erectiledysfunction in men prevention nd cure.pptx

prevention and cure

1. ERECTILE DYSFUNCTION

2. “Man survives earthquakes, experiences the horrors of illness, and all of the tortures of the soul. But the most tormenting tragedy of all time is, and will be, the tragedy of the bedroom.” Tolstoy

3. The consistent inability to achieve and/or maintain an erection adequate for satisfactory sexual intercourse. Definition of Erectile Dysfunction(ED) “This definition is simple, but the condition is not”

4. DSM-IV (American Psychiatric Association, 2000) Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection The disturbance causes marked distress or interpersonal difficulty The erectile dysfunction is not better accounted for by another Axis I disorder (other than a sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition

5. Anatomy of Penis

6. Normal Male Sexual Function requires: 1) An intact Libido 2) Detumescence 3 ) Ability to achieve and maintain penile Erection 4) Ejaculation Parasympathetic nerves S 2-4 mediate erection Sympathetic nerves T 11 -L 2 control ejaculation and detumescence

7. Penile erection is a neurovascular event modulated by psychological factors and hormonal status. On sexual stimulation, there is increased flow of blood into the lacunar network. Subsequent compression of the trabecular smooth muscle causes a closure of the emissary veins and accumulation of blood in the corpora. The corpora becomes non-compressible and blood cannot escape. Physiology Of Erection

8. Nerve impulses cause the release of neurotransmitters (NO) from the cavernous nerve terminals. Nitric oxide diffuses into cavernosal smooth muscle cells, activates Guanylate cyclase, which converts GTP to cGMP resulting in smooth muscle relaxation in the arteries and arterioles supplying the erectile tissue and a several fold increase in penile blood flow.

9. At the same time, relaxation of the trabecular smooth muscle increases the compliance of the sinusoids, facilitating rapid filling and expansion of the sinusoidal system.

10. Sinusoidal engorgement of the cavernosal tissues Flaccid Penis Erect Penis

11. The subtunical venular plexuses are thus compressed between the trabeculae and the tunica albuginea, resulting in almost total occlusion of venous outflow.

12. These events trap the blood within the corpora cavernosa and raise the penis from a dependent position to an erect position, with an intracavernous pressure of approximately 100 mm Hg (the phase of full erection).

13. Sexual impulse Neurotransmitter Release of NO & chemical substrates Smooth muscle relaxation Tumescence Venous occlusion Rigidity Erection Normal pathway to erection

14. Types of Erectile Dysfunction It can be primary or secondary Primary means present from the first attempt at intercourse or it may be secondary in which person develop ED after a period of normal function. In situational male ED, a man is able to have coitus in certain circumstances but not in others More common in older than younger men (in contrast to premature ejaculation)

15. Causes of ED

16. Psychogenic Performance anxiety Relationship problems/difficulties Loss of attraction to partner Depression and anxiety disorders Anxiety Depression Fatigue Guilt Stress Marital Discord Excessive alcohol consumption

17. Psychogenic ED

18. Vasculogenic (arterial or cavernosal): Atherosclerosis Hypertension Trauma

19. Caused by other systemic diseases and aging: Old age Diabetes mellitus Chronic renal failure Coronary heart disease

20. Neurogenic: Stroke or Alzheimer’s disease Spinal cord injury Radical pelvic surgery Diabetic neuropathy Pelvic injury

21. Hormonal: Hypogonadism Hyperprolactinemia

22. Drug-induced: Antihypertensive and antidepressant drugs Antiandrogens Alcohol abuse Cigarette smoking

23. Medications & ED More likely to affect sexual function Beta blockers( propranolol,atenolol ) Statins Diuretics(thiazide) Anti-depressants( fluoxetine,sertraline,amitriptyline ) Anti-psychotics( chlorpromazine,risperidone ) Less likely to affect sexual function Calcium channel blockers ACE inhibitors

24. Causes of ED Sydney Men’s Health

25. Clues differentiating psychogenic from organic causes Psychogenic Sudden onset Situational Normal waking and nocturnal erections Normal erection with masturbation Tumescence present Relationship problems Major Life event Anxiety, fear, depression Organic Gradual onset All situations Reduced or absent waking and nocturnal erections No erection with masturbation Lack of tumescence Normal libido, normal ejaculation Known Cardiovascular, endocrinal,, neurological conditions Operations, radiotherapy, trauma to testes/scrotum Medications, smoking, alcohol

26. Risk factors for ED Aging Chronic disease conditions Heart disease (1.8 times) HTN (1.6 times) DM (4.1 times) Peripheral vascular disease (2.6 times) Smoking (24%) Alcohol use Obesity (22%) Lack of physical activity Depression (1.8 times) Elevated cholesterol (1.7 times)

27. History Medical Surgical Psychiatric Medication Smoking Alcohol Recreational drug use

28. Assessment A thorough history (medical, sexual, and psychosocial) Has there been a previous period of normal function? Has the failure occurred with more than one partner? Does erection occur during foreplay? Does erection occur on waking or in response to masturbation? Is there evidence of alcohol or drug abuse? (ask the partner as well as the patient) Are there possible effects of any medications?

