Chapters Transcript Video Men's Sexual Health Hi I'm dr allium assistant professor of oncology in the Department of Urology at Roseau Comprehensive Cancer Center. Yeah. Yeah mm mm. Yeah. At the end of this activity participants should be able to understand the causes, evaluate diagnose and treat patients with erectile dysfunction. We'll start with a quick summary of the anatomy of the penis. It consists of three compartments to corporate cover nosa on the dorsal aspect and this contain the erectile tissue and blood sinus oils that's filled with blood during erection and the corpus populism on the ventral aspect. That includes the Aretha. Also a brief summary of the physiologic changes that occur in the penis during erection. This diagram summarizes the changes before and after erection. After sexual stimulation, neurotransmitters are released that causes relaxation of the smooth muscles within the corporate ever nosa. This increases the blood flow to the penis, causing erection and rigidity. At the same time the veins constrict to maintain the blood within the corpora contraction of the perennial muscles such as the rescue cover noses and bulbous pond uses can also increase the blood flow to the penis. Rectal dysfunction is defined as the inability to obtain or maintain peanut erection for a satisfactory intercourse, erectile dysfunction is a sign of cardiovascular health and has been associated with increased risk of serious cardiovascular events. Many men should consider erectile dysfunction as an opportunity to improve their cardiovascular health. Generally causes of erectile dysfunction can be organic psychogenic or a mix of both. Several studies have investigated the prevalence of erectile dysfunction among sexually active men. In summary, approximately 30-40% of men across different age groups suffer from some sort of erectile dysfunction and the incidents increases with age. A theology of erectile dysfunction can be vascular due to smoking, sedentary lifestyle, obesity and other components of the metabolic syndrome, as well as major pelvic surgery and radiation to the pelvis neurasthenic causes include central causes such as multiple sclerosis, Parkinson's disease, stroke and others preference neuropathy may occur with diabetes or renal failure, pelvic surgery or surgery to the urethra. Other causes include different diseases that can affect the penis, including penal cancer. In the Quran causes include diabetes, hypogonadism, hyperthyroidism, hypo and hyper cortical is um chronic illnesses can also affect erectile function. Medication induced erectile dysfunction is also one of the most common causes. And these include many anti hypertensive, anti depressants, anti psychotics, anti androgens and recreational drugs. Psychogenic causes can be generalized or situational, which would be partner related or traumatic and ideologies such as penile or pelvic fractures. Evaluation includes careful and thorough history taking, including past medical history, previous surgeries, social and sexual history and it's always preferred to include the sexual partner during the conversation validated questionnaires to assess erectile functions such as the international index for erectile function and it's short form the ship or the short health inventory for men. Physical examination should include evaluation of blood pressure, body mass index and focus pin island scrotal exam. Sexual activity can cause significant cardiac load and therefore in patients with significant cardiac history. Assessment of the cardiac condition should be performed. The Princeton criteria were developed for that purpose. These include the presence of symptoms, risk factors for cardiovascular disease history and type of angina history of my accordion, infarction, heart failure class and others. Then patients can be classified based on exercise tolerance into low intermediate and high risk Sexual activity is equivalent to walking one mile on the flat for 20 minutes or climbing two flights in 10 seconds. Low risk patients can resume sexual activity while high risk patients need evaluation by a cardiologist. Intermediate risk patients will need further evaluation by a stress test and then certified into low or high risk. Basic labs would include lipid profile and hemoglobin, A one c hormonal profile including testosterone. And then further investigations may be needed as clinically indicated, such as the follicle stimulating hormone, legitimizing hormone and prolactin and others. Advanced work up is not really indicated in every single case, but rather in specific situations. And these include peanut duplex, internal p dental arteriogram, fee and cavernous geography and others. Management includes general measures and lifestyle modifications, medical treatment, the use of the vacuum, erection device and surgical intervention, lifestyle modifications. These are as important as the specific measures. Anything that can improve the cardiovascular function can improve erectile function. These include smoking cessation, weight loss, exercise, balanced diet and control of co morbid conditions. Treatment of the cause such as testosterone replacements in patients with hypogonadism, consideration of penile revascularization in young patients with traumatic etiology of erectile dysfunction, psychiatrist evaluation and referral to sex therapists. In patients with psychiatric disorders, fossil is to raise five inhibitors represent the backbone of medical treatment. These include several agents such as sildenafil, the de la ville Vardan FL. And even if l the choice of one agent over the other. There is no comparative data between specific forceful histories, inhibitors, but the choice would rather depend on the frequency of sexual activity, patient response and personal experience and if there is associated lower urinary tract symptoms where daily low dose today Louisville will be preferred. One meta analysis suggested that patients who prioritize efficacy should use sildenafil, while those who prioritize to lure ability should use to Della fill. Counter indications include concomitant use of nitrates or unstable or in evaluated cardiac condition. Prescribers should consider possible interaction with anti hypertensive and start with a lower dose, especially in patients on multiple anti hypertensive anti trade based on tolerable itty and efficacy. Knowledge of the pharmacogenetics of different agents is essential for patient education. This is a comparison of the two most commonly used fossil histories inhibitors sildenafil into delightful sildenafil reaches acceptable level in the blood in almost one hour and its half life is about 3-4 hours. Patients should wait