Erectile Dysfunction(ED).ppt
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Erectile Dysfunction
Dr S Sailesh
Research Fellow/Specialist registrar
University of Warwick
Ejaculation
? Ejaculation - when semen is expelled through penis to outside of body
Definition
" Inability to achieve an erection that is adequate for intercourse to the mutual satisfaction of both partners"
Epidemiology
? Impossible to accurately define..
? Depends on age.. ? around 10%
- 10-18 million men (US)
- 2-3 million (UK)
? Large in western society..
? No difference in afro-Caribbean and Caucasian
Epidemiology
? Decline in sexual function with age
(Kinsey et al ...However selected population..based on interview)
? MMAS..1290 subjects (40-70yrs)
- 9.6% suffered from complete ED
- 25.2%moderate ED
- 17.2%minimal ED
- 5.1% at 40yrsto 15% at age 70
Epidemiology
? Brecher et al....59% men over the age of 70 were still having regular coitus with their wives 81% claimed to be sexually active
? Older men take longer to attain full rigidity and they had difficulty in sustaining
Phases of erection
? Phase 0Flaccid phase
? Phase 1Filling phase
? Phase 2Tumescent phase
? Phase 3Full erection phase
? Phase 4Rigid erection phase
? Phase 5Initial detumescence phase
? Phase 6Slow detumescence phase
? Phase 7Fast detumescence phase
Historical Note
?ED, once thought to be psychogenic
?Later, considered androgenic
?Now, found to be predominately vasculogenic
Aetiology
- Organic ( mainly older men not invariable)
- Inorganic (i.e. Psychogenic.. younger men )
Aetiology
? Diabetes Mellitus
- Assoc with poor diabetic control
- Spontaneous improvement of ED in diabetes is small
- Autonomic neuropathies
? Smoking
- 11%in smokers
- Atherosclerosis *
Aetiology
? Cardiovascular disease
- 45% men following myocardial infarction
? Vascular disease...atherothrombotic
- Hypertension is associated ..disease and drugs*
? 24.8% of treated hypertension
? 17.1% of untreated Hypertension
? 6.9% control
Cardiovascular
? CVD is the single leading cause of death
? About one sixth of all people killed by CVD are under age 65
? We should be asking more patients about ED to uncover those with asymptomatic coronary heart disease.
? Poor methods of tracking atheroscerotic disease progression.
? Relying on lab findings vs. clinical indicators.
? We have great medical therapies, but we use them too late.
ED and Cardiovascular Disease
? Men ages 40-70- 52% have ED
? 90% of ED patients demonstratepenile blood flow
? ED is small vessel disease that presents before large vessel disease.
? Could ED be the missing clue?
? Neurological diseases
- Spinal injury
- Demyelinating disease
? MS( 70-80%)
- Epilepsy
- MSA
- Psychiatric disease
Chronic disease
- CRF
- Chronic arthritis
- Infections
- Alcohol and liver disease
- Malignancies
? Trauma
- Cavernosal nerve damage
- vascular injury
Endocrine causes
? Hypogonadism
- Primary
- Secondary
? Hyperprolactinemia
? Hyperthyroidism
? hypothyroidism
Iatrogenic
? Surgey
- Pelvic surgery
- Prostate surgery
- Spinal surgery
- radiotherapy
? Drugs
Evaluation of erectile dysfunction
How Is Your Sexual Performance?
? Male Translation
? Fantastic-Confident "A" performer
? Great-Skilled A-
? Good-Solid "B+" performer
? Okay- Definite "C" student in denial
? Nonverbal-"D or F" and depressed
Erectile Dysfunction
Severity(Scale 1-10)
? 1-3 - Severe ED
? 4-6 - Moderate ED
? 7-8 - Mild ED
Treatment Algorythm
HTN
Lipid Erectile Dysfunction Diabetic
CHD
Therapies
? Predisposing factors
- Restricted upbringing
- Traumatic sexual experience
- Poor sexual education
- Family relationships
- Lifestyle
- personality
Therapies
Androgen replacement therapy
? ? Limited benefits
? Nocturnal erections
? Testosterone replacement
- Oral
- Intramuscular
- Scrotal patches (Testoderm)
- Transdermal (Andropatch)
- Implants
? Gonadotrophin treatment
Therapies
Topical
? Glyceryl trinitrate
? Triple cream
? Minoxidil
? PGE1
Intraurethral
? MUSE (Medicated Uretheral System for Erection)
- PGE 1
- Response 15 min
- Lasting 30 -60 min
Oral medication
? YohimbineAlpha adrenoreceptor antagonist
? Phentolamine
? ApomorphineD2 receptor agonist
? Bromocriptine
? Trazodone5HT reuptake inhibitor
Phosphodiesterase inhibitor
? Dipyridomole
? Zaprinast
? Sildenafil (VIAGRA)
- 100 time more potent
Sildenafil (Viagra)
? 21 placebo / controlled clinical trials
? More than 3000 men ages 19-87
Findings
82% Improved erections
60% Successful intercourse
2.5% Drop out rate
Sildenafil (Viagra)
Contradictions
? Patients using organic nitrates
? Patients that are allergic to Sildenafil
Sildenafil (Viagra)
Treatment
Use caution in patients with
? Difficult to control BP
? Hypotension
? Diabetes
? Heart Disease
Sildenafil (Viagra)
Side effects
? Headache16%
? flushing 10%
? Dyspepsia7%
? Nasal4%
? Visual Problems 3%
Sildenafil (Viagra)
Best Results
? Don't smoke before hand
? Take on an empty stomach......（后略) ......
