Erectile dysfunction

Question 1

Erectile dysfunction:

Prevalence?

Answer 1

5% of 40yo
10% of 60yo
15% 70yo
30 - 40% of 80yo

Question 2

Erectile dysfunction:

What are the concerning associations with cardiovascular disease?

Answer 2

• more than 50% of Erectile dysfunction patients have abnormal cardiac stress test even though they are asymptomatic
• 40% of those with Erectile dysfunction will have significant coronary artery disease

Question 3

Erectile dysfunction:

Physiological requirements for erection?

Answer 3

• adequate hormonal drive for libido and prevention of atrophy
• adequate peripheral nerve health
• arterial and smooth muscle relaxation
• increased blood flow
• functional venous occlusion
• penile skin stretch to support vascular expansion

Question 4

Erectile dysfunction:

What is a good tool to assess severity and monitor response to intervention?

Answer 4

Sexual Health Inventory for Men (SHIM)

Question 5

Erectile dysfunction:

Causes?

Answer 5

• Vascular/arterial disease (including venous valve failure)
• Diabetes (30 - 70% of type 2 Diabetics will have Erectile dysfunction)
• Endocrine (hypogynadism, hypothyroidism, hyperprolactinaemia)
• nerve damage
• Benign Prostatic Hypertrophy (mechanism unknown)
• Medications (Hydrochlorothiazides, alpha blockers, B2 blockers, SSRI’s, cannabis and alcohol)
• Psychosocial (depresion, anxiety, relationship stresser, performance anxiety)
• Pyeronies disease (physical restriction from scarring)

Question 6

Erectile dysfunction:

Appropriate investigations for Erectile dysfunction?

Answer 6

Everyone:
TSH
LH
Prolactin
morning total testosterone
fasting glucose 
fasting lipid profile
PSA (if 50yo or more or urinary symtpoms)

Consider Sex Hormone Binding Globulin (SHBG) if elderly, obese, liver cirrhosis, persistantly low testosterone or hypogonadism symptoms

If suspected cardiovascular concerns or diabetes - need cardiology assessment

Question 7

Erectile dysfunction:

Management strategies?

Answer 7

1) Address cardiovascular and diabetic risk factors and optimise control (glucose, BP, weight, cholesterol, smoking, alcohol)
2) Physical activity (middle aged men who begin to exercise have a 70% lower chance of Erectile dysfunction compared to those who are sedentary)
3) Address psychosocial contributions (sleep, stress, relationships difficulties, personal perceptions)
5) Medication

Question 8

Erectile dysfunction:

Medication management?

Answer 8

Phosphodieterase 5 inhibitors (PDE5is)

• 60% effective
• can be continuous use (Tadalfil) or on demand
• side effects can take 4 - 6 weeks to resolve if using continuous (headache, flushing, dyspepsia, myalgia, nasal congestion)
• be wary of coadminstered nitrates as they potentiate the effects

Alprostadil injections

• injected into penis prior to intercourse
• 72% effective

Question 9

Erectile dysfunction:

Special treatment groups and tips

Answer 9

Post prostatectomy

• typically will fail PDE5is
• high response rate to intracavernous injections which subsequently increased response to PDE5is and likelihood of return to spontaneous erections

Androgen blockades
-they reduced response to PDE5is by impacting nitrous oxide production and the PDE5 enzyme also

Question 10

Erectile dysfunction:

How to use PDE5i correctly?

Answer 10

• 81% of patients do not use correctly initially*
• they have higher success rates if modifiable risk factors are adjusted initially.*

Rules of use:

1) it can take 6 - 8 doses for optimal response
2) Alcohol and fatty foods can reduce absorption in some individuals (It must be absorbed for maximum effect)
3) Timing is required either 1hr (sidenafil, vardenafil, avanfil) or 2hrs (Tadalafil) prior to intercourse
4) Intercourse cannot be delayed beyond 4 - 8 hrs (sidenafil, vardenafil, avanfil) or 17.5hrs (Tadalafil) after dose
5) An erection is not spontaneous it requires adequate stimulation
6) if all the above has been fulfilled unsuccessfully try a different agent from the group