Erectile dysfunction.

 

Impotence- term no longer used.

Sympathetic = erection S2-4.

Parasympathetic = ejaculation.

 The consistent inability to achieve or maintain erection.

Overall prevalence is 10%

This will increase as our pop ages.

Complete ED = 5% at 40 but 15% at 70.

Can lead to embarrassment, low self-esteem, anxiety (both anticipatory and performance), depression and relationship difficulties.                                                  

Risk Factors.

  • Age.
  • Apothecary  B blockers.Thiazide diuretics.Cimetidine.Metoclopramide.Digoxin.Antidepressants-MAOI,TCAD,SSRI.Benzo’s. Anabolic steroids.                                  
  • Atheroma  - all causes.
  • Affect.
  • Alcohol.
  • Anxiety.
  • Abnormal anatomy – peyronies, cavernal fracture              
  • Allergy.
  • Arthritis.
  • Androgen insufficiency.
  • CNS/PNS pathology.
  • Anger.
  • After surgery - Prostatic,abdominal,spinal cord,bladder.Rarely transurethral.Rarely discectomy.


Approach to diagnosis.

Psychogenic v Organic (may be mixed).

Psychogenic

  • Sudden onset
  • Situational- can achieve erection if masturbates or awakens with.
  • Intermittent.
  • Relationship problems. worries re sti, performance, pregnancy.
  • Sexual development issues?
  • Desensitisation / pornography?

Organic

  • Gradual.
  • No erections.
  • Normal flaccid ejaculations. (except DM)

Management.

  • Detailed medical,drug, alcohol  and sexual history.
  • Exam-BP.pulses, secondary sex characteristics, external genitalia and PNS.
  • Investigations – if indicated.  FBC, U/E, Lipids, HbA1c - Perhaps- morning testosterone,prolactin
  • Begin treatment.

Treatment options.

  • Psychosexual counselling “Accord”.
  • Vacuum constrictor device.
  • Medical therapy.
  • Surgical therapy

Note sex may be C/I in some pop.

  • UAP
  • CCF
  • Multidrug BP drugs.
  • Recent MI / CVA.

Medical therapy..

  • Oral.
  • Transurethral.
  • Intercavernosal.


Sildenafil.                                                                                

  • PDE  5 inhibitor  by   -  cGMP.
  • Relaxes local smooth muscle.
  • Oral.
  • Acts in 1 hour. Needs stimulation etc. Alcohol can lessen effect.
  • Usual dose 50mgs -100.
  • Max dose = 100mgs and max TDD = 100mgs.

S/E

  • Vasomotor effects.
  • Headache.
  • facial flushing
  • dizziness
  • dyspepsia                                                                   
  • Blue visual tinge.
  • *Priapism*

****Vasomotor crisis if taken with Nitrates.****

p450 + (CYP3A4)----grapefruit, erythromycin, cimetidine, ketoconazole.

GMS 4 per month –if want more can pay or get 100mgs and half.

C/I

  • Nitrate therapy
  • 90/50.
  • 170/110
  • Recent  MI / CVA / arrythmia.
  • Hered retinal degeneration
  • Sex C/I

Alprostadil

PGE1

Relaxes SM whilst blocking venous return.

Can give 5 to 20 mcgs.

Alpha  - may prolong erection (BPH)

  1. Intercavernosal

Caverject / Viridal

  • Inject 30 mins prior.
  • May get priapism     
  • Max 1 per day and 3 per week.
  • Major problem is penile pain (75%)           

2.Transurethral.

Muse                                    

  • 125 to 1000 mcgs
  • can cause pain.
  • Max 2 per day and 7 per week.
  • Start at 250 mcgs
  • If partner pregant use a condom as can cause uterine contraction.

Priapism.

  • Leukaemia
  • Multiple myeloma.
  • Sickle cell.
  • Polycythaemia.
  • Thrombocytaemia.
  • VT.
  • Meds.