Erectile dysfunction (Treatment)

Treatment of Erectile Dysfunction: 

• Correct reversible causes 
• Alter lifestyle
• Stop smoking 
• Change medications
• Psychosexual therapy 
• Sex education 
• Psychosexual counselling
• Instruction on improving partner communication skills 
• Cognitive therapy
• Behavioural therapy 
• Pharmacotherapy 
• Drug therapy 
• PDE5 Inhibitors 
  
• sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra)
• Enhance cavernosal smooth muscle relaxation
• Block the breakdown of cGMP by phosphodiesterase
• Success 80% 
• Early use after RP is recommneded 
  
• Contraindications:
• Nitrates 
• Recent myocardial infarction
• Recent stroke
• Hypotension
• Unstable angina 
• NAION (Non arteritic anterior ischaemia optic nerve neuropathy) 
• Cautions
• Intermediate/high risk cardiovascular disease (needs cardiac review) 
• Alpha blockers use
• Groups with predisposition to priapism 
• Dopamine receptor agonist

• Apomorphine: sublingually, acts centrally on dopaminergic receptors in the paraventricular nucleus of the hypothalamus to enhance and coordinate the effect of sexual sitmuli. 
• 
  
• Intraurethral therapy http://www.muserx.com/hcp/local-vasodilation-therapy-for-ed/mechanism-of-action.aspx
• Synthetic prostaglandin E1 (PGE1) pellet (Alprostadil) intra urethrally
• PGE1 increases cAMP within the corporal smooth muscle, resulting in muscle relaxation. 
• SEs: Penile and urethral pain, priapism, local reactions. 
• Intracavernosal injection therapy
• Alprostadil (Caverjet ™) 
• papaverine (PDE inhibitor) 
• In combination with phentolamine (alpha antagonist) or PGE1
• Contraindications:
• Sickle cell disease 
• High risk candidates for priapism 
• Vaccuum erection device 
• When pharmacotherapies have failed. 
• Three components: 
• Vaccum chamber 
• Pump 
• Constriction band 
• Penis is placed in chamber, 
• Vaccum created increases blood flow to corpora cavernosa, 
• Constriction band is placed on the base of the penis to maintain rigidity.
• Contraindication: 
• Anticoagulation therapy  
• Side effects 
• Penile coldness
• Bruising
• Microvascular arterial bypass and venous ligation srugery
• Increase arterial inflow and decrease venous outflow
• Rarely used now. 
• Penile prosthesis 
• Semi rigid or Malleable 
• Inflatable (2 chamber, 3 chamber) 
• Indications 
• Other therapies failed 
• Peyronie’s disease
• Trauma
• penile fibrosis (i.e. secondary to priapism) 
• High satisfaction rates (90%) 
• SEs: 
• Infection 
• Erosion
• Mechanical failure 
• Penile shortening 
• Glans may not fully engorge 
• Testosterone replacement therapy 
• Indications 
• Hypogonadism 
• Oral
• Buccal
• Intramuscular
• Pellet 
• Transdermal patch
• Gel forms 
• PSA, Hb, LFT, before and after starting treatment 
• 
  

Erectile Dysfunction (History, Examination, Investigations)

Definition

consistent or recurrent inability to attain and/ or maintain a penile erection sufficient for sexual intercourse

Epidemiology

• 52 % of men aged 40-70 y (17% mild, 25% moderate, 10% severe) 
• Increases with age (40% of men in their 80’s)

Aetiology 

• Psychogenic causes
• Organic causes 

History 

• Sexual 
• Onset 
• Duration
• Erections (nocturnal, early morning, spontaneous)
• Ability to maintain erections 
• Loss of libido 
• Relationship issues (Frequency of intercourse, sexual desire)
• Questionnaire 
• IIEF 5
• Medical/ Surgical 
• Diabetes 
• Cardiovascular disease (Intermediate/high risk needs treatment before treating ED) 
• hypertension 
• Peripheral vascular disease 
• Endocrine disorders 
• Neurological disorders 
• Pelvic and penile surgery 
• Radiotherapy 
• Trauma 
• Psychosocial 
• Social stresses 
• Anxiety
• Depression
• Coping problems 
• Patient expectations 
• Relationship details 
• Drugs 
• Current medications 
• ED treatments already tried 
• Social 
• Smoking 
• Alcohol consumption

