 40 and 70years Diseases (diabetes, heart disease, kidney disease, alcoholism and others) account for as many as 70 of chronic ED cases Psychological factors ie stress, anxiety and depression may account for 10 20% of cases 35 50% of men with diabetes experience ED These figures from 1998 incidence now increasing and younger age group experiencing ED? Due to lifestyle, substance abuse, increasing alcohol intake, increasing ease of access and viewing of pornography Predicated that 322million men worldwide affected by 2025 (Qaseem etal 2009)
What s needed to get an erection? The Brain The master sex organ! Intact nervous system Intact blood supply to the penis Normal penile anatomy
What normally happens? - simplified In response to stimuli Nitrous oxide released from nerve endings and endothelial cells in the corpus cavernosum of the penis. An enzyme converts the Guanosine triphosphate(gtp) into cyclic guanosine monophosphate (cgmp) This causes the smooth muscle of the penis to relax which causes a significant inflow of blood inflow into the corpora cavernosa, which expands and becomes engorged as a result of the increased blood flow and pressure The internal structure of the penis consists of two cylinder shaped vascular tissue bodies the corpora cavernosa, that run through the length of the penis. Erectile tissue is enclosed by fibrous elastic sheaths (tunicae) When the blood engorges the corpora cavernosa the blood vessels that supply the penis are nipped against the fibrous elastic sheaths which prevents the blood from draining back into the body cgmp is then hydrolysed back to the inactive GMP by phosphodiasterase type 5 ( PDE5) detumescence occurs
Possible causes of ED PHYSICAL Due to disease ( including) IHD Diabetes Hypertension Benign Prostate disease (LUTS) MS ME Renal disease Prostate cancer PSYCHOLOGICAL Anxiety/stress Psychological trauma/abuse Sexual myths Relationship problems Depression Psychosis Trauma/injury - including Any pelvic surgery Penile injury Spinal injury Medications L.Montgomery 7
Possible effects of ED *MOST IMPORTANT* The effects of ED on both the man and their partners/relationships is usually grossly underestimated. Opening up and discussing ED is embarrassing and distressing. It can cause men to withdraw from those who care about them which can put a serious strain on relationships. ED can cause serious lifestyle change to both the men and their partners.
Talking Sex The assessment will often be the first time the man has spoken openly about his problem. May never had discussed the issue with his partner. Embarrassment Technical terminology Put them at ease
Role of the Nurse/Doctor Be aware of at risk patients Broach the subject, Ask the right questions in the right manner Give information Refer to the appropriate services Recognise the patient who looks like he has more to say L.Montgomery 10
Prescribing restrictions Drug Tariff Part XV111B Government restrictions on who can receive NHS scripts for ED treatments. With the exception of sildenafil, only persons suffering from certain conditions can receive NHS prescriptions these include:- Diabetics Prostate cancer renal dialysis Previous prostate surgery spina bifida MS spinal cord injury Spinal cord injury radical pelvic surgery Parkinsons disease prostatectomy including TURP Poliomyelitis kidney transplant Single gene neurological disease those who were receiving NHS prescriptions for ED prior to 14/9/1998 Severe distress as a result of ED ( specialist centres only) All presciptions must be endorsed SLS Those patients who do not qualify for SLS prescribing can only recive treatment on private prescription
The aim of assessment To accurately identify the patients complaint Identify any clinical signs of known risk factors To help the patient understand why this is happening To initiate treatment
Assessment of ED Sexual and psychosexual history determine type of sexual problem. Is it actually ED? Use the SHIM or IIEF score Lifestyle factors smoking, alcohol, exercise, obesity Past medical history anything which could cause ED? - Look for anything which could contra-indicate treatments Medicines history any medications particularly prone to cause erection problems could it be changed? Physical examination -- general characteristics - examination of genitalia peyronies, hypospadias, under development, phimosis? DRE Bloods Glucose Cholesterol/Lipids PSA Testosterone L.Montgomery 13
Build up a picture to determine treatment options After assessment:- Would they benefit from formal psychosexual referral? What does the patient expect or want from a treatment? What is safe for the patient?? Financial cost to the patient
Treatment in primary care Assessment and treatment of ED should be initiated in primary care and referred to specialist centres in the following circumstances:- Young men who have always suffered or had difficulty getting or maintaining an erection History of trauma to genital area, pelvis or spine Abnormality of penis or testicles If no response to maximum dose of sildenafil, ( AT LEAST 8 TABLETS) If hypogonadism is suspected -? Referral to endocrinology If patient is unsuitable for trial of PDE5i? For assessment of severe distress
