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Definition of Erectile Dysfunction (ED)
"The inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance" (NIH Consensus Development Panel on Impotence)Prevalence of ED
Approximately 5% of men at age 40, increasing to 15% - 25% by age 65
Prevalence increases with age, but ED is not an inevitable and untreatable consequence of aging
Causes of ED
Vascular disease
Neuropathy
Latrogenicfactors
Congenital abnormalities
Peyronie's disease
Psychological processes
Drugs
Diagnosis of ED: History
Detailed sexual and medical history, including:
Nature and frequency of ED
Risk factors for ED, eg:
Concurrent disease
Drug abuse
Psychiatric illness
Risk Factors for ED
Hypertension
Hyperlipidemia
Hypogonadism
Endocrine disorders
Smoking
Alcohol abuse
Trauma or surgery to the pelvis or spine
Depression
Drug abuse
Anemia
Vascular disease
Peyronie's disease
Vascular surgery
Drugs Associated with ED
Alcohol
Estrogens
Antiandrogens
H2 receptor blockers
Anticholinergics
Ketoconazole
Antidepressants
Marijuana
Antihypertensives
Narcotics
ß-blockers
Psychotropics
Cigarettes
Cocaine
Spironolactone
Lipid-lowering agents
NSAIDs
Cytotoxic drugs
Diuretics
Diagnosis of ED: Physical Examination
Assessment of secondary male sexual characteristics
Femoral and lower extremity pulses
Focused neurologicexamination
Perianal sensation
Sphincter tone
Bulbocavernosus reflex
Examination of penile vasculature
Evaluation of prostate size by digital rectal exam
Detection of Peyronie's plaques
Laboratory Tests
Morning serum testosterone specimen
Serum prolactin
Tests for other systemic disease
Complete blood count
Special Tests: Indications
Vasoactive agent injection
Intracavernosal injection therapy
Penile prosthesis implantation
Vascular surgery
Nocturnal penile tumescence, eg, Snap-Gauge, Rigiscan
Screen for psychogenic vs organic ED
Duplex ultrasonography
Vascular surgery
Treatment Options for ED
Psychosexual counseling
Hormonal replacement
Vacuum pumps and constriction devices
Penile implants
Vascular surgery
Injectable medications
Oral medications
Hormonal Therapy
Vacuum Constriction Devices
No tests required beyond initial evaluation
Transurethral Alprostadil (MUSE)
Efficacy
Approximately 2/3 of patients using the active drug had sexual intercourse (compared to 19% with placebo)The efficacy of transurethral alprostadil did not differ significantly depending on the etiology of the ED
Penile pain was reported for 10.8% of alprostadil administrations and by 32.7% of menOnly 2.4% of men discontinued because of pain
Vasoactive Intracavernosal Pharmacotherapy
Relaxes cavernous and arterial smooth muscle
Oral Pharmacologic Treatments
Existing oral therapies
Yohimbine
Trazodone
L-arginine
FDA-approved new agent
Sildenafil (Viagra)
New agents under investigation
Apomorphine (Spontane)
Phentolamine (Vasomax)
Sildenafil
Nitric oxide acts through a second messenger, cGMP, in the normal development of erectionscGMP relaxes corpus cavernosal smooth muscle cells, promoting blood flow into cavernosal spaces
cGMP broken down by PDE - the predominant enzyme of this type inthe corpus cavemosum is PDE type V
Sildenafil is a selective and potent inhibitor of PDE type V
Three UK clinical trials (N=12; N=42; N=351)
Apomorphine
PhentolamineCentral dopamine receptoragonistCauses a well-recognized erectile response in rats
Mechanism of Action
a-adrenoceptor antagonist
Inhibits adrenergic-induced contractile tone with resulting relaxation response causing:
Increased blood flow into the sinusoidal spaces of the cavernous
Penile Implants
Two types: semirigid and multicomponent inflatable
Patient satisfaction rates range from 81% to 97%
Average functional life of prostheses is 7 to 10 years
Vascular Surgery