Chronic Male GU Disorder: Erectile Disfunction: "Inability to…
Chronic Male GU Disorder:
"Inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance".
Males older than 40 years of age
33% of males have ED by 55 years of age
The rate increases as the rate of cardiovascular disease increases
Approximately 600,000 new cases diagnosed in the US annually
It may be difficult to estimate the number of men affected because they may be reluctant to seek medical attention
Transient, limited episodes that are not pathologic occur in about one-half of all adult males
Mild ED: if pt fails to achieve satisfactory erection in two out of 10 attempts
Moderate ED is the middle ground between mild and severe
Severe ED: All attempts at satisfactory erection fail
Plan of Care
Vacuum Constriction Device
Noninvasive procedure, complications are rare. Available over the counter and can cost between $300 and $500.
Reliable but invasive. More opporturnity for mechanical failure.
May help pts who have failed other methods. Allows for more spontaniety.
Very expensive, may e covered by some insurance plans.
Risks include infections, erosion, mehanical failure.
Most common types of implants are nonhydraulic and hydraulic
Healing takes 4-6 weeks, then patient may have intercourse
Pts with arterial disorders may be candidates for this procedure
May include endarterectomy and balloon dilation, or arterial bypass
Pts with venous disorders may also be candidates
Ligation of the deep dorsal vein or emissary vein or ligation of the crura of the corpora cavernosum may be effective
Males younger than 45 with severe pelvic trauma are the best candidates
A congenital shunt should be ruled out if pt reports they have never had a full erection
Low Intensity Shock Wave Therapy
Not yet approved in the United States but has been successful in Europe
Believed to promote the release of angiogenic factors that lead to revascularization of the penis
Some physicians offer this procedure off-label to refractory patients
Offered to pts in Europe with severe ED who are unresponsive to treatment wtih PDE5 inhibitors.
Testosterone Therapy administered by injection, oral medication, topical patches, or topical gels.
Androderm, Testoderm- Transdermal Patch may cause skin irritation
Androgel, Testim Gel, Axiron Solution- Transdermal Gel may cause burn like blistering or problems with urination
Testopel-Implantable Pellets may cause infection at implantation site or pellet extrusion
Striant- Buccal System may cause mouth or gum irritation, allergic reactions, swelling of ankles or legs, breathing problems including associated with sleep, and liver damage
Oral agents include Fluoxymesterone and Methyltestosterone
Difficult in achieving adequate blood levels due to first-pass metabolism in the liver.
Generally not recommended because of hepatotoxicity and unreliable androgenic efforts
May cause sodium retention with dependent edema, increased risk of bleeding, pain at injection site, mild gynecomastia, mood swings, and lipid abnormalities
Do not use in pts with serious liver, kidney, or cardiac disease; prostate or breast cancer; or in those with mercury allergy.
Peak and trough effects may lead to aggression, increased feeling of well-being, energy, increased libido within 72 hours of injection. As peak levels fall, pt may experience depressed mood and loss of libido.
Vasoactive Therapy- Phosphodiesterase-5 inhibitors and Prostaglandin E1
PDE5 inhibitors may cause headache, flushing, dyspepsia, nasal congestion, and visual color changes. They may also cause back and lower limb pain.
Sildenafil, Vardenafil, Tadalafil, Avanafil
Sildenafil: orally active cGMP specific phosphodiesterase inhibitor results in increased blood flow necessary for penile erection. Dose is 50 mg taken orally 1 hour before sexual activity. May cause severe hypotensive effects.
Do not use these agents in pts taking nitrates or alpha-adrenergic blockers due to increased risk of severe hypotension.
Wait 24 hours before giving nitrate medications after sildenafil or vardenafil and 48 hours for tadalafil.
Prostaglandin E1 may be given as an injectable or transurethral suppository.
Alprostadil Injectable- Caverject, Edex
May cause prolonged erection, penile pain, penile fibrosis, injection site hematoma, numbness, yeast infection, and priapism
May also cause URI, headache, dizziness, and hypotension
Taking with anticoagulants or heparin increases risk of bleeding. Pts with sickle cell anemia, penile fibrosis, coagulopathy, severe cardiovascular ds, myeloma, leukemia, penile deformity, morbid obesity, or penile implants should not use injectable or suppository.
Can be used once every 24 hours but no more than three times a week.
Transurethral Alprostadil- Muse
May cuase urethral irritation
Should not be used without a condom if partner is pregnant.
Cognitive behavioral therapy (CBT) is perhaps one of the most useful forms of therapy for addressing ED, especially related to performance anxiety, low self-esteem, and loss of sexual arousal.