for approximately half an hour to an hour after intake and the medication is usually effective for 6-8 hours. It's important to know that it's absorption is affected by food and therefore it should be taken four hours after the last meal to maximize its absorption, on the other hand, today, to fill reaches acceptable level in the blood after approximately two hours And its half life is around 18 hours. Patients should wait for approximately 15-30 minutes after intake And the medication is usually effective for 36 hours absorption of data for is not affected by food. Side effects in general, these medications are very tolerable medications since they increase the blood flow to the penis. The side effects are also related to the increased blood flow to different organs. They can cause headaches, flushing, dyspepsia, nasal congestion, dizziness, blue green vision with sildenafil, back pain and muscle aches with today lawful priapism can very rarely occur. Patient education has mentioned earlier is key. Patients should try the medication and dosage and give it an adequate trial. This was defined as six attempts in a recent study, adequate sexual stimulation is very important. Many patients think that once they take the medication they will have an erection, erection may only occur with adequate sexual stimulation. Patients may titrate the dose depending on the efficacy and tolerable ITty and patients need to make sure that they wait for the appropriate time and also avoid waiting for too much time after taking the medication, as mentioned earlier. For non responders, prescribers should first go over how the patients were taking the medication in terms of how many trials the dosage relation to food. If they are taking sildenafil the way time and so forth. After ensuring an adequate trial, non responders may be checked for hypogonadism. If this was not done earlier, they may try switching to a different agent or combined daily low dose today to fill with an on demand dozing, although there is no sufficient evidence to support this practice. Second option is intra urethral. Suppository with ultra saddle or muse Efficacy is probably around 50%, but only 30% of patients continue long term therapy. The first dose should always be performed in the office potential. Side effects include pain related to the method of administration, dizziness, with low blood pressure bleeding, A. U. T. I. Priapism, which is quite rare into recovered Nosal injection is very effective. The first dose again should always be performed in the office. Patients need to be trained on how and where to give the injection. Potential complications include pain, eye pain, priapism, fibrosis, bleeding and infection. Approximately half of the patients will stop the injections mainly within the first 2 to 3 months after initiation of treatment. Reasons for stopping the treatment include desire of a permanent modality, lack of a suitable partner, fear of needles or complications and the lack of spontaneous intercourse. The vacuum erection device with or without the construction ring. Um It works by drawing the blood passively into the penis and then the construction ring keeps the blood in the penis and maintain direction. It's very effective regardless of the cause of erectile dysfunction because it's totally mechanical. But satisfaction rate is around 60%. Potential complications include pain, inability to ejaculate due to compression of the urethra by the ring, Bruising numbness and the ring should only be used for a maximum of 20-30 minutes. It's not preferred in patients on blood thinners as they have a higher risk of bruising and skin complications. Shockwave therapy can be used in patients with my vascular erectile dysfunction, but more data is still needed, but for now the evidence remains weak and more studies are required before recommending shockwave therapy for erectile dysfunction. Penal implants are the last resort. This is the most invasive option, but with the highest satisfaction rates in both patients and partners. Potential complications include mechanical failure, which is less than 5% after five years infection currently at a rate of 1 to 2%. With the newer devices that are impregnated with antibiotics, erosion glands, ischemia, necrosis, glands, hypermobility and penal shortening, which is usually not too bad, but patients perceive it as more severe compared to the actual loss and length. There are three types of penile implants, the first in the semi rigid. As you can see, this is composed of two rods placed in the penis. The device is less concealed compared to the inflatable devices. However, it is easier to use. The patient just needs to move the penis upwards. It does not require manual dexterity and therefore suitable in older patients. The chance of mechanical failure is less compared to inflatable devices, as it only includes the rods without any other parts. The second type is the two piece inflatable penile prosthesis. As you can see, this is composed of two rods placed in the penis. In addition to the pump placed in the scrotum, the device is less concealed compared to the three piece uh When the patient is ready to use it, he would squeeze the pump in the scrotum and the rods are filled with fluid and become hard. After he is done, he would gently bend the penis and then the penis will return to the flaccid state. The three piece penal implant is composed of two rods placed in the penis, the pump in the scrotum and the reservoir, which is usually placed in the pelvis close to the bladder. It's more concealed and erections are potentially harder compared to the two piece penal implant. When the patient is ready, he would squeeze the pump in the scrutiny and the fluid shifts from the reservoir to the rods, filling them and causing erection. After the patient is done, he will press the button just above the pump and the fluid will shift back to the reservoir and the penis will return to the flaccid state. This is a summary uh for evaluation uh of patients with erectile dysfunction by the european Association of Urology, Comprehensive history taking with focused exam and lab testing, including glucose lipid profile and testosterone. And this is also a summary of management, starting with lifestyle modifications, less invasive options and penile implants as the last resort in case of inadequate outcome. In summary erectile dysfunction is a common problem that increases with age. It's an early sign of cardiovascular disease. Different management options are available, including general and lifestyle changes, behavioral pharmacologic and finally, surgical options. Mm. Created by
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