evaluation and treatment of erectile dysfunction · evaluation and treatment of erectile...
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Evaluation and Treatment of Erectile Dysfunction
General Internal Medicine ConferenceMarch 20, 2013
Siobhan D. Wilson, MD, PhDClinical Assistant Professor
Department of Medicine
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Case #2• 34 year old male, no PMH• HPI:
– wife made him come in to see you– progressive ED x few months– no libido– no morning erections– no substance use
• PE: mild testicular atrophy
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Case #2B• 56 year old male• PMH: chronic MSK pain, Hep C w/o cirrhosis.• SH: EtOH abuse in remission; no tobacco• Meds: methadone, naproxen• HPI:
– progressive ED x 10 years– libido down “some” – new partner, desires intimacy– no morning erections– able to masturbate to orgasm, but poor quality erection
• PE: body hair present though not dense; mild gynecomastia; testes normal size but somewhat soft, unremarkable phallus
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Case #3• 53yo male• PMH: doesn’t doctor much• SH: 30 pack year smoking history, no exercise.• HPI: progressive ED x 6-10 years• PE:
– Vitals: BP 152/94 HR 87 BMI: 35– Gen: central obesity– CV: RRR no m/r/g, Lungs CTAB– GU: normal circumcised phallus, no testicular atrophy
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Case #4
• 62 yo male • PMH: CAD s/p MI and CABG 7 years ago. • HPI:
– Progressive dyspnea = CHF dx 6 months ago– New meds: isosorbide mononitrate, hydralazine– CHF sx now controlled– Hx ED on PDE5i– Wants to resume intimacy with his wife
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Case #5• 50 yo male • PMH: hyperlipidemia, hypertension, depression • Meds: metoprolol, lisinopril, sertraline• HPI:
– Gradual onset ED x few years– Tried sildenafil and vardenafil without success.
• PE: obese, otherwise unremarkable
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Case #6• 62 yo male • PMH: hyperlipidemia, hypertension• Meds: simvastatin, HCTZ• HPI:
– Gradual onset ED x few years– Good libido– never tried a medication– likes spontaneity in his romantic life
• PE: unremarkable
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Objectives• Select patients appropriately for hormonal
testing• Compare available therapies for ED• Select therapies for a variety of patients
with ED• Evaluate treatment effect• Troubleshoot ED treatment failures
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Erectile dysfunction
• NIH Consensus Conference 1993– Erectile Dysfunction is the persistent inability to
achieve or maintain penile erection sufficient for satisfactory sexual performance.
• ED does not imply:– low libido– inability to ejaculate– inability to achieve orgasm– age-related latency
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ED: Epidemiology
• Incidence increases with age• 52% of men aged 40-70*
– 17.2% “minimal”– 25.2% “moderate”– 9.6% “complete”
• $2.7 billion (2005)
*Massachusetts Male Aging Study (1994)
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ED: Etiology
• ~80% organic• ~20% psychogenic
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ED: Etiology
• Organic causes:– Primarily vascular– Endocrine
• Testosterone deficiency: 12.5-25.3%• Hyperprolactinemia: 1.42-14.3%
– Neurologic– Iatrogenic– Substances
• Alcohol• Tobacco
– Anatomical– other
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ED: Diagnostic approach• Detailed history
– HPI: Libido, morning erections, performance anxiety, age related changes, relationship issues
– PMH: contributing conditions, substances, or meds• Physical exam
– Blood pressure, peripheral pulses, habitus, secondary sexual characteristics, gynecomastia, penile abnormalities, testicular exam, +/- prostate exam
• Diagnostic testing
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Guidelines included
• American Urological Association (AUA): 2005
• Agency for Healthcare Research and Quality (AHRQ): 2009
• American Association of Clinical Endocrinologists (AACE): 2003
• Endocrine Society (ES): 2010
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ED: Diagnostic approach• AUA:
– Labs as needed to exclude non-vascular organic cause – OR if failure of first line therapy (no grade)
• AHRQ: – does not recommend for or against routine hormonal testing
(insufficient evidence)• AACE:
– recommends routine blood tests: glucose, PRL, Free T (no grade)
• ES:
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When to consider labs
• Endocrine Society: – “suggest” testing with “more specific” sx– “suggest… consider” testing with “less specific” sx– (weak recommendation; very low quality evidence)
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When to consider labs: signs/symptoms
• “More specific”– Incomplete/delayed sexual
development– Low libido– Fewer spontaneous erections – Gynecomastia/tenderness– Losing body hair (shaving?)– Small/shrinking testes (<5ml)– Infertility; low/zero sperm– Low bone mass signs/sx– Hot flushes
• “Less specific”– Low energy– Depressed mood– Poor concentration– Sleep changes– Mild normocytic anemia– Decreased muscle bulk– Increasing body fat/BMI– Decreasing physical
performance
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When to consider labs: signs/symptoms
• There are no well validated “case detection” interview or questionnaire tools at this time.
