Erectile Dysfunction in 2010

Erectile Dysfunction in 2010

Erectile DysfunctionErectile Dysfunction

Erectile dysfunction is defined as the consistent inability to attain or maintain a penile erection of sufficient quality to permit satisfactory sexual intercourse.

The prevalence of this condition increases with age.

It has been estimated that the worldwide prevalence of erectile dysfunction will be 322 million cases by the year 2025.

The risk of ED was 26 cases per 1000 men annually, which increased with age, lower education, DM, heart disease, and hypertension.

Erectile Dysfunction: Prevalence & SeverityMassachusetts Male Aging Study (MMAS)1

No erectile dysfunction(48%)

Erectile dysfunction(52%)

Complete(10%)

Moderate(25%)

Minimal(17%)

1709 men aged 40 to 70 years

1. Feldman HA, et al. J Urol. 1994;151:54-61.

(International Society of Impotence Research 1999)

Common risk factors for EDCommon risk factors for ED

Atherosclerosis • Caused Vasculogenic ED, whereas endothelial damage is the

proposed mechanism. Aging

• Alterations in the levels of NO that occur as a consequence of the aging endothelium.

• Chronic illness, depression, and lack of a sexual partner are all prevalent in this aging population.

Chronic tobacco use • Caused vasculogenic ED because of its effects on the vascular

endothelium. • Blood nicotine levels rise after smoking, which increases

sympathetic tone in the penis and leads to nicotine-induced, smooth-muscle contraction in the cavernosal body.

• leads to decreased penile NOS activity and neuronal NOS content.

Common risk factors for EDCommon risk factors for ED

Diabetes Mellitus • In the MMAS, the diabetic subset had a threefold increased prevalence of

ED compared with nondiabetic subjects (28% versus 9.6%). • The overall incidence rate of ED was 26 cases per 1000 man-years in

nondiabetics and 50 cases per 1000 man-years in the diabetic population. • The pathogenesis of ED in the diabetic patient is related to accelerated

atherosclerosis, alterations in the corporal erectile tissue, and neuropathy.Hypertension

• Both antihypertensive agents as well as the disease itself also contribute to ED.

• Certain classes of antihypertensive medications are notorious for their negative impact on erectile function, such as thiazides and β-blockers.

Hyperlipidemia• Contributed to ED by its relationship to endothelial dysfunction. • Study showed that decreasing total cholesterol to less than 200mg/dL by

using atorvastatin (Lipitor) led to significant improvement of ED.

Clinical assessment of ED patientsClinical assessment of ED patients

Differentiate between decreased libido and ED: assess whether the patient has one or bothTobacco use: type, amount, durationAlcohol intakeHistory of depression or anxiety disorderPresence of social/relationship stressorsAbility to have erections while masturbating versus when with partnerList of all prescription, over-the-counter, and herbal medicationsKnowledge of whether nocturnal erections are presentHistory of drug use: marijuana, cocaine, ketamine, other recreational drugsHistory of genitourinary traumaHistory of prostatic disease, or possible related symptomsHistory of hypertension, hyperlipidemia, CAD, peripheral vascular disease, cerebrovascular diseaseHistory of DMHistory of spinal cord injuryHistory of penile plaques: possible Peyronie's diseaseFrequency of intercourse or attempted intercourseAbility to ejaculate

Tools for ED evaluationTools for ED evaluation

International Index of Erectile Function (IIEF)

Sexual Encounter Profile (SEP)

Global Assessment Question (GAQ)

International Index of Erectile Function (IIEF)International Index of Erectile Function (IIEF)

a standardized questionnaire designed to measure ED and detect treatment-related changes reported by Rosen in 1997.

It is a 15-item questionnaire addressing 5 different domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction.

The IIEF is the most frequently used efficacy measurement employed in ED drug trials. Using a scale from 1 (never/almost never) to 5 (almost always/always), men grade each domain.

