Week 13 ED and CVD Moodle Version)_2.pdf

CARDIOVASCULAR DISEASE AND ERECTILE DYSFUNCTION CMS150 TODAY’S LEARNING OBJECTIVES Understand the strong relationship between erectile dysfunction and cardiovascular disease Identify cardiovascular and non-cardiovascular risk factors for erectile dysfunction Compare and contrast medical t...

CARDIOVASCULAR DISEASE AND ERECTILE DYSFUNCTION CMS150 TODAY’S LEARNING OBJECTIVES Understand the strong relationship between erectile dysfunction and cardiovascular disease Identify cardiovascular and non-cardiovascular risk factors for erectile dysfunction Compare and contrast medical tests and laboratory findings used in the evaluation of erectile dysfunction TODAY’S LEARNING OBJECTIVES Prioritize issues to address in a patient encounter when erectile dysfunction is present Develop and refine a differential diagnosis based on patient symptoms and presentation in the context of erectile dysfunction Review pertinent physical exams and clinical evaluation in a patient presenting with erectile dysfunction Identify appropriate and strategic patient-centered interviewing skills to establish and sustain patient rapport in the context of erectile dysfunction  KEY TERMS An outdated and potentially disparaging label for Impotence what we now call ED. Loss of libido Loss of sexual interest. A distinct sexual problem, sometimes confused with ED. An adequate erection is lost through early Premature ejaculation involuntary climax. More common than ED in patients under 50. The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e >Chapter 43. Erectile Dysfunction Mark C. Henderson, Lawrence M. Tierney Jr., Gerald W. Smetana+ Date of download: 11/21/22 from AccessMedicine: accessmedicine.mhmedical.com, Copyright © McGraw Hill. All rights reserved. W H AT I S E R E C T I L E D Y S F U N C T I O N ? Erectile dysfunction (ED) is the inability to achieve and sustain an erection of the penis with sufficient rigidity for satisfactory sexual activity (Wessells, 2007) Approximately 20% of men over 20 suffer from ED, the prevalence increases significantly with advanced age 78% of males over the age of 75 are affected (Miner, 2014) W H AT I S E R E C T I L E D Y S F U N C T I O N ? There is a strong association between erectile dysfunction and cardiovascular disease One meta-analysis found that cardiovascular disease is: 45% more likely to occur in men with erectile dysfunction Coronary heart disease was 50% more likely Cardiovascular mortality was 14% more likely All-cause mortality was 25% more likely Myocardial infarction was 55% more likely Stroke was 36% more likely (Mostafaei et al, 2021) W H AT I S E R E C T I L E D Y S F U N C T I O N ? It appears that ED below age 40 has a greater tendency for a psychosomatic whereas older patients are more likely to be cardiometabolic/vasculogenic origin (DeWitte, 2014) Most of the available research is conducted on older men with significant cardiometabolic disease This makes our results less generalizable to all men (Miner, 2014) W H AT I S E R E C T I L E D Y S F U N C T I O N ? Hispanic and African American men are more likely to report erectile dysfunction than Caucasian men, especially in populations under 50 One theory is that Hispanic men have more poorly controlled diabetes mellitus or hypertension due to reduced access to care (Saigal, 2006) Other theories include a genetic disposition in Mexican populations or misunderstanding/poor translation of the statement “erection sufficient for intercourse” (Saigal, 2006) CAUSES OF ERECTILE DYSFUNCTION Etiology Approximate Frequency Psychogenic 20% Vascular 32% Drug-induced 12-25% Hormonal (thyroid, pituitary, gonadal) 3-19% Hormonal (diabetes) 5-24% Neurogenic 4% Other 5% Urologic Renal disease Sickle cell disease Sleep disorder Liver disease (Harris, 2012) CAUSES OF ERECTILE DYSFUNCTION Vasculogenic Chronic renal failure Psychogenic (stress) Radiation therapy (prostate cancer) Smoking Spinal cord trauma Metabolic syndrome Hypogonadism Cardiovascular disease Psoriasis Diabetes Neurogenic Pelvic surgery (prostatectomy) Neurodegenerative disorders CAUSES OF ERECTILE DYSFUNCTION C O N T. Thyroid disorders Sickle cell disease (hypo/hyper) Liver disease, including Cushing’s Disease NAFLD Situational (performance Benign prostate hyperplasia anxiety) Sleep apnea Inflammatory bowel disease Depression Hyperuricemia CAUSES OF ERECTILE D Y S F U N C T I O N C O N T. Drug-induced Immunomodulators Antihypertensives Anticonvulsants Antidepressants- Especially SSRIs Diuretics and SNRIs Cardiovascular agents (digoxin, Antipsychotics gemfibrozil) Antiandrogens Tranquilizers (e.g., Reactional & illicit drug use benzodiazepines) (amphetamines, barbiturates, Antiparkinson agents cocaine, marijuana) (Miller, 2000) Excessive alcohol use Antipsychotics Analgesics Antihistamines THE LINK BETWEEN C A R D I O VA S C U L A R D I S E A S E A N D ERECTILE DYSFUNCTION Erectile dysfunction can be an early manifestation of diabetes or cardiovascular disease Anyone presenting with erectile dysfunction should have a cardiovascular workup Erectile dysfunction could also point to an asymptomatic presentation of obstructive and non-obstructive coronary artery disease (Miner 2018) Men at high risk for cardiovascular disease, especially if they are symptomatic, should be referred to a cardiologist (Miner 2019) T H I N G S TO N OT E ED with the ability to have a normal morning erection implies a psychogenic cause, although the patient’s subjective assessment of his own early morning erections can be unreliable Sudden onset might point towards a psychogenic or drug-induced cause unless there was recent urologic surgery (radical prostatectomy) ED induced by a drug, hormonal causes or psychogenic are highly treatable, look for these causes (Harris, 2012) You also need to differentiate ED from other sexual disorders such as premature ejaculation and loss of libido (Miller, 2000) Presenting Symptom If Yes, Consider Known psychological stressor, relationship issues Psychogenic New drug or taking a drug associated with ED Change or discontinue if possible Pelvic trauma, radiation or surgery Refer to urologist Heat/cold intolerance, weight gain/loss Consider thyroid Decreased libido, decreased testicular size, loss of body hair Consider pituitary or gonadal disease disease Coronary artery disease, hypertension, hyperlipidemia Consider vascular Diabetes, foot numbness/tingling, bowel/bladder Consider neurologic incontinence Daytime sleepiness, snoring Consider sleep disorder DIAGNOSING ERECTILE DYSFUNCTION OVERALL S T E P S TO DIAGNOSIS Start by taking a comprehensive medical and sexual history of every patient presenting with erectile dysfunction Consider other psychosocial factors (current or past life stressors, cultural aspects) when discussing sexual performance with your patient Use a validated questionnaire for diagnosing ED, this can be a patient self- assessment or performed by the practitioner during the appointment Include physical exams that are pertinent to comorbid conditions or underlying medical diagnosis (i.e. hypertension, cardiovascular disease) Assess blood work and additional laboratory testing (Harris, 2012)  T H E PAT I E N T I N TA K E Patient reports ED Identify Identify Assess current Identify other common reversible psychological sexual causes causes status dysfunction Physical exams Penile Prostatic disease Signs of Signs of CVD deformities present hypogonadism Pertinent laboratory testing IIEF TESTING The International Index of Erectile Function (IIEF) is a widely available, patient- reported outcome measure to evaluate erectile dysfunction in men Score of ≤ 25: ED sensitivity: 0.97, specificity: 0.88 LR+: 8.1, LR-: 0.03 The Sexual Health Inventory for Men (SHIM): abbreviated 5-item version of the