Mr John TuckeyUrologist

Auckland Hospital

Auckland Spinal Unit

Ascot Central

8:30 - 9:25 WS #191: What to do When Viagra Does Not Work

9:35 - 10:30 WS #203: What to do When Viagra Does Not Work

(Repeated)

Erectile Restoration And What To Do When Viagra Does Not Work

JOHN TUCKEY

AUCKLAND

What we will cover today• how common and often is it treated in New Zealand?

• what to focus on in the history and examination

• discuss the role of behavioural modification

• review the options if Viagra does not work

• hear from Shane Way about his journey with ED

• time for questions at the end

Definition of Erectile Dysfunction

inability to attain or maintain an erection adequate for sexual intimacy

How common is it?

New Zealand Male Sexual Massachusetts Male Aging StudyFunction Study 2017 1980’s

38% of men in their 50’s 50% at 50 years

60% of men in their 60’s 60% at 60 years

How common is it?New Zealand Male Sexual Function Study

of the 42% of men who reported ED

50% have moderate to severe ED

16% medically diagnosed

23% on treatment 17% PDE52% natural remedies1% injectables1% vacuum pump, 1% testosterone

New Zealand Data• 295,000 men have ED 68,000 mild to moderate

39,000 moderate

25,000 severe

• For some men the decline in sexual activity significantly impacts their QOL

Why Should We Be Proactive?• erectile dysfunction has a significant impact on a man’s health

- self esteem

- mood, can cause depression, suicidal ideation

- relationship with their sexual partner

- significant negative effect in their QOL

When is the Best Time to Treat it?

• NOW!

• improve their QOL early

• use it or lose it

• atrophy causes loss of 2-12 cm in length every 14 months!

History• what is the problem?

• always ask and explore what their issue is

• some men use the term ED to describe - low libido

- early or late ejaculation

- Peyronie’s disease

• they may have more than one issue

History• any stressors in his relationship, at home or at work?

• how is the issue affecting his relationship with his partner?

• how is his partner feeling about it?

• how is it affecting him personally? self esteem

life outlook

depression

• has he tried anything?

History• Social history

smoking - dose related association between smoking and ED

alcohol - positive or negative effects

- smaller amounts reduce anxiety, improve erections and libido

- larger amounts produce CNS depression, reduced libido and transient ED

- chronic abuse lowers T, increased E2, neuropathy

History• Social history - does he exercise?

• Medications - any linked to the start of his ED?

- sometimes reversible

- what has he tried? supplements?

• PMHx - surgery, diabetes, CVD, metabolic syndrome

ED and Cardiovascular Disease• have the same risk factors - smoking, diabetes, dyslipidaemia

• endothelial dysfunction underpins both , linked through Nitric Oxide

• 15-20% of men with ED have asymptomatic CVD

• men who develop ED have a 50% higher chance of developing CVD

• severity of ED correlates to the severity of CVD

ED and Cardiovascular Disease• Why does ED develop first in some men?

penile arteries coronary arteries

1-2 mm 3-4 mm

• men with ED and risk factors should be evaluated for silent CVD

Examination• hands

• secondary sexual characteristics

• penis - nodularity

- waist or atrophy

Investigation• testosterone -8 am

- if low therapy can restore erectile function

• cardiovascular - lipids

- glucose

- BP

- if abnormal and no known CVD suggest a cardiology evaluation

Treatment• what do you think the problem is?

- stressors at work/home?

- hypogonadism?

- medication?

- ‘vascular’ factors

- ‘neural’ factors

Behavioural Modification• should be part of any assessment

• the challenge is any benefit is not immediate

• evidence exists that diet and exercise can improve erections

• obesity is a significant independent risk factor for ED

- via pro-inflammatory markers or lowering testosterone

Behavioural Modification• obesity and the metabolic syndrome associated with sexual problems

• Mediterranean diet and caloric restriction can improve ED

- improve sexual performance by 10 - 20%

- diet plus exercise with a dietician vsgeneral advice increases the chance of normalising erectile function from 38% to 56%

Behavioural Modification

• multiple studies show higher levels of exercise are associated with lower levels of chronic disease including CVD

• inverse relationship between physical activity and ED, intensity and duration

• increasing physical activity and caloric restriction can improve ED

- nutritionist + exercise resulted in 20% improvement in ED

- other studies 14 -86% improvement

- probably 6 months +, 40 mins 4 X per week

Psychosexual Counselling

• relationship issues

• stress related

• particularly effective if partner attends – 50-70% resolution rate

• usually 5 + sessions

• do you have an appropriate therapist in your area?

