Erectile Dysfunction & Premature Ejaculation #treatment of erectile dysfunction and premature ejaculation

Erectile Dysfunction & Premature Ejaculation 

 

Introduction 

Normal male sexual function for a male requires 

i. An intact libido
ii. The ability to achieve and maintain penile erection

iii. Ejaculation 

 

 

Epidemiology 

 

 

A community-based survey in the Massachusetts Male Aging Study (MMAS) of men age  40–70 revealed- 

• 52% with some degree of 

• 10% with complete ED 

• 25% complained of moderate ED 

• 17% with minimal ED 

 

In an another study the incidence is somehow high  among- 

• poor (14%)

• divorced (14%), and 

• less educated (13%)

 

 

 

Pathophysiology 

 

➣The erectile response is mediated by a combination of central (psychogenic) innervation and peripheral (reflexogenic) innervation 

➣Sensory nerves that originate from receptors in the penile skin and glans converge to form the dorsal nerve of the penis which travels to the S2-S4  dorsal root  ganglia via  the pudendal nerve.

➣Parasympathetic nerve fibers to the penis arise from neurons in the intermediolateral columns of the S2-S4 sacral spinal segments.
 

➣Sympathetic innervation originates  from the T11  to the L2 spinal  segments and descends through the hypogastric plexus.
 

 

ED may result from three basic mechanisms:

 

1. failure to initiate (psychogenic, endocrinologic, or neurogenic),

2. failure to fill (arteriogenic), and 

3. failure to store adequate blood volume within the lacunar network (venoocclusive dysfunction)

 

.

Aetiology 

 

➣Erectile dysfunction (ED) is not considered a normal part of the aging process.
 

 

➣Nonetheless, it is associated with certain physiologic and psychological changes related to age. 

The following three account for >80% of cases
of ED in older men- 

• Diabetic 

• Atherosclerosis 

Drug 

 

 

Risk Factors- 

 

o obesity 

o lower urinary tract symptoms secondary
to benign prostatic hyperplasia (BPH)

o Cardiovascular disease 

o peripheral vascular disease 

o Hypertension 

o decreased high-density lipoprotein (HDL)
levels
 

o diseases associated with general
systemic inflammation (e.g., rheumatoid
arthritis)
 

o Smoking is also a significant risk factor
in the development of ED.

o Psychological- 

o Depression 

o Anger & stress 

o Neurologic disorders- 

o Multiple sclerosis 

o Peripheral neuropathy 

o Pelvic surgery 

 

 

Drugs Associated with Erectile Dysfunction 

 

 

 

 ■  Thiazides 

■  Spironolactone 

 ■  Beta blockers 

 ■  Calcium channel blockersH 

 ■  Methyldopa 

 ■  Digoxin 

 ■  Selective serotonin reuptake inhibitors 

■  Tricyclic antidepressants 

■  Lithium 

 ■  Monoamine oxidase inhibitors 

 ■  Corticosteroids 

■  5α-Reductase inhibitors 

■  Methotrexate 

■  Anticonvulsants 

■  Recreational drugs- Cocaine, Marijuana 

 

 

 Clinical Evaluation 

It is important to discuss matters frankly with the patient, and to establish whether- 

■  Libido- intact/Lost ◦ 

 

 If intact libido- 

 Psychological (anxiety),atheroma, Neuropathic, Drugs ◦

 

  If intact libido- 

Hypogonadism, depression. 

 

■  If the patient has erections on wakening-

vascular and neuropathic causes are much less likely and a psychological cause should be suspected.

■ Social changes that may precipitate ED are also crucial to the evaluation, including- health worries, spousal death, divorce, relationship difficulties, and financial concerns.

■ Ejaculation is much less commonly affected than erection, but questions should be asked about whether ejaculation is normal, premature, delayed, or absent.

 

■ Drug History 

■ History of DM, HTN, coronary artery disease (CAD)

 

■ Vascular risk factors- Smoking, Alcohol, Obesity 

■ Reduced shaving frequency, Lethargy (Hypogonadism)

 

■ Pelvic trauma, surgery, or radiation.

 

■ Features of prostatism- Urgency, frequency,

 hesitancy 

■ Past history of CKD, CLD, Haemochrmoatosis, Thyrotoxicosis, Hypothyroidism 

 

 

The physical examination:

 

■ Hypertension 

■ Evidence of thyroid, hepatic, hematologic, cardiovascular, or renal diseases should be sought.