IIEF that was developed and separately validated as a brief, easily administered diagnostic tool - used as a screening tool by physicians SHIM is also referred to as the IIEF-5 Score of ≤ 21: ED of varying degrees sensitivity 0.98, specificity 0.88 (Rosen, 2002) LR+: 8.2, LR-: 0.02 S T E P S TO DIAGNOSIS The IIEF questionnaire contains 15 items, There are four levels of ED separated by five specific subscales that Normal erectile function (26–30 points) examine: Erectile function Mild ED (17–25 points) Orgasmic function Moderate ED (11–16 points) Sexual desire Severe ED (6–10 points) (Liu 2022) Intercourse satisfaction Overall satisfaction  IIEF TESTING The IIEF (International Index of Erectile Function) was developed alongside Pfizer's original trials of Viagra (Rosen, 2002) PROS- Most clinical trials and studies use the IIEF, which is helpful when comparing outcomes across research CONS- There has been some criticism for the scale regarding its focus on heterosexual relationships (vaginal intercourse), lack of discussion around orgasm/desire/pleasure and a poor assessment of premature ejaculation Studies on sildenafil (Viagra) do not show an increase in sexual desire I N T E R N AT I O N A L INDEX OF ERECTILE FUNCTION (IIEF) S E X U A L H E A LT H I N V E N TO R Y F O R MEN (SHIM) P R E M AT U R E E J A C U L AT I O N DIAGNOSTIC TOOL (PEDT)  However, Less Serious Causes Alarm Symptoms If Present, Consider: Include: Concurrent hip and buttock Abdominal aortic aneurysm Intermittent claudication, spinal cramps with walking stenosis Leg weakness or numbness, Spinal cord compression or Nerve root compression, perineal numbness pelvic mass peripheral neuropathy Bowel or bladder incontinence Spinal cord compression or Bladder infection, fecal pelvic mass impaction, others Galactorrhea (milk flow from the Pituitary tumor breast) Abnormal secondary sexual Pituitary tumor Normal variant, primary characteristics (loss of beard, testicular failure body hair, female body habitus) Visual fields cuts (loss of Pituitary tumor Other eye disorders portions of vision) (Harris, 2012) PHYSICAL EXAMS & HISTORY TAKING PHYSICAL EXAMS & H I S TO R Y TA K I N G Ask about a recent change/addition to medications or supplements (Rew, 2016) Review surgical history Take a detailed medical and sexual history, including a recent change in partners or sexual activity (i.e. patients trying to conceive) Ask about tobacco usage and smoking habits Screen for substance abuse including chronic use of marijuana (Ryan, 2012) Take note of how the patient is dressed and their overall physical demeanor You need to screen for depression with low mood as a differential diagnosis for erectile dysfunction (Harris, 2012) PHYSICAL EXAMS & H I S TO R Y TA K I N G Review dietary patterns and current level of physical activity Differentiate ED from loss of libido, lack of orgasm, and premature ejaculation through questioning Ask about personal and family medical history in relationship to cardiovascular disease Complete a Framingham Risk Score to assess for 10-year risk for cardiovascular disease Any perineal numbness or issues with bladder or bowel incontinence (Miller, 2000) (Harris, 2012) Send your patient for a sleep study to rule out sleep apnea if indicated (STOP-Bang questionnaire) (Carson, 2002)  FRAMI NG H AMRI SK SCORE (FRS) Date: Esti mati on of1 0-y earCar diovascul a rDi sease( CVD)Ri sk Patient’s Name: Step1 1 Step21 Step31 In the“ points”column entertheappr opr iatevalueaccor dingtothepa ti ent’ sa ge, H DL- C, total Usi ngthetotalpoints f rom Step1 ,deter minethe Usi ngthetotalpoints f rom Step1 ,deter mine chol esterol,systoli cbloodpressure, andiftheysmokeorha vediabetes.Ca lculatethetota lpoints. 10- yearCVD risk*(%). heartage( inyea r s). Risk Factor Risk Points Points Total Points 10-Year CVD Risk (%)* Heart Age, y Men Women Men Women Men Women - 3 orl ess 30 >80 ≥1 7 1 5+