Treatment of Erectile Dysfunction

Alex Shteynshlyuger MD

Board Certified UrologistDirector of Urology

New York Urology Specialists2014

www.NewYorkUrologySpecialists.com

Erectile Dysfunction (ED) (Impotence)

Definition of Erectile Dysfunction: Persistent (3 months or longer) or recurrent

inability to attain or maintain penile erection sufficient for sexual performance.”

Diagnosis based on history/complaints/patient perception of a problem

Can be self-diagnosed by a patient IIEF (International Index of Erectile Function) Questionnaire

is easy to self-administer Classification of Erections

Nocturnal Psychogenic/erotic Reflexogenic

Organic vs Non-Organic Organic traditionally refers to vascular or neurogenic (nerve

damage) causes Non-Organic traditionally refers to “Psychogenic” Classification is Based on Outdated understanding of

human physiology: Psychogenic problems are organic in origin, due to imbalances in neurotransmitter activity (as in depression) and treatable with medical management.

Patients respond to the same treatment approaches regardless of the cause:

PDE5 inhibitors are the staple of therapy – help with “confidence”, overcome ‘situational’ ED. Psychotherapy may be beneficial for all patients as there are always components of “psychogenic” in all cases of ED, whether primary or secondary.

Classification of Erectile Dysfunction

Psychogenic Neurogenic Vascular Mixed (Psychogenic and Organic

components) Iatrogenic

Medications Surgical trauma

Treatment of ED History

Pre 1970’s Psychosexual therapy; ED treated by psychiatrists

1970’s Pre-1998 (pre-Viagra) Penile implants (prosthesis) - the gold standard of

treatment Topical; Vacuum Pump 1980’s intraurethral and intracavernous injections

Post 1998-> Viagra = 1st line of therapy Cialis / Levitra, etc…

Evaluation of a patient with EDHistory

Onset; duration; IIEF, history of traumaMedications (TCAs, spironolactone, etc)

Nocturnal Penile Tumescence test Poor correlation with ED. Not recommended Cigarette Smoking and vascular risk factors are better

predictors of organic ED than NPTT

Audiovisual Sexual Stimulation (AVSS) useful in distinguishing psychogenic causes But does not change management

Non-surgical Treatment of ED 1st line of therapy: invariably PDE5 inhibitor

(sildenafil citrate/Viagra, Cialis, Levitra) Inhibits breakdown of cGMP, which produced from cGTP

by nitric oxide PDE 5 isoenzyme is enriched in the penis Metabolized by P450 Contraindicated in patients taking nitrates (Potentiates

the hypotensive effects of nitrates.) Relative contraindication in patients with ischemic

coronary disease, heart failure patients Effective in patients with organic, psychogenic and mixed

ED. Effective in 70-80% of patients after sufficient trial

Sildenafil citrate (cont) Improves erections in

70 % of pts with HTN 56 % of diabetics 42 % of RRPR patients 80 % of patients with spinal injury. 60 % of patients with TURP 70-80 % of patients with SSRI induced

arousal disorder

Non-surgical management of ED Lifestyle modification

Regular exercise Healthy diet *SMOKING CESSATION Alcohol Bicycling

Syndrome of general anesthesia and ED ED 2x as frequent in long distance bikers Ergonomic saddles

Meds implicated in ED Antihypertensives

Methyldopa, reserpine b/c of central action Thiazide diuretics, spironolactone

alpha-1 adrenergic antagonists Doxazosin – reduced incidence of ED

compared to placebo (Guthrie 1997).

TCAs, SSRIs

Meds implicated in ED Inhibit Testosterone

Production Spironolactone Ketoconazole Metronidazole Flutamide Cimetidine Cyproterone

Inhibit GnRH Progesterone Estrogen GnRH agonists

(leuprolide, goserelin) Prolactinoma Estrogen Phenothiazines TCAs Reserpine Cocaine/opioids

Treatment of Medication Induced ED

Change medication Decrease the dose (start low go

high) Drug holidays Only under medical supervision

Hormonal Therapy Testosterone

Reasonable to use in patient with documented hypogonadism

Prostate CA or Breast CA are contraindications for androgen supplementation (but this is evolving):

Bx to R/O prostate Bx based on clinical risk stratification No increased risk for developing prostate cancer May be safe in select men with history of treated prostate cancer DRE and PSA every 6 months

