ERECTILE DYSFUNCTION ___________________________

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ERECTILE DYSFUNCTION____________________
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• FOR THE GENERALIST

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ERECTILE DYSFUNCTION____________________
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• DEFINITION
• THE PERSISTENT INABILITY TO ACHIEVE OR MAINTAIN
  ERECTION SATISFACTORY FOR SEXUAL PERFORMANCE

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SCOPE AND IMPACT__________________________ERECTI
LE DYSFUNCTION

• 30 MILLION MEN IN THE USA
• 40 PREVALENCE AMONG MEN gt 40
• 70 PREVALENCE AMONG MEN gt 70

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Anatomy and Mechanism of Penile Erection
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Molecular Mechanism of Penile Smooth-Muscle
Relaxation
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Molecular Mechanism of Penile Smooth-Muscle
Contraction
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HISTORY-TAKING ERECTILE DYSFUNCTION

• SEQUENCE
• DICTION
• ATTITUDE
• LEVEL OF DETAIL

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HISTORY-TAKINGOVERCOMING RETICENCE ERECTILE
DYSFUNCTION

• ASSURE CONFIDENTIALITY
• UNIVERSALIZE
• EMPATHIZE

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HISTORY-TAKINGUSE THE PHASES OF THE SEXUAL
RESPONSE CYCLETO GUIDE YOUR INQUIRY

• DESIRE
• EXCITEMENT
• ORGASM
• RESOLUTION

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HISTORY-TAKINGERECTILE DYSFUNCTION
PSYCHOGENIC ORGANIC
Onset Abrupt Gradual
Course Selective Persistent
Degree Partial Absolute
Nocturnal or am Erection? Yes No
Associated Features Psychosocial stress Organic Disease
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DIAGNOSIS ERECTILE DYSFUNCTION

• HISTORY IS (almost) ALL
• PHYSICAL
• CONSIDER SERUM TESTOSTERONE
• OTHER TESTS USUALLY NOT INDICIATED

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DIAGNOSIS ERECTILE DYSFUNCTION

• R/O HORMONAL ETIOLOGY
• R/O SUBSTANCE ABUSE
• CONSIDER PSYCHOGENIC ETIOLOGY
• CONSIDER MEDICATION CHANGES

TRY TREATMENT
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Approach to the Diagnosis and Treatment of
Erectile Dysfunction
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Molecular Mechanism of Penile Smooth-Muscle
Relaxation
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PRESCRIBING
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PRESCRIBING

• Start with medium dose
• Minor side effects headache, flushing,
  dyspepsia, nasal discharge, visual change
• Consider cost and insurance coverage

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DEATH BY VIAGRA?________________________________
SAFETY

• REPORT TO FDA
• EXPECTED DEATHS PER SECOND
• HEMODYANIC STUDIES
• AHA GUIDELINES

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Deaths Associated with Sildenafil Therapy in the
United States
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Other Oral Meds ERECTILE DYSFUNCTION

• Yohimbine
• Trazodone
• Apomorphine
• Phentolamine

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Approach to the Diagnosis and Treatment of
Erectile Dysfunction
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Tranurethral Medication ERECTILE DYSFUNCTION

• Alprostadil Muse Prostaglandin E1
• Moderate Efficacy
• Expensive
• Causes pain frequently

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Mechanical Aids ERECTILE DYSFUNCTION

• Vacuum device
• Constriction rings

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Intracavernosal Therapy ERECTILE DYSFUNCTION

• Trimix of alprostadil, phentolamine, papaverine
• Almost always efficacious
• Requires referral, training, careful monitoring
• Risk of priapism and fibrosis

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Penile Prostheses ERECTILE DYSFUNCTION

• Effective
• Major surgery
• Expensive
• Significant risk of infection
• Usually have to be replace after 5-10 years

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Treatment Options for Men with Erectile
Dysfunction