John Reckless

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• John Reckless
• Diabetes Study Day
• 9th September 2009

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Erectile Dysfunction
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ERECTILE DYSFUNCTION

• ED or impotence the persistent inability to
  achieve or maintain an erection suitable for
  satisfactory SI or activity
• 110 in men in UK (approx 2.3 million men)
• Potentially affects all ages - double by 2025
• Incidence increases with age
• 50 ED pts take 2yrs to seek professional help
• Mostly always has an organic and psychogenic
  element

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Causes of Erectile Dysfunction

• Organic causes can be
• Chronic illness Diabetes, Cardiovascular and
  Neurological disease
• Surgery and trauma 23 spinal injury 26 DXT
  for loc Ca P, TURP 13.6
• Drugs and other modifiable factors
• Conditions associated with increasing age
• Peyronies disease and penile abnormalities

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Managing the risk factors
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Causes of Erectile Dysfunction

• Psychogenic includes
• Anxiety (about sex performance/identity)
• Stress due to work or financial matters
• Psychological trauma or abuse
• Sexual/relationship problems with partner
• Depression /chronic illness
• Psychosis
• Sexual myths/lack of education

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ED AND DIABETES

• Erectile failure rate of over 50 is reported by
  men with diabetes. (3-4 fold increased risk)
  BDA (Fraser, M 2004)
• Prevalence increases from
• 15 at 30-35 yrs (within 10yrs of diagnosis)
• 55 at 60 yrs and increases with age.
• Often related to severity/duration of disease
  correlates with glycaemic control.
• 14 due to emotional factors can have profound
  effect on QOL/self esteem.

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Risk factors in diabetes

• Arterial disease strong link retinopathy,
  Intermittent claudication (smooth muscle
  insufficiency)
• Neuropathy depletion neurotransmitters
  (acetycholine, VIP,)- reduced NO levels
• Endothelial dysfunction abnormal endo function
  metabolic active tissue producing NO,
  prostanoids, endothelium impairment-reduced
  smooth muscle relaxation
• Compounded by life style factors

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How an erection works!

• Sexual arousal (visual, auditory, olfactory,
  imaginative, touch)
• Brain sends signal through spinal cord via
  parasympathetic nerves (reflex arc at sacral
  plexus, low thoracic upper lumbar)
• Relaxes smooth muscle (nitric oxide)
• Dilates arterial walls increases blood flow to
  create an erection

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Diagnosis of ED-initial assessment and
investigations

• History vital to establish onset how long?
• Physical exam full neurological exam
• Weight /height body mass index
• Urinalysis
• Blood pressure
• Blood tests Testosterone, lipids, glucose, also
  Thyroid, PSA and Prolactin
• International Index of Erectile Function (IIEF)
  recognised tool for measuring ED.
• Life style issues

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Drugs that can impair ED.

• Antipsychotics Antidepressants
• Antihypertensives Anticholinergics
• Antiandrogens Hormones
• Cardiac drugs Diuretics
• H2 Antagonists NSAIDs
• Lipid lowering drugs Antiviral
• Miscellaneous

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TREATMENT PLAN

• Patient choice good communication
• Involve wife/partner support
  holistic approach
• Start early delay can cause fear of failure low
  self esteem, anxiety depression
• Education and training anatomy etc.
• Leaflets and videos
• Demonstrate treatment

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Treatment options

• PDE5 inhibitors
• Intra urethral Muse (PGE1)
• Prostaglandin injection therapy (Caverject)
• Vacuum Device
• Penile implants
• Counselling

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PDE5 Inhibitors

• Relaxes smooth muscle in arteries, allowing more
  blood flow to the penis. Does NOT improve sex
  drive libido.
• Oral medications include
• Viagra up to 60 mins 4-5 hr half life 6hrs
• Cialis 30-60 mins 17.5hr half-life 36 hr
• Levitra 15-60 mins 4-5 hrs half life 6-12
• Tolerable and less invasive

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Common side effects of PDE5 inhibitors

• Viagra Levitra
  Cialis
• Headache 16 15 15
• Flushing 10 11 3
• Indigestion 10 4 10
• Abn. vision 3 0 0
  
• Back pain 0 0 6
• Contraindicated with patients on nitrates!

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Intra urethral Muse

• Medical Urethral System for Erection
• Prostaglandin E medicine applied into urethra
• Erection occurs after 10-15 mins
• Less success than oral agents
• Less side effects more localised e.g.
  pain and testicular discomfort

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Penile Injection therapy

• Relaxes smooth muscle and increases blood flow to
  penis
• Tiny needle injected into corpora
• Natural and firm
• 5-10mins to work can titrate dose
• Can last 30mins - 2hrs
• Easy to teach patient and partner
• Warning on priapism

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Pumps, Caverjet and MUSE
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Vacuum Therapy

• Works with 3 mechanisms a large plastic tube, a
  pump and a constriction ring
• Creating a vacuum allows blood to flow into the
  penis
• Ring traps the blood at base and erection is
  maintained (ring only)
• Works for almost everyone, as often as possible,
  trial and error
• Diminished sensation, cost and pain

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Penile Implants

• A prosthetic device surgically implanted inside
  the penis.
• High rate of satisfaction
• Surgery carries risks bleeding, scarring,
  infection and numbness at the head.
• Costly if not on NHS

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Counselling

• ED is a common complication of Diabetes
• Can impair QOL, self esteem and relationships
  with partner -ve impact
• Involve Nurse Practitioners
• Refer for pyschological / couple therapy which
  will open up communication and ease tension /
  guilt in the relationship.

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Schedule 11

• Diabetes Prostatectomy
• Multiple Sclerosis Radical pelvic Surg
• Parkinsons Dis Renal Failure
• Poliomyelitis Prostate cancer
• Severe pelvic injury
• Spinal cord injury Spinal cord injury
• Single gene neurological disease
• Severe distress (confirmed by urologist)

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RUH advice from

• Sandra Ritch
• Department of Urology
• RUH, Bath

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The 5-Item Version of the International Index of
Erectile Dysfunction (IIEF-5)