dr. anmar nassir, frcs(c) fellowship in andrology (u of ottawa)

Dr. Anmar Nassir, FRCS(C)

Fellowship in Andrology (U of Ottawa)Fellowship in EndoUrology and Laparoscopy (McMaster Univ)

Chairman, Department of Surgery Umm Al-Qura UnivConsultant Urology, King Faisal Specialist Hospital, Jeddah

IntroductionChronic renal failure causes a wide-ranging

disturbance in men including sexual dysfunction.

Historically, the prevalence of ED among renal failure patients varied : 40 to 90%

Many recent studies reported similar prevalence (80-86%) of sexual dysfunction in male patients while on HD.

Levy 1972, Abram 1975Levy 1972, Abram 1975

Ali 2005, Rosas 2003, Neto 2002, Neya 2002, Aeslan 2002, Rosas 2001, Rosas 2000Ali 2005, Rosas 2003, Neto 2002, Neya 2002, Aeslan 2002, Rosas 2001, Rosas 2000

This wide range perhaps because of different questionnaires used in addition to variable sample size

Not all studies followed the accurate definition of ED as a persistent inability to achieve or maintain an erection sufficient to permit satisfactory sexual performance.

Ali 2005Ali 2005

There is not enough data about the effect of modern dialysis therapy on sexual function.data is controversial about whether dialysis is

helpful or harmful.

Retrospectively, most studies documented no relationship between the duration of dialysis and severity of ED.

One study demonstrated a significant correlation between the duration of dialysis and the presence of ED among HD patients.

Ali 2005Ali 2005

Mehrsai 2006, Soykan 2005, Miyata 2005, Rosas 2003, Neto 2002, naya 2002, Cerqueira 2002, Arslan 2002, Toorian 1997, Steele 1996, Rodger 1984Mehrsai 2006, Soykan 2005, Miyata 2005, Rosas 2003, Neto 2002, naya 2002, Cerqueira 2002, Arslan 2002, Toorian 1997, Steele 1996, Rodger 1984

Prospectively, a study on 25 male patient given a sexual questionnaire twice in a period of 6 month to examine the ongoing effect of dialysis on ED and observed no significant improvement.

Criticism :This study only looked at a subset of a small

number mixed of both genders. They did not assess the patients on entry to

dialysis, but randomly at any time between 12–192 months of HD, with a mean of 67 +/- 46.4 months.

Soycan 2005Soycan 2005

In other words:

Many previous studies failed to adopt standard criteria to define impotence or to subcategorize sexual dysfunction.

Absence of longitudinal studies planned to evaluate the impact of various renal failure therapies on ED.

Objectives

To determine the prevalence of sexual dysfunction in patients treated for renal failure.

To identify the contributory risk factors.

To determine the effect of standard renal failure treatment on sexual function, while on dialysis or post transplant.

Materials & Methods

Prospective studyStarted in 1998 with a follow up

divided in stages.On admission to dialysis Every 10-12 months

while on dialysis or post kidney transplantation.

Materials & Methods

The questionnaire used: The international index of erectile

function (IIEF) with its 5 domains, used to develop a semiquantitative

baseline score useful in follow up.

Other questions specially designed for our objectives

were added.

Results

Population:

52 pts (at NS, Canada) fulfilled the criteria and returned 149 Questionnaire.

52 filled 1 questionnaire,

45 filled 2 questionnaires




Mean age was 58.5 +/- 14.3 (SD)

Results

Renal Failure Therapy:

25 HD + 27 PD.

During f/u 16 pts received a Kidney Transplant.

F/U ranges from 0 to 48 months (average =20.5)

14 patients died during f/u.

The rest had a mean f/u of 26 months.

Erectile Function

On entry to dialysis:• 82.7 % have ED• Only 17.3 % were potent

Severity

Kidney TransplantationSome authors claimed that prevalence of ED

in transplanted men was not significantly lower than in dialysis patients.

Better designed studies, based on the IIEF-5 scores of 64 patients: 78.1% improved,12.5% experienced no change 9.4% had a lower score.

Toorians 1997Toorians 1997

Mehrsai 2006Mehrsai 2006

Kidney TransplantationIn a cross sectional study on 243 transplanted

patients, ED was found in 54.9%. Factors independently associated with ED were:

age, time on dialysis prior to transplant, and peripheral arteriopathy .

Our data supported the beneficial effect of transplantation on sexual function with an advantage continued in a chronological prospect.

Unmeasured variations in the previous studies probably resulted in the differences.

Rebollo 2003Rebollo 2003

EvaluationH & P

IIEF-5Ix:

Lab: CBC, Hb1ac, cholesterol, prolactin, Testosterone

Treatment

66.6 % of ED pt 66.6 % of ED pt are welling to are welling to have it treated.have it treated.

Only 12 % of ED pt had Only 12 % of ED pt had trt for it.trt for it.

Half of them received it Half of them received it at >30 months of f/uat >30 months of f/u

Although it is a major factor affecting quality of life in end stage renal disease (ESRD), SD in dialysis patients receives very limited attention by the medical team.

Despite its importance, only 25% of patients discuss sexual function with their physicians

Soykan 2005Soykan 2005

Diemont 2000Diemont 2000

Treatment

The reason for not seeking medical help is probably related to the high prevalence of psychological depression. This high prevalence is well documented.

Peng 2007, Kimmel 2000Peng 2007, Kimmel 2000

Treatment – why not ?There was significant correlation between the

total score of IIEF and daily activities, social activities, social support ,quality of life.