■ An assessment should be made of the endocrine and vascular systems, and the prostate gland.
 

 

■ The penis should be palpated carefully along the corpora to detect fibrotic plaques.

 

■ Reduced testicular size and loss of secondary sexual characteristics are suggestive of hypogonadism.

 

■ Neurologic  examination should include assessment of anal sphincter tone.

 

 

Investigations 

 

 

1. Blood glucose

2. Prolactin

3. Testosterone

4. Serum LH, FSH

.
(A number of further tests are available but are rarely employed because they do not usually influence management.

These include- 

■ Nocturnal tumescence monitoring (using a plethysmograph placed around the shaft of the penis overnight) to establish whether blood supply and nerve function are sufficient 

■ Intracavernosal injection of prostaglandin E1 to test the adequacy of blood supply 

 

■  Internal pudendal artery angiography 

 

 ■  Tests of autonomic and peripheral sensory nerve conduction.

 

 

 Management 

 

 Premature ejaculation usually is related  to  anxiety & usually responsive to- 

 

■  behavioral therapy or 

 

■  SSRIs SSRIs .

 

 Patient education is essential in the treatment of ED. It facilitates understanding of the disease, the results of the tests, and the selection of treatment.

 

  A.  Oral phosphodiesterase type 5 inhibitors- (First-line therapy)

 

 •  Sildenafil Sildenafil - 25–100 mg (Starting dose, 50 mg) 

 

•  Tadalafil Tadalafil - 2.5 or 5 mg for daily dose 

 

•  Vardenafil Vardenafil - 5–10 mg 

 

•  Avanafil 

 

 

Advantage/Mechanism- 

 

 

■  Elevate cyclic guanosine monophosphate (cGMP) levels in vascular smooth muscle cells of the corpus cavernosum, causing vasodilatation and penile erection.Elevate cyclic guanosine monophosphate (cGMP) levels in vascular smooth muscle cells of the corpus cavernosum, causing vasodilatation and penile erection.

■ These four medications have markedly improved the management of ED because they are effective for the treatment of a broad range of causes, including psychogenic, diabetic, vasculogenic, post radical prostatectomy (nerve-sparing procedures), and spinal cord injury.

 

■ There are no compelling data to support the superiority of one PDE-5i over another. 

 

Caution:

 

■ Initially, there were concerns about the cardiovascular safety of PDE-5i drugs. These agents can act as a mild vasodilator, and warnings exist about orthostatic hypotension with concomitant use of alpha blockers.

 

■ The use of PDE-5i is not contraindicated in men who are also receiving alpha blockers, but they must be stabilized on this blood pressure medication prior to initiating therapy.

 

The use of PDE-5i is not contraindicated in men who are also receiving alpha blockers, but they must be stabilized on this blood pressure  medication prior to initiating therapy.

 

 

■  Concerns also existed that use of PDE-5i would increase cardiovascular events. However, the safety of  these drugs has been confirmed in several controlled trials with no increase in myocardial ischemic events or overall mortality compared to the general population. 

 

 

Side effects associated with PDE-5i include- 

 

■  headaches (19%),

 

 ■  facial flushing (9%),

 

  ■  dyspepsia (6%), and nasal congestion (4%).

 

 ■  Approximately 7% of men using sildenafil may experience transient altered color vision (blue halo effect),

 

 ■  6% of men taking tadalafil may experience loin pain.

 

 

 

 

 

 PDE-5i is contraindicated in men receiving nitrate therapy for cardiovascular disease because of the risk of severe hypotension.  

 

 

 

A.  Other treatments for impotence include- 

 

 1.  self-administered intracavernosal injection 

 

2.urethral administration of
prostaglandin E1 

3. vacuum devices (a tourniquet around the base of the penis)

 

4. prosthetic implants- either a fixed rod or an inflatable reservoir.

 

B. Psychotherapy 

 involving the patient and sexual partner may be helpful for psychological problems.

 

C. If hypogonadism- 

 

Testosterone Enanthate

 replacement (Steroid also increases libido)

 

 

Prognosis 

■ Psychological causes are often transient and easily managed 

■ Erectile dysfunction associated with peripheral neuropathy and vascular disease is difficult to treat.