Patient needs from treatment When asked what they wanted from an ED treatment, patients cited the following: 1. Cure e.g. return to normal sexual function 2. Pleasure e.g. sensation, orgasm achieved 3. Partner sexual satisfaction 4. Duration 5. Reproduction e.g. ability to ejaculate 6. Naturalness of erection 7. Spontaneity So we are looking for a treatment that provides the patient with the above L.Montgomery 16
Treatment options for ED Psychosexual counselling Pelvic floor exercises??. Lifestyle change Testosterone replacement therapy PDE5 inhibitors Tadalafil Vardenafil Sildenafil Avanafil Intra-urethral alprostadil MUSE Topical alprostadil VITAROS Intra-cavernosal alprostadil CAVERJECT Vacuum pumps Surgery L.Montgomery 17
Oral Therapies Gold standard First line treatment phosphodiasterase inhibitors PDE5s ( if patient suitable) VIAGRA (sildenafil) on demand CIALIS (Tadalafil) on demand & once a day (OAD) AVANAFIL (Spedra) on demand LEVITRA (Vardenafil) on demand no longer on Gateshead/ Newcastle formulary The effects can last from 30 mins to 36 hours depending on which tablet you use. This can influence the type of PDE5s that you prescribe with regards to drug interactions etc. L.Montgomery 18
Contra-indications PDE5 s Nitrates both continuous and intermittent Where vaso-dilatation or sexual activity is inadvisable Hypotension Recent stroke Recent MI Recent unstable angina VIAGRAand Levitra hereditary degenerative retinal disorders CIALIS uncontrolled arrhythmias and uncontrolled hypertension L.Montgomery 19
Cautions PDE5 inhibitors Cardiovascular disease Anatomical deformity of the penis Predisposition to prolonged erection ie sickle cell, multiple myeloma or leukaemia Not recommended to be used in conjunction with other treatments for ED Potential for drug interactions Hepatic and renal impairment VIAGRA bleeding disorders or active peptic ulceration also reduced dose if patient on cimetedine L.Montgomery 20
Trial of PDE5 inhibitors Give sufficient number of tablets for trial. (12 if possible) Give information written and verbal re how to take timings and what to avoid Give information re possible side effects, which side effects would cause them to stop trial? If one trial does not work try the others Try psychosexual counselling technique Use the meds enjoy the foreplay but no intercourse!
Intra-urethral alprostadil -MUSE On average 7 minutes to take effect and lasts 30-60 minutes Trials show 66% achieved erection sufficient for intercourse Start with 100mg dose and? reduce dose according to response Important to teach patients technique Test dose administered in clinic to teach technique Wait in clinic 30 minutes to gauge effect and rule out side effects POSSIBLE SIDE EFFECTS Pain 10 13% Minor bleeding 5% Hypotension ( small risk) L.Montgomery 22
Topical alprostadil - VITAROS Newest topical form of Alprostadil. Absorbed through the glans. None invasive treatment Suitable for most men Remove from fridge 24 hours before use of warm in hands to bring up to room temperature Teach application technique
Intra-cavernosal alprostadil CAVERJECT Administered via injection Erection will usually occur with or without sexual stimulation Must teach injection technique Dose needs titrated patient information and teaching essential Ongoing support is essential Repeated clinic visits Provide full instruction and contact details in case of priaprism Cannot use if patients have coagulation problems Effective in approx 70% of patients Available in 2 forms Duo and Dual chamber 24 L.Montgomery
Caverject preparations Dual chamber 10 or 20 mcgs Caverject available in 10s, 20, 40 and? 60 mcg preparations
Vacuum Erection Device Usually the last choice of most men which is a shame as they are effective. Great to use before and after prostate surgery to exercise the penis and help prevent some complications Can be used shortly after surgery to enable intercourse. BUT You do need to practice! Can be fiddly and a bit cumbersome. Do need to have good manual dexterity. Needs to be fitted - type of constriction ring, size of device etc. Need to inform patients re different type of erection, time constriction ring left in place etc. Use with or without ring for penile workout
CONSTRICTION RINGS Able to get an erection but not maintain it? A tight constriction ring applied to an erect penis can prolong the erection long enough to enjoy intercourse. No drugs, no fiddly pumps or injections. Only able to keep ring in place for 30 minutes
Surgery If all fails:- 2 types of implant - inflatable implant - malleable implant ( rarely used)
Premature ejaculation Most difficult to treat and we always recommend referral to psychosexual counsellor. Most common ejaculatory problem.? 1 in 3 men can be affected What's normal? NO definition on how long it should last. Study showed average time between insertion and ejaculation is around 5 ½ minutes. Occasional episodes of premature ejaculation not uncommon no cause for concern Primary premature ejaculation affects approx 1 in 50 men in England
Causes of prem ejac Stress Relationship problems Anxiety over erection Previous traumatic sexual experiences Depression Medical conditions ie diabetes
Premature ejaculation treatments 1. Trial of PDE5s/ alprostadil 2. Double condoms 3. De sensitizing spray 4. Withdrawal 5. Vacuum device 6. PRILOGY (not available on formulary) 7. SSRIs
Any questions? Thank you for listening. L.Montgomery 32