Workshop 4 - Lowy ED & PE - Family Planning NSW

Family Planning NSWConference & Open DayPremature EjaculationErectile DysfunctionPatho-physiologyDr Michael LowySexual Health PhysicianSydney Men’s Healthmlowy@sydneymenshealth.com.auSydney Men’s HealthSexual Function Libido/desire – drive for sexual expression Arousal: erectile function/vulval congestion –excitement & vascular/genital response to sexualstimulation Ejaculation/orgasm – release of sexual tensionSydney Men’s HealthERECTILE DYSFUNCTIONis known as EDErectile dysfunction is the persistent inability toachieve and/or maintain an erection sufficient forsatisfactory sexual intercourseSydney Men’s Health

Erectile DysfunctionED can mask as yet undiagnosed co-morbid conditionssuch as cardio-vascular disease and diabetesIrrespective of the aetiology, ED will almost beaccompanied by psychological symptoms if the man is“bothered” by his condition (performance anxiety)Sydney Men’s HealthED may have organic, psychologicalor mixed causes Medical conditions (organic) Psychological issues Mixed (commonest)Sydney Men’s HealthThe Deadly Quartet (high risk ED)Metabolic SyndromeDiabetesObesityHypertensionDyslipidemiaSydney Men’s Health

8 Sydney Men’sHealthWestern Australia Men’s Health Study Age& Prevalence (%) of EDPrevalence of ED (%)IIEF-5ScoresAge (Yrs)Risk factors for EDTraditional Age High LDL cholesterol Low HDL cholesterol Hypertension Diabetes SmokingUnderlying Obesity Sedentary lifestyle Atherogenic dietEmerging Insulin resistance Metabolic syndromeSydney Men’s Health

Prevalence of ED with specificmedical conditionsCondition Prevalence (%) Age 40-70 years 10 Severe depression 90 Post myocardial infarction 40 Diabetes 35 Hypertension 25 Smokers 20Sydney Men’s HealthSydney Men’s HealthImpaired glucose toleranceIncreased waist circumferenceDyslipidaemiaHypertensionMetabolic syndromeErectile dysfunctionHypogonadismPresentingsymptomPrimary hypogonadismSecondary hypogonadismLate onset hypogonadismSydney Men’s Health

Sydney Men’s Health15Sydney Men’s HealthErectile function as a barometer ofmetabolic and vascular health ED is a cardio-vascular risk factor ED and IHD share common risk factors ED may be a marker of silent vascular disease ED may indicate the presence of hypogonadism,insulin resistance and metabolic syndromeSydney Men’s Health

Medications & EDLess likely to affect sexual function Calcium channel blockers ACE inhibitorsMore likely to affect sexual function Beta blockers Statins DiureticsPsychotropic medications Anti-depressants Anti-psychoticsSydney Men’s HealthSinusoidal engorgement of thecavernosal tissuesFlaccid PenisErect Penis1. NIH Consensus Development Panel on Impotence.NIH Consensus Statement. Impotence 1992;10(4):1–33.Sydney Men’s HealthSydney Men’s Health

The sponge effect – Prof Tom Liu Atonic – priapism Hypotonic – erection (muscle relaxation) Isotonic – flaccidity Hypertonic - EDSydney Men’s HealthNitric Oxide-cGMP Mechanism of Corpus CavernosalSmooth Muscle Relaxation and Penile ErectionSydney Men’s HealthMechanism of Action Penile stimulation causes a decrease in thesympathetic activity to the penis and a subsequentincreased parasympathetic activity to the penisassociated with a cascade of biochemical reactions Nitric oxide is considered the most importantneurotransmitter in the erectile process Nitric oxide relaxes smooth muscle via secondmessenger cGMP and with co-mediator vasoactivepolypeptide Smooth muscle relaxation maintains the erection1Sydney Men’s Health

Atherosclerosis and ErectileDysfunctionAtherosclerosis in narrow penilearteries may manifest as EDbefore becoming apparent inother arteries. 1Detecting atherosclerosis inone set of blood vesselsincreases chance of findingit in other vessels. 1Sydney Men’s HealthArterial blockage compromises penis first Penile artery 1-2mm Coronary artery 3-4mm Internal carotid artery 5-7mm Femoral artery 6-8mmSydney Men’s HealthSexual impulseNeurotransmitterRelease of NO & chemical substratesSmooth muscle relaxationTumescenceVenous occlusionSydney Men’s HealthNormalpathway toerectionRigidityErection

Diabetic erectile dysfunction Arises from both vascular and neural damage(endothelial dysfunction) Often concomitant with disorder such ashypertension Chronic disease: emotional distress common MultifactorialSydney Men’s HealthSydney Men’s HealthGENERAL HISTORY Vascular risk factors Medical history– diabetes, cardio-vascular disease Psychological history– anxiety, depression Medications Use of substances– tobacco, alcohol, recreational drugs Stress factors– relationship, financial, familySydney Men’s Health

