Dr Hilgard Ackermann FC (Urol)academic.sun.ac.za/stellmed/CourseMaterial/Annual GP Conference...
Transcript of Dr Hilgard Ackermann FC (Urol)academic.sun.ac.za/stellmed/CourseMaterial/Annual GP Conference...
GP Refresher Course – 2017
Dr Hilgard Ackermann FC (Urol)
Premature Ejaculation
Erectile Dysfunction
Penile Curvature
Ejaculatory Disorders
New consensus statement Ejaculation that always or nearly always occurs prior
to or within about 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE).
The inability to delay ejaculation on all or nearly all vaginal penetrations.
Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.
ISSM Consensus Statement 2016
Different types of PE?
Life-long
Acquired
▪ Natural variable vs Subjective
▪ PE-like ED
Etiology largely unknown
Theories exists: anxiety, penile hypersensitivity, and 5-HT receptor dysfunction
Important from the history▪ Onset of problem (Classify)
▪ Time to ejaculation
▪ Perceived control
▪ Distress and interpersonal difficulty related to the ejaculatory dysfunction
▪ Subtype ? Premature Ejaculation Diagnostic Tool (PEDT) ▪ No role in clinical context
Important from the physical examination▪ Anatomical deformities, urethritis, prostatitis
Dapoxetine 30mg / 60mg (Priligy©)
FDA approved: On-demand usage
Tmax 1.3hr; ½ life 24 hrs.
2.5- and 3.0-fold increases IELT
Safe to use with PDE5-Inhibitors (risk syncope)
▪ Tadalafil combination tablet = Tadapox (FDA)
EAU 2017
Anejaculation▪ Involves complete absence of antegrade or retrograde ejaculation
Retrograde ejaculationTtotal, or sometimes partial, absence of antegrade ejaculation as a result of semen passing backwards through the bladder neck into the bladder.
Anorgasmia▪ Inability to reach orgasm and can give rise to anejaculation. It is a
primary condition and its cause is usually psychological.
Asthenic / delayed ejaculation
Pitfalls in management
Beware of SSRI withdrawal syndrome
Careful prescription of SSRI in young men < 18yr or with MDE / Bipolar
Impact of condom usage on marital partner
Topical anaesthetic agents reduces effect on both partners.
The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.
There is increasing evidence that ED can be an early manifestation of coronary artery and peripheral vascular disease.
HormonalPelvic Trauma
PSA TT +- LH
HbA1C; Creat; Lipogram
EAU 2017
SildenafilVardenafilTadalafil*Avanafil
CaverjectBimixTrimixQuadmix
1st 2nd
All PDE5Is are contraindicated in:▪ Patients who have suffered from a myocardial
infarction, stroke, or life-threatening arrhythmia within the last 6 months
▪ Patients with resting hypotension (blood pressure < 90/50 mmHg) or hypertension (blood pressure > 170/100 mmHg)
▪ Patients with unstable angina, angina with sexual intercourse
▪ Congestive heart failure categorised as New York Heart Association Class IV.
PDE5Is
Drug-interactions▪ Nitrates (all forms) – contra-indicated
▪ Anti-hypertensives – safe (take care with Doxasozin)
Dosage adjusments▪ Needs higher dose: Phenytoin, Carbamazepine, Phenobarbitol
▪ Needs lower dose: Ketokonazole, Itraconazole, Clazithromycin.
Conditions: ▪ Renal failure, hepatic failure ?
Intracavernosal injections
Alprostadil (Caverject®)
▪ 5-40 mcg
▪ Test dose first
▪ Physician instructed
▪ Side-effects: Pain, hematoma, fibrosis, priapism
Stronger alternatives: BiMix, TriMix, QuadMix
EAU 2017
3rd MalleableInflatable
Correct dosage?Taken at least 6?Grey product?Waiting too long?No sexual stimuli?
Malleable Inflatable penile prosthesisR19,000 R80,000
Important to note
Different types: Malleable vs Inflatable Penile Prosthesis (IPP)
Recognition of complications
▪ Inguinal hernia formation
▪ Erosion / extrusion of corporal cylinder
▪ Mechanical failure signs
▪ SST (supersonic transporter) or sigmoid deformity
Pitfalls in management▪ Inadequate patient counselling
▪ Drug interactions / dosage adjustments
▪ Not evaluating the cardiovascular risk status
▪ When to refer to a Urologist?
Congenital
Rare (< 1%)
Disproportionate development of the tunica albuginea of the corporal bodies, usually ventral.
Referral to Urologist
Acquired
Peyronie’s Disease
0.4-9%, age 55-60, diabetics with ED
Important from the history Degree of Erectile Dysfunction (Score: IIEF score)
Ability to penetrate / successful sexual intercourse
Duration of onset (< or > 12m)
Degree of curvature (<30°, 30°-60°, >60°)
Presence of pain?
History of prior treatment
Important from the physical
General
▪ Examine hands – Duputreyn’s contractures [Ortho]
▪ Examine foot soles – Lederhose disease [Ortho; Podiatrist]
▪ Examine ears – Tympanosclerosis [ENT prn]
Penis
▪ Plaque (ventral / dorsal / lateral / size), presence of pain
▪ Degree of curvature –# Selfie by patient
Rationale behind medical treatment
Acute (painful) phase, interact with presence of growth factors
Natural process of plaque
▪ 48% stabilize; 18 % regress ; 25% worsen
Medical treatment options
▪ Oral, intralesional and external options
▪ Xiaflex: Newly approved by FDA.
Rationale behind surgical options
Reduce degree of penile curvature, chronic phase
Surgical options
▪ Degree of curvature important – 60 degrees
▪ “Penile lengthening” vs “shortening” options
▪ Risk of de novo erectile dysfunction
▪ Penile prosthesis if significant ED and curvature exists
NESBIT
GRAFT
Pitfalls in management
Investigating penile pain – examine closely for plaques.
Associated pathology.
Complications of penile prosthesis
Side effects of medical management.
Timely referral to Urologist