4/1/2019 How to have sex in a canoe: Oar maintenance and troubleshooting Francisco J. Garcia MD, FRCSC Clinical Assistant Professor, University of Saskatchewan Consultant in Urology, Specialist in Andrology and Sexual Medicine Follow: @drfjgarcia Email: [email protected] 1 Objectives: • Be familiar with the domains of male sexual dysfunction (MSD) • Be able to identify common disorders of each sexual domain • Be able to educate patients on their disorder/dysfunction • Be able to initiate 1st line therapies for common MSD diagnoses • Be familiar with erectile dysfunction as a cardiac marker • Be familiar with anatomical diseases of the penis • Be familiar with low testosterone diagnosis, risks and therapy 2 1 4/1/2019 Domains of sexual function • Desire • Orgasm • Ejaculation • Erectile function • Anatomy Image source: Google Images 3 Orgasmic dysfunction • Delayed orgasm • Painful orgasm • Hypo‐orgasmia • Anorgasmia • Persistent Genital Arousal Disorder 4 2 4/1/2019 Ejaculatory Dysfunction • Premature ejaculation • Delayed Ejaculation • Painful Ejaculation • Retrograde Ejaculation • Anejaculation Image source: Google Images 5 Erectile Dysfunction • Arteriogenic • Anatomic • Neurogenic • Endocrine • Psychologic Image source: testshock.com 6 3 4/1/2019 Anatomic • Peyronie’s Disease • Congenital Penile curvature • Penile fractures • Iatrogenic/self‐inflicted 7 Desire • TDS/ADAM/Hypogonadism • Psychological • Situational • Iatrogenic (medication/treatment related) • Metabolic disease (Cardiac, Metabolic syndrome, diabetes, thyroid disease, etc) Image source: Google Images 8 4 4/1/2019 Erectile dysfunction • Lessons to learn: • ED is not luxury diagnosis • Asking about it is not only relevant but crucial to your practice • Every erectile problem is ultimately fixable. • “I’ve yet to meet a penis I can’t make erect.” Created by: Dr. F. Garcia 9 How to save a life as a penis doctor... • Penis as the barometer of cardiac health • Dorsal penile arteries – lumen 1‐2 mm • Coronary arteries – lumen 2‐4 mm • A man’s penis and its function is important and changes are often noticed – but ignored. • Am I just trying to justify sexual medicine? Created by: Dr. F. Garcia 10 5 4/1/2019 Can sexual medicine save lives? • 133 T2DM men with confirmed silent CAD on angio and 127 T2DM men with negative stress EKG, 48 hr ambulatory ECG and stress echo • IIEF‐5 questionnaires to both groups • More ED in those with silent CAD then in those without (33% vs 5%) • ED most potent predictor of silent CAD (vs HDL, apolipoprotein a, LDL, smoking, and microalbuminuria): OR 14.8; 95% CI (3.8‐56.9) • Ok – so maybe its important to diabetics.... Created by: Dr. F. Garcia 11 ED as the “canary in the coal mine” • Erectile dysfunction: • Is associated with angiographic CAD in 19% of those presenting with presumed vascular ED • European Urology 48 (2005) 996–1003 • Decreased rigidity is predictive of 6 year myocardial event in Danish population (OR 1.2 moderate, 2.6 severe) • International Journal of Impotence Research (2008) 20, 92–99 • US study (n=10,000) showed that ED diagnosis has an OR 1.45 of CVEs at 10 years, and new ED diagnosis has an OR of 1.25 of CVE • JAMA, December 21, 2005—Vol 294, No. 23 • Has a 65% relative risk increase of CVE and stroke at 10 years • European Urology 48 (2005) 512–518 • Severity predicts CAD severity – OR 2.2 for severe ED • J Sex Med 2009;6:3425–3432 • Younger age at diagnosis increases OR of events: • 20‐29: OR 7.6, 30‐39: OR 7.4, 40‐49: OR 3.4, 50‐59: OR 2.2 • J Sex Med 2010;7:192–202 Created by: Dr. F. Garcia 12 6 4/1/2019 ED and CVD Meta‐analysis • Framingham Risk Score on ED patients: • Moderate and severe ED have 65% and 43% increased risk of CVD and stroke respectively • ED alone doesn’t outcompete FRS, but may be as effective in identifying those at risk • Duplex ultrasound of the penis: If patient has abnormal EKG and PSV < 35, 50% sens, 100% spec, 100% PPV, and 60% NPV to identify ischemic heart disease. Created by: Dr. F. Garcia 13 • Calcium scores: • Negatively correlate with SHIM/IIEF‐5 scores • ED patients had increased risk of highest quartile of calcium and volume compared to controls (OR 3.68) • Biomarkers: • ED correlated with hs‐CRP, phopholipase A2, HgbA1c and microalbuminuria Created by: Dr. F. Garcia 14 7 4/1/2019 Created by: Dr. F. Garcia 15 Can an ED diagnosis be useful in primary care? • Symptoms of ED appear 2‐3 years before CAD symptoms and 2‐5 years before CAD events • Opportunity for intervention?!? Created by: Dr. F. Garcia 16 8 4/1/2019 Fine...perhaps an important signal, but why bother treating it?