SEXUAL HISTORY Is the problem ED? How have the erectionschanged? Who initiates? Frequency of sex? Was the change suddenor gradual? Nocturnal/morningerections? Is the problem globalor situational? State of relationship– partner know of visit? Past history of sexualdysfunction? Other factors:- parental- religious- cultural attitudes- sexual abuseSydney Men’s HealthOrganic Vs PsychologicalORGANIC Gradual onset Older man Consistent problem Global problem Morning erections poor Masturbatory changes Orgasm/ejac intact Presence of risk factorsPSYCHOLOGICAL Sudden onset Younger man Variable problem Situational problem Morning erections OK Masturbation OK Orgasm/ejac varies Health goodSydney Men’s HealthNormal Changes of Ageing Longer to achieve erection More difficult to sustain erection More tactile stimulation required Less intense orgasm Reduced ejaculation Longer refractory period Medical conditions affect ED Use it or lose itSydney Men’s Health

A Practical Evaluation of Men with EDPhysical Examination Blood pressure Examine penis– Peyronie’s disease, phimosis Determine size and consistency of testes Digital rectal exam Focused vascular exam/peripheral pulses Focused neurologic examSydney Men’s HealthA Practical Evaluation of Men with EDLaboratory Tests Urinalysis – Fasting glucose if elevated PSA in men over 45-50 Testosterone (evidence of hypogonadism) Thyroid function, Lipid profile, Liver function, CreatinineSydney Men’s HealthPeyronie’s DiseaseRepetitive microtrauma to tunica of erect penis nearseptum on dorsum. Incidence 9% in men of all ages.Co-morbidities: Dupytren’s, diabetes, low T, ED,lipids, hypertensionPresents with– plaque– curvatureSydney Men’s Health

Sydney Men’s HealthPeyronie’s treatment - remodelling Potaba, vitamin E, L-Carnitine Short wave therapy, Xray therapy Trental, PDE5 inhibitors, tamoxifen Penile traction Intralesional therapy– Verapamil– Interferon– Collagenase Surgery– Nesbitt procedure (plication) – less severe bend– Incision & graft – bigger deformitySydney Men’s HealthSydney Men’s Health

Low T & OSA causes loss of nocturnalerectionsErections during sleep help to keep the penis healthySydney Men’s HealthSydney Men’s HealthHistory of ED treatments 1960s – sex therapy, counselling 1970s – implants, vacuum devices 1980s – penile injections 1990s – oral medication - Viagra 2000s – Cialis, Levitra 2010s – gene & stem cell therapiesSydney Men’s Health

Sydney Men’s HealthSociety has a negative attitude tosexuality in older men and womenOther important issues are fluctuating desire availability of a partner presence of medical illnesses rigid sexual script- lack of sexual repertoire- focus on intercourseSydney Men’s HealthSydney Men’s Health

ED treatment algorithmIst line – lifestyle changes,hormone issues2 nd line – oral medication,counselling3 rd line – penile injections,vacuum devices4 th line – implants, vascularsurgerySydney Men’s HealthSexual dysfunction: an earlysymptom in pathway to diseaseShabsigh R: J Urol 2005Lifestyle changes:Lack of exerciseOvereatingSmokingStressOverworkingSexual symptom:EDLow desireLow TMedical & lifestyle interventionMetabolic syndromeSydney Men’s HealthPENILE INJECTIONSSydney Men’s Health

Prostaglandin - PGE1 Standard is mono-therapy – prostaglandin (PGE1)least fibrosis Caverject Impulse10 & 20 mcg alprostadil (PGE1) Naturally occurring substance Localised activity to penis Acts rapidly via cAMP cycle Risks of pain, scarring, priapism Other agents: phentolamine, papaverine, calledBimix & Trimix Works better for severe EDSydney Men’s Health48Sydney Men’s HealthPRIAPUSPriapismSydney Men’s Health

The first oral tabletsSydney Men’s HealthNatural AphrodisiacsRany Shamloul JSM 2010;7:39-49Plant Related Yohimbine Tribulus Epimedium (horny goat weed) Muira Puama (potency wood) Saw Palmetto (dwarf palm) Ginseng Cacao (chocolate) Maca (lepidium meyenii) AlcoholSydney Men’s HealthNatural AphrodisiacsRany Shamloul JSM 2010;7:39-49Non-plant aphrodisiacs Ambrein (sperm whale gut) Bufo toad Spanish fly (beetle)Other miscellaneous Kebob (BBQ beef) Oysters, shark fin Rhinoceros horn, snake blood, tiger penis Camel hump, leechesSydney Men’s Health

