Erectile Dysfunction
Community Health
MEDC 4032
Halimah Mohammed, Vasha Suklal, Folade Roberts, Masud Niles, Che-Ann Stewart, Tanuja Armaday, Bakhita
Johnston, Keshan Ramnarace, Dianni Weekes
What is Erectile Dysfunction?
ED is the consistent or recurrent
inability to acquire or sustain an
erection of sufficient rigidity and
duration for sexual intercourse.
Incidence:
9%
In men ages 50-59
years…
18%
37%
Incidence:
9%
In men ages 50-59
years…
18%
37%
Incidence:
In men ages 70-75 years, incidence increases to:
37%
Rosen, R. C., & Khera, M. (n.d.). Epidemiology and Etiologies of Male Sexual Dysfunction. UpToDate. Retrieved from
https://www.uptodate.com/contents/epidemiology-and-etiologies-of-male-sexual-dysfunction#!
CAUSES OF ERECTILE DYSFUNCTION
● What are some causes of erectile dysfunction?
CLASSIFICATION OF ERECTILE
MALE SEXUAL DYSFUNCTION (AAFP)
RESPONSE CYCLE
ORGANIC CAUSES
Vasculogenic Endocrinologic
Pudendal Nerve
(Sacral)
Comorbidities
Taken from the International Journal of Clinical Practice, Volume 63, Issue 8.
“The burden and extent of comorbid conditions in patients with erectile
dysfunction”
Prevalence of comorbid conditions in men with Erectile
Dysfunction vs men without Erectile Dysfunction.
What does having any comorbidity mean for ED?
❖ Increased likelihood of developing ED
❖ Earlier onset
❖ Severity
❖ Responsiveness to treatment
Clinical Presentation
● Trouble getting an erection
● Trouble keeping an erection
● Low self-esteem
● Reduced sexual desire
● Depression
● Performance anxiety
● Symptoms of another health conditions
Diagnosis
Diagnosing Erectile Dysfunction:
SHIM (Sexual Health Inventory for Men) Questionnaire
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 (entering your partner)?
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?
Cause of Erectile Dysfunction
Diagnosis
Cause of Erectile Dysfunction
1. History (with focus on R/F)
PMHx: HTN, DM, Hyperlipidemia, Cardiovascular disease,
Hypogonadism, Hyperthyroidism, Hyperprolactinemia,
Neurological trauma, Psychological condition
Social Hx: Strained relationship, Low sexual arousal, Smoking, Alcoholism
Drug Hx: Thiazide, Propranolol, Fluoxetine, Antihistamine, NSAIDs
2. Examination: General, Genitals
3. Laboratory investigations: Complete blood count, HbA1c, Lipid profile, Urinalysis,
Thyroid function test, Hormones (Prolactin, Testosterone, LH)
4. Other: Overnight erection test,
Penile Doppler ultrasound (with Intracavernosal papaverine test)
Treatment
Treatment: Non- pharmacological
1. Lifestyle changes and Risk Factor Modification
a. Weight loss and Increased Physical Activity
b. Smoking Cessation
2. Therapy
a. Cognitive Behavioural Therapy: For men suffering with psychogenic erectile dysfunction, tied to factors
such as depression, low self esteem or anxiety or other interpersonal factors, the patients thoughts and
feeling are addressed, skill-building -sexual enhancement me
b. Relationship and Sexual Therapy: allow couples to have a better understanding of the issue and how to
cope with dysfunction.
1. Herbal Routes
Nettle leaf, gingko (improves genital blood flow and improves pleasure and arousal)
Ginseng (increase testosterone and enhance sexual responses), maca root, oyster meat ( reproductive
health and endurance), pumpkin seeds and zinc.
Locally: Parinari Campestris :Barbanday/Bois Bande
Treatment: Pharmacological
FIRST LINE TREATMENT
1) Phosphodiesterase Type 5 Inhibitors (Slidenafil, Vardenafil)
Most effective for men with diabetes,spinal cord injury and sexual dysfunction associated with
antidepressants)
Mechanism of Action: Uses nitric oxide induced vasodilation mediated by cGMP levels. PDE5 increase
in intracavernosal cyclic GMP levels by inhibiting PDE5 enzyme resulting in increase in the number and
duration of erections in men.
Sexual Stimulation is required!
Dose: Usually taken 1 hour before sexual activity (Slidefanil),Usually taken on an empty stomach (50
mg to 100mg in on an empty stomach, high fat meals delay absorption.)Taladafil- 10 to 20 mg about 30
minutes before sexual activity and can be taken daily.
Absolute Contraindications:
● regular or intermittent use of nitrates due to severe hypotension and syncope
● Recent MI (within the last 90 days, 6 months for vardenafil])
● Recent CVA (within the last 6 months)
● Unstable angina or uncontrolled arrhythmias
● Hypotension Uncontrolled hypertension
● Severe hepatic impairment
Caution in:
● patients >65 years old
● hepatic and renal impairment
● Concomitant use of potent cytochrome P450 3A4 inhibitors
● Alpha 1-Blockers
Side Effects- headaches, diarrhoea, rhinitis, epistaxis and visual disturbances
Testosterone
Testosterone therapy is not recommended as monotherapy, however it should be used in men
with hypogonadism in conjunction with other therapies such as phosphodiesterase 5 inhibitors.
Note, it is not to be used in men without hypogonadism.
