Erectile dysfunction in diabetes
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Transcript of Erectile dysfunction in diabetes
Erectile Dysfunctionin Diabetes
Jamie Smith
Etiology of ED: Psychogenic and Organic
Organic Psychogenic
• ED commonly involves a combination of psychogenic and organic factors1
1. Hackett G, Dean J, Kell P, et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp in July 2008
Feldman HA et al. J Urol. 1994;151:54-61.
Men aged 40 to 70 years (N=1290)
No ED48%
ED52%
Minimal17%
Moderate25%
Complete10%
Massachusetts Male Aging Study (US): Key Prevalence Study of ED
Minimal ED, “usually able to get or keep an erection.”Moderate ED, “sometimes able to get and maintain an erection.”Complete ED, “unable to get and keep an erection.”
Prevalence of Erectile Dysfunction in Torbay Hospital and GP Diabetes Clinics
0
5
10
15
20
25
30
35
40
Severe ED Mild/Moderate ED Normal
Hospital
GP
%
p=NS
SHIM<10 = Severe ED SHIM10<20 = Mild/Mod ED SHIM 20 = normal
* *
*
Lockett et al. Diabetes & Primary Care 2007
ED in the man with diabetes
• ED incidence increases with age, duration of diabetes and deteriorating diabetic control1
• Compared to men without diabetes, men with diabetes tend to:
• Suffer ED from an earlier age2
• Suffer more severe ED3
• Have worse disease-specific health-related quality of life3
• Be less responsive to treatment4
1. Fedele D et al. Diabetes Care 1998;21:1973-1977. 2. Feldman H et al. J Urol 1994;151:54-61. 3. Penson D et al. Diabetes Care 2003;26:1093-1099. 4. Eardley I et al. Int J Clin Pract 2007;61:1446-1453
Why Diagnosing ED Is Important
• ED screening may:– Identify underlying coronary artery disease1
– Uncover diabetes (as ED may be the first symptom in up to 20%)1
– Detect dyslipidaemia1
– Reveal the presence of hypogonadism1 – Identify occult cardiac disease1
• Many men with ED show:– Distress2
– Depressive symptoms2
– Decreased self-esteem2
– Diminished quality of life2 – Marked effect on interpersonal relationships1
• Many men perceive their relationship or marriage to be threatened due to the inability to have a satisfactory sexual relationship
1. Hackett G, Dean J, Kell P, et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp in July 2008
2. Lee J et al 2006. BJU Int; 98(3):623-629.
• A detailed medical, psychosexual history and a focused physical examination1
• Patient and if possible partner education about their ED medication1,2
• Patient follow up and adequate exposure to the drug therapy2
The essentials in treating ED
1. Wespes E et al. Eur Urol. 2006;49:806-8152. Hatzimouratidis K et al. Eur Urol. 2007;51:75-89
Drugs that may contribute to ED
•AntihypertensivesMethyldopa, Clonidine, Reserpine,
Beta-blockers, Guanethidine & Verapamil
•DiureticsThiazides & Spironolactone
•Cardiac/circulatoryClofibrate, Gemfibrozil & Digoxin
•TranquilisersPhenothiazines & Butyrophenones
•AnticholinergicsDisopyramide & Anticonvulsants
•AntidepressantsTricyclic antidepressants, MAOIs, Lithium & SSRIs
•HormonesOestrogens/progesterone,
Corticosteroids, Cyproterone acetate, 5-Alpha reductase inhibitors &LHRH agonists
•H2antagonistsCimetidine & Ranitidine
•Cytotoxic agentsCyclophosphamide, Methotraxate& Roferon-A
Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp
Examinations
• All patients should have a focused physical examination.
• A genital examination is recommended – Essential if there is a history of rapid onset of pain, deviation of the penis
during tumescence, the symptoms of hypogonadism or other urological symptoms
• A digital rectal examination (DRE) of the prostate is not mandatory in ED– Should be conducted in the presence of genito-urinary or protracted
secondary ejaculatory symptoms
• Blood pressure, heart rate, weight and waist circumference
Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp
MET equivalents to sexual activity
lower range (‘normal’) 2-3upper range (vigorous activity) 5-6
Lifting and carrying objects (9-20 kg) 4-5Walking one mile in 20 minutes on the level 3-4Golf 4-5Gardening (digging) 3-5DIY, wallpapering, etc 4-5Light housework, e.g. ironing, polishing 2-4Heavy housework, e.g. making beds, scrubbing floors 3-6
Sexual intercourse with established partner
Daily activity METs
Hackett G et al. (2007), ‘British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction’, accessed from http://www.bssm.org.uk/downloads/default.asp
IHD, Nitrates and PDE5 Inhibitors
Angina problematic
Consider appropriate drug treatment
ETT / referral to cardiology for angiography
Defer ED treatment
Angina quiescent
Stop nitrates (long-acting for 1 week)
Encourage exercise
If symptom-free:-
Prescribe PDE5 inhibitor – advice re nitrates (avoid within 24hrs)
Assessment of a patient with erectile dysfunction:
Local guidance
Hypogonadism in diabetic vs nondiabetic men with ED1
22.3
34.0
All ages
ED no diabetes Diabetes
0
10
20
30
40
50
30-39 40-49 50-59 60-69 >70Age (Years)
