Erectile Dysfunction

John Ewan
Sandyford
Glasgow

Overview
Epidemiology
Anatomy

and Physiology

History
Examination
Investigations
Treatment

Definition of ED
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

Epidemiology

Massachusetts Male Aging Study, Feldman et al. J Urol 1994; 150:54-61

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 7

Anatomy and Physiology of erection

Reproduced from Carson C, Holmes S, Kirby R. Fast Facts- Erectile Dysfunction. Oxford: Health Press Limited; 2002: 8

Anatomy and Physiology of erection

Parasympathetic nerves S2-4 mediate erection

Sympathetic nerves T11-L2 control ejaculation and
detumescence
Smooth muscle relaxation

Nitric oxide diffuses into cavernosal smooth muscle cells,

activates Guanylate cyclase converts guanosine
triphosphate to cGMP resulting in smooth muscle
relaxation. Effect of cGMP stopped by Phosphodiesterase
type 5 which exists primarily in corpora cavernosa.

Veno-occlusive Mechanism

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 :12

History
Detailed

description of problem, is it ED?

Causative factors
Sexual desire/libido
Ejaculatory disorders
Impact on quality of life and on relationship
Expectations of treatment

Clues differentiating psychogenic from

organic causes

Psychogenic

Sudden onset
Situational
Normal waking and
nocturnal erections
Normal erection with
masturbation
Relationship problems
Life event
Anxiety, fear, depression

Organic

Gradual onset
All situations
Reduced or absent
waking and nocturnal
erections
No erection with
masturbation
Penile pain

Relationship issues
Current

relationship status
Length of relationship
Previous sexual partners and relationships
Partner issues e.g. menopause/pain/cancer

History
Medical
Surgical
Psychiatric
Medication
Smoking
Alcohol
Recreational

drug use

Arteriogenic Cause of ED
Hypertension
Smoking
Diabetes
Hyperlipidaemia
Peripheral

vascular disease
Blunt perineal or pelvic trauma
Pelvic irradiation

Neurogenic causes of ED

Lesions of medial preoptic nucleus, paraventicular nucleus,

hippocampus
Spinal trauma
Myelodisplasia (spina bifida)
Pelvic surgery/radiotherapy
Multiple sclerosis
Intervertebral disc lesion
Peripheral neuropathies

Alcohol
Diabetes
HIV

Psychogenic and Psychiatric causes

Anxiety
Loss

of attraction to partner
Relationship difficulties
Stress
Depression

Psychogenic ED

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 33

Endocrine causes of ED
Hypogonadism

Low testosterone
Raised SHBG
Raised Prolactin

Thyroid

disease

Drugs associated with ED

Antihypertensives

Antidepressants

Thiazides
B blockers
Centrally acting drugs
Tricyclics
MAO inhibitors
SSRI

Anticholinergics

Atropine

Antipsychotics

Anxiolytics

Phenothiazines
Benzodiazepines

Psychotropic drugs

Alcohol
Opiates
Amphetamines
Cocaine

Examination
Blood

pressure
Peripheral pulses, palpate for AAA
Testes size and consistency
Secondary sexual characteristics
Penis for Peyronies plaques, phimosis

ED and Coronary Artery Disease

Generalised

atherosclerosis
Penile arteries smaller than coronary arteries
ED pre-dates coronary artery disease
Man with ED and no cardiac symptoms is a
cardiac patient until proven otherwise

Investigations
Fasting

glucose and lipids

Morning
If

testosterone and SHBG

testosterone is low or borderline repeat with

Prolactin, FSH and LH
Thyroid function
PSA

Specialised Investigations
Vascular

studies

Young patients with primary ED

History of trauma e.g. penile fracture
Patients unresponsive to medical therapies

Treatment of ED General Measures

Smoking

cessation
Reduce alcohol
Weight loss
Exercise

Endocrine Disorders
Hypogonadism
Hyperthyroidism
Hyperprolactinaemia
Endocrinology

referral

Psychosexual therapy
Even

if cause of ED is physical the patient

will develop psychosexual issues
Performance anxiety
Sensate focus exercises
Relationship counselling

Drugs for ED
Oral

agents

Centrally acting dopamine-receptor agonist

Apomorphine (discontinued in UK)
Phosphodiesterase type 5 inhibitors

Intra-cavernosal

Prostaglandin E1 Alprostadil

Intra-urethral

Alprostadil

PDE5 inhibitors

Sildenafil (Viagra) 25mg, 50mg, 100mg

Tadalafil (Cialis) 10mg, 20mg

30 minutes before sexual activity

36 hour window
Absorption not affected by food

Tadalafil (Cialis) 5mg

1 hour before sexual activity

4-6 hour window
Absorption delayed by fatty meal

daily

Vardenafil (Levitra) 5mg, 10mg, 20mg

30-60 minutes before sexual activity

4-6 hour window
Absorption delayed by fatty meal

PDE5 Physiology

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 40

PDE5 Inhibitors Side Effects

Facial flushing
Headache
Nasal congestion
Dizziness
Dyspepsia
Visual disturbance (blue halo)
Priapism
Non-arteritic anterior ischaemic optic neuropathy

PDE5 Contraindications

Recent cardiovascular event

Nitrates
Hypotension
Anatomical deformity

Angulation, cavernosal fibrosis, Peyronies

Predisposition to prolonged erection

Sickle cell disease

Multiple myeloma
Leukaemia

PDE5 Drug Interactions

Nitrates

Cytochrome P450 inhibitors

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)
Protease inhibitors especially Ritonavir use very small dose
Cimetidine, Ketoconazole, Erythromycin

Alpha blockers

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: penoscrotal pain, haematoma, fibrosis at
injection sites, priapism

Papaverine, Phentolamine, Aviptadil (vaso-intestinal

peptide) been used sole or with Alprostadil

Intracavernosal Injections

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 53

Intraurethral
Alprostadil

(Muse) 125mg, 250mg, 500mg,1g

Pellet inserted with applicator

Massage penis to aid absorption
Side effects: Penile pain, dizziness, priapism rare

Intraurethral Alprostadil

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 55

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

Vacuum devices

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 61

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

Penile Prosthesis

Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 66

NHS Prescription for ED

Diabetes
Multiple sclerosis
Parkinsons Disease
Poliomyelitis
Prostate cancer
Prostatectomy incl TRP
Radical pelvic surgery
Severe pelvic injury

Renal failure

On dialysis
Transplant

Single gene neurological

disease
Spinal cord injury
Spina bifida
Receiving NHS Rx
14/9/1998
Severe distress

Private Prescription
Pharmacy

costs vary
Sildenafil 100mgX4 25-40
Pharmacy2U 25

Conclusions
ED

is a common problem
Impact on patient and partner/s
Overlap of psychological and physical
May be initial presentation of diabetes or
coronary artery disease
Good range of safe and effective therapies
If YOU dont ask your patient may be too
embarrassed to tell you