Contemporary blue design template

Definition


“Inability of a man to maintain an
erection sufficient for satisfying
sexual activity”
http://oxforddictionaries.com/definition/english/erectile-dysfunction
History

2500 BC: Ancient Chinese philosophers believed that a
man’s yin and yang were out of balance by age 60, and
without enough life-giving yin, he was bound to run dry on
sexual energy. They used potions to treat as they still do
today

1600 BC: The Egyptians believed that impotence was the
result of a natural disorder or an evil spell. They had many
remedies to ward of the ED curse — including grinding up
baby crocodile hearts to rub on the penis.

1000 BC: The Mayans also used Lotus Flowers as the
Egyptians.
History

300 BC: Aphrodisiacs and the Goddess of Love - The word
"aphrodisiac" comes from Aphrodite, the Greek goddess of
love. In about 300 BC, Aristotle, the Greek philosopher,
extracted an aphrodisiac from the dried bodies of beetles
also known as Spanish flies. We now know it is too toxic and
ineffective to treat ED.

The Dark Ages: Blame It on the Devil? - In the 13th
century, the medieval theologian Thomas Aquinas believed
that demons were the most likely cause.

Men with impotence problems were urged to track down
the women who had bewitched their penises and persuade
them, with violence if necessary, to restore their erections.
History

1600-1900: From a Woman's Hand to the Hands of Science

During the 1600s, the general view on erectile dysfunction
was that if a woman's touch couldn’t cure a flaccid penis,
nothing else would. However, by the end of the century,
scientists had discovered that it was actually the bloodsupplying arteries that lead to an erection.

Researchers got to work, and by 1873 the first surgical
treatment for erectile dysfunction had arrived. An Italian
doctor successfully treated ED by blocking veins that
drained blood away from a penile erection.
History

Early 20th Century: Weird Science – In 1918, a Russian
doctor came up with the idea of transplanting monkey
testicle tissue into humans (seriously!!!!).

1960s: The Rise of the Penile Implant - The earliest penile
implants were based on the observation that many animals
had actual penile bones. But attempts to implant bone or
cartilage into the human penis failed because the grafts were
quickly absorbed.
History

1970s: Penises Get Pumped Up - In the 1970s, a Pentecostal
minister with a tye repair business on the side figured out
how to attach a tire pump to a cylinder, create negative
pressure, place the cylinder over his penis, and pump up an
erection.

1980s: Introducing Penis Injections - This medical advance
occurred accidentally. A French surgeon unintentionally
injected the drug papaverine, used to open up blood vessels,
into someone’s penis, and it caused an instant erection, the
beginnings of intra-cavernosal injection ED therapy.
“Blue Pill”

1990s - Present: The Little Blue Pill Is Born - In 1994,
another accident occurred. Researchers found that sildenafil,
a drug being studied to treat angina, also caused erections.
In 1998, the FDA approved Viagra to treat impotence, and it
was soon followed by Cialis and Levitra. And just five years
after oral ED drugs appeared, erectile dysfunction diagnoses
had increased by 250 percent.
Risk Factors

Lack of exercise

Obesity

Smoking

Hypercholesterolaemia

Hypertension

Metabolic syndrome

Diabetes mellitus
Drugs

Antihypertensives

Beta-blockers

Diuretics

Antidepressants: both tricyclics and selective serotonin reuptake inhibitors (SSRIs)

Antipsychotics: phenothiazines, risperidone

Hormonal agents: cyproterone acetate, luteinising hormone-releasing hormone
analogues

Anticonvulsants: phenytoin, carbamazepine

Antihistamines

Recreational drugs

H2 antagonists cimetidine and ranitidine
The Big Question???

It’s about your confidence, not only in asking the question
but taking a thorough history and how you approach this.
Taking a History

How long has this been going on?

Was it sudden or gradual onset?

Are you getting early morning erections?

Do you get good quality erections when you masturbate?

If you get an erection does it disappear when you go on to make
love?

Do you have an understanding partner?

BLOODS???