Testosterone replacement can be done via multiple routes such as IM, intranasally, oral,
subcutaneous, or applied topically which is usually preferred.
Once on replacement therapy testosterones levels must be monitored to ensure that they
remain in the therapeutic range (500-600ng/dL)
Contraindications include: prostate cancer, breast cancer, erythrocytosis, sleep apnea, heart
failure
SECOND LINE TREATMENT
Vacuum Assisted Erection Devices
Mechanism uses the partial vacuum to increase the blood into the
corpora cavernosa resulting in an erection which is maintained by
occlusive rings at the base of the penis to limit venous outflow.
Contraindications:
● Not recommended in men with sickle cell disease or blood
dyscrasias
● Not recommended in men on anticoagulants.
Drawbacks:
● There is usually a learning curve with this device and requires
some dexterity.
● This device prevents ejaculation as the urethral meatus is
compressed by the occlusive rings.
SECOND LINE TREATMENT
Intraurethral Alprostadil
Mechanism - In a suppository form, is a gel delivered by the applicator in the meatus
Prostaglandin E1 analog, binds to GPCR to PGE1 receptors,activating cAMP pathway leading to
calcium sequestration resulting in smooth muscle relaxation, tumescence then an erection.Direct
Agonist, stimulation is not required.
Use: 5 to 10 minutes before sex, usually lasts for 1hour
Contraindication: Sickle Cell Anemia or any other blood dyscrasia that increase risk of priapism,
deformity of the penis
Side Effects: local penile pain, urethral bleeding, dizziness and dysuria
SECOND LINE TREATMENT
Intracavernous Injection of Alprostadil (Caverject): Preferred.
Can also be with papaverine or phentolamine.
Useful after spinal cord injuries or after major pelvic surgery as intact nerve supply not required,
injected into the sides/base of the penis
Erections usually lasts about 30-40 minutes, occurs 5-15 minutes after penile injection
Side effects: penile pain, hematoma, palpable nodules, priapism
Disadvantages: Dislike of penile self-injection, Requires a sterile technique, Can’t be used more than
once in 24hrs or more than 3 days a week
Patients should be warned that medical attention is needed if erections last >4 hours (leads to necrosis
and fibrosis of corpora cavernosa).
SECOND LINE TREATMENT
Topical Alprostadil Cream
Second line treatment for patients who fail to respond to PDE5 inhibitors or intolerant
If there is drug-drug interaction, in men undergoing treatment with nitrate, alpha blockers and/or
antihypertensive agents.
May be associated with vaginal burning and itching in partners
Avoid with pregnant partners (cream and injections)
Penile Prosthesis
Q- If patient comes to you in clinic, worried about a heart attack after taking
Viagra, how do you deal with this situation?
1.During the evaluation of this patient, there would have been cardiovascular risk assessment
● Based on the Prostate Cancer Prevention Trial determined that men with ED have a significantly greater likelihood of
having angina, myocardial infarction etc compared with men without ED.
● Erectile Dysfunction can be an indicator of systemic endothelial dysfunction.
● Risk basis activity
2.. Evidence -
Large placebo-controlled studies and observational studies did not show statistically significant or clinically significant
increases in major adverse cardiovascular events with the use of PDE5 inhibitors
However,MI or stroke can be triggered by exertion, anger, emotion or, more rarely, sexual activity, but in many cases the
trigger is unknown. There are no guarantees can be given that a person with pre-existing cardiovascular disease is 100% risk-
free from further cardiovascular adverse events in the short or long term.
Based on the risk assessment, men
in the lower risk,asymptomatic group
are able to engage in sexual activity
and there risk of developing
symptoms during sex is equivalent to
gardening or golfing.Advise the
patient on avoiding vigorous sexual
activity.Men in the high risk- avoid
sexual activity all together.
References
● Milan B. Erectile Dysfunction: Pathogenesis. 2018.https://calgaryguide.ucalgary.ca/erectile-dysfunction-pathogenesis/
● Karl T, Joel J. Erectile Dysfunction. 2016.doi:2016;94(10):820-827.
https://www.aafp.org/pubs/afp/issues/2016/1115/p820.html
● Textbook of Family Medicine. 8th Edition. Rakel Robert and Rakel David. 2011.
● Edward David Kim, M. D. (2022, July 19). Erectile dysfunction. Practice Essentials, Background, Anatomy. Retrieved from
https://emedicine.medscape.com/article/444220-overview#a4
● https://www.hindawi.com/journals/ijclp/2022/5229702/tab3/
● https://www.auajournals.org/doi/10.1097/JU.0000000000002554.01
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3949699/
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313297/
● Anaissie J, Hellstrom W. Clinical use of alprostadil topical cream in patients with erectile dysfunction: a review. Res Rep Urol.
2016;8:123-131
● https://doi.org/10.2147/RRU.S68560
● Hackett, G., Kirby, M., Wylie, K., Heald, A., Ossei-Gerning, N., Edwards, D., & Muneer, A. (2018). British Society for Sexual
Medicine Guidelines on the management of erectile dysfunction in men—2017. The Journal of Sexual Medicine, 15(4), 430–
457. https://doi.org/10.1016/j.jsxm.2018.01.023
● HEIDELBAUGH, J. J. (n.d.). Management of Erectile Dysfunction. Management of Erectile Dysfunction | AAFP. Retrieved
January 27, 2023, from https://www.aafp.org/pubs/afp/issues/2010/0201/p305.html
Thank you!
