Erectile DysfunctionErectile DysfunctionAlso Known as ImpotenceAlso Known as Impotence

OverviewOverview

►Erectile dysfunction (ED) is the Erectile dysfunction (ED) is the inability of a man to achieve or inability of a man to achieve or maintain an erection sufficient for his maintain an erection sufficient for his sexual needs or the needs of his sexual needs or the needs of his partner. Most men experience this at partner. Most men experience this at some point in their lives, usually by some point in their lives, usually by age 40, and are not psychologically age 40, and are not psychologically affected by it.affected by it.

OverviewOverview

►Some men, however, experience chronic, Some men, however, experience chronic, complete erectile dysfunction complete erectile dysfunction (impotence), and others, partial or brief (impotence), and others, partial or brief erections. Frequent erectile dysfunction erections. Frequent erectile dysfunction can cause emotional and relationship can cause emotional and relationship problems, and often leads to diminished problems, and often leads to diminished self-esteem. Erectile dysfunction has self-esteem. Erectile dysfunction has many causes, most of which are many causes, most of which are treatable, and is not an inevitable treatable, and is not an inevitable consequence of aging.consequence of aging.

Is this Is this reallyreally an Important an Important Problem?Problem?

► 18 million men aged 40 to 70 years will 18 million men aged 40 to 70 years will have experienced erectile dysfunction at have experienced erectile dysfunction at some point in their life.some point in their life.

► If you include partial erectile dysfunction, If you include partial erectile dysfunction, that number increases to 30 million men.that number increases to 30 million men.

► That number is suppose to increase to > That number is suppose to increase to > 300 million by 2025. 300 million by 2025.

► In a study, where the average of the person In a study, where the average of the person was 70 years old, the percent of ED was was 70 years old, the percent of ED was 34%34%

► In the Baltimore Aging Study, the In the Baltimore Aging Study, the prevalence of ED was 75% in patients 80 prevalence of ED was 75% in patients 80 years and older.years and older.

Effects of ED on Self EsteemEffects of ED on Self Esteem

►Because sexual performance is often a big Because sexual performance is often a big part of a man's self-esteem, experiencing part of a man's self-esteem, experiencing ED can be devastating not only to a man's ED can be devastating not only to a man's sex life, but to his entire sense of being. sex life, but to his entire sense of being. Men with ED can become uncertain of Men with ED can become uncertain of themselves and avoid intimate situations themselves and avoid intimate situations with their partners; this only increases the with their partners; this only increases the pressure and anxiety associated with a pressure and anxiety associated with a condition which is often treatable.condition which is often treatable.

Effects of ED on Self EsteemEffects of ED on Self Esteem

► In addition, erectile dysfunction can In addition, erectile dysfunction can cause men to feel inadequate in their cause men to feel inadequate in their roles. Men who are suffering from ED roles. Men who are suffering from ED tend to isolate themselves from their tend to isolate themselves from their relationships and withdraw from their relationships and withdraw from their partners. partners.

Effects of ED on Self EsteemEffects of ED on Self Esteem

►The psychological effects of ED can The psychological effects of ED can invade every aspect of a man's life, invade every aspect of a man's life, from his relationship with his partner, from his relationship with his partner, to his interactions on a social level, to to his interactions on a social level, to his job performance.his job performance.

Effects of ED on Self EsteemEffects of ED on Self Esteem

►Therefore, it is important for a man Therefore, it is important for a man who is suffering from ED to feel as who is suffering from ED to feel as comfortable as possible discussing his comfortable as possible discussing his condition with his partner, and with his condition with his partner, and with his physician, in order to discover the physician, in order to discover the treatment strategy which can best treatment strategy which can best help overcome this condition.help overcome this condition.

Physiology of ErectionPhysiology of Erection

►The physiological process of erection The physiological process of erection begins in the brain and involves the begins in the brain and involves the nervous and vascular systems. nervous and vascular systems. Neurotransmitters in the brain (e.g., Neurotransmitters in the brain (e.g., epinephrine, acetylcholine, nitric oxide) are epinephrine, acetylcholine, nitric oxide) are some of the chemicals that initiate it. some of the chemicals that initiate it. Physical or psychological stimulation Physical or psychological stimulation (arousal) causes nerves to send messages (arousal) causes nerves to send messages to the vascular system, which results in to the vascular system, which results in significant blood flow to the penis. significant blood flow to the penis.

Physiology of ErectionPhysiology of Erection

►Two arteries in the penis supply blood Two arteries in the penis supply blood to erectile tissue and the corpora to erectile tissue and the corpora cavernosa, which become engorged cavernosa, which become engorged and expand as a result of increased and expand as a result of increased blood flow and pressure.blood flow and pressure.