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When to consider labs: targeted screening
• Sellar mass, XRT, etc. hx• Meds: chronic GC/narcotic use• HIV-associated weight loss• ESRD on HD• Moderate to severe COPD• Infertility• Male osteoporosis/fragility fx (esp if younger)• DM2
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Bhasin S et al. JCEM 2010;95:2536-2559
Evaluation of androgen deficiency
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Evaluation of androgen deficiency
• 8AM total testosterone• 8AM free or bioavailable testosterone• SHBG altering conditions:
Increases SHBG Decreases SHBG•obesity•nephrotic syndrome•hypothyroid•glucocorticoids•diabetes
•age•hepatic dysfunction•hyperthyroid•anticonvulsants•HIV
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Treatment of Erectile Dysfunction
• Lifestyle modification • exercise • weight loss• SMOKING CESSATION!!!• alcohol cessation
• Treat underlying disorders
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ED: First line medical therapy
• Phosphodiesterase type 5 inhibitors (PDE5i)• sildenafil (Viagra)• vardenafil (Levitra)• tadalafil (Cialis)
– AHRQ: strong rec; high-quality evidence– AUA: Standard of care (expert opinion)– AACE: no grade
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PDE5i: patient selection
• Everyone without otherwise treatable organic cause
• Absolute contraindications: – Unstable cardiac conditions– Use of nitrates (PDE-5i potentiate vasodilation)
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GTPcGMP
GMP
Guanylatecyclase
PDE-5
Corpus Cavernosum smooth muscle cell
PDE5i: mechanism of actionExternal sensory stimuli
PDE-5i
Relaxation
Endothelial cell
L-arginineeNOS
NO
NO
NANC cavernous
nerveL-arginine
nNOS
NO
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PDE5i: drug selection
• AHRQ: based on patient preferences– weak recommendation; low-quality evidence
• AUA/AACE: no recs– prior to comparative studies
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PDE5i: drug selection
• Cost• Pharmakokinetics• Patient preferences• Comorbidities
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PDE5i selection: cost
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PDE5i selection: cost
Per dose (mid range) at UWNavitus Cash
sildenafil (Viagra) $8.75 (#4/month)
$27.30
vardenafil (Levitra) -- $18.98
tadalafil (Cialis) -- $33.41
tadalafil daily (#30)
-- $145.90(per month)
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PDE5i cost tips
• Can split pills
• Target/Wal-Mart cheapest in town– store dependent, call ahead
• Walgreens is most expensive• Revatio will be coming off patent 3-6 mo
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PDE5i selection: pharmacokinetics
Medscape Education: PDE5 inhibitor therapy: Overview of Safety and Efficacy
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PDE5i: drug interactions
• CYP3A4 inhibitors raise PDE5i blood levels– amiodarone– some HIV medications– some azoles– some CCBs– fluoxetine– GRAPEFRUIT
• Cialis sig if taking CYP3A4: q72hrs
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PDE5i: dosingRange (mg) >65yo Hepatic
dysfunction
Sildenafil 25, 50, 100 25 start 25
Vardenafil 2.5, 5, 10, 20 5 max 10
Tadalafil 2.5, 5, 10, 20 - max 10
Tadalafil daily
2.5, 5 - caution
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PDE5i: keys to success
• Identify and treat underlying conditions• Titrate dose• Manage patient expectations• Optimize use of medication
– Food/drug interactions– Timing/frequency– Lack of adequate sexual stimulation– Heavy alcohol use– Partner/relationship issues
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PDE5i: efficacy
• 68-69% vs 33-35% placebo
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PDE5i: side effects
• Common– Headache– Flushing– Rhinitis– dyspepsia
• “Serious”– Equal to placebo– hypotension, AION,
vision loss, hearing loss, seizures, syncope, angina, MI
• Less common– Visual changes
• sildenafil
– Myalgia– Nausea– Diarrhea– Vomiting – Dizziness– Chest pain
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Princeton Consensus Conference
• ED identifies increased CVD risk• Most low-risk patients can initiate or
resume sexual activity and begin ED treatment without further testing or evaluation.– Low risk: 4 Mets exercise tolerance
• NYHA class I, II CHF (>5 Mets)• Successfully revascularized CAD• Controlled hypertension
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Princeton Consensus Conference
• Intermediate risk patients may need further evaluation before pursuing PDE5i– past MI 2-8 wks– mild/mod, stable angina– Hx PAD, CVA, TIA
• High risk patients (unstable cardiac conditions) cannot use PDE5i
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Second-line therapies for ED
• Vacuum constriction devices • Intra-urethral suppositories• Intracavernous injections
• Side effects: local pain, priapism (inj: fibrosis)• AUA: panel consensus
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Vacuum constriction device
• Available OTC; needs limiter; $140-190
Image from NKUDIC/prostatecancer.orgImage from postvac.com/products/erec-tech/
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Image from Up to Date, “Treatment of Male Sexual Dysfunction”
Intracavernous injections
• alprostadil• papaverine• phentolamine
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IU/injectable treatments: cost
Per doseCash
IU alprostadil (Muse) $56.50
alprostadil (Caverject) $68.50
papaverine* $0.85-1.70
custom tri-mix (alprostadil-papaverine-phentolamine)
$8-10
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“Third-line:” Penile Prostheses
• Semirigid rods • Inflatable
prostheses
Image from Harvardprostateknowledge.org Image from NKUDIC/prostatecancer.org
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Evaluating Treatment Response
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International Index of Erectile Function (IIEF-15 and IIEF-5)
IIEF-5Over the past 6 months:1. How do you rate your confidence that you could get and
keep an erection?2. When you had erections with sexual stimulation, how often
were your erections hard enough for penetration?3. During sexual intercourse, how often were you able to
maintain your erection after you had penetrated (entered) your partner?