% H
yp
og
on
ad
ism
(T
<1
2n
mo
l/L
) p <0.0001p <0.0001
1. Corona G et al. Eur Urol 2004; 46(2): 222-228.
n=1027 men with ED with and without type 2 diabetes mellitus
+ ED
04/11/2023 © Schering
0
1
2
3
4
5
Week 4 Week 8 Week 12 Endpoint
Placebo +Sildenafil100mgTestosterone+ Sildenafil100mg
1. Shabsigh R et al. J Urol 2004; 172: 658-663
p=0.029
Testosterone converts sildenafil non-responders to responders in men with hypogonadism and erectile dysfunction1
p=ns
p=nsp=ns
Mea
n ch
ange
from
bas
elin
eIIE
F er
ectil
e fu
nctio
n do
mai
n
n=75 hypogonadal men with ED
Pharmacologic Differences: PDE5 Inhibitors
• The mean terminal half-lives of sildenafil citrate and vardenafil HCl are 3 - 5 hours1 and 4 - 5 hours2, respectively
• The mean terminal half-life of tadalafil is 17.5 hours3
• The longer terminal half life of Cialis may be associated with a period of responsiveness up to 36hrs3
1. Viagra® (sildenafil citrate) Summary of Product Characteristics 2. Levitra® (vardenafil HCl) Summary of Product Characteristics3. Cialis® (tadalafil) Summary of Product Characteristics
Cialis Therapeutic Indications• Cialis is indicated for the Treatment of erectile dysfunction
• Cialis 10mg and 20mgs– In general the recommended dose is 10mg taken prior to anticipated
sexual activity. In patients who experience an inadequate effect, 20mg might be tried.
– The maximum dose frequency is once per day however continuous daily use is not recommended
• Cialis 5mg and 2.5mg– In responder patients to an on-demand PDE5 inhibitor regimen who
anticipate sex more than once per week a once daily regimen 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
Cialis Summary of Product Characteristics. Eli Lilly and Company Limited.
Vacuum Erection Devices
Drug injected directly into the corpus away from midline
Corpus cavernosum
Midline
Cross-section of the shaft of the penis
Intracavernosal Injectione.g. alprostadil
How should we screen for ED in Diabetes?
• Review the issue of ED with men annually• Provide assessment and education for men with
ED to address contributory factors and treatment options
• Offer a PDE-5 inhibitor if ED is a problem• If PDE-5 inhibitors are unsuccessful refer to a
service offering specialist management
NICE 2008
NO
67%
Yes
24%
NO
76%
Yes
NR=3%
X2 = 2.81
P=0.09
Has a Dr/ nurse ever asked you about problems getting an erection? If so, who?
Torbay Hospital Clinic Local GP practice
30%
2005 Audit Lockett et al. Diabetes & Primary Care 2007
NO
67%
NO
76%
NR=3%
X2 = 2.81
P=0.09
Have you been asked about ED at your Diabetes annual review at the GP surgery (n52)
Yes35%
No63%
Not answered2%
2009 Audit
During your annual diabetic review, do you think you should be asked about problems getting an erection? Local GP
practice
6717
11
3
1
0 10 20 30 40 50 60 70
Yes- All male pts should beasked
Dr/ Nurse should only ask ifthey think it's appropriate
Only discussed if pt asks
No- Not be included
Not rec
%2005 Audit
2005 AuditLockett et al. Diabetes & Primary Care 2007
NO
67%
NO
76%
NR=3%
X2 = 2.81
P=0.09
If you have a problem with ED, do you feel satisfied that it has been properly discussed &
assessed (n27)
Yes56%
No33%
N/A7%
Not answered8%
2009 Audit
Reasons for not being satisfied…
4 pts Not asked
I have tried two different tablets and didn’t work
I enquired about a daily pill rx passed by NICE and was told no such
drug available I would have to provide GP with the name of the drug
Dr ? Didn’t reply to my enquiry through Diabetic.Nurse when myself and my then wife were looking at options 3 years ago
Not offered drug
Only basic knowledge discussed with GP
I have seen two doctors and consultants about ED and although I
have medication for this I do not have much of a sex life and I find
this difficult I am now 50
2009 Audit
Number surveyed who would like further advice or help
• 13/27 (48%) patients would like further advice/help
2009 Audit
How do we screen for erectile dysfunction?
Make a statement rather than posing a question……………“Your diabetes may have an effect on your erections – if
that happens let me know as it can often be sucessfully treated.”
Be direct……………………..“Are your erections hard enough for penetration?” NO
indicates ED“If you get a good erection does it go away quickly?” YES
indicates ED
Conclusions
ED is usually managed in Primary Care
Patient education and dose optimisation may rescue PDE5 inhibitor “failures”
Early success is important for patient motivation and continued success with treatment
Testosterone deficiency can be associated with ED and can give rise to PDE5i failure1,2
Testosterone therapy can restore responsiveness to PDE5is in hypogonadal men with ED1,2
Measure testosterone in men with ED
Refer to Secondary Care only in specific circumstances
1. Yassin AA et al. Andrologia 2006;38:61-68 2. Shabsigh R et al. J Urol August 2004 Vol 172, 658-663