Transcript
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Copyright © 2011 by Nelson Vergel
Nelson VergelProgram for Wellness Restoration
PoWeRUSA.orgAuthor of “Built to Survive” and “Testosterone: A Man’s Guide”
Preserving and BoostingPreserving and BoostingSexual Function: Sexual Function: A Guide for MenA Guide for Men
This information (and any accompanying printed This information (and any accompanying printed
material) is not intended to replace the attention or material) is not intended to replace the attention or
advice of a physician or other health care professional. advice of a physician or other health care professional.
Anyone who wishes to embark on any dietary, drug, Anyone who wishes to embark on any dietary, drug,
exercise, or other lifestyle change intended to prevent exercise, or other lifestyle change intended to prevent
or treat a specific disease or condition should first or treat a specific disease or condition should first
consult with and seek clearance from a qualified health consult with and seek clearance from a qualified health
care professional.care professional.
Goals and ObjectivesGoals and Objectives
nn Discuss the most common causes of Discuss the most common causes of Erectile Dysfunction (ED)Erectile Dysfunction (ED)
nn Review a practical evaluation of men Review a practical evaluation of men with EDwith ED
nn Review the treatment optionsReview the treatment options
A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDED QuestionaireED Questionaire³³
nn When you had erections with sexual When you had erections with sexual stimulation, how often were your stimulation, how often were your erections hard enough for penetration?erections hard enough for penetration?
nn How do you rate your confidence that How do you rate your confidence that you could get and keep an erection?you could get and keep an erection?
³The International Index of Erectile Function, Urol 1997;49:822³The International Index of Erectile Function, Urol 1997;49:822--830830
A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDQuestionaire (cont.)Questionaire (cont.)
nn During sexual intercourse, how often During sexual intercourse, how often were you able to maintain your erection were you able to maintain your erection after you had penetrated your partner?after you had penetrated your partner?
nn During sexual intercourse, how difficult During sexual intercourse, how difficult was it to maintain your erection to was it to maintain your erection to completion of intercourse?completion of intercourse?
nn When you attempted sexual When you attempted sexual intercourse, how often was it intercourse, how often was it satisfactory for you?satisfactory for you?
A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDSexual History (cont.)Sexual History (cont.)
nn Do you have any problems with intimacy with Do you have any problems with intimacy with your partner?your partner?
nn Do you have early morning erections?Do you have early morning erections?
nn Do you have erections with selfDo you have erections with self--stimulation?stimulation?
nn Are you able to consistently obtain and Are you able to consistently obtain and maintain an erection sufficient for sexual maintain an erection sufficient for sexual intimacy?intimacy?
nn Does it hurt to have an erection or Does it hurt to have an erection or intercourse?intercourse?
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A Practical Evaluation of Men with EDA Practical Evaluation of Men with EDSexual History (cont.)Sexual History (cont.)
nn Do you ejaculation sooner than you Do you ejaculation sooner than you would like?would like?
nn Does it take too long to reach an Does it take too long to reach an orgasm?orgasm?
nn Do you fail to reach an orgasm?Do you fail to reach an orgasm?
nn Did your erection problems start Did your erection problems start suddenly or over time?suddenly or over time?