It is very sensitive and specific, and has been validated in 20 languages.

IIEF-5IIEF-5

To provide doctors with a “checklist” on erectile function that could be used in an office setting, an abridged 5-item version of the IIEF-15 has been developed by Rosen in 1999. 4 items are taken from the erectile function domain, plus another item addressing sexual intercourse satisfaction; it was chosen to reflect the central element in the NIH Consensus Panel (1992) definition of ED, which ties erectile function to satisfaction: “maintain erection of sufficient rigidity and duration to permit satisfactory sexual performance.” Perhaps the most important difference between the IIEF-15 and the IIEF-5 is that the latter asks patients to self-assess erectile function and satisfaction over the past 6 months, a more clinically relevant and practical time frame than 4 weeks. ED severity is classified into five categories based on the IIEF-5: severe (5 to 7), moderate (8 to 11), mild to moderate (12 to 16), mild (17 to 21), and no ED (22 to 25).

Sexual Encounter Profile (SEP)Sexual Encounter Profile (SEP)

SEP is a five-question survey provided to patients with ED in clinical studies of oral therapies. The survey is completed after each sexual attempt.

• 1.    Were you able to achieve at least some erection?• 2.    Were you able to insert your penis into your partner's

vagina?• 3.    Did your erection last long enough to have successful

intercourse?• 4.    Were you satisfied with the hardness of your erection?• 5.    Were you satisfied with the overall sexual experience?

Answers to questions 2 and 3 are the ones most often used in the literature.

Global Assessment Questions (GAQ)Global Assessment Questions (GAQ)

GAQ is usually administered at the end of the treatment period during efficacy studies.

Question 1: Has the treatment taken during the study improved your erections?

Question 2: If yes, has the treatment improved your ability to engage in sexual activity?

This is very subjective, and its responses tend to be valued less than SEP and IIEF.

In 2005, There Was the GBSSIn 2005, There Was the GBSS

GBSS = Global Better Sex Survey

October 2005 – March 2006

Authoritative global survey focusing on sexual aspirations and unmet needs of men and women

12,563 sexually active adults, aged 25-74 years

27 countries, including Australia, Japan, South Korea, Hong Kong Singapore, Taiwan, Indonesia, Malaysia, Thailand

5Mulhall JP, et al. J Sex Med. 2008;5:788-795. Data on file – Pfizer Inc

The Next StepThe Next Step

GBSS

2005 2008

AP SHOWAP SHOW

Gather information on attitudes to sexual health, specifically for the Asia Pacific

• A diversity of cultural beliefs and practices

• Many people are uncomfortable talking about sexual health and many do not seek help

Help people understand the importance of sexual health to overall health and wellbeing

Encourage people to seek help for issues with sexual health

The erection hardness scale (EHS) is used

Asia Pacific Sexual Health and Overall Wellness (AP SHOW)

9

The EHS Provides a Clear Treatment Goal The EHS Provides a Clear Treatment Goal

Goldstein I, et al. N Engl J Med 1998;338:1397-1404.

Severe ED Moderate EDSuboptimal

ErectionOptimal

Erection

Penis is larger but not hard

Penis is hard but not hard enough for penetration

Penis is hard enough for penetration

but not completely

hard

Penis is completely hard and fully rigid

Towards Optimal Erection Hardness

11

Asia Pacific SHOWAsia Pacific SHOW

13 countries/regions

3,957 sexually active men (2,016) and women (1,941)

Face-to-face interviews (self-completed questionnaire) / online self-administered method