Older men ? Prostate EXAM but not really related to ED
Biochemistry of Erection
Pathophysiology of
Erection
Prescribing Policy-ED
•
•
•
•
•
•
The prescribing of drugs for ED on FP10 was formerly covered by Schedule 11 and has since been
enshrined in Part 3 para. 42(2) of the National Health Service (GMS Contracts) Regulations 2004.
This laid down clear criteria for prescribing, in that treatment on the NHS should only be made in
men who:
– Have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe
pelvic injury, single gene neurological disease, spina bifida or spinal cord injury.
– Are receiving dialysis for renal failure.
– Have had radical pelvic surgery, prostatectomy or kidney transplant.
– Were receiving Caverject, Erecnos, MUSE, Viagra or viridal for ED, at the expense of the NHS,
on 14 September 1998.
– Are suffering severe distress as a result of impotence – prescribed in specialist centres on
FP10HP and NOT by GPs on FP10
The policy of Mid Essex Clinical Commissioning Group (CCG) is that NOT more than FOUR doses
per month should be prescribed.
Pumps for erectile dysfunction can be prescribed on FP10 and should be endorsed ‘SLS’, they can
only be prescribed for patients falling into the first three categories listed above.
GPs should NOT prescribe PDE-5 inhibitors for penile rehabilitation since this does not meet ‘SLS’
criteria for prescribing on FP10s and should refer all patients back to the consultant
recommending treatment for ongoing management.
Guidance on the CCG website-http://www.midessexccg.nhs.uk/Your%20NHS/obstetricsgynaecology-and-urinary-tract-disorders.htm
12 month ED expenditure MECCG
BNF Name
Mediwatch UK ErectEase Vacuum Pump
Osbon ErecAid Classic Vacuum Pump
Osbon ErecAid Esteem Vacuum Pump
iMEDicare Select Maint Set Constrictor Ring
iMEDicare SomaCorrect Vacuum Pump
iMEDicare SomaCorrect Xtra Vacuum Pump
iMEDicare SomaErect Response II Vacuum Pump
iMEDicare SomaErect Response II XL Vacuum Pump
iMEDicare Ultimate (Surefit) Maint Set Constrictor Ring
iMEDicare Ultra Maint Set Constrictor Ring
Total Items Total Act Cost
1
£86.64
1
£96.41
1
£171.22
1
£26.78
1
£146.63
7 £1,156.34
17 £2,523.51
4
£593.44
22
£816.22
4
£156.93
59 £5,774.12
Which ED drug?
BNF Name
Alprostadil
Sildenafil (Erectile Dysfunction)
Tadalafil
Vardenafil
Total ItemsTotal Act Cost
488
£23,421.14
9,115
£247,789.07
5,642
£194,520.20
905
£23,629.20
16,150
£489,359.61
Tadalafil (Cialis) has been recently licensed for benign prostatic hypertrophy
but remains non-formulary for all indications and therefore should not be
prescribed.
Technology Appraisal Guidance No. 273 January 2013
NICE is unable to recommend the use in the NHS of tadalafil for the
treatment of symptoms associated with benign prostatic hyperplasia
because no evidence submission was received from the manufacturer of the
technology.
Annual cost of ED drugs
Annual cost of Sildenafil 100mg 4 per month is now £18.00 (Oct 2013)
Erectile Dysfunction-Prescribing Guidance
•
•
•
Prescribe generic Sildenafil first line since Viagra® is now off patent-June 2013.
Avoid branded prescribing. Savings on sildenafil £20,000 per month from Oct 13 as
now Cat M.
Prescribing of Tadalafil (including daily Cialis®) and Vardenafil (Levitra®) is nonformulary and not supported. Ensure that all patients prescribed on the NHS meet
‘SLS’ requirements and are not prescribed more than 4 tablets per month.
For Prescribing Incentive Scheme Upper threshold for generic sildenafil is 75%.
Treatments

PDE5 blockers

Pumps

Caverject

Psycho-sexual counselling +/- relationship counselling –
including sensate focus

A word or 2 re MUSE
Implants

Last resort as once erectile tissue removed if complications
no going back.

Bendy implants and pumps.

Main complications are infections and erosion

Not available on the NHS
Conclusion
Extra: The PSA Debate &
any other questions?