IncidenceIncidence
nn 2020--30 million American men suffer ED30 million American men suffer ED
nn Age dependentAge dependent
–– 2% men age <40 years2% men age <40 years
–– 25% men age 6525% men age 65
–– 75% men >75 years75% men >75 years
nn Not a necessary occurrence of the aging Not a necessary occurrence of the aging processprocess
An Erection Requires a Coordinated An Erection Requires a Coordinated Interaction of Multiple Organ Interaction of Multiple Organ
SystemsSystems
nn PsychologicalPsychological
nn EndocrineEndocrine
nn VascularVascular
nn NeurologicNeurologic
Cause of EDCause of ED
nn Psychogenic Causes:Psychogenic Causes:
–– AnxietyAnxiety
–– DepressionDepression
–– FatigueFatigue
–– GuiltGuilt
–– StressStress
–– Marital DiscordMarital Discord
–– Excessive alcohol consumptionExcessive alcohol consumption
Causes of EDCauses of ED
nn Organic CausesOrganic Causes
–– Cardiovascular diseaseCardiovascular disease
–– Diabetes mellitusDiabetes mellitus
–– Surgery on colon, bladder, prostateSurgery on colon, bladder, prostate
–– Neurologic causes (lumbar disc, MS, CVA)Neurologic causes (lumbar disc, MS, CVA)
–– Hormonal deficiencyHormonal deficiency
Causes of EDCauses of EDRisk FactorsRisk Factors
Massachusetts Male Aging StudyMassachusetts Male Aging Study¹¹
nn Treated heart diseaseTreated heart disease 39%39%
nn Treated diabetesTreated diabetes 28%28%
nn Treated hypertensionTreated hypertension 15%15%
¹Feldman Ha, J Urol 1994; 151:54¹Feldman Ha, J Urol 1994; 151:54--6161
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Causes of EDCauses of EDOther risk Factors Other risk Factors ²²
nn DiabetesDiabetes 27% 27% -- 59%59%
nn Chronic renal failureChronic renal failure 40%40%
nn Hepatic failureHepatic failure 25% 25% -- 70%70%
nn Multiple SclerosisMultiple Sclerosis 71%71%
nn Severe depressionSevere depression 90%90%
nn Other (vascular disease, low HDL, high Other (vascular disease, low HDL, high cholesterol)cholesterol)
²Benet et al. Urol Clinic North Am. 1995; 151:54²Benet et al. Urol Clinic North Am. 1995; 151:54--6161
Causes of EDCauses of ED
nn Hormone DeficiencyHormone Deficiency
nn Blockage of Blood VesselsBlockage of Blood Vessels
nn Venous LeakVenous Leak
Causes of EDCauses of ED
nn Spinal cord injuries: 5% Spinal cord injuries: 5% -- 80%80%
nn Pelvic and urogenital surgery and Pelvic and urogenital surgery and radiationradiation
nn Substance abuseSubstance abuse
nn Alcohol: >600ml/wkAlcohol: >600ml/wk
nn Smoking amplifies other risk factorsSmoking amplifies other risk factors
nn Medications may be responsible for Medications may be responsible for ~25% of cases of ED~25% of cases of ED
nn Bicycle ridingBicycle riding
Causes of EDCauses of ED
Medication:Medication:
nn Most common cause of ED in men >50Most common cause of ED in men >50
nn Many men are polymedicatedMany men are polymedicated
nn Also have coAlso have co--morbid conditionsmorbid conditions
Causes of EDCauses of ED
Medications (cont.)Medications (cont.)
nn AntiAnti--hypertensive drugshypertensive drugs
–– All capableAll capable
–– Common: thiazides and beta blockersCommon: thiazides and beta blockers
–– Uncommon: calcium channel blockers, Uncommon: calcium channel blockers, alphaalpha--adrenergic blockers, and ACE adrenergic blockers, and ACE inhibitorsinhibitors
Causes of EDCauses of ED
Medications (cont.)Medications (cont.)
nn CNS drugs:CNS drugs:
–– Antidepressants, tricyclics, SSRIsAntidepressants, tricyclics, SSRIs
–– TranquilizersTranquilizers
–– SedativesSedatives
–– AnalgesicsAnalgesics
nn H1 and H2 receptor blockersH1 and H2 receptor blockers
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Causes of EDCauses of ED
Medications (cont.)Medications (cont.)