Usually first referral if no underlying illness. Urologists specialize in treating conditions that affect the urinary tract and the male reproductive system, including ED. A urologist can diagnose ED and investigate what is causing it
Urologists are skilled at Injection tests: This test involves a provider injecting medicine that causes an erection into the base of the penis. If an erection does not result, it may suggest there is a problem with blood flow.
Urologists use Penile Doppler ultrasound: For this test, the provider injects medicine that produces an erection into the penis. They then use ultrasound to see how well blood flows in and out of the penis through the arteries and veins.
ED can be an early warning sign of current or future heart problems
Erectile dysfunction does not always indicate an underlying heart problem. However, research suggests that men with erectile dysfunction who have no obvious cause, such as trauma, and who have no symptoms of heart problems should be screened for heart disease before starting any treatment
Likewise, if you have heart disease, getting the right treatment from a cardiologist might help with erectile dysfunction.
Your provider might recommend seeing an endocrinologist if the underlying cause of ED is diabetes or hormonal. Endocrinologists will look for and treat diabetes, low testosterone, thyroid disease, and prolactin levels.
Couples Counseling/Sex Therapist
Erectile dysfunction not only has the potential to impact a man’s sexual satisfaction and self-esteem, but also his partner’s sexual satisfaction and their intimate relationship.
Working together in couples counseling can help you and your partner team up around erectile dysfunction versus creating more criticism. Couples therapy can help distant couples regain a sense of playfulness and laughter beyond sexual needs. Also, couples therapy can help emphasize desire in ways beyond having physical sex.
If medication doesn't successfully treat erectile dysfunction, your doctor may recommend surgery or the use of a penile device.
Surgery may also be the only treatment option for men with severe erectile dysfunction due to a physical trauma, prior surgery in the pelvis, or a medical condition, such as cancer.
The goal of treating ED is to enable a man to achieve and maintain an erection so that he can have sexual intercourse. Depending upon the cause of ED, treatment may include one or more of the following:
Lifestyle changes — Improving diet, exercise, and sleep and reducing stress can all potentially improve sexual problems such as ED and low libid
Drugs and alcohol — Ask your doctor if one of your medications could be contributing to your ED. Quitting smoking and reducing or stopping alcohol can also be beneficial.
Phosphodiesterase-5 inhibitors — Phosphodiesterase-5 (PDE-5) inhibitors work by increasing chemicals that allow the penis to become and remain erect
Anyone who has used a PDE-5 inhibitor and then develops cardiac problems and requires nitrate medications should NOT use the PDE-5 inhibitor in the future. If you develop chest pain, contact your health care provider or go to the emergency department immediately.
Resuming sexual activity after a prolonged period of inactivity is similar to beginning a new exercise routine. Men considering a PDE-5 medication should be able to participate in an activity that is approximately equal to the energy required for sex.
To assess whether your heart can tolerate sexual activity, your health care provider might ask if you are able to walk 1 mile in 20 minutes or climb up 2 flights of stairs in 10 seconds.
A number of sources claim to sell medications such as Viagra, Cialis, Levitra, or herbal supplements for ED through the internet or by mail for a reduced cost, often without a prescription. These sources are not known to be safe or reliable, and it is not possible to know whether the pills from these sources contain the actual drug or are counterfeit.
Psychological causes of ED include: performance anxiety, a strained relationship, lack of sexual arousability and mental health disorders, including depression and schizophrenia.
Many medicines can affect the ability to have sex. Medicines can decrease the ability to have an erection. Medicines can also affect the level of interest in sex and the ability to have an orgasm.
The most common cause of erectile dysfunction is problems with the blood vessels that carry blood to the penis. In some men, the blood vessels narrow and don't allow the increased blood flow needed for a full erection.
Conditions that cause the blood vessels to narrow include atherosclerosis (hardening of the arteries), high blood pressure, high cholesterol levels and long-term smoking
With the patient's permission, the partner should also be present for history as they can give a different perspective on the relationship and their views are very useful in measuring the response to therapy. Having the sexual partner involved in the treatment process greatly improves the outcome.
Telehealth, for a more discrete appointment
The Tenuto 2 vibrating device For ED
HIMS App-based home delivery for ED meds
Mojo Sexual Wellbeing App
Roles of the Client-Family-Community
The proposal that exposures to environmental or occupational substances may affect erection ability is a tenable one and would add to a growing list of pathogenic risk factors associated with erectile dysfunction
Several environmental toxicants to include lead, organic solvents, and pesticides have been implicated as possibly hazardous agents.
Effects on the nervous and hormonal systems have been proposed as the leading mechanisms by which environmental toxicants adversely impact erectile function.
