• common disorder

• organic

  • gradual onset

  • difficulty becomes progressively worse with time

  • early morning erections usually decreased or absent

• pscyhogenic

  • suddenly

  • complete/immediate loss of seual function

  • vary with partner or situation

  • may be indistinguishable caused by organic

  • maintained theri early morning erections

• likely combined

  • not mutually exclusive

History

• understand;

  • nature of complaint

  • imact on himself, partner and relationship

• how man and partner have adapted to this condition

• determine liekly cause

• identify co-morbidities

• other sexual difficulties

  • low sexual desire

  • rapid ejaculation

  • associated sexual difficulties for partner

Physiology of erection

• sexual stimulation, physical mental

  • release NO from penile nerves

    • stimulates cyclic huanosine monophosphate (cGMP)

      • within vasuclar smooth muscle of corpora cavernosae

• cGMP induces smooth muscle relaxation

  • vascualr lakes fill with blood

    • penile veins passively compressed

    • restricts venous return

• cGMP -> 5’GMP by action of PDE5

  • sildenafil, tadalafil and vardenafil inhibit this enzyme

Exam

• cardiovascular risk assessment

• genital examination

  • occ. identify anatomical abnormalities

    • signs of hypogonadism

    • more importantly taking condition seriously

• diabeties

• DRE -> suspected prostate disease

Investigations

• unexplained low libido or suspected hypogonadism

  • testosterone and prolactin @ 0800hrs

  • CVRA

associated medications:

• Betablockers, CCB

• Thiazides, spironolactones

• SSRI, TCA, MAOi

• Phenothiazines, carbamazepin, risperidone

• Cyproterone, finasteride (5a-reductase

• H2 antagonist

• EtoH, meriguana, cocaine

Risk factors

• metabolic syndrome

• cardiovascular disease

  • PDE5i contraindicated until specialsit

    • unstable angina

    • uncontrolled tn

    • chf Class 3/4

    • very recent MI (\<2w)

    • high risk arryhtmia

    • obstructive hypertrophic cardiomyopathies

    • moderate- severe valvular disease

Treatment

• Suitability for PDE5:

  • does exertion, stress, sexual activity cause any symptoms

  • what is most strenusous activity?

  • do you accept risk of taking this medicaiton

• PDE5 first line

  • tadalafil has longer half life

  • no evidence of superiority of one vs other

  • require sexual stimuliation to have an efefct

  • take at least 40minutes to 1 hr before sexual activity

  • fattyfood/etoh may delay onset of action

  • contraindicated

    • nitrates

      • potentiate hypotensive effects of organic nitrates

      • safe time interval not dertmined

        • 24hr sildenafil

        • 48hrs tadalafil

  • adverse effects;

    • headahce

    • flushing

    • gastric upset

    • diarrhoea

    • nasal congestion

    • light headedness

    • Sildenafil and vardenafil have some cross-reactivity

• Injection therapies

  • act directly by relaxing smooth msucle in corpora cavernosum

  • do not require sexual stimulation

  • firstdose administered under medical supervision

  • small risk of priaprism

  • Alprostadil (caverject)

  • phentolamine (invicorp)

• Penile devices

  • prosthese

  • vacuum devices

• Testosterone therapy not usually indicated for men with nroaml testosterone levels

  • appropriate whne man with ED has hypogonadism

  • Hynaecomastia, increased haematocit, changed lipid, htn, infertility = seide effects

  • increase risk of prostat cancer