nn AnticholinergicsAnticholinergics
nn LHRH agonists (Lupron, Zolladex)LHRH agonists (Lupron, Zolladex)
nn AlcoholAlcohol
nn TobaccoTobacco
nn Drug abuseDrug abuse
nn Estrogens, KetoconazoleEstrogens, Ketoconazole
Treatment OptionsTreatment Options
nn Oral medications Oral medications -- Viagra, Levitra, CialisViagra, Levitra, Cialis
nn Urethral suppositories (MUSE)Urethral suppositories (MUSE)
nn Injection therapy Injection therapy -- Caverject, Trimix, Caverject, Trimix, BimixBimix
nn Vacuum constriction deviceVacuum constriction device
nn SurgerySurgery
nn Sex therapySex therapy
Nonpharmacologic Treatment Nonpharmacologic Treatment OptionsOptions
Lifestyle changes:Lifestyle changes:
nn Reduce fat and cholesterol in dietReduce fat and cholesterol in diet
nn Decrease or limit alcohol consumptionDecrease or limit alcohol consumption
nn Eliminate tobacco use and substance Eliminate tobacco use and substance abuseabuse
nn Weight loss if appropriateWeight loss if appropriate
nn Regular exerciseRegular exercise
MedicationMedication(PDE Inhibitors)(PDE Inhibitors)
Side effects:Side effects:
nn HeadacheHeadache
nn FlushingFlushing
nn DyspepsiaDyspepsia
nn Nasal congestionNasal congestion
nn Visual disturbancesVisual disturbances
nn PriapismPriapism
MedicationMedication(PDE Inhibitors)(PDE Inhibitors)
Contraindications:Contraindications:
nn Organic Nitrites:Organic Nitrites:
–– OralOral
–– SublingualSublingual
nn Severe cardiac diseaseSevere cardiac disease
–– Obtain stress testingObtain stress testing
nn Careful with Careful with NorvirNorvir since it boosts PDE since it boosts PDE blood levelsblood levels
Sexual Dysfunction Oral DrugsSexual Dysfunction Oral Drugs
DrugDrug Onset of Onset of ActionAction
Duration Duration of Activityof Activity
ViagraViagra 60 minutes60 minutes 44--5 hours5 hours
LevitraLevitra 30 minutes30 minutes 44--5 hours5 hours
15 minutes15 minutes 36 hours36 hoursCialisCialis
Side Effects: Heartburn, GI upset, head aches,Side Effects: Heartburn, GI upset, head aches,nasal congestion, flushing, “blue vision” (Viagra only)nasal congestion, flushing, “blue vision” (Viagra only)
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Daily Cialis Use
Free 30 day supply at Cialis.com
Penile Injection TherapyPenile Injection TherapyCaverject, Edex, Tri/BiCaverject, Edex, Tri/Bi--MixMix
nn Mechanism of action: smooth muscle Mechanism of action: smooth muscle vasodilatorvasodilator
nn Administration: 10, 20, 40ugAdministration: 10, 20, 40ug
nn Inject directly into corporeal bodies of Inject directly into corporeal bodies of the penisthe penis
nn Results: 70%Results: 70%--90%90%
nn Dropout rates: 25%Dropout rates: 25%--60%60%
nn Side effects: pain (36%), priapism Side effects: pain (36%), priapism (4%), fibrosis(4%), fibrosis
Trimix (Papavarine+ Phentolamine + alprostadil)
Available by prescription from compounding pharmacies
Other Options for ED
Penile Implants
Vacuum Constriction Devices
Penile ProsthesisPenile Prosthesis
Indications:Indications:
nn Patients who have failed other therapiesPatients who have failed other therapies
nn Peyronie’s diseasePeyronie’s disease
nn Severe vasculogenic diseaseSevere vasculogenic disease
ThreeThree--Piece Inflatable ProsthesisPiece Inflatable Prosthesis
nn Most closely approximates the feel of a Most closely approximates the feel of a natural erectionnatural erection
nn Cylinders expand in girthCylinders expand in girth
nn Some cylinders have the potential to expand Some cylinders have the potential to expand in lengthin length
nn When inflated, it feels more firm and more When inflated, it feels more firm and more full than other prosthetic erectionsfull than other prosthetic erections
nn When deflated, it feels softer and more When deflated, it feels softer and more flaccid with better conceal ability than with flaccid with better conceal ability than with other prosthetic devicesother prosthetic devices
