Male Pelvic Health following Pelvic Surgery

Radical Pelvic Surgery Associated Sexual Dysfunction Pathophysiology

Post Radical Prostatectomy (RP) Sexual Dysfunctions Erectile dysfunction (ED) Anejaculation Anorgasmia Dysorgasmia (painful ejaculation) Orgasm associated urine leak Penile length alterations Penile curvature

Sexual Health A fundamental human right Important to overall health and quality of life Satisfaction provides many benefits to patients and their partners Proceedings of a Regional Consultation convened by Pan American Health Organization (PAHO). World Health Organization (WHO) in collaboration with the World Association for Sexology (WAS). May 19-22, 2000; Antigua Guatemala, Guatemala.

Sexual Dysfunction Characterized by disturbances in sexual desire and in the psychophysiologic changes associated with the sexual response cycle Causes personal distress or interpersonal difficulty May signal the presence or progression of underlying disease (eg, cardiovascular disease [CVD], heart disease, vascular insufficiency, depression) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994. Jackson G, et al. Int J Clin Pract. 1999;53:445-451. Nicolosi A, et al. Urology. 2013;61:201-206.

Definition of ED the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual performance Recommendations of the 1st International Consultation on Erectile Dysfunction. In: Jardin A, et al, eds. Erectile Dysfunction. Plymouth, United Kingdom: Health Publication, Ltd; 2000:711-726.

Physiology of Normal Erections Erections are a complex event, requiring Intact arterial and venous system Normal innervation Normal hormonal factors Functioning erectile tissue (the penis) Abnormalities in any or all of these will lead to ED.

Physiology of Normal Erections Nerve signals Release of nitric oxide Smooth muscle relaxation in capillary bed of corporal bodies Increase in blood flow, filling penis Draining veins compressed Normal Erection

ED and CVD Penile vascular bed is unique, with smaller vessels feeding it 57% of men in one study who had had bypass surgery had prior ED 64% of men in one study hospitalized for myocardial infarction (MI) had experienced prior ED ED is a likely indicator of systemic vascular disease and probably an early warning for increased risk of MI or stroke Gundle MJ, et al. Am J Psychiatry. 1980;137:1591-1594. Jackson G, et al. Int J Clin Pract. 1999;53:363-368. Marwick C. JAMA. 1999;281:2173-2174. Pritzker MR. Abstract presented at: Proceedings of the American Heart Association; November 7-10, 1999; Atlanta, Ga. Abstract 104561. Wabrek AJ, et al. Arch Sex Behav. 1980;9:69-77.

Percent ED May Be Clinically Evident Prior to CAD Symptoms Among 300 patients with CAD and angina All ED Severe ED Prevalence of ED among patients was 49% Mean time between onset of ED symptoms and onset of CAD is 38.8 months (range 1-168) 60 50 40 30 20 ED symptoms prior to CAD All patients with type 1 diabetes had ED prior to CAD 10 0 CAD=coronary artery disease Montorsi F. Eur Urol. 2013;44:360-364.

Relationship of ED to Silent MI in Type 2 Diabetes 133 men with type 2 diabetes and documented asymptomatic CAD were compared with 127 men with type 2 diabetes and negative cardiac evaluation ED was highly correlated with the presence of asymptomatic silent MI and CAD Men with type 2 diabetes who present with ED and no cardiac history need cardiac evaluation Gazzaruso C, et al. Circulation. 2014;110:22-26.

ED as a Predictor of Heart Attack In a study of >25,000 men Men with ED had almost twice the risk of heart attack vs men without ED Men aged >40 years with ED had 3 to 4 times the risk of heart attack vs younger (aged 30-39) cohort 13 11 9 7 5 3 1 Odds Ratio (95% CI) 3.8 4.0 1.99 Total Aged 40-44 Aged 50-55 Blumentals WA. Int J Impot Res. In press. February 26, 2004. Available at: http://www.nature.com/cgi-taf/dynapage.taf?file=/ijir/journal/vaop/ncurrent/abs/3901309a.html.

Is ED a Sentinel of Early Atherosclerosis? 45 men with ED but no vascular risk factors (VRFs), 45 men with ED and VRFs, 25 healthy men (aged 25-67 years) Measures Endothelial cell activation proteins (ECA), P-selectin, intercellular adhesion molecule, vascular cell adhesion molecule-1, endothelin Vascular injury assessed by ultrasound intima-media thickness of carotid arteries and pharmacologically stimulated peak systemic velocity of cavernous arteries Results after correcting for body mass index (BMI) and smoking Elevated ECAs in men with ED compared with controls (P<0.01) Endothelin is best predictor for ED Vascular studies show no damage in those with ED and no VRFs Increase in ECAs associated with ED independent of VRFs and overt vascular damage ED is sentinel of early atherosclerosis Bocchio M, et al. J Urol. 2004:171:1609-1610.

Causes of ED: Neurogenic Factors Radical pelvic surgery 1-3 Pelvic/spinal cord injury 1-3 Multiple sclerosis or other demyelinating conditions 3 Neuropathies 1-3 Pudendal nerve injury 4-6 Stroke, Alzheimer s disease, or Parkinson s disease 1 1. Lue TF. N Engl J Med. 2000;342:1802-1813. 2. NIH Consensus Development Panel on Impotence. JAMA. 1994;270:83-90. 3. Romeo JH, et al. J Urol. 2000;163:788-791. 4. Lewis RW. Urol Clin North Am. 2001;28:209-216. 5. Cherington M. Semin Neurol. 2000;20:247-253. 6. Ricchiuti VS, et al. J Urol. 1999;162:2099-2100.