Sydney Men’s HealthMany proposed benefits of PDE5inhibitors by enhancing endothelialfunction Lower urinary tractsymptoms (LUTS) Premature ejaculation Pulmonary hypertension Heart failure Blood pressure Altitude sickness Daily dosing post prostatecancer treatment Peyronie’s disease Stuttering priapism Raynaud’s disease Jet lag AsthmaSydney Men’s HealthContraindicationsNitrates and PDE5 inhibitors must not beused togetherIncludes use of amyl nitrateAny treatment for ED is contraindicated inmen for whom sexual intercourse isinadvisable due to cardiovascular riskfactorsSydney Men’s Health

Sydney Men’s HealthSydney Men’s HealthSydney Men’sHealth58

Compare the 3 PDE5Sydney Men’s HealthAdverse Events Flushed face Headache Nasal congestion Gastric reflux Muscle/back painSydney Men’sHealth60Oral medications At least on first time avoid alcohol Wait minimum 1 hour (2 hours for tadalafil) Stimulation required and conditions need to be right Lack of spontaneity due to waiting time more anissue with oral than injectable medicationSydney Men’s Health

Oral Medication – PatientExperiences Generally accepted as first line Convenience factor Mostly good erectile reponse Side effects mostly acceptable (reflux) Cost is a problem (cut in half) Cardiac nitrate issues Not good for severe ED Media reporting on cardiac risksSydney Men’s HealthWhy do men stop oral treatment? Inadequate instructions, dose too low Ineffective, severe venous leak or neurogenic Expensive Side effects Attitude of patient, fear, perception of quality oferection Lack of good conditions for sex/relationship Confidence & attitude of doctorSydney Men’s HealthCardiovascular Safety of SildenafilFDA monitoring during 1998, when approximately 6,200,000prescriptions of Viagra were dispensed, concluded that there did notappear to be an increase in deaths due to MI in patients taking Viagracompared with the incidence in the general populationSydney Men’s Health

Apomorphine sub lingual(Uprima – not in Australia)Sydney Men’s HealthSydney Men’s HealthVacuum devices – patientexperiences Liked by older, committed couples Non invasive One cost only, includes customer service Takes time and practice Different “look” of erection Ejaculation block Cheap copies aka penis enlargersSydney Men’s Health

Sydney Men’s HealthSydney Men’s HealthEjaculationCOMPONENTS Emission Ejaculation OrgasmTYPES Rapid/premature Delayed/retarded RetrogradeSydney Men’s Health

PESydney Men’s HealthStages of normal ejaculatoryphysiology Emission (sympathetic T10-L2)– Bladder neck closure– Deposition of seminal fluid into posterior urethra Ejection (parasympathetic S2-S4)– Expulsion of seminal fluid from the urethra– Relaxation of the external sphincter– Co-ordinated pelvic floor, bulbospongiosis contraction Orgasm– A sensory experience via pudendal nerve associated with allthese eventsSydney Men’s HealthArousalEjaculationSydney Men’s Health

NormalejaculationtimeFasterejaculationSydney Men’s HealthSydney Men’s HealthISSM definition of PE Ejaculation which always or nearly always occursprior to or within about 1 minute of vaginalpenetration Inability to delay ejaculation on all or nearly allvaginal penetrations Negative personal consequences, such as distress,bother, frustration &/or the avoidance of sexualintimacySydney Men’s Health

Intra-vaginal ejaculation latency time (IELT) PE level of distress depends if mild or severe IELT median time 5.4 minutes (range 1-45 min) IELT < 1 minute – definite PE IELT 1-1.5 minutes – probable PESydney Men’s HealthPE SYNDROMEMarcel Waldinger Primary or lifelong (younger men) Secondary or acquired (older men) Natural Variable PE PE like ejaculation syndromeSydney Men’s HealthTREATMENT OF PREMATUREEJACUALTION Incorporate into sexual practice Behavioural techniques - stop/start, squeeze Oral medication - SSRI, clomipramine, PDE5i Intra-cavernosal injections Anaesthetic spray (Stud) Pelvic floor exercises Surgery to dorsal nerve (Brazil)Sydney Men’s Health

Treatment PE cont’d Treatment aim: restore IELT, address relationshipissues, restore confidence Sensate focus: tailor to clients, work on intimacy Sexual script change: extend foreplay, modify rigidsex patterns, “partner first”Sydney Men’s HealthSydney Men’s HealthDapoxetine - Priligy T max 1.2 hours T ½ 18 hours IELT 30mg 3.48x IELT 60mg 3.68x Side effects: nausea,headache

Sydney Men’s HealthSydney Men’s HealthSydney Men’s Health

86Sydney Men’s Health