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Penile ProsthesisPenile ProsthesisInsurance ReimbursementInsurance Reimbursement
nn Covered by most companies, including Covered by most companies, including MedicareMedicare
nn No coNo co--payment for men with Medicare payment for men with Medicare supplemental insurancesupplemental insurance
Future ED Products
§ Intracavernous Bone Marrow Stem-cell Injection
§ Udenafil (Zydena®)
§ Avanafil
§ LY2452473
§ SK-3530
Signs and Symptoms of Low Testosterone
ØØ Loss of muscle mass and strength Loss of muscle mass and strength
ØØ Loss of libido and erectile dysfunctionLoss of libido and erectile dysfunction
ØØ Depression Depression
ØØ Lethargy (fatigue, lack of focus)Lethargy (fatigue, lack of focus)
ØØ Bone lossBone loss
ØØ Some regression of secondary sexual Some regression of secondary sexual characteristics (body hair loss, etc)characteristics (body hair loss, etc)
ØØ Low or no sperm countLow or no sperm count
Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987
Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html
Testosterone and AgingTestosterone and Aging
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Testosterone Deficiency (Hypogonadism)
• Normal levels in blood:
Men... Total test. 300-1100 ng/dL,
Free test. 5 - 21 ng/dL
Women... Total test. 10-50 ng/dL
Free test. 0.10-0.85 ng/dL
• Symptoms of testosterone deficiency:
Fatigue, low or lack of sex drive, poor appetite,
loss of muscle mass & strength, depression
Albumin-bound T38%
Free T2%
SHBG-bound T60%
T = testosteroneOnly 2% is free testosteroneand 98% is bound
Testosterone Fractions in the Blood
(binds testosterone)
TestosteroneReplacement Benefits
Sexual function
Mentalfocus
Stamina and Bone Strength
LeanBodyMass
Testosterone Options
Injections
Patch
Pellets
Buccal
Gels
Gels
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Potentially Approved in the Next 12-24 Months
The Top 10 Mistakes Made by Men The Top 10 Mistakes Made by Men on Testosteroneon Testosterone
ØØ Using “street sources” of testosteroneUsing “street sources” of testosterone
ØØ Not exploring what testosterone option is best Not exploring what testosterone option is best
ØØ Not using the right doseNot using the right dose
ØØ Cycling on and off testosteroneCycling on and off testosterone
Ø Stopping testosterone abruptly due to an unrelated side effect
Ø Not knowing how to manage potential side effects
ØØ Having a life style that is not “testosterone friendly”Having a life style that is not “testosterone friendly”
ØØ Not reading or staying “networked” with other patientsNot reading or staying “networked” with other patients
Ø Not switching doctors when you have to
Ø Poor compliance
The HPT Axis
Potential Side Effects
Polycythemia
Benign Prostatic Enlargement
Acne
Gynecomastia Increased BP
Testicular AtrophyDecreased sperm count
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For More Information:TestosteroneWisdom.com
For More InformationFor More Informationnn More details in “Built To Survive” and More details in “Built To Survive” and
”Testosterone”Testosterone-- A Man’s Guide” A Man’s Guide” www.amazon.comwww.amazon.com or any bookstoreor any bookstore
nn Email:Email:
Nelson Nelson VergelVergel –– NelsonVergel@yahoo.comNelsonVergel@yahoo.com
nn Websites:Websites:
www.powerusa.comwww.powerusa.com
www.testosteronewisdom.comwww.testosteronewisdom.com
www.facialwasting.orgwww.facialwasting.org
www.TheBody.comwww.TheBody.com
nn Join my Internet discussion group by sending a blank Join my Internet discussion group by sending a blank email to email to PozhealthPozhealth--subscribe@yahoogroups.comsubscribe@yahoogroups.com
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