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
5. When you attempted sexual intercourse, how often was it satisfactory for you?
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Objectives• Select patients appropriately for hormonal
testing• Compare available therapies for ED• Select therapies for a variety of patients
with ED• Evaluate treatment effect• Troubleshoot ED treatment failures
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Case #2• 34 year old male, no PMH• HPI:
– wife made him come in to see you– progressive ED x few months– no libido– no morning erections– no substance use
• PE: mild testicular atrophy
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Case #2B• 56 year old male• PMH: chronic MSK pain, Hep C w/o cirrhosis.• SH: EtOH abuse in remission; no tobacco• Meds: methadone, naproxen• HPI:
– progressive ED x 10 years– libido down “some” – new partner, desires intimacy– no morning erections– able to masturbate to orgasm, but poor quality erection
• PE: body hair present though not dense; mild gynecomastia; testes normal size but somewhat soft, unremarkable phallus
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Case #2• 34 year old male, no PMH• HPI:
– wife made him come in to see you– progressive ED x few months– no libido– no morning erections– no substance use
• PE: mild testicular atrophy• Labs (8AM):
– Total testosterone 123 ng/dL (280-1250)– Free testosterone 3.1 pg/mL (12-40)– Prolactin 396 ng/mL (<13)
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Case #3
• 53yo male• PMH: doesn’t doctor much• SH: 30 pack year smoking history, no exercise.• HPI: progressive ED x 6-10 years• PE:
– Vitals: BP 152/94 HR 87 BMI: 35– Gen: central obesity– CV: RRR no m/r/g, Lungs CTAB– GU: normal circumcised phallus, no testicular atrophy
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Case #4
• 62 yo male • PMH: CAD s/p MI and CABG 7 years ago. • HPI:
– Progressive dyspnea = CHF dx 6 months ago– New meds: isosorbide mononitrate, hydralazine– CHF sx now controlled– Hx ED on PDE5i– Wants to resume intimacy with his wife
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Case #5• 50 yo male • PMH: hyperlipidemia, hypertension, depression • Meds: metoprolol, lisinopril, sertraline• HPI:
– Gradual onset ED x few years– Tried sildenafil and vardenafil without success.
• PE: obese, otherwise unremarkable
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Case #6• 62 yo male • PMH: hyperlipidemia, hypertension• Meds: simvastatin, HCTZ• HPI:
– Gradual onset ED x few years– Good libido– never tried a medication– likes spontaneity in his romantic life
• PE: unremarkable
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References• Bhasin, et al. Testosterone Therapy in Men with Androgen Deficiency Syndromes: An Endocrine
Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism. 2010; 95(6):2536–2559.
• Guay, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Male Sexual Dysfunction: A couple’s Problem - 2003 update. Endocrine Practice. 2003;9(1);77-95.
• Montague, et al. Erectile Dysfunction Guideline Update Panel. Chapter 1: The management of erectile dysfunction: an AUA update. Journal of Urology. 2005;174:230-239.
• Nehram, et al. The Princeton III Consensus Recommendations for the Management of Erectile Dysfunction and Cardiovascular Disease. Mayo Clinic Proceedings. 2012:87(8):766-778.
• Qaseem, et al. Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine.2009;151:639-649.
• Rosen RC, Cappelleri JC, Smith MD, et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International Journal of Impotence Research. 1999 Dec;11(6):319-26.
• Tsertsvadze, et al. Oral Phosphodiesterase-5 Inhibitors and Hormonal Treatments for Erectile Dysfunction: A Systematic Review and Meta-Analysis. Annals of Internal Medicine. 2009;151:650-661.
• Tsertsvadze, et al. Diagnosis and Treatment of Erectile Dysfunction. AHRQ Evidence Report/Technology Assessment no. 171. Bethesda, MD: Agency for Healthcare Research and Quality; May 2009. AHRQ publication no. 08(09)-E016. Accessed at www.ahrq.gov/downloads/pub/evidence/pdf/erectiledys/erecdys.pdf on 10 Nov 2012.
Thanks to: Adam Tierney, MD (Dean Urology); Andy (UW East Clinic Pharmacist)
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Princeton Consensus Conference
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Princeton Consensus Conference
TABLE 1Relative Risks for Men With Erectile Dysfunction
RR 95% CI P valueOverall 1.48 1.25-1.74 <.001Coronary heart disease 1.46 1.31-1.63 <.001Stroke 1.35 1.19-1.54 <.001All-cause mortality 1.19 1.05-1.34 .005
Adapted from J Am Coll Cardiol.15