Sexual problems in the ageing male: ED Prism IV September 25-26 Bruges, Belgium Dr. HHJ Leliefeld and Prof. FMJ Debruyne, urologists The Netherlands
Erectile disfunction Definition & Prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction
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.
Sexual problems in men Decrease of sexual desire Excitement disfunction/erectile disfunction (ED) Orgasm-disfunction/ejaculationdisturbance Pain during sex
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?
Age and erectile disfunction "20.000 men survey, Cologne" 60 57,3 40 erectile disfunction 34 % 20 4 9,1 19,7 0 30-39 40-49 50-59 60-69 70-80 age
Age and erectile disfunction
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): 578-81
Erectile disfunction Definition and prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction
The Erectile mechanism Hippocrates (5de-4de eeuw BC) De aëre aquis et locis Aristoteles (384-322 BC) Pneuma as physiologic concept Leonardo da Vinci (1452-1519) Increase of bloodflow
Leon ar do da V i n ci ±± 1500 t he copu lat i on
Willibrord Weijmar Schultz UMCG (BMJ 1999)
Regnier de Graaf 1641-1672, Inventor of the syringe
The Lériche-syndrome (1879-1955)
Psychische Impotenz Freud 1856-1939
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; 1999:207-220.
A. Flaccid penis B. Penis in erection EM
GMP Mechanism of Erection 5 Erection Stimulation 1 Neural Stimulation 2 Relaxation smooth muscles 4 Ca ++ 3 cgmp Cellular Activation Phosphodiesterase (PDE)
Mechanism of the erection Visual stimulation Tactile stimulation Olfactory stimulation: feromones Neural stimulation Hormonal stimulation Lead to a vasculair reaction
Erectile disfunction Definition & prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction
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
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): 115-28.
Not everything is organic!!!
Psychological causes Depression Fear Excessive stress Relation problems Distress,sorrow Lack of problemsolving capacity
Erectile disfunction Definition & prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction
ED: physical examination Bloodpressure? Gynecomastia? Vascular problems? Penile disorders? Hypotrofy of the testicle? Abdominal hairdistribution: rhomboid or terminal?
Examination ED
Frenulum breve
Trauma due to false penetration during intercourse: penile fracture
Paraphimosis
Peyronie s disease
Francois de la Peyronie (1678-1747)
Correction after Nesbit-procedure
Erectile disfunction Definition and prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction
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: 1188 91. 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;86:1210-13.
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
Diameter of arteries of the body
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;22:699-709.
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
STOP smoking! Smoking doubles the chance of moderate to serious ED
Erectile disfunction Definition & prevalence The erectile mechanism Causes of erectile disfunction(ed) Physical examination Risk factors Treatment of erectile disfunction
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
Treatment modalities Sexuological treatment Oral substances Vacuum Devices Prosthesis Injections Testosteron
Consultation
Bear in mind: Men are more focused on Sex Genitals Penetration Women are more focused on The relation Contact` Intimity Orgasm
Media Hype 1998
Drug therapy / oral medication Sildenafil (Viagra) Tadalafil (Cialis) H 3 Vardenafil (Levitra)
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;55:115-128. GMP phosphodiesterase 5 PDE5 inhibitors PDE5 inhibitors are competitive inhibitors that resemble cgmp (the substrate) and bind to the active site of PDE5
Time of onset and duration Tadalafil = 25-30 minutes 36 hour Cialis R Sildenafil = 25-30 minutes 4 5 hour Viagra R Vardenafil = 15-25 minutes 4 5 hour Levitra R
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 2002 168:1332-6
Contra-indications Use of nitrates Within 6 months after MI or CVA Retinitis pigmentosa IB tekst Cialis
Oral medication Watch out! Combination with an alfablocker Combination with CYP3A4 inhibitors as HIV-proteaseinhibitors, certain macrolids/ antibiotics, some SSRI s, cimetidine and
Vacuum devices Problems: Insufficient rigidity Haematoma Painful ejaculation Painful scrotum inside the cylinder
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: 10.1111/jsm.12445 http://onlinelibrary.wiley.com/doi/10.1111/jsm.12445/full#jsm12445-fig-0001
Testosterone therapy In non-responders of PDE 5-I s: if T < 12 nmol/l: a short trial of TRT: salvage therapy
ED: Self-injections ANDROSKAT=PAPAVERINE/PHENTOLAMINE
Complications self-injections Priapism Haematoma Fibrosis Non-cooperative partner Prerequisite: Adequate instruction 24-hours availability Exclusion of..
Prosthesis models
Satisfaction percentage must be (!) greater than 80 %
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 2004 64 (14) 1533-1545
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