• Because sex is fun... • Most relationships are forged with a component of sexuality • Why is the development of an asexual relationship considered acceptable as the relationship matures? • SF‐36 • SF‐36 of erectile dysfunction: 43.6 +/‐ 15 • SF‐36 of treated ED: 74.4 +/‐ 13 Created by: Dr. F. Garcia 17 Not just important to the men... • Worse QoL in the partners of those with ED Created by: Dr. F. Garcia 18 9 4/1/2019 How do we investigate it? • History and Physical Examination • Gradual/rapid onset, situtational/generalized, pelvic surgery/rads/trauma, voiding dysfunction, meds, diseases, degree of bother, failed txs, hypogonadal symptoms, etc. • Blood work • Cardiac profile • Screen for diabetes, cholesterol, etc • Hormone profile x 2 • Imaging • Duplex ultrasound of the penis. ** • Testing • “test dosing” Created by: Dr. F. Garcia 19 How to treat it? * Insured service in all provinces except in SK Created by: Dr. F. Garcia 20 10 4/1/2019 Abridged treatments • If abnormal T, symptomatic and appropriate candidate, strongly consider T replacement • PDE5‐Is • On demand full dose prn • Can attempt double dosing • Attempt a month of daily dosing before declaring PDE5‐I resistant • If T is low and PDE5‐I resistant, correct T and rechallenge • Unless a specific reason, move to intracavernosal injection therapy. Created by: Dr. F. Garcia 21 Intracavernosal injection therapy • Multiple compounded therapies available. • Trimix (prostaglandin e1, papaverine, phentolamine) • Standard • Plus • Forte • Ultra • Bimix (Papaverine and phentolamine) • Standard • Plus • Quadmix (Trimix + atropine) • Quintmix (Quadmix + forskolin) Created by: Dr. F. Garcia 22 11 4/1/2019 ICI troubleshooting • Penile pain/Throbbing • Usually due to alprostadil/prostaglandin dosing. Reduce or remove from the mixture • Penile curvature at injection site • Patient not varying the location of injection. Avoid that location and should self resolve • Priapism • Present to emergency department if persists for more than 4 hours. Often responds quickly to intracavernosal phenylephrine. • Bleeding • Patient likely injured a superficial vessel. Visibly confirm no vessels before insertion of needle • Urethral bleeding • Missed the cavernosal body and injected the urethra/spongiosum • Unable to visualize penis for injection • Adipositypractice with a mirror (this takes lots of practice but is doable) or partner injection • Visual defect/disabilitypartner injection or consider penile implant 23 Technique • Draw up correct dose (takes some teaching to do depending on solution) • Lateral injection into corporal cavernosal body • BURY the needle (1/2” 30 g) • Challenges? • Obesity • Needle phobias Image source: Menshealthinstitute.ca Created by: Dr. F. Garcia 24 12 4/1/2019 Impact of ED correction outside the bedroom • Improvements in confidence and self esteem • Althof, S. E. et al. J. Gen. Intern. Med. 21, 1069–74 (2006). • Increases in non‐sexual touching and intimacy • SMSNA 2014 – unpublished data Created by: Dr. F. Garcia 25 Peyronie’s Disease • 3‐9% of the male population • Benign, incurable disease • Can prevent intromission during sexual encounters, and associated with ED • Variability in curve number, direction, severity and arc contribute to the “embarrassment” barrier to allow study • Pts often complain of length loss and changes in rigidity Created by: Dr. F. Garcia 26 13 4/1/2019 The many shapes... Created by: Dr. F. Garcia 27 Natural Hx • Acute phase (6‐24 mo) • 15 resolve/45 stabilize/40 worsen • Chronic phase • Associated conditions • Tympanosclerosis • Dupuytren’s • Ledderhosen’s • Paget’s • Associated with hypogonadism (30% by TT, 75% by FT) • Role of T as an inflammatory mediator • Importance of T in maintenance of viscoelastic properties of the tunica Created by: Dr. F. Garcia J Sex Med 2009;6:1729–1735 28 14 4/1/2019 My assessment of PD • Hx • Hx of trauma with intercourse • Onset of pain and curvature • Does the pt have photos • Psychosexual hx • Hearing loss/plantar contracture/dupuytren’s • P/E • Palpate the plaque • Examine for contractures (hand/foot) • Ix • Duplex U/S OR Standard U/S • Hormone profile, CBC, lytes, BUN, Cr Created by: Dr. F. Garcia 29 Oral management • Oral therapies • Potaba • Vitamin E • L‐carnitine • PTX • Colchicine* • Some evidence when acute • Tamoxifen • PDE5‐Is ** • U/S evidence of scar resolution and curve improvement Created by: Dr. F. Garcia 30 15 4/1/2019 Traction Therapy • “Stretch” therapy has a long successful history with joint contractures • Difficulty in stretching flaccid penile plaque • Mechanical forces on neighbouring fibroblasts promote scar remodelling • Oldest therapy • Allows patient participation Created by: Dr. F. Garcia 31 Intralesional treatments • Verapamil • 10 mg in 10 cc q 2wk x 6‐12 txs • Interferon • Collagenase (Xiaflex)* FDA approval • Others • Steroids...etc. Created by: Dr. F. Garcia 32 16 4/1/2019 My “aggressive conservative” approach • Parallel trimodal therapy • Daily Cialis (5 mg or 2.5 mg) • Improved erectionsplaque stretching • Antifibrotic effect • Intralesional therapy • Mechanical disruption of scar • Scar remodelling • Traction therapy • Mechanical stretch of scar (open up disrupted plaques) • Fibroblast remodelling with mechanical transduction • 1‐2cm length gain with diligent use • Patient empowerment • Results? • Approx 40‐60% of men have response enough to avoid surgical intervention • Average curve correction of 15‐45 degrees. Created by: Dr.