Physiology of ErectionPhysiology of Erection

►Because blood must stay in the penis Because blood must stay in the penis to maintain rigidity, erectile tissue is to maintain rigidity, erectile tissue is enclosed by fibrous elastic sheathes enclosed by fibrous elastic sheathes (tunicae) that cinch to prevent blood (tunicae) that cinch to prevent blood from leaving the penis during erection. from leaving the penis during erection. When stimulation ends, or following When stimulation ends, or following ejaculation, pressure in the penis ejaculation, pressure in the penis decreases, blood is released, and the decreases, blood is released, and the penis resumes its normal shape.penis resumes its normal shape.

PhysiologyPhysiology

►Erectile Dysfunction is essentially a Erectile Dysfunction is essentially a vascularvascular diseasedisease. It is often . It is often associated with other vascular associated with other vascular diseases and conditions such as diseases and conditions such as diabetes, hypertension, and coronary diabetes, hypertension, and coronary artery disease. Other conditions artery disease. Other conditions associated with ED include neurologic associated with ED include neurologic disorders, endocrinopathies, benign disorders, endocrinopathies, benign prostatic hyperplasia, and depressionprostatic hyperplasia, and depression..

Why do Geriatric Patients get Why do Geriatric Patients get ED?ED?

► Atherosclerotic disease accounts for almost Atherosclerotic disease accounts for almost 50% of the ED in men>60 years old.50% of the ED in men>60 years old.

► In geriatric patients, 70 years or older, who In geriatric patients, 70 years or older, who had diabetes, over 90% of patients had diabetes, over 90% of patients experienced ED.experienced ED.

► In a study with patients with hypertension, In a study with patients with hypertension, the prevalence was 68.3% that had some the prevalence was 68.3% that had some degree of ED.degree of ED.

Causes of EDCauses of ED

►There are many underlying physical There are many underlying physical and psychological causes of erectile and psychological causes of erectile dysfunction. Reduced blood flow to the dysfunction. Reduced blood flow to the penis and nerve damage are the most penis and nerve damage are the most common physical causes. Underlying common physical causes. Underlying conditions associated with erectile conditions associated with erectile dysfunction include the following:dysfunction include the following:

Causes: Vascular DiseaseCauses: Vascular Disease

►Vascular Disease is the most common Vascular Disease is the most common cause of EDcause of ED

► Arteriosclerosis, the hardening and narrowing Arteriosclerosis, the hardening and narrowing of the arteries, causes a reduction in blood of the arteries, causes a reduction in blood flow throughout the body and can lead to flow throughout the body and can lead to impotence. It is associated with age and impotence. It is associated with age and accounts for 50% to 60% of impotence in men accounts for 50% to 60% of impotence in men over 60.over 60.

►NOTE: ED may be the initial sign NOTE: ED may be the initial sign preceding an MI or a stroke.preceding an MI or a stroke.

Causes: Vascular DiseaseCauses: Vascular Disease

►Risk factors for arteriosclerosis include: Risk factors for arteriosclerosis include: ►Diabetes mellitus ►High blood pressure ►High cholesterol ►Smoking, which can lead to any of the , which can lead to any of the

above risk factors, is perhaps the most above risk factors, is perhaps the most significant risk factor for impotence significant risk factor for impotence related to arteriosclerosis.related to arteriosclerosis.

Causes: Diabetes MellitusCauses: Diabetes Mellitus

►Diabetes MellitusDiabetes Mellitus Chronic high levels of blood sugar Chronic high levels of blood sugar associated with diabetes mellitus often associated with diabetes mellitus often damage small blood vessels and nerves damage small blood vessels and nerves throughout the body, which can impair throughout the body, which can impair nerve impulses and blood flow nerve impulses and blood flow necessary for erection. About 60% of necessary for erection. About 60% of men with diabetes experience men with diabetes experience impotence.impotence.

Causes: DrugsCauses: Drugs

►DrugsDrugs Over 200 commonly prescribed drugs Over 200 commonly prescribed drugs are known to cause or contribute to are known to cause or contribute to impotence, including drugs for high impotence, including drugs for high blood pressure, heart medications, blood pressure, heart medications, antidepressants, tranquilizers, and antidepressants, tranquilizers, and sedatives. A number of over-the-sedatives. A number of over-the-counter medications also can lead to counter medications also can lead to impotence..impotence..

Causes: DrugsCauses: Drugs

►Long-term use of alcohol and illicit Long-term use of alcohol and illicit drugs may affect the vascular and drugs may affect the vascular and nervous systems and are associated nervous systems and are associated with erectile dysfunctionwith erectile dysfunction

Causes: Hormone Causes: Hormone ImbalancesImbalances

►Hormone ImbalancesHormone Imbalances Hormone disorders account for fewer Hormone disorders account for fewer than 5% of cases of impotence. than 5% of cases of impotence. Testosterone deficiency, which occurs Testosterone deficiency, which occurs rarely, can result in a loss of libido rarely, can result in a loss of libido (sexual desire) and loss of erection.(sexual desire) and loss of erection.

