Etiology and Prevalence of Erectile Dysfunction ED Following Prostate Cancer Therapy

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Etiology and Prevalence ofErectile Dysfunction
(ED) FollowingProstate Cancer Therapy

• MARK K. HIRSCHHORN MD FACS
• Department of Urology
• Southern Maine Medical Center

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Prostate Cancer Prevalence

• Prevalence
• 16 of American men will be diagnosedwith
  prostate cancer during their lifetimes1
• 33 of all cancer cases in 2003 will beprostate
  cancer2

1. American Cancer Society. What are the key
statistics about prostate cancer? Available at
http//www.cancer.org/docroot/CRI/content/.
Accessed October 20, 2003. 2. American Cancer
Society. Cancer facts and figures 2003. Available
at http//www.cancer.org/downloads/STT/CAFF2003PW
Secured.pdf. AccessedOctober 20, 2003.
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Estimated Cancer Incidence for 2003

• Prostate
• USA 220,900
• Maine 900
• Lung
• USA 171,900
• Maine 1,000
• Colorectal
• USA 147,500
• Maine 800

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Prostate Cancer Treatment Options

• Surgical procedures
• Radical prostatectomy
• Radiation therapy
• External beam radiation therapy (EBRT)
• Brachytherapy
• Watchful waiting
• Combination therapy including hormonal therapy

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Treatment by Modality
All treatments lead to ED
1. National Cancer Institute. Know your options
understanding treatment choices for prostate
cancer. Available at http//www.nci.nih.gov.
Accessed October 20, 2003. 2. Harlan LC et al. J
Natl Cancer Inst. 2001931864-1871.
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How Do Erections Occur?
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Etiology of ED FollowingProstate Cancer Therapy

• Physical
• Neurological
• Secondary smooth muscle dysfunction
• Arterial insufficiency
• Hormonal
• Psychogenic
• Psychosocial impact of disease on patientand
  partner

1. Podlasek CA et al. Int J Impot Res.
200113(suppl 5)S1-S15.
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ED is a Side Effect of Treatment
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Sexual Function After Radical Retropubic
Prostatectomy (RRP)
Recovery rates diminish with increasing age.
N600. Quinlan DM et al. J Urol.
1991145998-1002.
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Key Take-Home Messages

• All prostate cancer treatment options lead to ED
• Treatment options
• RRP (50-70)
• EBRT(25 40)
• Brachytherapy (25 40)
• Hormonal therapy (75 )
• For men with ED following prostate cancer
  therapy, there is a need for safe and effective
  treatment options

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WHY TREAT ED?ED Is an Important Health Concern

• Lowers Self Esteem
• Anxiety
• Depression
• Decreased Quality of Life
• Partners of Men With ED
• Guilty
• Inadequate

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Treatment Strategies for Erectile Dysfunction
(ED) Associated With Prostate Cancer Therapy A
Urologists Perspective
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Treatment Alternatives for Postprostatectomy
Patients With ED

• Expectant (watchful waiting)
• Medical
• Oral drugs (sildenafil, tadalafil, and
  vardenafil)
• MUSE
• Intracavernosal injection (prostaglandin1 PGE1
  mixtures)
• Vacuum erection device
• Penile implants
• Combination therapy

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Medical Treatement The PDE-5 Inhibitors

• VIAGRA (NASCAR)
• 25, 50, 100 mg
• LEVITRA (FOOTBALL)
• 5, 10, 20 mg
• CIALIS (BATHTUB)
• 10 20 mg

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How well do they work?

• Overall 60
• Radical Prostatectomy 40
• Radiation 45-60

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Medical Treatement The PDE-5 Inhibitors HOW
DO THEY WORK?

• Enhance normal erectile process
• Prolong smooth muscle relaxation leading to
  increased blood flow into the penis
• They DO NOT supply a spontaneous erection

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PDE5 Inhibitors Onset and Duration of Activity
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Most Frequently OccurringAdverse Events (AEs)
Summary
1. Zippe CD et al. Urol. 200055241-245. 2.
Montorsi F et al. Int J Impot Res. 200315(suppl
5)S170. Abstract 21. 3. Brock G et al. Eur
Urol. 2002(suppl 1)152.
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COST OF MEDICATION

• All tablets/strengths cost 8-10 / pill
• Maximize your investment
• ..cut your pills in ½!