Traditional Treatments

Egypt 1600 BC

PDE-5 revolution

PDE5 Inhibitors• effective in up to 80%

• block the “off” switch - so erections stronger and last longer

• require intact nerves and stimulation

• take 30 - 60 mins before activity

• contraindications nitrates systemic dilatation/hypotension

PDE5 Inhibitors

• well tolerated

• side effects - pounding headache commonest

- indigestion

• funding - insurance no but ACC fund 1 -2 tablets/week

What if it doesn’t work?• discussing how they use it – this can salvage around 30%

• what doses have they tried?

• are they waiting 30 +mins?

• are they using stimulation?

• are they taking Viagra with fatty food ?

What if it doesn’t work?

• data suggests the chance of success increases with time up to 6 tabs

• try a different medication

• less effective in those wit neural injury – post-surgery or diabetics

Other Delivery Systems• not available in pharmacies

• intranasal

• sublingual

• sourcing overseas - cheap

- but what is in them?

Herbal Ignite

• Horny Goat Weed - Epimedium

- active agent Icariin

- PDE5-like effects and may increase testosterone

• Tribulus Terrestis - fruit producing Mediterranean plant

- limited evidence for use

• Avena Sativa - oats

Supplements• Ginseng - promotion of nitric oxide

• Arginine - precursor of nitric oxide

• Ginko Biloba - purported to increase circulation

- no evidence for use

Low-Intensity Shock Wave Lithotripsy• investigational in ED but verified in musculoskeletal disorders

• mechanism of action unknown ? angiogenesis

? tissue regeneration

? stem cells

• change in IIEF is only 2-3 /25 ? clinical significance

• randomised studies required

Vacuum Pump

Vacuum Pump

• create a vacuum

• produce a venous erection

• can be tricky to use

• shave around the penis for a good seal

• hinge effect

Vacuum Pump

• mostly used by those in a stable relationship

• around $600

• only a small number continue to use it

Intracavernosal Injections

Intracavernosal Injections• stimulates increased blood flow into the corpora

• high oxygen content blood nourishes the corporal tissues

• more effective than PDE5 inhibitor or vacuum devices

• particularly useful in penile rehabilitation after surgery

Intracavernosal Injections

• different agents exist - Prostaglandin E1

- Papaverine

- Regitine

- combinations – Bimix, Trimix

Intracavernosal Injections

• easy to learn

• teach patient to self inject

• 10 or 2 o’clock

• start with a low dose 5mcg Alprostadil

• erection produced in 5 minutes

• titrate the dose until the desired effect is achieved

Intracavernosal Injections

• auto injectors can be helpful for the anxious

• side effects - pain

- scarring

- using too high doses / double dosing

- priapism - cold shower, pseudoephedrine

- drainage

Intracavernosal Injections

• commercial preparation Caverject more expensive

• two strengths 10 or 20 mcg Alprostadil

• you can make up syringes or vials

• can add in Papaverine and Regitine if required

• best for penile rehab post surgery

Intracavernosal Injections

• drawbacks - spoil the spontaneity

- inconsistency of effect

- do not always work

i.e venous leak

- need to keep in the fridge, last 3 months

- have to take them with you

Penile Prostheses

Penile Prostheses

• solves the issues with other treatments

efficacy

spontaneity

Advantages• produces a very rigid natural-looking erection

• works the same every time

- reduces anxiety

- increases confidence

- restores self esteem

• you always have it with you

• takes seconds to inflate, reintroduces spontaneity

Types of Prosthesesmalleable rod

Types of Prostheses2 piece inflatable (hydraulic)

Ambicor (AMS)

Types of Prostheses3 piece inflatable (hydraulic)

AMS and Coloplast

Erection Satisfaction

excellent/satisfactory total

patient 48%/50% 98%

partner 17%/66% 83%

Montorsi et al

Sexual Activity Satisfaction

excellent/satisfactory total

patient 70%/22% 92%

partner 28%/68% 96%Montorsi et al

Satisfaction

Other series

satisfaction

partner 75-91%

patient 79-96%

Who is suitable?