Causes of ED: Vascular Factors Atherosclerosis 1-3 and associated risk factors 4-7 Smoking 4,6 Diabetes 5 Dyslipidemia 5 Hypertension 5 Obesity 7 Venous leaks 8,9 Pelvic or perineal trauma 10 Perineal arterial compression from cycling 9,10 1. Miller TA. Am Fam Physician. 2000;61:95-104, 109-110. 2. NIH Consensus Development Panel on Impotence. JAMA. 1994;270:83-90. 3. Azadzoi KM, et al. J Urol. 1998;160:2216-2222. 4. Kaiser FE, et al. J Am Geriatr Soc. 1988;36:511-519. 5. Lue TF. N Engl J Med. 2000;342:1802-1813. 6. McVary KT, et al. J Urol. 2001;166:1624-1632. 7. Esposito K, et al. JAMA. 2004;291:2978-2984. 8. Munarriz RM, et al. J Urol. 1995;153:1831-1840. 9. DePalma RG, et al. J Vasc Surg. 1989;10: 117-121. 10. Sommer F, et al. Eur Urol. 2001;39:720-723.

Causes of ED: Hormonal Factors Hypogonadism 1,2 Hypothyroidism, hyperthyroidism 1,3 Pituitary tumor, hyperprolactinemia 1,4 1. AACE Male Sexual Dysfunction Task Force. Endocr Pract. 2003;9:77-95. 2. Morales A, Heaton JP. Urol Clin North Am. 2001;28:279-288. 3. Lue TF. N Engl J Med. 2000;342:1802-1813. 4. Johri AM, et al. Int J Impot Res. 2001;13:176-182.

Intracavernosal Injections PGE 1 (Caverject, Edex) 60% to 70% success rate Penile pain Combination therapy Up to 90% success rate Minimal incidence of penile pain Is there an intrinsic advantage to PGE 1? Intracavernosal injection (ICI) is the treatment modality used in Montorsi study Pain reduction maneuvers Change in formulation Nonsteroidal anti-inflammatory agent Local anesthetic Montorsi F, et al. J Urol. 1997;158:1408-1410.

Penile Injection Therapy Smooth muscle relaxing medication injected directly into the penis (papaverine, phentolamine, PGE 1 )

Oral Medications Viagra Cialis Tadalafil Vardenafil

Results 14 of 51 (27%) patients receiving sildenafil experienced return of spontaneous functional erections (IIEF 3+4=8) 1 of 25 (4%) in the placebo group (P=0.0156) Sildenafil may improve long-term return of functional erections Mechanisms? Oxygenation during nocturnal erections Endothelium protection (DeSouza et al, Diabetes Care, 2002) Neuronal regeneration (Zhang et al, Stroke, 2002)

Penile Injection Therapy: Advantages Highly effective Mimics natural physiology of erection No effect on sensation, ejaculation, fertility Higher level of discretion, thus spontaneity

Penile Prosthesis Pros High patient satisfaction rate 7 to 10 years average functional prosthesis life Higher spontaneity Discreet, normal appearance Erection longevity controllable Significant clinical data on procedure and results

Penile Prosthesis (cont d) Cons Potential for infection, device malfunction Major surgery, postoperative pain, irreversible Additional surgery at product end-of-life Potential decreased sensation, glans sensitivity, ability to ejaculate/reach orgasm Complications include infection, device malfunction, need for additional surgical procedures

Penile Prostheses Some workers suggest prosthesis placement during RP in men with poor preoperative erectile function Preoperative ICI challenge Staged approach No documented increased incidence of prosthetic infection with this approach Timing of implant surgery following RP?

Male Incontinence

Indications for Male Sling Mild to Moderate Incontinence Sphincteric Incompetence Post-Surgical Incontinence Radical prostatectomy TURP Congenital disorders Myelomeningocele (adults only) Sacral agenesis

Male Sling

AMS Sphincter 800

AMS Sphincter 800: Components

AMS Sphincter 800 The device is implanted in the body and cannot be seen. The cuff can be placed at the bulbous urethra or at the bladder neck. The Sphincter allows the patient to control his/her urinary function.

AMS Sphincter 800: Mechanism of Action

Occlusive Cuff Pressure Regulating Balloon

Patient Selection Criteria Sterile Urine Incontinence due to an incompetent external sphincter Adequate manual dexterity Incontinence present for at least 6 months Bladder capacity of at least 200cc Motivated patient Urine flow greater than 10ml/sec Low residuals

Contraindications Chronic urinary tract infections An irreversibly obstructed urinary tract Patients with low-volume detrusor hyperreflexia Unstable urethral stricture disease or a urethral diverticulum at the potential cuff site Females with SUI due to hypermobility and descent of the bladder neck and proximal urethra

AMS Sphincter 800 Results 90% of male patients reported satisfaction with the AMS Sphincter 800. 80% of males were socially continent using 0-1 pad per day at 7 years. 92% of male patients would have the AMS Sphincter 800 placed again. For over 25 years, the AMS Sphincter 800 has been the gold standard to treat urinary incontinence.

The best interest of the patient is the only interest to be considered. William J. Mayo, M.D. 1861-1939