Causes: Hormone Causes: Hormone ImbalancesImbalances

►Among other conditions, an excess of Among other conditions, an excess of the hormone prolactin, caused by the hormone prolactin, caused by pituitary gland tumor, reduces levels pituitary gland tumor, reduces levels of testosterone. of testosterone. Hormone Hormone imbalancesimbalances can also result from can also result from kidney or liver disease.kidney or liver disease.

Causes: Neurologic Causes: Neurologic ConditionsConditions

►Neurologic Conditions Neurologic Conditions Spinal cord and brain injuries (e.g., Spinal cord and brain injuries (e.g., paraplegia, stroke) can cause impotence paraplegia, stroke) can cause impotence when they interrupt the transfer of when they interrupt the transfer of nerve impulses from the brain to the nerve impulses from the brain to the penis. Other nerve disorders, such as penis. Other nerve disorders, such as multiple sclerosis (MS), Parkinson's multiple sclerosis (MS), Parkinson's disease, and Alzheimer's disease, may disease, and Alzheimer's disease, may also result in impotence.also result in impotence.

Pelvic Trauma, Surgery, Pelvic Trauma, Surgery, Radiation TherapyRadiation Therapy

Trauma to the pelvic region or spinal Trauma to the pelvic region or spinal cord can damage veins and nerves cord can damage veins and nerves needed for erection. Surgery of the needed for erection. Surgery of the colon, prostate, bladder, or rectum colon, prostate, bladder, or rectum may damage the nerves and blood may damage the nerves and blood vessels involved in erection. vessels involved in erection.

Pelvic Trauma, Surgery, Pelvic Trauma, Surgery, Radiation TherapyRadiation Therapy

Prostate and bladder cancer surgery Prostate and bladder cancer surgery often require removing tissue and often require removing tissue and nerves surrounding a tumor, which nerves surrounding a tumor, which increases the risk for impotence.increases the risk for impotence.

Pelvic Trauma, Surgery, Pelvic Trauma, Surgery, Radiation TherapyRadiation Therapy

New nerve-sparing techniques aimed at New nerve-sparing techniques aimed at lowering the incidence of impotence to lowering the incidence of impotence to 40% to 60% are now being developed 40% to 60% are now being developed and used in these surgeries. Temporary and used in these surgeries. Temporary impotence is also associated with these impotence is also associated with these procedures, even those in which nerve-procedures, even those in which nerve-sparing techniques were used. It can take sparing techniques were used. It can take as long as 6 to 18 months for full as long as 6 to 18 months for full erections to return.erections to return.

Pelvic Trauma, Surgery, Pelvic Trauma, Surgery, Radiation TherapyRadiation Therapy

Radical cystectomy (for bladder cancer) Radical cystectomy (for bladder cancer) and prostatectomy (for prostate cancer) and prostatectomy (for prostate cancer) require cutting or removing nerves that require cutting or removing nerves that control penile blood flow. These nerves control penile blood flow. These nerves do not control sensation in the penis and do not control sensation in the penis and are not responsible for orgasms; only are not responsible for orgasms; only erection is affected by these procedures.erection is affected by these procedures.

Pelvic Trauma, Surgery, Pelvic Trauma, Surgery, Radiation TherapyRadiation Therapy

Radiation therapy for prostate or Radiation therapy for prostate or bladder cancer also can permanently bladder cancer also can permanently damage these nerves.damage these nerves.

Causes: Peyronie’s DiseaseCauses: Peyronie’s Disease

►Peyronie's disease is a rare Peyronie's disease is a rare inflammatory condition that causes inflammatory condition that causes scarring of erectile tissue. Scarring scarring of erectile tissue. Scarring produces curvature of the penis that produces curvature of the penis that can interfere with sexual function and can interfere with sexual function and cause painful erections.cause painful erections.

Causes: Psychological Causes: Psychological ConditionsConditions

►Psychological Conditions Psychological Conditions Depression, guilt, worry, stress, and Depression, guilt, worry, stress, and anxiety all contribute to loss of libido anxiety all contribute to loss of libido and erectile dysfunction. If a man and erectile dysfunction. If a man experiences loss of erection, he may experiences loss of erection, he may worry that it will happen again.worry that it will happen again.

Causes: Psychological Causes: Psychological ConditionsConditions

►This can produce anxiety associated This can produce anxiety associated with performance and may lead to with performance and may lead to chronic problems during sex. If the chronic problems during sex. If the cycle is inescapable, it can result in cycle is inescapable, it can result in impotence. Psychological factors in impotence. Psychological factors in impotence are often secondary to impotence are often secondary to physical causes, and they magnify physical causes, and they magnify their significance.their significance.