Some patients without sexual activity didn’t perceive their deficiency as a problem and considered this situation inherent to the ageing process .

Martín-Díaz 2006Martín-Díaz 2006

Treatment

Among different modalities treating ED in ESRD patients, the simplest is using oral medication.

Most studied were done on Sildenafil.

Treatment by Sildenafil

It is recommended to be used on days off dialysis.

Next day after HD has better efficacy. Some authors showed that ED in two-

thirds of HD patients can improve by sildenafil.

Yenicerioglu 2002Yenicerioglu 2002

Treatment using Sildenafil




The ROC curve of the erectile function domain score beforetreatment for predicting the outcome of sildenafil treatment inpatients with ESRD (area under the curve, 0.790)

ROC = (receiver operating

characteristic)

Treatment using Sildenafil For the erectile function domain the ROC

curve patients with a score of ≥ 17 seem to

respond better to sildenafil treatment (with a sensitivity of 71% and a specificity

of 67%).


The response rate was 80% in those using HD when advised to take pills only on days with no dialysis;

Some authors reported transient hypotension after a 50-mg dose of sildenafil in patient on HDpatients may remain relatively hypovolaemic for

some time after dialysis, they recommended that sildenafil should be used on days with no dialysis.

Mohamed et al. 2002Mohamed et al. 2002


Recommendation:Recommendation:All patients were started on a 25-mg

dose, Increased to 50 mg if there was no

response after two trials.


Double-blind, randomized, placebo-controlled study50 mg sildenafil Inclusion:

patients with ED. Patients on HD for at least 6 mo With stable relationship with a female sexual

partner

SEIBEL et al, 2002SEIBEL et al, 2002

Exclusion:Patients older than 70 yr penile anatomic abnormalities, cirrhosis, diabetes, angina, severe anemia, on nitrate treatment recent history of stroke or MI .


Treatment

When subdivided, diabetic patients responded less (37.5%) compared to non diabetics (83.3%).

Hyodo 2004Hyodo 2004

Side effectsSide effects - Sildenafil At least one side effect side effect was seen in 17/40

patients (43%);5/40 (13%) pts reported more than one

side-effect

1 pt severe hypotension in the PD group. 12 pt (30%) flushing. 7 pts (18%) mild headache1 pt blurred vision


Salvage Treatment 12 patients (8 Tx- & 4 HD) who complained of

ED with hypogonadism and cavernosal insufficiency.

Before treatment

all patients had severe ED with a poor IIEF score 11 had diminished libido.

11 pts had diminished testicular volume 6 had elevated FSH

Chatterjee 2004Chatterjee 2004

Salvage Treatment Received

250 mg IM/m testosterone cypionate and 50–100 mg sildenafil orally once or twice / w

12 moAll patients had a good response


Sildenafil in Kidney TxEven after renal transplant, those patients

who still suffer from ED Sildenafil can be effective in 60%.

Multictr phase IV50 pt post Tx w EDSildenafil: 50 mg then inc or decX 3 mo

Barrou 2003Barrou 2003

Castro 2001Castro 2001

65 ED patients with normal graft function for 3-12 months after kidney Tx were involved in our study.

Erectile dysfunction was diagnosed in all the patients by the IIEF.

Among them, 10 patients were in light degree; 32 patients in moderate degree,23 patients in severe degree according to IIEF

score. Zhang et al, 2005Zhang et al, 2005

Sildenafil in Kidney Tx

In each patient, the IIEF score, were compared before and after taking sildenafil citrate at an initial dose of 50 mg every night.

Zhang et al, 2005Zhang et al, 2005


ResultsResults26 patients without ED before

transplantation suffered ED after the operation,

32 patients with ED before transplantation noticed worsening.

Taking sildenafil citrate was effective in 53 patients (81.54%).




66% of patients believed treatment had improved their erections.

Patients reported improvements in their sexual life and partner relationships and a high level of satisfaction with treatment


Sildenafil in Kidney Tx30/ 51 patients (58.8%) presented with at

least one SE during the study. Most of them were mild to moderate.


Sildenafil in Kidney Tx5 patients (9.8%) presented with at least one

serious adverse event, which led to 3 patients being withdrawn from the study.

2 of the serious SE were considered possibly attributable to the study drug. 1 pt angina pectoris 1 day after the

beginning of treatment 1 pt non-serious aggravated depression.


Sildenafil in Kidney TxAt the end of the study:

27 patients (53%) were taking a dose of 100 mg/day,

1 patient (2%) was taking a dose of 75 mg/day, 22 patients (43%) were taking a dose of 50

mg/day one patient (2%) was taking a dose of 25 mg/day.

The average number of tablets taken per week between inclusion and the end of the study was 3.3+/-1.7 tablets. Barrou 2003Barrou 2003

ConclusionsAs life expectancy for these patients continues

to improve and given the availability of oral medication for ED, physicians are urged to acknowledge the high prevalence of ED in ESRD and proactively question all patients with ESRD regarding their ED.

This will improve the recognition of this condition among these patients, which can lead to adequate treatment and improved quality of life. Neto 2002Neto 2002

Conclusions

Sexual dysfunction is very common among patients who have dialysis dependant renal failure.

Sexual dysfunction is not altered by dialysis therapy.

Renal Transplantation may improve erectile function.

Conclusions

Early evaluation of sexual function upon entry to dialysis is necessary.

Provision of effective therapy to those with ED needs to be improved.

dr. anmar nassir, frcs(c) fellowship in andrology (u of ottawa)

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