Erectile Dysfunction
Dr S Sailesh
Research Fellow/Specialist registrar
University of Warwick
Ejaculation
? Ejaculation - when semen is expelled through penis to outside of body
Definition
" Inability to achieve an erection that is adequate for intercourse to the mutual satisfaction of both partners"
Epidemiology
? Impossible to accurately define..
? Depends on age.. ? around 10%
- 10-18 million men (US)
- 2-3 million (UK)
? Large in western society..
? No difference in afro-Caribbean and Caucasian
Epidemiology
? Decline in sexual function with age
(Kinsey et al ...However selected population..based on interview)
? MMAS..1290 subjects (40-70yrs)
- 9.6% suffered from complete ED
- 25.2%moderate ED
- 17.2%minimal ED
- 5.1% at 40yrsto 15% at age 70
Epidemiology
? Brecher et al....59% men over the age of 70 were still having regular coitus with their wives 81% claimed to be sexually active
? Older men take longer to attain full rigidity and they had difficulty in sustaining
Phases of erection
? Phase 0Flaccid phase
? Phase 1Filling phase
? Phase 2Tumescent phase
? Phase 3Full erection phase
? Phase 4Rigid erection phase
? Phase 5Initial detumescence phase
? Phase 6Slow detumescence phase
? Phase 7Fast detumescence phase
Historical Note
?ED, once thought to be psychogenic
?Later, considered androgenic
?Now, found to be predominately vasculogenic
Aetiology
- Organic ( mainly older men not invariable)
- Inorganic (i.e. Psychogenic.. younger men )
Aetiology
? Diabetes Mellitus
- Assoc with poor diabetic control
- Spontaneous improvement of ED in diabetes is small
- Autonomic neuropathies
? Smoking
- 11%in smokers
- Atherosclerosis *
Aetiology
? Cardiovascular disease
- 45% men following myocardial infarction
? Vascular disease...atherothrombotic
- Hypertension is associated ..disease and drugs*
? 24.8% of treated hypertension
? 17.1% of untreated Hypertension
? 6.9% control
Cardiovascular
? CVD is the single leading cause of death
? About one sixth of all people killed by CVD are under age 65
? We should be asking more patients about ED to uncover those with asymptomatic coronary heart disease.
? Poor methods of tracking atheroscerotic disease progression.
? Relying on lab findings vs. clinical indicators.
? We have great medical therapies, but we use them too late.
ED and Cardiovascular Disease
? Men ages 40-70- 52% have ED
? 90% of ED patients demonstratepenile blood flow
? ED is small vessel disease that presents before large vessel disease.
? Could ED be the missing clue?
? Neurological diseases
- Spinal injury
- Demyelinating disease
? MS( 70-80%)
- Epilepsy
- MSA
- Psychiatric disease
Chronic disease
- CRF
- Chronic arthritis
- Infections
- Alcohol and liver disease
- Malignancies
? Trauma
- Cavernosal nerve damage
- vascular injury
Endocrine causes
? Hypogonadism
- Primary
- Secondary
? Hyperprolactinemia
? Hyperthyroidism
? hypothyroidism
Iatrogenic
? Surgey
- Pelvic surgery
- Prostate surgery
- Spinal surgery
- radiotherapy
? Drugs
Evaluation of erectile dysfunction
How Is Your Sexual Performance?
? Male Translation
? Fantastic-Confident "A" performer
? Great-Skilled A-
? Good-Solid "B+" performer
? Okay- Definite "C" student in denial
? Nonverbal-"D or F" and depressed
Erectile Dysfunction
Severity(Scale 1-10)
? 1-3 - Severe ED
? 4-6 - Moderate ED
? 7-8 - Mild ED
Treatment Algorythm
HTN
Lipid Erectile Dysfunction Diabetic
CHD
Therapies
? Predisposing factors
- Restricted upbringing
- Traumatic sexual experience
- Poor sexual education
- Family relationships
- Lifestyle
- personality
Therapies
Androgen replacement therapy
? ? Limited benefits
? Nocturnal erections
? Testosterone replacement
- Oral
- Intramuscular
- Scrotal patches (Testoderm)
- Transdermal (Andropatch)
- Implants
? Gonadotrophin treatment
Therapies
Topical
? Glyceryl trinitrate
? Triple cream
? Minoxidil
? PGE1
Intraurethral
? MUSE (Medicated Uretheral System for Erection)
- PGE 1
- Response 15 min
- Lasting 30 -60 min
Oral medication
? YohimbineAlpha adrenoreceptor antagonist
? Phentolamine
? ApomorphineD2 receptor agonist
? Bromocriptine
? Trazodone5HT reuptake inhibitor
Phosphodiesterase inhibitor
? Dipyridomole
? Zaprinast
? Sildenafil (VIAGRA)
- 100 time more potent
Sildenafil (Viagra)
? 21 placebo / controlled clinical trials
? More than 3000 men ages 19-87
Findings
82% Improved erections
60% Successful intercourse
2.5% Drop out rate
Sildenafil (Viagra)
Contradictions
? Patients using organic nitrates
? Patients that are allergic to Sildenafil
Sildenafil (Viagra)
Treatment
Use caution in patients with
? Difficult to control BP
? Hypotension
? Diabetes
? Heart Disease
Sildenafil (Viagra)
Side effects
? Headache16%
? flushing 10%
? Dyspepsia7%
? Nasal4%
? Visual Problems 3%
Sildenafil (Viagra)
Best Results
? Don't smoke before hand
? Take on an empty stomach......（后略) ......