Dr Jonathan Lewis GP Caterham, Surrey

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Dr Jonathan LewisGPCaterham,Surrey
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Erectile dysfunction

• Huge impact in Quality of Life
• Marker for IHD
• Marker of severity of IHD
• Ischaemic Penile Disease

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Erectile dysfunction

• NOT IMPOTENCE

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Background to ED

• Small subset of sexual dysfunction
• Loss of libido
• Hypoactive sexual desire disorder
• Disorder
• Sexual desire
• Hypoactive

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Sexual Disorders

• Desire disorders
• Arousal disorders
• Orgasm disorders
• Pain disorders
• Erection disorders
• 35 yr old African barrister

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Impact of ED on patients

• Huge
• Actual quotes from my patients

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What Patients Say

• Its all I ever think about
• It pervades everything in your life
• I feel a failure
• Treatment has saved my marriage
• People who dont have a problem dont
  understand

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What Patients Say

• It has turned my life around
• Its given me more time to concentrate on my
  business

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What the BMJ says

• Health professionals should be aware of the
  extreme distress that erectile dysfunction can
  cause.
• 1st May 2004

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How would you score your quality of life now,
after oral therapy?

• 25 - 100 better

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Viagra safety

• DRSU report 2001
• Lower than expected death rate
• ? Cardio-protective
• Caerphilly cohort study

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E D as a risk factor for IHD

• Increasing evidence
• Vascular cause
• Marker of severity
• Check cholesterol
• Tight BP control

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How much does having ED increase your risk of IHD?

• 4157 males (all ages)
• 423 Hypertensive
• Of these 74 (17.5) have IHD
• 46 Hypertensive and ED
• Of these 11 (24) have IHD
• Increase of 37

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Treatment options

• Pre PDE5 inhibitors mostly referral to
  secondary care
• Oral treatments revolutionised approach
• In public consciousness
• Post PDE5 inhibitors mostly managed in primary
  care

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What could a GP offer before there were PDE5
inhibitors?

• Yohimbine
• Vacuum devices
• Psycho-sexual counselling
• Testosterone
• Nitrate patches
• Injections
• Muse
• Implants

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4 types of GP

• 1 Keen
• 2 Feel they should
• 3 No knowledge / no interest
• 4 Positively against

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Difficult to talk about

• Patients very reticent to admit to it
• Enough to cope with already
• Health care workers find it difficult to talk
  about
• Most frequently skipped over on templates

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Medical assessment

• Past Medical History
• Drugs / alcohol
• Sudden / gradual onset
• Sex drive
• Nocturnal / morning erections
• Grade 0 - 4
• Performance anxiety
• Premature ejaculation
• What does your partner want?

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Medical assessment

• Urine glucose
• Blood pressure
• Testes
• Penis
• Pulses

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Medical assessment

• Nitrates
• 1 hour
• Sexual stimulation
• Empty stomach
• Avoid fatty foods
• At least 8 doses

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Schedule 11

• Blacklist
• Grey list
• Valium
• Clobazam
• SLS
• Used by DoH to limit costs of Viagra
• Unique- no generic equivalent

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Schedule 11

• Good erectile dysfunction
• Diabetes
• Multiple sclerosis
• Prostate cancer
• Prostatectomy
• Renal dialysis/transplant
• Radical pelvic surgery

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Schedule 11

• Poliomyelits
• Spina bifida
• Parkinsons disease
• Spinal cord injury
• Severe pelvic injury
• Severe distress
• Single gene neurological disease

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Single gene neurological disease

• Muscular dystrophy
• Huntingtons chorea
• Tuberous sclerosis
• Neurofibromatosis
• Colour blindness!

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Bad erectile dysfunction

• Arterial disease
• Hypertension
• Psychological causes
• Hypercholesterolaemia
• Iatrogenic
• i.e. vast majority

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SCHEDULE 11

• NIGHTMARE
• PCO Chair PCO Prescribing lead
• Unique
• Unfair
• Huge workload
• 2 tips
• Private prescription VIAGRA
  NHS prescription sildenafil
• Private prescription repeat x 6

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Any Questions?
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The 5 EDs

• Erectile dysfunction
• Endothelial dysfunction
• Early detection
• Exercise and diet
• Early death