Only DHEA and DHEAS are effective Improves libido; ED improvement. Side Effects:

Suppress LH/FSH -> infertility Breast tenderness/gynecomastia Erythrocytosis risk of stroke. Monitor Hematocrit; LFTs

Androgen replacement (cont)

Parenteral preparations Depo preparations do not resemble the circadian rhythm Testosterone enanthate and cypionate IM q2-4 weeks

200-400 mg Transdermal preparations – often best option

Can resemble circadian rhythms (importance not known). Oral preparations

Poor bioavailability due to first-pass metabolism Toxic to the liver (hepatitis, hepatoma, liver cysts,

hepatocellular Ca. Injectable Depot or implants

Convenient; work well

Hyperprolactenemia Testosterone supplementation of

no benefit Eliminate the offending drugs

Estrogens, morphine, sedatives, neuroleptics

Treatment: Medical: bromocriptine Surgical: Excision

Yohimbine & Trazodone Centrally acting alpha-2 antagonist No benefit to patients with organic ED vs

placebo (Morales, 1997) Better than placebo in patients with

psychogenic ED (62% vs 16%). Often prescribed with Trazodone.

TRAZODONE Mild antidepressant with rare incidence of priapism SSRI

Apomorphine for ED Not an opiate Dopaminergic agonists acts on the

paraventricular nucleus in the brain, the sexual drive center in humans.

Stimulates pro-erectile signaling Requires sexual arousal to work Rapid onset of action, 12 min to erection; More effective than placebo (Uprima Pharm). Not in clinical use

L-arginine No better than placebo for

treatment of ED

Intraurethral Therapy Alprostadil, PGE1 (Prostaglandin

E1) Via intracavernous or intra-urethral routes

Urethral route (MUSE) Stimulates adenyl cyclase, which raises cAMP that

leads to lower Ca++ and relaxation of smooth muscle

Penile pain is a major side effect with incidence of 10-30%

Hypotension and syncope with MUSE – 1st administration in the office.

Transdermal Therapies Nitroglycerin (no longer used)

Smooth muscle relaxant More effective than placebo for ED

(Heaton 1990). Minoxidil vs Placebo Vs Nitroglycerin:

Double blinded studyMinoxidil more effective than Placebo or Nitro in ED.

Intracavernous Injections Papaverine

Very effective in psychogenic or neurogenic ED

Erection sufficient for penetration in 98% of tetra/quadra-plegic patients

Priapism (0-35%) Corporal Fibrosis (1-33%)

As monotherapy 55% effective

Intracavernous Injections (cont) Alprostodil (Caverject, Prostin VR)

Smooth muscle relaxation, vasodilation, inhibition of platelet aggregation

96% locally metabolized Full erections in 70-80% patients Lower incidence of fibrosis and priapism than

with papaverine but higher incidence of painful erections

Triple therapy Trimix (papaverine, phentolamine, alprostadil) mixture for ICI of alprostadil failure or for pain with alprostadil; as effective as alprostadil alone

Efficacy of Intracavernous Injections

ICI 80-100% successful in treatment of ED in patients with non-vascular disease

In vascular disease, higher dosage and more trials required

Contraindicated in patients with: Sickle cell disease Psychiatric illness Severe systemic disease

Herbal Supplements for ED Many herbal supplements have been tried No randomized trials ever to show benefit Billions in Profits Successful supplements: Recalled by FDA

because they had Viagra/Cialis mixed in.

Vacuum Erection Devices

Effective, safe treatment of ED Penis is engorged by negative

pressure, a ring is applied at the base.

Can be used with failed penile prosthesis

35% use the device long term 10% incidence of hematoma

Treatment of Erectile Dysfunction: SUMMARY

Initial Treatment: PDE5 inhibitor: Viagra / Cialis / Levitra /

Staxyn If fail repeated high dose Viagra (100 mg)

Alprostadil (PGE1) intracavernous injection or intraurethrally

Vacuum Pump If failed alprostadil,

Triple therapy Trimix (papaverine, phentolamine, alprostadil)

Penile Implant Surgery for medical failure

Treatment of ED in NYC

Contact us to schedule an appointment:ED Treatment Center at the New York Urology Specialists

http://www.newyorkurologyspecialists.com