Examination 

• Full physical examination
• Cardiovascular 
• Abdomen
• Neurological 
• BP
• DRE
• Secondary sexual characteristics
• External genitalia (phimosis, penile deformities (peyronie’s plaques))
• Testicles (presence, size, location) 
• The bulbocavernosus reflex (integrity of S2-4) (glans squeeze —> anal sphincter contraction) 

Investigations 

• Blood tests 
• Fasting glucose 
• Serum (free) testosterone (8-11 am) 
• Fasting lipid profile 
• SHBG; U&E; LH/FSH; prolactin; PSA; Thyroid function test (selective cases) 
• Nocturnal penile tumescence and rigidity testing 
• Rigiscan device 
• number, duration, rigidity of nocturnal erections 
• useful for diagnosing psychogenic ED 
• Penile colour doppler Uss: 
• Arterial peak systolic and end diastolic velocities pre and post PGE1 injection
• Cavernosography:
• Measurement of penile blood flow after intracavernosal injection of contrast and artificial erection (to identify venous leaks) 
• Penile arteriography 
• Pudendal arteriography before and after erection to identify those needing arterial bypass surgery
• MRI
• Assess penile fibrosis and severe cases of Peyronie’s disease 

Surgery for stress incontinence: Male tapes

Male tapes


Many tapes are available in the market. Probably the most common are

• AdVance male sling (AMS)
• Mild to moderate SUI (3-4 pads per day)
• Success rates at 1y are 60-80%
• InVance male sling (AMS)
• Success rates 70-80% at 3-4y 

Artificial urinary sphincter 

• Inflatable cuff
• Pressure regulating baloon
• Balloon pressure  61-70 mmHg (bulbar urethral placement)
• Balloon pressure 71-80 mm Hg (bladder neck placement)
• Activating pump
• Indications: 
• Moderate to severe SUI 
• Normal bladder capacity and compliance 
• In men after: RP, Rx, pelvic fracture, complicated urethral reconstruction 
• In women: failure of other treatments for incontinence
• In both sexes for neuropathic sphincter weakness (e.g. SCI, spina bifida) 
• Contraindications:
• Bladder neck stenosis
• Poor manual dexterity or cognition 
• Active infection
• If OAB and ISD treat OAB first
• Success: long term is 70-90% 
• Revision rates: 20-30% 
• Complications 
• Urethral atrophy (10%)
• Mechanical failure 
• Urethral erosion (5%)
• Infection (1-5%)
• Bladder overactivity or reduced compliance 
• 
  

Surgery for stress incontinence: suburethral tapes and slings

Types of sling

• Synthetic tapes 
• monofilamentous polypropylene mesh
• Retropubic tape (TVT) 
• Transobturator tape (TOT) 
• Autologous 
• Rectus fascia, fasica lata, vaginal wall 
• Non-autologous 
• Fascia lata from cadaveric tissue

Retropubic tapes (TVT): 

• Midline anterior vaginal incision over the mid-urethra 
• Trocars inserted either side of the urethra and perforate through the endopelvic fascia into the lower abdominal wall in the midline, just above the pubic bone
• Success rates 90% at 1 y 80% at 5 y 
• TVT vs colposuspension 
• Ward Hilton studies, similar efficacy at 5y. 
• TVT have lower OAB symptoms and prolapse (1.8% vs 7.5%) 

Transobturator tapes (TOT, TVTO)  

• Midline anterior vaginal incision over the mid-urethra 
• Two small incisions lateral to labia majora at level of clitoris 
• Trocar passed through skin incision, downwards though obturator foramen, exiting alongside urethra on each side (outside to inside) 
• In TVTO, trocar passes from (inside to outside) 
• TOT vs TVT: 
• Similar subjective cure rates at 1 y
• TVT better objective cure rates (88% vs 84%) 
• TOT less voiding dysfunction, blood loss, bladder perforation, shorter operating time
• TOT higher vaginal injuries/erosion and pain in the groin/thigh 
• TVTO vs TVT:
• Similar objective cure rates 
• Increased risk of leg pain

Mini tapes 

• Self retaining, inserted via a single vaginal incision 
• short-term success 80-90% 
• results may not be sustained over time 

