Erectile Dysfunctionin Diabetes

Jamie Smith

Etiology of ED: Psychogenic and Organic

Organic Psychogenic

• ED commonly involves a combination of psychogenic and organic factors1

1. Hackett G, Dean J, Kell P, et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp in July 2008

Feldman HA et al. J Urol. 1994;151:54-61.

Men aged 40 to 70 years (N=1290)

No ED48%

ED52%

Minimal17%

Moderate25%

Complete10%

Massachusetts Male Aging Study (US): Key Prevalence Study of ED

Minimal ED, “usually able to get or keep an erection.”Moderate ED, “sometimes able to get and maintain an erection.”Complete ED, “unable to get and keep an erection.”

Prevalence of Erectile Dysfunction in Torbay Hospital and GP Diabetes Clinics

0

5

10

15

20

25

30

35

40

Severe ED Mild/Moderate ED Normal

Hospital

GP

%

p=NS

SHIM<10 = Severe ED SHIM10<20 = Mild/Mod ED SHIM 20 = normal

* *

*

Lockett et al. Diabetes & Primary Care 2007

ED in the man with diabetes

• ED incidence increases with age, duration of diabetes and deteriorating diabetic control1

• Compared to men without diabetes, men with diabetes tend to:

• Suffer ED from an earlier age2

• Suffer more severe ED3

• Have worse disease-specific health-related quality of life3

• Be less responsive to treatment4

1. Fedele D et al. Diabetes Care 1998;21:1973-1977. 2. Feldman H et al. J Urol 1994;151:54-61. 3. Penson D et al. Diabetes Care 2003;26:1093-1099. 4. Eardley I et al. Int J Clin Pract 2007;61:1446-1453

Why Diagnosing ED Is Important

• ED screening may:– Identify underlying coronary artery disease1

– Uncover diabetes (as ED may be the first symptom in up to 20%)1

– Detect dyslipidaemia1

– Reveal the presence of hypogonadism1 – Identify occult cardiac disease1

• Many men with ED show:– Distress2

– Depressive symptoms2

– Decreased self-esteem2

– Diminished quality of life2 – Marked effect on interpersonal relationships1

• Many men perceive their relationship or marriage to be threatened due to the inability to have a satisfactory sexual relationship

1. Hackett G, Dean J, Kell P, et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp in July 2008

2. Lee J et al 2006. BJU Int; 98(3):623-629.

• A detailed medical, psychosexual history and a focused physical examination1

• Patient and if possible partner education about their ED medication1,2

• Patient follow up and adequate exposure to the drug therapy2

The essentials in treating ED

1. Wespes E et al. Eur Urol. 2006;49:806-8152. Hatzimouratidis K et al. Eur Urol. 2007;51:75-89

Drugs that may contribute to ED

•AntihypertensivesMethyldopa, Clonidine, Reserpine,

Beta-blockers, Guanethidine & Verapamil

•DiureticsThiazides & Spironolactone

•Cardiac/circulatoryClofibrate, Gemfibrozil & Digoxin

•TranquilisersPhenothiazines & Butyrophenones

•AnticholinergicsDisopyramide & Anticonvulsants

•AntidepressantsTricyclic antidepressants, MAOIs, Lithium & SSRIs

•HormonesOestrogens/progesterone,

Corticosteroids, Cyproterone acetate, 5-Alpha reductase inhibitors &LHRH agonists

•H2antagonistsCimetidine & Ranitidine

•Cytotoxic agentsCyclophosphamide, Methotraxate& Roferon-A

Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp

Examinations

• All patients should have a focused physical examination.

• A genital examination is recommended – Essential if there is a history of rapid onset of pain, deviation of the penis

during tumescence, the symptoms of hypogonadism or other urological symptoms

• A digital rectal examination (DRE) of the prostate is not mandatory in ED– Should be conducted in the presence of genito-urinary or protracted

secondary ejaculatory symptoms

• Blood pressure, heart rate, weight and waist circumference

Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp

MET equivalents to sexual activity

lower range (‘normal’) 2-3upper range (vigorous activity) 5-6

Lifting and carrying objects (9-20 kg) 4-5Walking one mile in 20 minutes on the level 3-4Golf 4-5Gardening (digging) 3-5DIY, wallpapering, etc 4-5Light housework, e.g. ironing, polishing 2-4Heavy housework, e.g. making beds, scrubbing floors 3-6

Sexual intercourse with established partner

Daily activity METs

Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp

IHD, Nitrates and PDE5 Inhibitors

Angina problematic

Consider appropriate drug treatment

ETT / referral to cardiology for angiography

Defer ED treatment

Angina quiescent

Stop nitrates (long-acting for 1 week)

Encourage exercise

If symptom-free:-

Prescribe PDE5 inhibitor – advice re nitrates (avoid within 24hrs)

Assessment of a patient with erectile dysfunction:

Local guidance

Hypogonadism in diabetic vs nondiabetic men with ED1

22.3

34.0

All ages

ED no diabetes Diabetes

0

10

20

30

40

50

30-39 40-49 50-59 60-69 >70Age (Years)

