Erectile dysfunction –a growing problem

Dr Thomas Fox

Endocrine SpR

Royal Cornwall Hospital, Truro

Erectile Dysfunction (ED)

Definition Epidemiology Aetiology Clinical features

History Examination

Investigation Treatment

Definition

The consistent inability to obtain and maintain penile erection sufficient to complete satisfactory sexual performance

Epidemiology

Estimated to affect 152m men worldwide Non-diabetic men 0.1-18.4% prevalence In a study of 541 diabetic males

35% in diabetic men 5.7% in 20-24 year olds 52.4% in 55-59 years olds

ED is a growing problem Massachusetts Male Aging Study estimate an

11% world increase by 2015

Aetiology

Vascular Neurological Endocrine Psychological Pharmacological Penile tissue abnormalities Others

Vascular

Arterial insufficiency Endothelial dysfunction (up to 95%) Discrete lesions

Venous leakage Failure of venule constriction

Neurological

Damage to autonomic nervous system Predominant parasympathetic damage

Endocrine

Hypogonadism Most commonly primary testosterone deficiency Secondary hypogonadism

Hypothyroidism Hyperprolactinaemia

Other causes of ED

Penile Balinitis Phymosis Penile finrosis Tumours Trauma

Pharmacoloical

Clinical features

History Examination

History

Patient’s description of the problem Patient’s and partners expectations Duration Speed of onset Intermittent/progressive? History of sexual partners Nocturnal erections? Libido

PMH Glycaemic control Vascular/neurological disease Urological PSH and trauma

DH Anti-hypertensives Androgen antagonists Sedatives Drugs that cause hyperprolactinaemia

(phenolthiazides) Alcohol

Psychological assessment

Examination

General Vascular Neurological Genitalia DRE

Investigation

Diabetic/vascular Endocrine

9am Testosterone Thyroid function tests Pituitary hormones (LH,FSH,PRL)

Imaging

Management

Multidisciplinary approach Involvement of partner Couples expectations and desires

Oral therapies

Phosphodiesterase V inhibitors Sildenafl (Viagra) 4hr Tadalafil (Cialis) 17hrs Vardenafil (Levita) 4 hrs

Side effects flushing, headache and GI disturbance

Contraindications - nitrates

Efficacy of PDE-V inhibitors

Hundreds of studies internauinally Improved erections and increased successful

episodes of sexual intercourse vs placebo (15 RCTs)

Levinson et al 1998

254 males over 18 with clinical diagnosis of ED for >6 months

Randomised double blind placebo controlled trial

Primary end-point Index of Erectile Function (IEF)

Variable dose 25mg-100mg adjusted by the patients

IEF Q3 ability to obtain erection

IEF Q4 ability to maintain erection p<0.0001

IEF7 satisfaction with therapy

Improved erections at 12 weeks

p<0.0001

% successful sexual attempts in last 4 weeks p<0.0001

PDE V inhibitor prescribing

Following conditions DM PD, MS, polyiomyelitis Pinal cord injuries, spina bifida Radical prostatectomy

Trial of 8 doses with dose titration before classifying as failure of treatment

Once correct dose achieved then can prescribe 1 tablet per week

Vacuum devices Can improve erection Messy and user dependent Satisfaction varies 35-80%

Intracavernosal injections

Intracavernosal injections with prostaglandins Alprostadil (prostaglandin E1)

One large RCT found increased rate of satisfactory erections when alprostadil injected compared to placebo

Side effects – pain, priapism

Testosterone replacement

Improves erectile function and libido Preparations

Topical (testim gel) Im testosterone Long-acting depots

Testosterone replacement improving diabetes? Kapoor et al 2006 Small double-blind placebo controlled crossover trial (n=24) T II DM with testosterone deficiency (10 on insulin therapy) 3 months treatment with testosterone (200mg im 2-

weekly)replacement and 3 months with placebo (1 month washout)

Endpoints – fasting glucose, HbA1C and HOMA in non-insulin treated subjects (homeostatic model index)

Secondary endpoints waist circumference, BP and lipids

Results HbA1C reduced by 0.37% (p=0.03) Fasting glucose reduced by

1.58mmol/L(p=0.03) HOMA index reduced 1.73 (p=0.02) Waist circumference reduced 1.73cm (p=0.03) Total cholesterol reduced 0.4mmol/L (p=0.03) No effect on BP

Conclusions Testosterone replacement can improve T II diabetic

control

Intraurethral alprostadil Effective but requires sufficient training

required

Penile implant

•Inflatable

•Malleable

Psychosexual counselling

Talking therapies for men and couples

Summary

ED Common Marker for other forms of neurovascular

complications in diabetes Psychologically damaging Treatable Treat associated hormonal deficiencies

References

Efficacy and safety of sildenafil citrate (Viagra®) for the treatment of erectile dysfunction in men in Egypt and South Africa International Journal of Impotence Research (2003) 15, Suppl 1, S25–S29.Levinson et al

Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with Type II Diabetes

Kapoor et al European Journal of Endocrinology 2006

Diabetes Chronic conplication

Wiley press, Shaw et al

The role of testosterone in erectile dysfunction

Gooren et al