General complications of tapes 

• Voiding dysfunction (retention, de novo bladder overactivity)
• Vaginal, urethra, and bladder perforation or erosions
• Pain (groin/thigh with TO route) 
• Damage to bowel or blood vessels (rare) 

Pubovaginal (autologous) slings 

• Not commonly used as a first line surgical procedures for SUI
• Commonly a segment of rectus fascia (10-20 cm) is harvested and sutured placed on both ends  
• Sling placed under mid urethra though endopelvic fascia 
• Suture ends tied 
• Autologous slings vs colposuspension 
• Autologous slings have better outcome 
• Autologous slings have higher complications (UTI, Voiding dysfunction, urge incontinence) 

Pubovaginal (autologous) slings

Surgery for stress incontinence (Injection therapy, Retropubic suspension)

1- Injection therapy 

Injection of bulking material into bladder neck and periurethral muscles 


Indication: 

Female stress incontinence secondary to ISD with normal bladder function 
There is evidence of benefit in urethral hypermobility


Contraindications 

• UTI
• Untreated OAB
• Bladder neck stenosis

Success rates (50-80%). Repeat treatments are often required. Therefore bulking agents are not commonly used as a first-line intervention. 

Complications: 

• Temporary retention (2-15%)
• De novo UI (6-12%) 
• UTI (5%) 
• Haematuria (5%)
• Distant migration of particles (granuloma formation) 

2- Retropubic suspension


Indication

• Urethral hypermobility 
• Lower chance of benefit in patients with significant ISD. 

Types of Surgery

• Burch colposuspension 
• Vagino-obturator shelf/ paravaginal repair 
• Marshall-Marchetti-Krantz procedure (MMK)

Burch colposuspension

• Most widely used technique
• Vaginal wall is elevated and attached to lateral pelvic wall
• It is an option for patients with concurrent SUI and anterior vaginal wall prolapse. 
• Approximating the paravignal fascia to the iliopectineal ligament of Cooper’s 
• Success rates (90%) at 1y and 970%) at 5 y. 
• Complications 
• Posterior compartment prolpase (10-25%) 
• De novo urgency incontinence (15%) 
• Voiding dysfunction (10%)

                                      “Burch Colposuspension” 

Vagino-Obturator shelf/paravaginal repair 

• In some cases a cystocele develops because the front vaginal wall tears away from its lateral attachment to the pelvic sidewalls, resulting in a paravaginal defect. When this happens, a simple anterior repair is not appropriate, as it won't correct the problem
• Variant of the Burch procedure 
• Sutures from the paravaginal fascia are passed through the obturator fascia to attach to the arcus tendoneus fascia
• The aim is to dispense the tension on the paravesical tissues laterally to reduce the risk of prolapse. 
• Success rate 85%

Marshall-Marchetti-Krantz (MMK) Procedure 

• Sutures are placed on either side of the urethra at the bladder neck level and tied to the hyaline cartilage of the pubic sympysis.
• Short term succes 90% (declines over time)
• Complications: 3% risk of osteitis pubis. (analgesia, bed rest, steroids) 

Stress urinary incontinence

Stress Urinary Incontinence (SUI)

• 50% OF UI in women
• Intrinsic loss of urethral strength and/or
• Urethral hypermobility

Risk factors for female SUI 

• Childbirth
• Ageing
• Oestrogen withdrawal
• Previous pelvic surgery
• Obesity 

Risk factors for male SUI

• EUS damage (pelvic *, RP, Pelvic surgery, Rx) 

Other risk factors 

• Neurological disorders (SCI, MS, Spina bifida) 

Investigation of SUI 

• Women

• Stress test (cough)
• Pad test (no and weight of pads)
• Pelvic exam 
• POP
• Elevation of an existing anterior wall prolapse will unmask any occult sphincter incompetence
• Oestrogen status 
• Q-tip test 
• Lithotomy position 
• Bladder comfortably full 
• Well lubricated sterile cotton-tipped applicator inserted into bladder
• Applicator withdrawn to point of resistance (bladder neck) 
• Resting angle from horizontal recorded 
• Patient asked to strain and the degree of rotation is assessed 
• > 30 degree resting or straining angle from the horizontal defines hypermobility. 
• Urethral pressure profile 
• Urodynamics recommended before surgery for SUI if 
• Suspicion of DO
• Previous surgery for SUI or anterior compartment prolapse 
• Voiding dysfunction 