As of 2018, researchers have identified a genetic variant that increases the risk of erectile dysfunction (ED)
The genetic variant is near a gene called SIM1 and may affect this gene’s activity.
A twin study of middle-aged males reported that about one-third of ED risk is heritable—meaning that there is a genetic component(s), but specific genetic variants had not been identified
Attitudes to sex and the perceived role of sexual activity are very strongly influenced by cultural values
It is important to be aware of cultural influences on sexual behavior. Laws, power relationships in terms of sex and gender, levels of stress and economic resources are all of significance.
Cultures define what is deviant and from where help is sought.
Education, tailored therapy and a flexible approach are the cornerstones of effective treatment.
Psychogenic erectile dysfunction is the inability to achieve or maintain an erection during sex due to psychological factors.
These factors can include stress and anxiety, depression, guilt, low self-esteem, or relationship concerns
Although erectile dysfunction involves an interaction between physiological and psychological pathways, the psychosocial aspects of ED have received considerably less attention
Complain of one or more: "Loss of sexual desire, inability to maintain an erection, premature ejaculation, absence of emission or inability to achieve an organism"
Palpate testes: if length is < 4cm, consider hypogonadism
Palpate all pulses (including penile pulse)
Neuro exam: with erectile reflex to include anal sphincter tone, perineal sensation, and bulbospongiosus reflex
Assess for peripheral neuropathy: distal muscle weakness & loss of DTR, testing for impaired vibratory, position, tactile or pain sensation
Thorough genital exam to r/o any penile abnormalities
Medical History Questions
What medications are you taking?
When was the last time you had a spontaneous erection occur?/ Awake with an erection?
Do you drink alcohol/how much? Do you smoke/how much?
Do you ever feel numbness/tingly in your lower extremities?
Do you have concerns in your current relationship?
Have you been experiencing increased stress? In work, home life, self..ect?
Has there been anxiety over performing?
Has this ever happened before?
1 more item...
How often are you attempting?
Does lack of erecting occur during coitus or self masturbations or both?
Without a full erection, can you still ejaculate?
Normal Sexual Function has 5 phases: Libido; erection; ejaculation; orgasm & detumescence (postcoital resolution)
Non-Psychogenic causes of ED include:
Penile Disorders/Structural Causes
Failure of Detumescence, Priapism, Penile Trauma, Peyronie's Disease
Trauma: ex: Prolonged bicycling
Damage to the pudendal & cavernous arteries
Persistent erection (Priapism) disrupts vascular network and can lead to fibrosis and failure-to-store defect
Impedance of blood flow into the penis d/t obstruction of the distal aorta at the bifurcation of the common iliac arteries
Atherosclerosis: causing failure of the vascular system to fill
Risk factors: Heart disease; Cigarette smoking; DM; Aging; Dyslipidemia; HTN
Obstructive Sleep Apnea
Anterior Temporal Lobe Lesions
Disease of the Spinal Cord, Loss of Sensory Input
(secondary to DM or Polyneuropathies),
Tabes Dorsalis, Disease of Nervi Erigentes
(secondary to complete prostatectomy, rectosigmoid operations or aortic bypass)
Ex: Pt's with DM can develop retrograde ejaculation due to failure of the bladder neck to close during ejaculation
Retrograde ejaculation is when semen enters into the bladder instead of expelled during an orgasm
Phenothiazines, Thioridazine, Imipramine, Methyldopa, Guanethidine, Reserpine, Spironolactone, Alcohol, Heroin, Methadone, Estrogen, Beta Blocker, Thiazide Diuretics, Antihypertensives
Testicular Failure (primary or secondary), Hyperprolactinemia
Hyperthyroidism or Hypothyroidism
Obesity/Lack of exercise/increased stress
Depression and SSRI use
Other sexual dysfunction (fear of humiliation)
LUTS: Lower Urinary Tract Symptoms
coupled with advanced age (one study conducted had aged 50-80 yrs surveyed with high prevalence)
: commonly results in retrograde ejaculation
Can cause insufficient relaxation of the corporeal smooth muscle
Fasting Blood Glucose to r/o DM
Fasting Lipid profile to r/o Dyslipidemia
Testosterone levels below 300ng/dL
Serum prolactin level
Established ED pt add on labs:
CBC & PSA as young as 40 yrs
Specialized test if cause is still unknown
Nocturnal penile tumescence and rigidity (NPTR)
Color Doppler Sonography of the penis
Assesses vascular causes by measuring integrity of arterial influx in the cavernous artery during erection
Tests pt's physical ability to achieve an erection