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Optimizing PDE5 Inhibitor Therapy

• Incorrect use treatment failure
• Patients should be advised that
• Sexual stimulation is needed
• A number of drug trials may be required
• Sildenafil and vardenafil may be taken with food
  but onset of action may be delayed

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WARNINGS !!!!!!!

• DO NOT MIX PDE5 INHIBITOR DRUGS WITH
  NITROGLYCERIN
• YOU MAY DIE!
• Be careful with certain medications for BPH
  (Flomax, Doxazosin and Terazosin)

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Return of Nocturnal Erections With Sildenafil
After BNS Prostatectomy
36 weeks of daily Viagra v. Placebo
Responders()
Bilateral nerve-sparing procedure. 48 weeks
after RRP and 8 weeks after discontinuation of
drug treatment, responders had combined score of
?8 to IIEF Q3 and Q4 and positive response to GEQ
(quality of erections sufficient for sexual
activity). Padma-Nathan H et al. Poster
presented at American Urological Association
Annual Scientific Meeting April 26-May 1, 2003
Chicago, Ill.
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Return of Normal Erections With Sildenafil After
Prostatectomy

• Conclusions
• Significant increase in the return of spontaneous
  erections compared with placebo
• Treatment was well tolerated
• Sildenafil may improve nocturnal erection
  oxygenation that may lead to neuronal regeneration

Bilateral nerve-sparing procedure. Padma-Nathan
H et al. Poster presented at American Urological
Association Annual Scientific Meeting April
26-May 1, 2003 Chicago, Ill.
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Responsiveness Rates and Tolerability Following
Radical Prostatectomy
1. Costabile RA et al. J Urol. 19981601325-1328.
2. Claro Jd et al. Sao Paulo Med J.
2001119135-137. 3. Montorsi F et al. J Urol.
19971581408-1410. 4. Baniel J et al. BJU Int.
20018858-62.
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Vacuum Erection Device
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Penile Implants vs. Other Treatment Options
ERECTILE RESTORATION
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Penile Prosthesis

• Long-term, US multicenter study of AMS 700CX
  3-piece inflatable penile prostheses
• 86 mechanical reliability after 5 years (n372)
• 91 erection suitable for coitus (n172)
• gt85 would undergo surgery again and/or recommend
  procedure to a friend (n178)

Carson CC et al. J Urol. 2000164376-380.
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Non-inflatable Penile Implant
ERECTILE RESTORATION

• ADVANTAGES
• Easy for you or your partner to activate
• Good option for men with limited dexterity
• Totally concealed in body
• The simplest surgical procedure
• Least expensive

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Non-inflatable Penile Implant
ERECTILE RESTORATION

• DISADVANTAGES
• Stays firm when not in erect position
• May show through clothes

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2 Piece InflatablePenile Implant
ERECTILE RESTORATION

• ADVANTAGES
• Simple to use
• Fast and simple one-step deflation
• Totally concealed in body
• Natural flaccidity compared to non-inflatable
  implants

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2 Piece InflatablePenile Implant
ERECTILE RESTORATION

• DISADVANTAGES
• Requires some manual dexterity
• Possibility of leakage or malfunction
• Flaccidity not as natural as 3-piece

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3 Piece InflatablePenile Implant
ERECTILE RESTORATION

• ADVANTAGESSame advantages as2 piece plus

• Acts and feels more like a natural erection
• Expands the girth of the penis
• More firm and full than other implants
• Feels softer and more flaccid when deflated

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3 Piece InflatablePenile Implant
ERECTILE RESTORATION

• DISADVANTAGES
• Requires some manual dexterity
• Possibility of leakage or malfunction
• Possibility of unintentional erections

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Prostheses Patient Satisfaction
1not at all satisfied 5extremely
satisfied Carson CC et al. J Urol.
2000164376-380.
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Key Take-Home Messages

• Maintaining at least partial penile innervation
  is important during surgical intervention
• Consider prophylactic treatment and early
  intervention for ED as adjunct to prostate cancer
  therapy
• Providing nutrient supply to erectile tissue may
  be a protective mechanism for future erections
• When medications do not work, consider penile
  prostheses

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REMEMBER

• ED is common
• You are not alone
• Treatments are available
• See your doctor