% H

yp

og

on

ad

ism

(T

<1

2n

mo

l/L

) p <0.0001p <0.0001

1. Corona G et al. Eur Urol 2004; 46(2): 222-228.

n=1027 men with ED with and without type 2 diabetes mellitus

+ ED

04/11/2023 © Schering

0

1

2

3

4

5

Week 4 Week 8 Week 12 Endpoint

Placebo +Sildenafil100mgTestosterone+ Sildenafil100mg

1. Shabsigh R et al. J Urol 2004; 172: 658-663

p=0.029

Testosterone converts sildenafil non-responders to responders in men with hypogonadism and erectile dysfunction1

p=ns

p=nsp=ns

Mea

n ch

ange

from

bas

elin

eIIE

F er

ectil

e fu

nctio

n do

mai

n

n=75 hypogonadal men with ED

Pharmacologic Differences: PDE5 Inhibitors

• The mean terminal half-lives of sildenafil citrate and vardenafil HCl are 3 - 5 hours1 and 4 - 5 hours2, respectively

• The mean terminal half-life of tadalafil is 17.5 hours3

• The longer terminal half life of Cialis may be associated with a period of responsiveness up to 36hrs3

1. Viagra® (sildenafil citrate) Summary of Product Characteristics 2. Levitra® (vardenafil HCl) Summary of Product Characteristics3. Cialis® (tadalafil) Summary of Product Characteristics

Cialis Therapeutic Indications• Cialis is indicated for the Treatment of erectile dysfunction

• Cialis 10mg and 20mgs– In general the recommended dose is 10mg taken prior to anticipated

sexual activity. In patients who experience an inadequate effect, 20mg might be tried.

– The maximum dose frequency is once per day however continuous daily use is not recommended

• Cialis 5mg and 2.5mg– In responder patients to an on-demand PDE5 inhibitor regimen who

anticipate sex more than once per week a once daily regimen might be considered suitable, based on patient choice and the physician’s judgement

– In these patients, the recommended dose is 5mg taken once a day at approximately the same time of day. The dose may be decreased to 2.5mg once a day based on individual tolerability

Cialis Summary of Product Characteristics. Eli Lilly and Company Limited.

Vacuum Erection Devices

Drug injected directly into the corpus away from midline

Corpus cavernosum

Midline

Cross-section of the shaft of the penis

Intracavernosal Injectione.g. alprostadil

How should we screen for ED in Diabetes?

• Review the issue of ED with men annually• Provide assessment and education for men with

ED to address contributory factors and treatment options

• Offer a PDE-5 inhibitor if ED is a problem• If PDE-5 inhibitors are unsuccessful refer to a

service offering specialist management

NICE 2008

NO

67%

Yes

24%

NO

76%

Yes

NR=3%

X2 = 2.81

P=0.09

Has a Dr/ nurse ever asked you about problems getting an erection? If so, who?

Torbay Hospital Clinic Local GP practice

30%

2005 Audit Lockett et al. Diabetes & Primary Care 2007

NO

67%

NO

76%

NR=3%

X2 = 2.81

P=0.09

Have you been asked about ED at your Diabetes annual review at the GP surgery (n52)

Yes35%

No63%

Not answered2%

2009 Audit

During your annual diabetic review, do you think you should be asked about problems getting an erection? Local GP

practice

6717

11

3

1

0 10 20 30 40 50 60 70

Yes- All male pts should beasked

Dr/ Nurse should only ask ifthey think it's appropriate

Only discussed if pt asks

No- Not be included

Not rec

%2005 Audit

2005 AuditLockett et al. Diabetes & Primary Care 2007

NO

67%

NO

76%

NR=3%

X2 = 2.81

P=0.09

If you have a problem with ED, do you feel satisfied that it has been properly discussed &

assessed (n27)

Yes56%

No33%

N/A7%

Not answered8%

2009 Audit

Reasons for not being satisfied…

4 pts Not asked

I have tried two different tablets and didn’t work

I enquired about a daily pill rx passed by NICE and was told no such

drug available I would have to provide GP with the name of the drug

Dr ? Didn’t reply to my enquiry through Diabetic.Nurse when myself and my then wife were looking at options 3 years ago

Not offered drug

Only basic knowledge discussed with GP

I have seen two doctors and consultants about ED and although I

have medication for this I do not have much of a sex life and I find

this difficult I am now 50

2009 Audit

Number surveyed who would like further advice or help

• 13/27 (48%) patients would like further advice/help

2009 Audit

How do we screen for erectile dysfunction?

Make a statement rather than posing a question……………“Your diabetes may have an effect on your erections – if

that happens let me know as it can often be sucessfully treated.”

Be direct……………………..“Are your erections hard enough for penetration?” NO

indicates ED“If you get a good erection does it go away quickly?” YES

indicates ED

Conclusions

ED is usually managed in Primary Care

Patient education and dose optimisation may rescue PDE5 inhibitor “failures”

Early success is important for patient motivation and continued success with treatment

Testosterone deficiency can be associated with ED and can give rise to PDE5i failure1,2

Testosterone therapy can restore responsiveness to PDE5is in hypogonadal men with ED1,2

Measure testosterone in men with ED

Refer to Secondary Care only in specific circumstances

1. Yassin AA et al. Andrologia 2006;38:61-68 2. Shabsigh R et al. J Urol August 2004 Vol 172, 658-663