Erectile Dysfunction in 2014: Causes and Treatment Options discusses common causes of ED, treatment options including penile prosthesis, Viagra, Cialis.

1. Treatment of Erectile Dysfunction
Alex Shteynshlyuger MD
Board Certified Urologist
Director of Urology
New York Urology Specialists
2014
www.NewYorkUrologySpecialists.com

2. Erectile Dysfunction
(ED) (Impotence)
 Definition of Erectile Dysfunction:
 Persistent (3 months or longer) or recurrent
inability to attain or maintain penile erection
sufficient for sexual performance.”

Diagnosis based on history/complaints/patient perception of a
problem

Can be self-diagnosed by a patient

IIEF (International Index of Erectile Function) Questionnaire is
easy to self-administer
 Classification of Erections

Nocturnal

Psychogenic/erotic

Reflexogenic

3. Organic vs Non-Organic
 Organic traditionally refers to vascular or neurogenic (nerve damage)
causes
 Non-Organic traditionally refers to “Psychogenic”
 Classification is Based on Outdated understanding of
human physiology: Psychogenic problems are organic in origin,
due to imbalances in neurotransmitter activity (as in depression) and
treatable with medical management.
Patients respond to the same treatment approaches regardless
of the cause:
PDE5 inhibitors are the staple of therapy – help with “confidence”,
overcome ‘situational’ ED. Psychotherapy may be beneficial for all
patients as there are always components of “psychogenic” in all cases
of ED, whether primary or secondary.

4. Classification of Erectile Dysfunction
 Psychogenic
 Neurogenic
 Vascular
 Mixed (Psychogenic and Organic
components)
 Iatrogenic
 Medications
 Surgical trauma

5. Treatment of ED
 History
 Pre 1970’s Psychosexual therapy; ED treated
by psychiatrists
 1970’s  Pre-1998 (pre-Viagra)

Penile implants (prosthesis) - the gold standard of
treatment

Topical; Vacuum Pump

1980’s intraurethral and intracavernous injections
 Post 1998->

Viagra = 1st
line of therapy

Cialis / Levitra, etc…

6. Evaluation of a patient with ED
History
Onset; duration; IIEF, history of trauma
Medications (TCAs, spironolactone, etc)
Nocturnal Penile Tumescence test

Poor correlation with ED.

Not recommended

Cigarette Smoking and vascular risk factors are better
predictors of organic ED than NPTT
Audiovisual Sexual Stimulation (AVSS)

useful in distinguishing psychogenic causes

But does not change management

7. Non-surgical Treatment of ED
 1st
line of therapy: invariably PDE5 inhibitor
(sildenafil citrate/Viagra, Cialis, Levitra)
 Inhibits breakdown of cGMP, which produced from cGTP by
nitric oxide
 PDE 5 isoenzyme is enriched in the penis
 Metabolized by P450
 Contraindicated in patients taking nitrates (Potentiates the
hypotensive effects of nitrates.)
 Relative contraindication in patients with ischemic coronary
disease, heart failure patients
 Effective in patients with organic, psychogenic and mixed
ED.
 Effective in 70-80% of patients after sufficient trial

8. Sildenafil citrate (cont)
 Improves erections in
 70 % of pts with HTN
 56 % of diabetics
 42 % of RRPR patients
 80 % of patients with spinal injury.
 60 % of patients with TURP
 70-80 % of patients with SSRI induced
arousal disorder

9. Non-surgical management of ED
 Lifestyle modification
 Regular exercise
 Healthy diet
 *SMOKING CESSATION
 Alcohol
 Bicycling

Syndrome of general anesthesia and ED

ED 2x as frequent in long distance bikers

Ergonomic saddles

10. Meds implicated in ED
 Antihypertensives
 Methyldopa, reserpine b/c of central action
 Thiazide diuretics, spironolactone
 alpha-1 adrenergic antagonists
 Doxazosin – reduced incidence of ED compared to
placebo (Guthrie 1997).
 TCAs, SSRIs

11. Meds implicated in ED
 Inhibit Testosterone Production
 Spironolactone
 Ketoconazole
 Metronidazole
 Flutamide
 Cimetidine
 Cyproterone
 Inhibit GnRH
 Progesterone
 Estrogen
 GnRH agonists (leuprolide,
goserelin)
 Prolactinoma
 Estrogen
 Phenothiazines
 TCAs
 Reserpine
 Cocaine/opioids

12. Treatment of Medication Induced ED
 Change medication
 Decrease the dose (start low go high)
 Drug holidays
 Only under medical supervision

13. Hormonal Therapy
 Testosterone
 Reasonable to use in patient with documented hypogonadism
 Prostate CA or Breast CA are contraindications for androgen
supplementation (but this is evolving):

