Drs Sundeep Ruder and Kgomotso Mathabe recently presented a webinar for Medical Chronicle: Managing erectile dysfunction – from primary care to specialist, Part 2.
This webinar was sponsored by Eli Lilly.
Dr Sundeep Ruder is an endocrinologist currently working at Life Fourways Hospital. He is an associate lecturer at the University of Witwatersrand in the field of internal medicine and endocrinology.
Dr Kgomotso Mathabe is a specialist urologist practicing at Steve Biko Academic Hospital. The following is based on their presentations.
Dr Sundeep Ruder looked at the topic from an endocrinologist’s perspective.
Erectile dysfunction (ED) is the inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity. Patients may still call it ‘impotence’. It affects an estimated 30 million men in the US to some degree. It was estimated that in 1995 there were >152 million men worldwide with ED. Projections for 2025 show a prevalence of approximately 322 million men with ED.
Sexual impulse ‘textures’
A simplified approach of sexual impulse textures is:
- Impotent – no or low sexual drive, may be a defect or inherent, problematic to partner with a higher desire pattern
- Passive – need provocation, slight to extreme
- Active – periodic activation of sexual impulse, the frequency varies from person to person
- Promiscuous – meant in a non-judgmental sense, is unhindered sexual impulses, never satisfied, problematic to partner with lower desire pattern
Endocrine causes of ED include:
- Hypogonadism (low testosterone and dehydroepiandrosterone)
- Hyperprolactinemia (testosterone deficiency, dopaminergic pathway interference)
- Severe malnutrition
- Liver disease
- Renal issues
- Cardiac issues.
ED is associated with other serious treatable disorders. Approximately 60% of men with ED have dyslipidaemia and 56% of men with ED have a positive cardiovascular stress test, while 42% of men with ED have hypertension. Approximately 40% of men with ED have significant coronary occlusions, 20% of men with ED have diabetes mellitus and 11% of men with ED have depression.
Why diagnosing ED is important
ED screening may signal underlying diseases, such as diabetes, hypertension, dyslipidaemia, coronary artery disease, as well as depression. It can result in anxiety, decreased self-esteem, reduced quality of life, and negative effect on relationships.
ED & diabetes
In terms of quality (QoL) of life, ED affects a third of diabetic patients, and is related to health status perception and reduced QoL. It is associated with frustration and discouragement. In a lower acceptance of diabetes, there is worse metabolic control and higher levels of depression, which is a risk factor for cardiovascular disease, hypertension, and mortality.
Pitfalls in management
Men with ED do not generally seek treatment for reasons of misinformation, ignorance, embarrassment. Physicians may be inexperienced in its treatment and in identifying the problem. They need the correct conversational skills, which might be lacking (two-thirds of patients are never asked about sexual health). Some practitioners do not consider sexual health an important medical problem.
Address risk factors and comorbidities. Counsel patient and partner if possible. Initiate treatment based on patient preference, partners sexual function or cardiovascular risk.
Both the American Diabetes Association and European Society of Cardiology/European Association for the Study of Diabetes guidelines on management of patients with diabetes stress the importance of a multifactorial approach for the control of CV risk. This includes management of hypertension, dyslipidaemia, hyperglycaemia, and risk of thrombosis, as well as the cessation of smoking.
The efficacy of Tadalafil 5mg and 20mg were similar in all patient groups.
- ED is a global health problem
- Has received substantial attention because of its association with poor cardiovascular health
- It is an early sign of heart disease
- Sexual dysfunction often precedes the onset of coronary artery disease by as much as three years
- Patients with ED should be considered at increased risk of CVD, the two share the underlying causative factor of endothelial dysfunction along with many common and mutual risk factors.
Managing the difficult ED patient
Dr Kgomotso Mathabe presented on managing the ‘difficult’ ED patient.
In terms of EAU guidelines, PDE-5 inhibitors are first-line therapy. Sildenafil 25-100mg and
vardenafil 5-20mg are effective in the short term (up to four-eight hours – effective 30 mins after taking). Tadalafil 20mg is effective in the long term (up to 36 hours – effective 30 min after taking).
Success of treatment
Two treatment features that are important to patients
- Early treatment success
- Continued treatment success in those successful on the first attempt (maintenance of success).
As patients continue to receive treatment for their ED, the likelihood of success may improve over time.
Challenges with first-line therapy
In terms of cardiovascular dysfunction, all PDE5Is are contraindicated in:
- Patients who have suffered from a myocardial infarction, stroke, or life-threatening arrhythmia within the last six months
- Patients with resting hypotension (blood pressure <90/50 mmHg) or hypertension (blood pressure >170/100 mmHg)
- Patients with unstable angina, angina with sexual intercourse, or congestive heart failure categorised as New York Heart Association Class IV
- Renal or hepatic dysfunction.
Nitrates are contraindicated with PDE5is, as are antihypertensive drugs. There are also α-blocker interactions. Dosage adjustment is necessary for drugs that induce/ inhibit the drug metabolising mechanism of the cytochrome P450 system.
Failure of conventional therapy
We need to establish what is truly a failure and what works for the patient in this definition as well as what is their measure of success? It is important to manage couples’ expectations and debunk myths.
Compliance and correct administration depends on factors such as food intake and how long the treatment is taken before planned intercourse. Monitor possible side effects and duration of treatment. Look at managing any underlying conditions/ co-morbidities, as well as testosterone levels.
An initial diagnosis that is difficult to treat:
Vascular: Vasculopathies: arterial, venous (veno-occlusive disease) and vascular injuries, being pelvic/ perineal trauma. It might be necessary to involve a vascular surgeon in specific vascular testing and imaging.
Nerves: This is often following radical surgery for life-threatening cancers: radical prostatectomy and abdominoperineal resection. Managing this involves:
- Pre-operative: counselling and managing expectations is key, validated questionnaire (SHIM) to determine baseline erectile function, physiotherapy and/or the initiation of PDE5is
- Intra-operative: nerve-sparing approach, bipolar diathermy, laparoscopic surgery for better vision
- Post-optatively: physiotherapy, PDE5is.
- Previous priapism: surgical intervention (shunt), cavernositis.
An underlying condition that is difficult to treat or which is incurable include:
- Neurological conditions: Multiple sclerosis, Parkinson’s disease
- Physical abnormalities:
- of the body
- of the external genitals – complications of circumcisions (traditional or medical), following penile surgery/ trauma
- Special mention:
- Lack of resources compounding this issue in the state sector
- Long-term indwelling catheter for untreated, but not-incurable conditions.
There may be multiple conditions competing for treatment prioritisation. Bear in mind mandatory medication which causes ED which cannot be changed/ stopped or drug contraindication based on interaction.
Male dyspareunia is defined as recurrent or persistent genital or pelvic pain with sexual activity or sexual dysfunction that is present for three months or longer.
Is the psychological distress a cause or an effect of the ED? Possibilities must be addressed differently. Is the issue pre-existing from childhood or due to current psychosocial distress including partner conflict?
Options: WHO Guidelines
This is a stepwise approach addressing modifiable risk factors including weight loss and lifestyle modification. Oral agents vary by formulation and frequency of ingestion. Local therapies include prostaglandins, single agent or combination (alprostadil, papaverine, phentolamine), as well as surgical treatments.
Weight reduction and regular activity result in improved erectile function.
- Oral: PDE5i
- Local: Intracavernosal injections, intraurethral prostaglandin E1
- Mechanical: Vacuum device.
Surgical options include penile prosthesis, penile revascularisation and correction of penile deformity.
If you can’t help, be open with the patient and possibly refer to a sexologist or psychologist who might be able to help.