• Men

• Abdominal exam (palpable bladder) 
• External genitalia exam (penile abnormalities) 
• DRE 
• Flow Rate and PVR 
• Upper tract imaging if BOO 

Treatment of SUI

Conservative treatment 

• PFMT
• Eight contractions, three times per day
• Improves symptoms in 30% of women with mild SUI
• Lifestyle modification
• Weight loss 
• Stop smoking 
• Avoid constipation
• Modify fluid intake 
• Biofeedback
• Info on strength of PF contraction is presented as visual, auditory or tactile signal. 
• Medication
• Duloxetine: inhibits reuptake of both serotonin and noradrenaline increases sphincteric muscle activity during bladder filling. 
• Extracorporal magnetic innervation
• pulsed magnetic field to stimulate the nerves of the sphincter and pelvic floor 
• High frequency electrical stimulation 
• No proven benefit in SUI

Surgical treatment 

• Urethral bulking agents 
• Retropubic suspension 
• Suburethral slings 
• Artificial urinary sphincters 

Evaluation of urinary incontinence

History 

It’s very important to ask about the following in the history 

1. Type of incontinence (SUI, UUI, MUI)
2. LUTS (storage or voiding) 
3. Triggers (cough, sneezing, exercise, position, urgency) 
4. Frequency of incontinence episodes 
5. Severity of incontinence (usually assessed with no of pads)
6. Degree of bother 
7. Bowel function
8. Sexual dysfunction 
9. POP in women
10. Validated questionnaire (ICIQ-UI short form)
11. RED FLAG symptoms
    
    (PAIN, HAEMATURIA, RECURRENT UTI, VOIDING SYMPTOMS, HX OF PELVIC SURGERY OR RADIOTHERAPY) 
12. Risk factors: 

• Abdominal/pelvic surgery (RED FLAG)
• Rx (RED FLAG) 
• Neurological disorders
• Obsteteric and gynaecology history
• Medications (alpha blockers/agonists, diuretics, colchicine, caffeine, sedatives, antidepressants, antipsychotics, and antihistamines)

Physical examination: 

Women

• Pelvic examination (Supine, Standing, LL position w Sim’s speculum)
• Ask to cough and inspect for 
• Anterior and posterior vaginal wall prolapse
• Uterine or vaginal vault descent
• Urinary leakage (stress test)
• Internal pelvic examination to assess 
• Strenght of pelvic floor muscle 
• Bladder neck mobility
• Inspect vulva for oestrogen deficiency
• Calculate BMI

Both sexes 

• Examine abdomen (palpable bladder)
• Neurological examination (gait, anal reflex, perineal sensation, lower limb funciton)
• DRE to exclude 
• Constipation
• Rectal mass
• Test anal tone 
• RED FLAG SIGNS
  
  (NEW NEUROLOGICAL DEFICIT, HAEMATURIA, URETHRAL, BLADDER OR PELVIC MASSES, AND SUSPECTED FISTULA).  

Basic investigations

• Bladder diaries 
• Fluid intake 
• Frequency and volume of urine voided 
• Incontinent episodes
• Pad usage
• Degree of urgency 
• Urinalysis and culture 
• Flow rate and post-void residual (PVR) volume
• 150 ml for accurate result
• PVR Less than 50 normal more than 200 abnormal, 50-200 requires clinical correlation)  
• Pad testing 
• Performed with a full bladder 
• Pad weight gain more than 1 g is + for 1h test 
• Pad weight gain more than 4 g is + for 24h test 

Further investigations

• Blood tests, imaging (USS) and cystoscopy: indicated for
• Complicated cases with persistent or severe symptoms
• Haematuria 
• Bladder pain
• Voiding difficulties
• Recuurent UTIs
• Abnormal neurology
• Previous pelvic surgery
• Previous Rx 
• Suspected extraurethral incontinence 
• Urodynamics 
• In SUI distinguishes between 
• Hypermobility ALPP > 90-100 cmH2O
• ISD ALPP < 60 cmH2O
• Detects DO contractions during filling or abnormal pressure rise with position change 
• Detects poor bladder compliance 
• Ambulatory urodynamics: more physiological 
• Videourodynamics: 
• movement of proximal urethra and bladder neck with filling or provocation, also DSD, VUR) 
• Sphincter EMG: 
• provides information on synchronization between the detrusor and EUS.