Bx to R/O prostate Bx based on clinical risk stratification

No increased risk for developing prostate cancer

May be safe in select men with history of treated prostate cancer

DRE and PSA every 6 months
 Only DHEA and DHEAS are effective
 Improves libido; ED improvement.
 Side Effects:

Suppress LH/FSH -> infertility

Breast tenderness/gynecomastia

Erythrocytosis  risk of stroke. Monitor Hematocrit; LFTs

14. Androgen replacement (cont)
 Parenteral preparations

Depo preparations do not resemble the circadian rhythm

Testosterone enanthate and cypionate IM q2-4 weeks 200-400
mg
 Transdermal preparations – often best option

Can resemble circadian rhythms (importance not known).
 Oral preparations

Poor bioavailability due to first-pass metabolism

Toxic to the liver (hepatitis, hepatoma, liver cysts,
hepatocellular Ca.
 Injectable Depot or implants

Convenient; work well

15. Hyperprolactenemia
 Testosterone supplementation of no
benefit
 Eliminate the offending drugs
 Estrogens, morphine, sedatives,
neuroleptics
 Treatment:
 Medical: bromocriptine
 Surgical: Excision

16. Yohimbine & Trazodone
 Centrally acting alpha-2 antagonist
 No benefit to patients with organic ED vs placebo
(Morales, 1997)
 Better than placebo in patients with psychogenic ED
(62% vs 16%). Often prescribed with Trazodone.
 TRAZODONE
 Mild antidepressant with rare incidence of priapism
 SSRI

17. Apomorphine for ED
 Not an opiate
 Dopaminergic agonists acts on the
paraventricular nucleus in the brain, the
sexual drive center in humans.
 Stimulates pro-erectile signaling
 Requires sexual arousal to work
 Rapid onset of action, 12 min to erection;
 More effective than placebo (Uprima Pharm).
 Not in clinical use

18. L-arginine
 No better than placebo for treatment of
ED

19. Intraurethral Therapy
 Alprostadil, PGE1 (Prostaglandin E1)
 Via intracavernous or intra-urethral routes

Urethral route (MUSE)
 Stimulates adenyl cyclase, which raises cAMP that leads to
lower Ca++ and relaxation of smooth muscle
 Penile pain is a major side effect with incidence of 10-30%
 Hypotension and syncope with MUSE – 1st
administration in
the office.

20. Transdermal Therapies
 Nitroglycerin (no longer used)
 Smooth muscle relaxant
 More effective than placebo for ED
(Heaton 1990).
 Minoxidil vs Placebo Vs Nitroglycerin:
Double blinded studyMinoxidil more
effective than Placebo or Nitro in ED.

21. Intracavernous Injections
 Papaverine
 Very effective in psychogenic or
neurogenic ED

Erection sufficient for penetration in 98% of
tetra/quadra-plegic patients

Priapism (0-35%)

Corporal Fibrosis (1-33%)
 As monotherapy 55% effective

22. Intracavernous Injections (cont)
 Alprostodil (Caverject, Prostin VR)
 Smooth muscle relaxation, vasodilation, inhibition
of platelet aggregation
 96% locally metabolized
 Full erections in 70-80% patients
 Lower incidence of fibrosis and priapism than with
papaverine but higher incidence of painful
erections
 Triple therapy Trimix (papaverine, phentolamine,
alprostadil) mixture for ICI of alprostadil failure or
for pain with alprostadil; as effective as alprostadil
alone

23. Efficacy of Intracavernous Injections
 ICI 80-100% successful in treatment of ED in
patients with non-vascular disease
 In vascular disease, higher dosage and more
trials required
 Contraindicated in patients with:
 Sickle cell disease
 Psychiatric illness
 Severe systemic disease

24. Herbal Supplements for ED
 Many herbal supplements have been tried
 No randomized trials ever to show benefit
 Billions in Profits
 Successful supplements: Recalled by FDA because
they had Viagra/Cialis mixed in.

25. Vacuum Erection Devices
 Effective, safe treatment of ED
 Penis is engorged by negative
pressure, a ring is applied at the base.
 Can be used with failed penile
prosthesis
 35% use the device long term
 10% incidence of hematoma

26. Treatment of Erectile Dysfunction: SUMMARY
 Initial Treatment:
 PDE5 inhibitor: Viagra / Cialis / Levitra / Staxyn
 If fail repeated high dose Viagra (100 mg)
 Alprostadil (PGE1) intracavernous injection or
intraurethrally
 Vacuum Pump
 If failed alprostadil,
 Triple therapy Trimix (papaverine, phentolamine,
alprostadil)
 Penile Implant Surgery for medical failure

27. Treatment of ED in NYC
Contact us to schedule an appointment:
ED Treatment Center at the New York Urology
Specialists
http://www.newyorkurologyspecialists.com