May to July 2008

The erection hardness scale (EHS) was used

12

COUNTRY

Australia

China

Hong Kong

India

Indonesia

Japan

South Korea

Malaysia

New Zealand

Philippines

Singapore

Taiwan

Thailand

Country Method Number Language

Australia Internet 209 English

China F-to-F* 600 Simplified Chinese

Hong Kong Internet 230 Traditional Chinese

India F-to-F* 400 English

Indonesia Internet 578 Bahasa Indonesia

Japan Internet 407 Japanese

S. Korea Internet 298 Korean

Malaysia Internet 202 Malay

New Zealand Internet 210 English

Philippines Internet 200 Tagalog/English

Singapore Internet 223 English

Taiwan Internet 200 Traditional Chinese

Thailand F-to-F* 200 Thai

Face-to-face or Internet Questionnaires

*subjects intercepted on street and handed a paper questionnaire to complete 13

150 males and 150 females

AP SHOW data : The Regional Results

AP SHOW data : The Regional Results

Past Month Frequency of Sexual Intercourse Past Month Frequency of Sexual Intercourse

Sex is very importantSex is very important

% of people who indicate sex as very important in their lives

People very satisfied with sexPeople very satisfied with sex

% of people are very satisfied with sex in their lives

AP SHOW : The Hong Kong Results

AP SHOW : The Hong Kong Results

AP SHOW – Key ResultsAP SHOW – Key Results

1) In Hong Kong, 66% of men and 69% of women are not very satisfied with sex.

2) Greater satisfaction with sex is strongly associated with greater satisfaction with other aspects of life.

3) One in two men are not experiencing optimal erection hardness (EHS 4) during sexual activity. 60% of women report that their partners do not have optimal erection hardness (EHS 4) during sexual activity.

4) Men with and women whose partners have optimal erection hardness (EHS 4) are more satisfied with sex than men with and women whose partners have suboptimal erection hardness (EHS 3).

5) Men with suboptimal erection hardness (EHS 3) report they have less sex than they should, and are less satisfied with sex and other aspects of the sexual experience than men with optimal erection hardness (EHS 4).

15

In Hong Kong, 66% of men and 69% of women are not very satisfied with sex.

Greater satisfaction with sex is strongly associated with greater satisfaction with other

aspects of life.

16

1

Many Men and Women Are Not Very Satisfied with SexMany Men and Women Are Not Very Satisfied with Sex

Overall, 66% of men and 69% of women are not very satisfied with sex

MEN WOMEN

66% 69%

COMPLETELY SATISFIED

VERY SATISFIED22%

13%

25%

6%

19

Those More Satisfied with Sex Are More Satisfied with Top Priorities in Life

Being a spouse/partner

Family life

Being a parent

Overall physical health

Financial well-being

Less than satisfied with sex

Satisfied with:

Men: 1) Being a spouse/partner; 2)Family life; 3) Overall Physical health; 4) Financial well-being ; 5) Being a parentWomen: 1) Overall Physical health; 2) Being a spouse/partner; 3) Family life and being a parent; 5) Financial well-being

21

60-93%

More than satisfied with sex

0-19%

MENWOMEN

One in two men are not experiencing optimal erection hardness (EHS 4) during sexual activity. 60% of women report that their partners do not have optimal erection

hardness (EHS 4) during sexual activity.

20

2

Optimal erection hardness

Men with and women whose partners have optimal erection hardness (EHS 4) are more satisfied with sex than men with and women

whose partners have suboptimal erection hardness (EHS 3)

22

3

MEN WOMEN

22% vs. 38%

Erectile hardness and Satisfaction with sex

Men with suboptimal erection hardness (EHS 3) report they have less sex than they should, and are less satisfied with sex and

other aspects of the sexual experience than men with optimal erection hardness (EHS 4)

25

4

Frequency of sexual intercourse – less than the right amount

*p<0.0529

Men with suboptimal erection hardness (EHS 3) report they have less sex than they should than

men with optimal erection hardness (EHS 4)

Men with Suboptimal Erections Are Less Satisfied with Aspects of Sexual Experience

Mor

e th

an S

atis

fied

(%)

Ability to achieve climax

Physical foreplay

Orgasm intensity

Feeling attracted to

partner

Ability to use different

positions

Time right after climax

EHS 4 EHS 3 EHS 4 EHS 3 EHS 4 EHS 3 EHS 4 EHS 3 EHS 4 EHS 3 EHS 4 EHS 3

30

AP show Hong Kong resultsAP show Hong Kong results

In Hong Kong, 66% of men and 69% of women are not very satisfied with sex.

