Evaluation and Treatment of Erectile Dysfunction
John Clinton House, MD
Goals and Objectives • • • •
Review medications that cause ED. Cardiac evaluation of the ED patient. Discuss herbal therapies for ED. Mechanism and Efficacy of PDE-5 inhibitors • Does Viagra cause Melanoma or AMI?
The ability to get and keep an Erection • Incidence of ED – 50% by age 50 – 70% by age 70
• Psychogenic ED (10%) – – – – –
Younger men Performance anxiety Major life stressors Gets better or goes to therapy.
• Organic ED (90%) – Vasculogenic – Neurogenic – Endcrine • Low T • Prolactinoma • hypothyroidism
SHIM or IIEF-5 • Scores from 1 to 5 in five domains – – – – –
Confidence Penetration Maintenance Completion Overall Satisfaction
• Severe ED – 5-7
• Moderate – 8-11
• Mild to Moderate – 12-16
• Mild – 17-21
• No ED – 22-25
Initial Evaluation of ED • Sexual History – Libido – nocturnal erections
• Medical History – – – –
DM Atherosclerosis Depression Substance abuse • ETOH, Opioids
• Differentiate between ED and premature ejaculation. • Smoking cessation and regular cardiovascular exercise may reverse ED in some cases • Duration of ED
Drug-induced ED • Thiazides and Beta-blockers are the HTN meds most associated with ED. • 70% of men who think that a med caused their ED will stop that med. HCTZ
Propranolol
Finasteride
Dutasteride
Flexeril
Ativan
Methyldopa
Clonidine
Verapamil
Benadryl (transient)
Cimetidine (high dose)
Naproxen
Antidepressants
Cardiac Evaluation • Intercourse is equivalent to 3 to 4 Mets – Walking a 20 minute mile
• Low Risk – No cardiac evaluation
• Intermediate Risk – Stress test – Stable CAD and more than 3 risk factors • • • • • •
Controlled HTN Stable Angina Prior AMI Prior revascularization Class I CHF Mild Valvular heart disease
Cardiac Evaluation • High Risk – Unstable Angina – Uncontrolled HTN – Recent AMI/CVA • (within 6 weeks)
– Goes to Cardiology
Lab Testing • Hematocrit • Fasting lipids • BMP – Fasting glucose
• • • •
PSA TSH Prolactin, LH Testosterone – If libido, energy level
Treatment of ED • AUA recommends a trial of PDE-5 inhibitor, prior to invasive testing
• PDE-5 inhibitors – Inhibits breakdown of cGMP leading to smooth muscle relaxation in corporal body. – Ultimately venous occlusion and tumescence.
Viagra (Sildenafil) • Onset 15 -60 minutes • Efficacy for 4 hours • Average SHIM increases by about 4.5 to 6. • Blurred vision, headache, facial flushing
• Do not take within 6 hours of alpha blocker. • Do not take with nitrates. • Priapism very rare • Nonarteritic anteriorischemic optic neuropathy (1/1,000,000)
Levitra (Vardenafil) • Onset of action 15-60 minutes • Efficacy 4-8 hours • Increases SHIM score by 4.6 • Headache, flushing, myalgias, backache
• Not with nitrates • Not with alpha blockers
Cialis (Tadalafil) • Onset 15 -120 minutes • Duration 24-36 hours • Increases SHIM scores by about 5.3 • Headache, flushing
• Not with nitrates • Not with alpha blockers • Questionable in advanced age.
Adequacy of PDE-5 trial • Headache? – Tylenol or motrin
• Timing? • Taken with non-fatty meal? • Sexual stimulation? • Tried more than once?
• Cost – Canadian pharmacy – Coupon cards – Generic 20mg sildenafil
Prostaglandin E1 • Intracaverousal PGE1 – AUA states that test dose injection should be performed under supervision by healthcare provider – 89% efficacy – Risks fibrosis, priapism and pain
• Muse – Intraurethral Alprostadil – AUA recommends supervised trial dose. – 3% symptomatic hypotension
Vacuum Erection Device • • • •
Safe Inexpensive Little published data Low patient acceptability
– But, they might ask you how to use it…
Not for ED • Trazodone – Helps rats – The non-ED drug most associated with priapism – AUA: “…Not recommended in the treatment of ED”
• Testosterone – AUA: “Men with a normal serum testosterone level should not be given testosterone therapy for the treatment of ED.”
Herbal Therapies for ED (Someone is buying and using them)
• Yohimbine – – – – –
From bark of West African tree Alpha-2 adrenergic antagonist Grandfathered by FDA in 1976 May cause anxiety, tremor, HTN, tachycardia, irritability, Do not use with MAOIs or SSRIs
– AUA: • Not recommended due to insufficient data”
Korean Red Ginseng (Panax Ginseng)
• One small RCTs showed benefit over placebo • 900 mg TID (not prn) • May cause nausea, Euphoria, HTN, insomnia • Do not use if on Coumadin
• AUA – “ Insufficient Data…” – “disparity in raw materials used” – “Deliberate contamination of some herbal products with therapeutic levels of PDE-5 inhibitors”
Horny Goat Weed (yin-yang huo, Epimedium, rowdy lamb herb, randy beef grass)
• Taken a daily supplement • Efficacy unproven • May act on the cGMP/PDE-5 pathway • May cause dry mouth, arrhythmia, mood changes, mania, respiratory spasm
• Active ingredient is Icarin, which is believed to act on PDE-5 – 80% less effective – Shouldn’t be taken with nitrates, due to reports of hypotension.
L-Arginine • Converted to Nitric Oxide in Vivo • Side effects rare – Hypotension – Abdominal pain – Bleeding risk
• Common dosage: – 5 grams per day
• Efficacy is seen in men with mild ED and low urinary nitrate and nitrite levels. – 24 hour test is available, but very rarely used and not readily available
Does Viagra Cause Melanoma • Health professionals longitudinal Study • 84% increase in melanoma in men self reporting Viagra use over a 10 year period.
• Not replicated • Probably, older men take Viagra and older men are at higher risk for melanoma
Does Viagra Cause AMI? • Sexual activity is 3-4 mets. • Determinants of MI Onset study. • 2.5X risk of AMI within 2 hours of sex • Risks increase in those with sedentary lifestyle.
• A little less than 1% of AMI have sexual activity as a immediate cause • Viagra appears to not add additional risk, unless taken with nitrates.
Review • Beta Blockers and HCTZ are the drugs most associated with ED. • L-arginine is the least crazy herbal therapy • Try PDE-5 inhibitors first • Smoking cessation and exercise may improve mild ED