Erectile Dysfunction (ED): Definition
“. . . the persistent inability to attain and/or maintain an erection sufficient for sexual performance.
Although ED is not perceived as a life-threatening condition, it is closely associated with many important physical conditions and may affect psychosocial health.
As such, ED has a significant impact on the quality of life of patients and their partners ”
Organic Causes of ED
Organic
Vascular Neurogenic Hormonal Penile injury/disease Medications
Psychogenic Causes of ED Psychogenic
Depression Performance anxiety Relationship problems Psychosocial problems Psychological distress
Etiology of ED: Psychogenic and Organic
• ED commonly involves a combination of psychogenic and organic factors1
Psychogenic Organic Organic and Psychogenic
n=639 (45 years of age) 90% Never seek care 10% Seek or receive treatment Under-treatment of ED
What are Men Looking for in ED Treatment? • Men consider the following to be important dimensions of successful treatment: – Cure – Pleasure – Partner satisfaction – Reproduction – Naturalness – Control – Duration – Spontaneity
and Depression A Mutually Reinforcing Triad
ED CVD Depression Medications Lifestyle factors
Psychosocial factors Demographic factors ED, CVD,
•
• n=14,534 *A serious CVTEAE was defined as myocardial infarction, cardiovascular death or cerebrovascular death
Kloner RA et al. Am J Cardiol 2006; 97: 1778-1784.
A retrospective analysis of 36 Cialis clinical trials assessing serious* CVTEAEs in ED patients
Why Take A Sexual History
• Sexual
• Sexual
•
• Sexual
• Important
problems may be the harbinger of underlying disease
health is an Unalienable right of every patient
Has the potential to improve patient –physician relationship
problems are eminently treatable
part of setting realistic expectations
Sexual Problem Assessment • Phases Affected – Tumescence Ejaculation Orgasm • Lifelong vs acquired ( timeline ) • Generalized vs situational • Sudden vs gradual • Distress = Bother • Partner based vs self stimulation • Rigidity • Sustaining capability • Nocturnal erections
Role of NO & cGMP Flaccidity Guanylate Cyclase Erection Nitric Oxide GTP cGMP PDE5 5’-GMP NO is released cGMP formed Lower intracellular calcium Penile smooth muscle relaxation And increased blood flow leads to Erection PDE5 terminates NO/cGMP signaling leading to flaccidity
NO Receptor • Diseases with abnormal NO Production • Hypertension • Obesity • Dyslipidemias • Diabetes I and II • Heart Failure • Atherosclerosis • Aging • Cigarette smoking
1990’s Vascular Agents • Phosphodiesterase Inhibitors • Sildenafil Viagra • Vardenifil Levitra • Tadenafil Cialis • Prostaglandin • Alprostadil • Caverjet
Urologists
• Assess • Investigate • Appropriate option
Penile Implants
•An Option For men who have tried other option without success •40 year history •High patient and partner satisfaction
Physician trends • Prescriptions for ED Constant 2007-10 • Primary Care Physicians prescribe majority Medicines followed by Urologists • Urologists Start twice as many new prescriptions
Patients
• PDE5 I – 50 % dissatisfied • Cost • Product performance • Spontaneity
What Are
Looking For
What Are Patients Looking For • Preferences depend on • Age • Duration ED • Prior Rx Experience • Sexual Dynamics 70- 40 vs 70 -70 • Dynamics and frequency sexual relationships • Side effects • Duration of Action • Consistency of response • Partner satisfaction
• Patient – Embarrassment – Shame – Ignorance re normal – Cultural beliefs – Religious beliefs Physician – Discomfort – Lack of Knowledge – Personal Bias – Time constraints
Barriers to Discussing ED
Drugs and ED • Diuretics ED (twice as placebo) • β blocker (nonselective) ED • β1 blocker (selective) None • α1 blocker Decreases ED rate • α2 blocker ED • Angiotensin-converting enzyme inhibitor None • Angiotensin II receptor blocker Decreases ED rate • Calcium channel blocker None
Odds Ratio of ED • Diabetes mellitus 2.9 • Hypertension 1.6 • Cardiovascular disease 1.1 • Hypercholesterolemia 1.0 • Benign prostate enlargement 1.6 • Obstructive urinary symptoms 2.2 • Increased body mass index (>30 kg/m2)1.5 • Physical inactivity 1.5 • Current cigarette smoking 1.6 • Antidepressant use 9.1 • Antihypertensive use 4.0
ED Treatment is Temporally Linked with Sexual Activity
• Historically pharmacologic ED treatment has been linked to anticipated sexual activity. This required men to inject vasoactive drugs into the penis or apply mechanical devices such as a vacuum device just before sexual activity1 .
• Oral PDE5 inhibitors alleviate many inconveniences and complications, but, treatment requires that dosing and sexual activity occur within a restricted time window1 .
Cialis 5mg Once a Day Indication Statement
• Cialis® (tadalafil) is indicated for the treatment of erectile dysfunction.
– In patients who anticipate a frequent use of CIALIS (i.e., at least twice weekly) a once daily regimen with the lowest doses of CIALIS might be considered suitable, based on patient choice and the physician's judgement.
–
In these patients, the recommended dose is 5mg taken once a day at approximately the same time of day. The dose may be decreased to 2.5mg once a day based on individual tolerability.