Greater satisfaction with sex is strongly associated with greater satisfaction with other aspects of life.

48% men are not experiencing optimal erection hardness (EHS 4) during sexual activity. 60% of women report that their partners do not have optimal erection hardness (EHS 4) during sexual activity.

Men with and women whose partners have optimal erection hardness (EHS 4) are more satisfied with sex than men with and women whose partners have suboptimal erection hardness (EHS 3).

Men with suboptimal erection hardness (EHS 3) report they have less sex than they should, and are less satisfied with sex and other aspects of the sexual experience than men with optimal erection hardness (EHS 4).

ERECTILE DYSFUNCTION AND CARDIOVASCULAR DISEASESERECTILE DYSFUNCTION AND CARDIOVASCULAR DISEASES

Erectile Dysfunction = Endothelial DysfunctionErectile Dysfunction = Endothelial Dysfunction

DeBusk R et al. Am J Cardiol 2000 Jul 15;86(2):175–181.

1. Increasing age

2. Male

3. Hypertension

4. Diabetes mellitus

ED and cardiovascular disease share common risk factorsED and cardiovascular disease share common risk factors

5. Obesity

6. Cigarette smoking

7. Dyslipidemia

8. Sedentary lifestyle

ED and CVD often co-exist

There is now evidence that ED • is a risk factor for CAD

• may be the sentinel symptom of silent myocardial ischaemia

• is a potential predictor of subsequent cardiac events including death

ED and CADED and CAD

CVD and ED develop in response to endothelial dysfunctionCVD and ED develop in response to endothelial dysfunction

CV disease

ENDOTHELIAL DYSFUNCTION

OXIDATIVE STRESS

HYPERTENSIONHYPERTENSION

HEART FAILUREHEART FAILURE ATHEROSCLEROSISATHEROSCLEROSIS SMOKINGSMOKING

DIABETESDIABETES

Adapted from Rubyani. J Cardiovasc Pharmacol 1993;22 (suppl 4): S1–S4.

ERECTILE DYSFUNCTION

The penis is a highly vascular organ

The penis is an early warning system for CV diseaseThe penis is an early warning system for CV disease

Symptoms of vascular disease may appear earlier in penis compared with other sites because arterial luminal diameter is small

Differentiation between penile and coronary vasculatureDifferentiation between penile and coronary vasculature

6–8 mmFemoral

5–7 mmCarotid

3–4 mmCoronary

1–2 mmPenis

Lumen DiameterArtery

Montorsi P et al. Eur Urol 2003;44:352-354

Coronary Vessels Penile Arteries

The ‘artery size hypothesis’ explains why ED occurs earlier than CVDThe ‘artery size hypothesis’ explains why ED occurs earlier than CVD

Due to:

• the small diameter of the cavernosal arteries

• the high content of endothelium and smooth muscle on a per gram of tissue basis (compared with other organs)

The penile vascular bed is a sensitive indicator of systemic endothelial cell and smooth muscle dysfunction The penile vascular bed is a sensitive indicator of systemic endothelial cell and smooth muscle dysfunction

Sinusoids in the corpus cavernosum

ED increases the risk of developing cardiovascular disease (CVD) by about 2 times the normal rate of incident CVD

The risk of CVD in men ages 40-60 with ED is greater than the risk of CVD in men older than 60

ED increases the risk of death from CVD by 50%

ED precedes the onset of CVD by about 2-5 years

ED is a potential predictor for cardiovascular disease as other common risk factors such as smoking, family history of CVD and dyslipidaemia

Take-Home MessagesTake-Home Messages

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