29. The International Index of Erectile Function (IIEF-5) Questionnaire

30. Questions 1 2 3 4 5 1. How do you rate your confidence that you could get and keep an erection? Very low Low Moderate High Very high 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always/always 3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time ) Almost always/always 4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Extremely difficult Very difficult Difficult Slightly difficult Not difficult 5. When you attempted sexual intercourse, how often was it satisfactory for you? Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always/always Over the Past 6 Months

31. The IIEF-5 score is the sum of the ordinal responses to the 5 items. 22-25: No erectile dysfunction 17-21: Mild erectile dysfunction 12-16: Mild to moderate erectile dysfunction 8-11: Moderate erectile dysfunction 5-7: Severe erectile dysfunction Scoring System

32. Examination Blood pressure Peripheral pulses, palpate for AAA Testes size and consistency Secondary sexual characteristics Penis for Peyronie’s plaques, Phimosis

33. Investigations Serum Testosterone Serum Prolactin Screening Profile Sugars Lipids Thyroid Functions

34. Test for erections during REM sleep It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. Nocturnal penile tumescence (NPT)

35. Treatment of Erectile Dysfunction

36. General Measures Psychosexual Therapy Drug Therapy Vacuum devices Surgical treatments

37. ED treatment algorithm 1 st line – lifestyle changes, hormone issues 2 nd line – oral medication, counseling 3 rd line – penile injections, vacuum devices 4 th line – implants, vascular surgery

38. Treatment of ED General Measures Smoking cessation Reduce alcohol Weight loss Exercise

39. Psychosexual therapy Even if cause of ED is physical the patient will develop psychosexual issues Performance anxiety Sensate focus exercises Relationship counselling

40. Drugs for ED Oral agents: Phosphodiesterase type 5 inhibitors Oral phentolamine and apomorphine Yohimbine Intra-cavernosal Prostaglandin E1 Alprostadil P apaverine Intra-urethral: Alprostadil

41. PDE5 inhibitors Sildenafil (Viagra) 25mg, 50mg, 100mg 1 hour before sexual activity 4-6 hour window Absorption delayed by fatty meal Tadalafil (Cialis) 5mg, 10mg, 20mg 30 minutes before sexual activity 36 hour window Absorption not affected by food Vardenafil (Levitra) 5mg, 10mg, 20mg 30-60 minutes before sexual activity 4-6 hour window Absorption delayed by fatty meal

42. Most commonly usedPDE5 Inhibitor-Sildenafil Sildenafil is a selective inhibitor of phosphodiesterase type 5, which inactivates cyclic GMP. When sexual stimulation releases nitric oxide into the penile smooth muscle, inhibition of phosphodiesterase type 5 by sildenafil causes a marked elevation of cyclic GMP concentrations in the glans penis, corpus cavernosum , and corpus spongiosum , resulting in increased smooth-muscle relaxation and better erection. Sildenafil has no effect on the penis in the absence of sexual stimulation, when the concentrations of nitric oxide and cyclic GMP are low.

43. PDE5 Physiology PDE5 Inhibitors

44. PDE5 Inhibitors Side Effects Facial flushing Headache Nasal congestion Dizziness Dyspepsia Visual disturbance (blue halo) Priapism Non-arteritic anterior ischaemic optic neuropathy

45. PDE5 Inhibitor Contraindications Recent cardiovascular event Nitrates Hypotension Anatomical deformity Angulation, Cavernosal fibrosis Peyronie’s disease Predisposition to prolonged erection Sickle cell disease Multiple myeloma Leukaemia

46. PDE5 Inhibitors Drug Interactions Nitrates Glyceryl trinitrate, isosorbide mono or dinitrate Chest pain after taking Sildenafil/Vardenafil no nitrates 24 hours, Tadalafil no nitrates 48 hours Recreational amyl nitrate (Poppers) Cytochrome P450 inhibitors Protease inhibitors especially Ritonavir use very small dose Cimetidine, Ketoconazole, Erythromycin Alpha blockers

47. Comparision of the 3 Major PDE5 Inhibitors

48. Intracavernosal Injections Alprostadil (Caverject, Viridal) 5-40 mcg Independent of intact nervous system Manual dexterity, adequate vision, training Contraindicated: bleeding disorders, sickle cell anaemia, multiple myeloma, leukaemia Side effects: peno-scrotal pain, haematoma, fibrosis at injection sites, priapism Papaverine, Phentolamine, Aviptadil (vaso-intestinal peptide) been used sole or with Alprostadil

49. Intracavernosal Injections

50. Intraurethral Alprostadil (Muse) 125mg, 250mg, 500mg, 1g Pellet inserted with applicator Massage penis to aid absorption Side effects: Penile pain, dizziness, priapism rare

51. Intraurethral Alprostadil

52. Vacuum Devices Blood trapped in intracorporal and extracorporal compartments of penis Constricting ring at base of penis Cyanosis, oedema, cold Pivots at base below ring Maximum time 30 minutes

53. Vacuum Devices

54. Penile Prostheses Semi-rigid rods 2 piece inflatable prosthesis 3 piece inflatable prosthesis with abdominal reservoir Risks Infection Destroys corpora cavernosa Erosion and extrusion Mechanical failure

55. Penile Prosthesis

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