What are Doctors Doing About What are Doctors Doing About It?It?

►Despite a general belief that older patients are Despite a general belief that older patients are “not interested in sex” or have “decreased “not interested in sex” or have “decreased libido”, a survey of 1202 men aged 58-94, libido”, a survey of 1202 men aged 58-94, showed that 70% were interested in sexual showed that 70% were interested in sexual behavior and 67% thought satisfying sex was behavior and 67% thought satisfying sex was an important aspect of life.an important aspect of life.

►However, only 33% of patients who experience However, only 33% of patients who experience ED reported the problem to a physician.ED reported the problem to a physician.

► A study of patients with ED found that only 10% A study of patients with ED found that only 10% of doctors discussed this problemof doctors discussed this problem

TreatmentsTreatments

►Non-pharmacological TreatmentsNon-pharmacological Treatments Vacuum PumpVacuum Pump Intracavernosal injectionsIntracavernosal injections Psychological therapyPsychological therapy Implants (last treatment of choice)Implants (last treatment of choice)

►Pharmacological TreatmentsPharmacological Treatments Viagra (Sildenafil)Viagra (Sildenafil) Levitra (Vardenafil)Levitra (Vardenafil) Cialis (Tadalafil)Cialis (Tadalafil)

Siladenafil (Viagra)Siladenafil (Viagra)

► Sildenafil is by far the most extensively studied Sildenafil is by far the most extensively studied PDE5 inhibitor.PDE5 inhibitor.

► Over 20 million men worldwide has used sildenafil Over 20 million men worldwide has used sildenafil in 110 countries.in 110 countries.

► Over 1000 studies have been done with sildenafil.Over 1000 studies have been done with sildenafil.► Typical dosage is 50mg 1 hour before sexual Typical dosage is 50mg 1 hour before sexual

activity, although 25mg can be used in elderly.activity, although 25mg can be used in elderly.► Most common side effect is HA, flushing, Most common side effect is HA, flushing,

dyspepsia.dyspepsia.► The only contraindication with Viagra is The only contraindication with Viagra is

concommitant use with nitrates.concommitant use with nitrates.► There is a slight hypotensive effect of 5-10mmHg There is a slight hypotensive effect of 5-10mmHg

in normotensive patients.in normotensive patients.

Levitra (Vardenafil)Levitra (Vardenafil)► Vardenafil is a selective PDE5 inhibitor, with a Vardenafil is a selective PDE5 inhibitor, with a

maximal concentration at approximately 60 maximal concentration at approximately 60 minutes.minutes.

►Dosages are typically 10mg to 20mg, but in the Dosages are typically 10mg to 20mg, but in the elderly, can consider 5 mg.elderly, can consider 5 mg.

►Has all the same similar side effects and Has all the same similar side effects and contraindications as Viagra, AND . . . contraindications as Viagra, AND . . .

► Because it is metabolized by liver, should not be Because it is metabolized by liver, should not be used with erythromycin or HIV meds.used with erythromycin or HIV meds.

► Because of its hypotensive effect, it is Because of its hypotensive effect, it is contraindicated with alpha-blockers. One study contraindicated with alpha-blockers. One study showed 6 out of 8 pts had SBP <85 mmHg after showed 6 out of 8 pts had SBP <85 mmHg after taking 10mg of vardenafil and 10 mg of terazosin.taking 10mg of vardenafil and 10 mg of terazosin.

Cialis (Tadalafil)Cialis (Tadalafil)

► Tadalafil is a new potent, highly selective Tadalafil is a new potent, highly selective reversible inhibitor of PDE5.reversible inhibitor of PDE5.

► Tadalafil has a maximum plasma concentration at Tadalafil has a maximum plasma concentration at 2.0 hours, and an elimination half-life of 17.5 2.0 hours, and an elimination half-life of 17.5 hours.hours.

►Dosing is typically 10-20 mg, but studies have Dosing is typically 10-20 mg, but studies have been done up to 100mg.been done up to 100mg.

► Like vardenafil, tadalafil is contraindicated with Like vardenafil, tadalafil is contraindicated with nitrates, pts with retinitis pigmentosa, and alpha-nitrates, pts with retinitis pigmentosa, and alpha-blockers except Flomax 0.4mg.blockers except Flomax 0.4mg.

►Other side effects besides HA, flushing, and Other side effects besides HA, flushing, and rhinitis, include myalgia and back pain.rhinitis, include myalgia and back pain.

► Pts with CRI or liver impairment, max dose is Pts with CRI or liver impairment, max dose is 10mg.10mg.