Restoring Erectile FunctionChris Deibert MD MPHAssistant Professor of Urology – UNMCMen’s Health Program – Nebraska Medicine

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The faculty and Planning Committee members listed below, have no conflicts of interest to disclose.Christopher Deibert, MD, MPH; Brenda Ram, CMP, CHCP; Jeannie Trichel, MHRM; and Jackie Siebels, BSN, RN-BC

Series of ActivitiesAvailable Online

UNMC-CCE offers topics of interest to medical professionals that are available online for CME credit at:

www.unmc.edu/cce/outreach

OutlineBackgroundDefining Sexual DysfunctionEvaluationTreatment options

1) Recognize that many sexual dysfunction symptoms predict early cardiovascular disease

2) Identify other metabolic diseases that can mimic sexual dysfunction

Why me to discuss this today?- Director of Nebraska Medicine Men’s Health Clinic- Fellowship in Male Fertility, Sexual Dysfunction, Andrology

Chris Deibert has no funding disclosures related to this discussion.

Erectile DysfunctionDefinition: inability to achieve erection sufficient for penetration or unable to sustain the erection

Frequency of ED increases with age

MMHS 1994

40%

30%

15%

6%

5%3% 1%

Vascular

Diabetes

Vascular

Diabetes

Medication

Pelvic Surgery, Radiationor TraumaNeurological Causes

Endocrine Problems

Other

Medication

Erectile Dysfunction Causes

Normal Erections

Nitrous Oxide and Erections

Mechanism of creating erectionsNO is ubiquitous in bodyLeads to muscle relaxation and increased penile blood flowNO means more substrate for enzymes leading to erections

Symptoms: Things Guys Tell Me

• Change in quality/strength of erections• Difficulty with penetration• Gradual onset• NEW onset curvature to the penis• Sometimes painful with erections

• Most men indicate “emotional distress”, stress on relationships and poor self image

• Partners also affected

Symptoms: Things I Ask• We see this all the time in our office• What is the quality of his erections?

Erection Hardness Score (EHS)• Is there curvature to the penis? How much, when did this begin? Is pain present or a lesion/plaque?• Does this interfere with sexual activity?• How bothered is this man? • Is his partner?

Symptoms: Things I AskSexual Health Inventory for Men1) How do you rate your confidence that you could get and

keep an erection?2) How often were your erections hard enough for

penetration?3) How often were you able to maintain the erection after

penetration with your partner?4) How difficult was it to maintain your erection to the

completion of intercourse?5) How often was intercourse satisfactory to you?

Physical Examination

General physical examRectal exam – should this man be screened for prostate cancer? (age 55-69, family history) Colon cancer (age>50, family history)Penis – plaque(s) location, size, stretched length, measuring degree of curvature with erect penisHands – for evidence of contractures of fingers

May do an office ultrasound of the erect penis to examine erection quality, look for any plaque or curvature prior to treatment

Erectile DysfunctionTreatment

Lifestyle Modification- Smoking cessation, cut back or quit- Goal of ideal body weight- Regular exercise- Tight diabetes/sugar control (causes 30% of ED)- Good blood pressure management (causes 40% of ED)- Counseling

- The goal with many of these is to increase nitrous oxide availability and delivery to the penile tissues

Erectile DysfunctionTreatment

Risk Factors Shared• Smoking• Diabetes type 2• Dyslipidemia• Hypertension• Obesity• Increasing age• Sedentary lifestyle

Not really treating ED but reducing Cardiovascular disease risk

ED without CVD confers OR 1.25-1.48 in the next 5 years

Araujo; Princeton IIIADVANCEJY Dong 2011

Smoking and EDSmoke causes endothelial dysfunction and dysregulation of the Nitrous Oxide pathway

It doubles the likelihood of EDMixed data on dose-dependent relationship on erections

Smoking Cessation

Even 24 hours of smoking cessation improves rigidityImprovement seen when using nicotine patch

Massachusetts Male Aging Study showed that cessation at least stops progression of ED

No data on vaping yet

Guay AT Endocr Pract 1998Biebel MG J Sex Med 2016MMAS

Alcohol

Mild Alcohol1-2 drinks daily reduces ED risk OR 0.79

Excessive AlcoholSuppresses NO and leads to structural changes in penis and ED

Blood Pressure35-68% of men with hypertension have ED.This is a complex relationship

Khatana A 2008Burchardt M 2000Baumhakel M 2011

- beta blockers-/+ Calcium channel blockers-/+ ACE inhibitors-/+ Angiotensin II blockers

Glycemic Control

For diabetes, decreasing HbA1c signifies better glycemic control. Erection quality improves substantially for each point of A1c improvement

Romeo JH 2000

Obesity

Obesity inflammatory cytokines and insulin resistanceThis increases ROS and decreases vascular NO

The effect of obesity is independent of DM, cholesterol, hypertension

Esposito K JAMA 2004

Weight LossContinuous effect: the more weight loss, the better the erections

Esposito K JAMA 2004

Weight loss/Exercise None

Exercise:The Greatest of These

Sedentary lifestyle increases ED risk 2-10 fold

Mechanism of improvement:Increases NO, improves glucose sensitivity

Daily exercise produces 4x the NO compared to just 1 intense workout

Selvin E Am J Med 2007Haram PM 2006

When Lifestyle Change is Not Enough: ED Treatment

Oral Therapies: Phosphodiesterase inhibitors

- Viagra- Levitra- Cialis- Stendra

- 35-75% are able to have intercourse on therapy

Erectile DysfunctionTreatment

Drug Sildenafil(Viagra)

Vardenafil(Levitra)

Tadalafil(Cialis)

Peak effect 0.5-1 hr 0.7-0.9 hr 2 hr

Alcohol or fatty meal decreases absorption

Yes Yes Yes

Duration of effect

4 hr 4 hr 24-36 hr

Side effects Visual changes Back and limb muscle pain

Side effects (all) •Decreased blood pressure, headache, flushing (12%-16%)•Nasal congestion (2%-4%)•Gastric reflux, nausea (5%-7%)•Priapism (very rare)

FDA-Approved Phosphodiesterase Inhibitors for Erectile Dysfunction

Erectile DysfunctionTreatmentVacuum Erection Devices- 80% success

SpecializedUrology

Erectile DysfunctionTreatmentUrethral Suppository

Injectable therapies- Self injection at base of penis- Like an insulin injection for Diabetics- 85% success

Zotarolimus-Eluting Peripheral Stents for the Treatment of Erectile Dysfunction in Subjects With Suboptimal

Response to Phosphodiesterase-5Inhibitors

Erectile DysfunctionTreatment

Surgery: Penile Prosthesis- Final option- Completely inside body- Consistent erection quality- Patient and partner satisfaction

are >90%

Erectile DysfunctionTreatment

Surgery: Penile Prosthesis- Risks:

- Infection- Erosion - Mechanical failure (95%

work at 7 years)

- Consistent erection quality

Treatment Plan

• Try to determine cause of the Erectile Dysfunction• Improve lifestyle first: weight, blood pressure,

diabetes, smoking• If vascular, often trial an oral medication first• Try a different oral medication• Consider vacuum or injection therapy• If none of the above works, consider prosthesis

surgery

Conclusion

Erectile Dysfunction causes are many

Lifestyle modification can improve erectile function and those same changes improve other health parameters as well

The ACTIVITY CODE is:40468

For the webinar you will need this ACTIVITY CODE so you can complete your evaluation form and receive your CME Certificate.Instructions are also on the website at:

www.unmc.edu/cce/outreach

Men’s Health Program402-559-4292