• men who fail or dislike other treatments - diabetic

- pelvic surgery

• Peyronie’s disease who fail injections

• Erectile dysfunction after priapism

• try simple options first

• funded by insurers

Pre-operative Counseling• very important to set expectations

• penile length unchanged – man’s memory!

• glans does not engorge

• complications uncommon - infection

- erosion

Post-operative• 1 night hospital stay

• 2 week recovery time

• inflate at clinic 4 - 6 weeks later

Patient PresentationHow long have you had ED for?

How did it impact your life?

What other treatments did you try?

How did you find out about implant treatment?

Were you nervous about getting an implant?

How was your recovery?

How easy is it to use?

How has it changed your life?

What does your wife think of the implant?

What suggestions do you have for other men with ED?

Summary• ED is common in New Zealand and largely untreated

• ED is at least a marker for CVD

• behavioural modification can be effective but takes time and effort

• a range of options exist if Viagra does not work

• penile prostheses are very effective

Questions

3-Piece implant

Major Advances have been with Complications

ComplicationsInfection

- usually within 6 months

- body reaction -> capsule

- relatively avascular, protected cavity

ComplicationsInfection

- Staphylococcus epidermidis

- biofilm

- rate 1.6 - 4.8%

- can this rate be reduced?

Infection

In vitro studies with antibiotic treated device material and susceptible strains of S. epidermidisand S. aureus shows a microbial “zone of inhibition” around the test material.

Test auger plate inoculated with S.aureus,

incubated at 37 Celsius shown at one day in vitro.

InfectionInhibiZone™

infection rate

pre-inhibizone 1.59%

post-inhibizone 0.28%

Carson J Urol 2004

Inhibizone - Proprietary combination of rifampin and minocycline

•Low dose of drugs act

directly on & around IPP

•Drug elution strongest when

risk of infection greatest –

immediately after implantation

Mentor Titan prosthesis hydrophilic coating absorbs antibiotics

infection rate 1.06% vs 2.07% for uncoated

Colonisation common148 patients undergoing revision surgery

- non-infectious - swab of fluid around pump or biofilm, - culture capsule

- 66% of swabs positive - 43% cultures positive - 25% culture positive after washout

Henry et al J Urol 2008

Infection Revision surgery

Washouts reduced the infection rate from 10%-3% possibly due to

- the removal of biofilm - reduction in bacterial load - reactivation of bacteria

- Inhibizone less effective

Wilson et al J Urol 2007

ComplicationsMechanical failure

Reliability good

Survival

2 piece 93% 3-5 yrs

3 piece 86-96% 5 yrsMentor 93-96% 5 yrs

Complications Mechanical failure

- advances

Mentor pump reinforcement65.3% ->88.6%

AMS CX Paralyne coating 200188.4%->97.9%

Complications Mechanical

- advances

AMS CX Tactile pump Momentary squeezeAutoinflation lockout

ComplicationsMechanical failure

- usually after 4 years

- fluid leakage, autoinflation

- lower with newer models

Viagra

Complications

Erosion

- remove prosthesis

- 3-8%

Conclusions

perfect treatment does not exist

important part of armamentarium

expectations important

satisfaction rates high

Conclusions

major advances with- reduction in

infections- mechanical reliability

- post-operative care

Patient SatisfactionMontorsi

- 59 month follow-up

- AMS 700

- 92% using prosthesis

- 1.7 times per week

Euro Urol 2000;37:50-55