Transcript ERECTILE DYSFUNCTION

ERECTILE
DYSFUNCTION
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FOR THE GENERALIST
ERECTILE
DYSFUNCTION
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DEFINITION
THE PERSISTENT INABILITY TO ACHIEVE
OR MAINTAIN ERECTION SATISFACTORY
FOR SEXUAL PERFORMANCE
SCOPE AND IMPACT
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ERECTILE DYSFUNCTION
• 30 MILLION MEN IN THE USA
• 40% PREVALENCE AMONG MEN > 40
• 70% PREVALENCE AMONG MEN > 70
Anatomy and Mechanism of Penile Erection
Molecular Mechanism of Penile Smooth-Muscle Relaxation
Molecular Mechanism of Penile Smooth-Muscle Contraction
HISTORY-TAKING
ERECTILE DYSFUNCTION
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SEQUENCE
DICTION
ATTITUDE
LEVEL OF DETAIL
HISTORY-TAKING
OVERCOMING RETICENCE
ERECTILE DYSFUNCTION
• ASSURE CONFIDENTIALITY
• UNIVERSALIZE
• EMPATHIZE
HISTORY-TAKING
USE THE PHASES OF
THE SEXUAL RESPONSE CYCLE
TO GUIDE YOUR INQUIRY
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DESIRE
EXCITEMENT
ORGASM
RESOLUTION
HISTORY-TAKING
ERECTILE DYSFUNCTION
PSYCHOGENIC
ORGANIC
Abrupt
Gradual
Course
Selective
Persistent
Degree
Partial
Absolute
Yes
No
Psychosocial
stress
Organic Disease
Onset
Nocturnal or
am
Erection?
Associated
Features
DIAGNOSIS
ERECTILE DYSFUNCTION
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HISTORY IS (almost) ALL
PHYSICAL
CONSIDER SERUM TESTOSTERONE
OTHER TESTS USUALLY NOT
INDICIATED
DIAGNOSIS
ERECTILE DYSFUNCTION
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R/O HORMONAL ETIOLOGY
R/O SUBSTANCE ABUSE
CONSIDER PSYCHOGENIC ETIOLOGY
CONSIDER MEDICATION CHANGES
TRY TREATMENT
Approach to the Diagnosis and Treatment of Erectile Dysfunction
Molecular Mechanism of Penile Smooth-Muscle Relaxation
PRESCRIBING
PRESCRIBING
•Start with medium dose
•Minor side effects – headache,
flushing, dyspepsia, nasal discharge,
visual change
•Consider cost and insurance coverage
DEATH BY VIAGRA?
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SAFETY
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REPORT TO FDA
EXPECTED DEATHS PER SECOND
HEMODYANIC STUDIES
AHA GUIDELINES
Deaths Associated with Sildenafil Therapy in the United States
Other Oral Meds
ERECTILE DYSFUNCTION
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Yohimbine
Trazodone
Apomorphine
Phentolamine
Approach to the Diagnosis and Treatment of Erectile Dysfunction
Tranurethral Medication
ERECTILE DYSFUNCTION
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Alprostadil = Muse = Prostaglandin E1
Moderate Efficacy
Expensive
Causes pain frequently
Mechanical Aids
ERECTILE DYSFUNCTION
• Vacuum device
• Constriction rings
Intracavernosal Therapy
ERECTILE DYSFUNCTION
• “Trimix” of alprostadil, phentolamine,
papaverine
• Almost always efficacious
• Requires referral, training, careful
monitoring
• Risk of priapism and fibrosis
Penile Prostheses
ERECTILE DYSFUNCTION
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Effective
Major surgery
Expensive
Significant risk of infection
Usually have to be replace after 5-10 years
Treatment Options for Men with Erectile Dysfunction