Erectile Dysfunction (1 of 11) 1 Male patient presents w/ symptoms of erectile dysfunction (ED) for ≥3 months 2 DIAGNOSIS No ALTERNATIVE Does patient’s sexual DIAGNOSIS history confirm ED? Yes 3 EVALUATION • Identify comorbidities & psychosexual dysfunctions • Evaluate cardiac function 4 RISK STRATIFICATION Intermediate • Do basic cardiovascular (CV) High-risk assessment (usually include a stress test) to classify patient’s • Refer to a CVD risk • Refer for CVD Cardiologist for management further CV • Follow up for No/Low- risk evaluation, treatment of ED assessment & risk once cardiac management status has improved TREATMENT © MIMSSee next page B1 © MIMS 2019 Erectile Dysfunction (2 of 11) PATIENTS W/ NO OR LOW CVD RISK A Non-pharmacological therapy • Patient & partner education - Lifestyle modifi cation ERECTILE DYSFUNCTION - Treat psychosocial factors - Discontinue off ending medications B Pharmacological therapy • Correct any existing medical risk factors or cause • Endocrine therapy for ED caused by hypogonadism/testosterone defi ciency • Nonspecifi c therapies for ED - 1st-line for ED w/ no evidence of endocrinopathy - Phosphodiesterase inhibitors (PO) C CONTINUE FOLLOWUP Yes Is patient satisfi ed TREATMENT w/ results? No A Non-pharmacological therapy • Sexual counseling & education • Vacuum constriction devices B Pharmacological therapy • Phosphodiesterase inhibitors (PO) • Alprostadil (topical) • Apomorphine (sublingual) • Yohimbine (PO) • Intracavernosal inj therapy • Intraurethral therapy C CONTINUE FOLLOWUP TREATMENT Yes • Is patient satisfi ed Follow-up w/ patient w/ results? every 6 mth No D Surgical intervention • Penile vascular surgery © • PenileMIMS drug delivery (implanted) devices • Penile implants Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B2 © MIMS 2019 Erectile Dysfunction (3 of 11) 1 ERECTILE DYSFUNCTION (ED) • Inability to attain & maintain an erection enough to have satisfactory sexual performance for at least 3 months • Increasing evidence have shown that erectile dysfunction can be an early manifestation of coronary artery & peripheral vascular disease • Erectile dysfunction has common risk factors as w/ cardiovascular diseases • Studies have shown that erectile dysfunction has been associated w/ lower urinary tract symptoms, benign prostatic hyperplasia, & sexual dysfunction regardless of age & other comorbidities & various lifestyle factors ERECTILE DYSFUNCTION Symptoms • Complete loss of penile rigidity is uncommon • A patient may complain of partial erection that could not attain vaginal penetration • Initial penile erections can penetrate but early detumescence occurs without ejaculation • Nocturnal penile tumescence • Inability to maintain erection during private masturbation &/or erections related to erotic material or other partners 2 DIAGNOSIS Sexual History • Patient consistently or recurrently is unable to maintain/attain an erection that is adequate for sexual satisfaction • May use validated psychometric questionnaires, eg International Index for Erectile Function (IIEF) 3 EVALUATION • orough sexual, medical & psychosocial history - Erectile dysfunction may be the fi rst presentation of an underlying serious medical condition (eg hypertension, diabetes mellitus) • Physical exam: Abdomen, penis, testicles, secondary sexual characteristics & lower extremity pulse, digital rectal examination (DRE) - A digital rectal examination is not mandatory in erectile dysfunction but should be done in the presence of a genitourinary or protracted secondary ejaculatory symptoms • Lab tests - Fasting blood glucose or HbA1c, lipid profi le, testosterone assay to evaluate hypothalamic-pituitary-gonadal axis, urinary microscopy, etc as necessary - Prostate-specifi c antigen (PSA) is measured before initiating & at regular intervals during testosterone therapy Comorbidities & risk factors that contribute to erectile dysfunction should be identifi ed: Arteriogenic • Diabetes mellitus • Hypertension • Cardiovascular disease • Hyperlipidemia & the metabolic syndrome • Heavy smoking • Peripheral vascular disorders • Recreational drug abuse Neurogenic • Trauma • Spinal cord injury • Diabetes mellitus Endocrine • Hypogonadism/testosterone defi ciency • Hyperprolactinemia • Hyper- & hypothyroidism • Obesity Psychiatric & Psychogenic • Depression© MIMS • Anxiety disorders • Relationship issues • Stress B3 © MIMS 2019 Erectile Dysfunction (4 of 11) 3 EVALUATION (CONT'D) Comorbidities & risk factors that contribute to erectile dysfunction should be identifi ed: (Cont'd) Psychiatric & Psychogenic (cont'd) • Performance anxiety • Loss of attraction Drugs • Antiandrogens (eg Finasteride) ERECTILE DYSFUNCTION • Antihypertensives (beta-blockers, Spironolactone, Methyldopa, thiazide diuretics) • Narcotics • Cimetidine • Antidepressants • Tranquillizers • Others Penile Disorders • Peyronie’s disease • Severe phimosis Others • Alcohol abuse • Obstructive sleep apnea • Pelvic & prostatic radiation therapy • Pelvic & prostate surgery [eg transuretheral resection of the prostate (TURP), radical prostatectomy] • Sedentary lifestyle 4 RISK STRATIFICATION BASED ON CARDIOVASCULAR RISK FACTORS Treatment of erectile dysfunction in patients w/ cardiovascular disease is associated w/ a small increase in the risk of myocardial infarction (MI) related to sexual activity independent of the method of treatment Cardiovascular risk levels: • High-risk - Should not receive therapy for sexual dysfunction until cardiac condition becomes stable - Unstable/refractory angina - Uncontrolled hypertension - Systolic blood pressure (SBP) >180 mmHg - Left ventricular dysfunction (LVD) or congestive heart failure (NYHA class IV) - Recent myocardial infarction or cerebrovascular accident (CVA) within the past 2 weeks - High-risk arrhythmias - Hypertrophic obstructive & other cardiomyopathies - Moderate-severe valvular disease • Intermediate-risk - Should be referred for further evaluation of cardiac status before receiving treatment - Recent myocardial infarction or cerebrovascular accident (ie within the last 2-6 weeks) - Left ventricular dysfunction or congestive heart failure (NYHA class III) - Asymptomatic but ≥3 risk factors for coronary artery disease (CAD) (excluding gender) - Moderate, stable angina - Murmur of unknown cause - Recurrent transient ischemic attacks (TIA) - Heart transplant • Low-risk - All 1st-line therapies may be considered - Asymptomatic coronary artery disease - Less than 3 risk factors for coronary artery disease (excluding gender) - Controlled hypertension - Mild, stable angina that has been evaluated &/or being treated - Post-successful coronary revascularization - Uncomplicated previous myocardial infarction - Mild valvular heart disease - Left ventricular© dysfunction or congestiveMIMS heart failure (NYHA class I or II) Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B4 © MIMS 2019 Erectile Dysfunction (5 of 11) A NON-PHARMACOLOGICAL THERAPY Goals of erapy • Identify & treat any curable causes of erectile dysfunction • Initiate lifestyle & risk factor modifi cations • Provide education & counseling to patients & their partners Patient & Partner Education • Some men may only need reassurance that decline in sexual function is due to aging, medication or chronic ERECTILE DYSFUNCTION illnesses & is not necessarily a sign of serious illness - ey may refuse treatment • Education & reassurance may help in preventing further erectile failure due to the above causes • Discuss w/ patient & partner (if possible) the important treatment options & their associated risks & benefi ts • Cultural, religious & economic factors should be taken into consideration • e choice of treatment should be decided together by physician, patient & partner Lifestyle Modifi cation • Modifying possible risk factors may be helpful - Resolving partner relationship issues - Smoking cessation - Reduce alcohol/drug abuse - Regular exercise & weight management Treat Psychosocial Factors • Confronting depression or substance abuse • Sexual education/correction of misinformation Discontinue Off ending Medications • Many common medications may aff ect male sexual function - Eg antidepressants, antipsychotics, anti-arrhythmics, many antihypertensives, anti-androgens & steroids Sexual Counseling & Education • Encompass sex therapy, psychosocial therapy & marital therapy • May be appropriate for patient &/or partner • May be used to address & correct relationship issues, stress factors (eg work, fi nances, family, etc) • Decreased sexual drive may be due to psychologic issues & individual may benefi t from sexual therapy • Use as adjunct to other erectile dysfunction therapy to address patient’s psychological reaction to their need for erectile dysfunction treatment • Sexual counseling & education may be preferred by patients/partners because it is noninvasive & has broad applicability Vacuum Constriction Device • Negative pressure is applied to the pendulous penis causing blood to be drawn into the penis • Blood is retained in penis by elastic band placed at the base • Highly eff ective in inducing erections regardless of erectile dysfunction etiology • Only devices w/ a vacuum limiter should be used • Preferred by patients who do not want to use pharmacological therapy or in whom medication is contraindicated • Contraindicated in patients w/ bleeding disorders or on anticoagulant therapy