7 minute read
Erectile dysfunction & Peyronie’s disease
Managing erectile dysfunction and Peyronie’s disease
By Dr Shane La Bianca, Urologist, Murdoch
Erectile dysfunction (ED) is common as males age. Unusual below age 30 (estimated <10%). it may affect more than 75% of men over the age of 70. Peyronie’s disease (PD) prevalence varies (2- 10%) greatly between populations studied, most likely reflecting variations between social views on self-reporting and clinical detection methodology. Only 10-20% of PD cases resolve spontaneously. ED and PD have similar aetiologies. Both are associated with cardiovascular co-morbidities: diabetes, obesity, hypertension, dyslipidaemia, smoking, low testosterone and pelvic/prostate surgery. Penile trauma is reported in around 10% of cases.
The underlying pathophysiologic mechanism for PD plaque is poorly understood. Plaque formation may relate to trauma or repetitive microvascular injury to the (semi-) erect penis. The pathophysiology of PD is likely multifactorial – genetic predisposition, trauma, tissue inflammation and aberrant wound healing all contributing. Patient evaluation requires a comprehensive clinical history focused on disease status (acute or chronic), ED nature (e.g. lack of response to stimulation, loss during penetration, penile curvature, change over time, prior treatments) and other medical co-morbidities that might affect treatment options and outcomes.
Physical examination includes the genitals, circumcision status, PD plaque size and location, assessment of the degree of penile deformity based on digital photography (dorsal and lateral views) and assessment of peripheral pulses. Modifying risk factors is critical to addressing ED. Both conditions can compromise sexual function and quality of life. Distress over symptoms, penile appearance, and erectile function must be considered. Treatments Phosphodiesterase-5 inhibitors (PDE5i) are a safe option for all men with ED or PD, except those with symptomatic angina. A trial of daily 5-7.5mg Tadalafil should be considered in both conditions as initial therapy to improve baseline erectile function. L-Arginine is a useful adjunct to PDE5i, acting via nitric oxide dependant pathways. Additional oral agents such as curcumin and colchicine may be of use in early PD (painful inflammatory phase) but dosing is complex. Acetyl L-Carnitine and Pentoxifylline (another PDEi) may also improve curvature, decrease plaque formation and improve erectile function. All these oral therapies are supported by level two evidence at best. Penile traction therapy may have some benefits in PD (level three evidence) in terms of correcting penile pain, curvature and improving corporal elasticity and erectile response. It should be used in combination with oral therapies and for at least six months.
Low intensity Shock Wave Therapy (LiSWT) is not supported by recently published trials. Intralesional therapy with collagenase is effective (level two evidence), but not available here. Despite no large-volume or highlevel evidence-based data to suggest the best treatment option in PD, surgery offers the most rapid and reliable outcome addressing advanced aspects of PD, such as extensive plaque, severe ED and complex penile deformities.
Author competing interests- nil
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Men, COVID and alcohol –time to review the guidelines
By Dr Michael Christmass, Addiction Medicine, East Perth
A poll commissioned by the Foundation for Alcohol Research and Education conducted in April 2020 provided a sobering update on Australian alcohol use during the COVID-19 pandemic. Twenty percent of households reported purchasing more alcohol than usual and, of these households, 70% reported using more alcohol than usual. In these households, 34% admitted daily alcohol use and 32% were concerned about alcohol use in the home. Another consequence of COVID-19 may be more patients presenting to medical practitioners with alcohol-related problems. Many will be male. Let’s take a brief look at draft guidelines regarding alcohol consumption.
CONSUMPTION ALCOHOL DAILY
5.9%
DAILY
77% consumed alcohol daily in past 12 months
Table 1
7.6% 4.2%
It is clear that problematic alcohol consumption is more common amongst males than females (Table 1). Men experience more overall harm from alcohol than women despite the well-established outcome that, at higher levels of consumption, risk of harm increases faster for women than men (Table 2). Importantly, more than 50% of harm attributable to alcohol in Australia is from harm to others. When we help a man with alcohol
ABOVE LIFETIME RISK ABOVE SINGLE OCCASION RISK
24% 9.5% 45% 27%
use disorder, we reduce harm to another individual. Latest advice Data on lifetime and single occasion risk (Table 1) correspond to outdated NHMRC guidelines (2009). In December 2019, based on updated evidence, the NHMRC released Draft Australian Guidelines to Reduce Health Risks from Drinking Alcohol.
Now offering video and in person consultations for Neuro Spinal Surgical Services
Neurospine Institute is a multi-disciplinary specialist practice offering advice and treatment across the full range of spine and brain conditions.
Dr Paul Taylor Spinal Surgeon Spine Surgeon
Also offering: Spine Focused Physiotherapy Treatment Service for patients in need of treatment for back and neck pain, rehabilitation or recovery following injury or spinal surgery.
Dr Paul Taylor Dr Greg Cunningham Spinal Surgeon Spine Surgeon
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We welcome Dr Greg Cunningham to the team. Dr Cunningham utilises some of the most advanced techniques in spinal surgery available worldwide and is available now to see privately insured patients.
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Key messages
Alcohol purchase and consumption has increased during the pandemic Problematic drinking is more common in males New guidelines are being released this year.
The lifetime risk guideline has been reduced from 14 to 10 standard drinks a week. Single occasion risk remains at four standard drinks. Based on mathematical modelling and systematic evidence reviews, risk of death from alcohol-related disease or injury is less than one in 100 where alcohol is consumed within this guideline. Modelling indicates risk of death caused by alcohol increases with total amount consumed (e.g. per week) but also in consuming over fewer days (i.e. higher consumption/episode). It is important to recognise uncertainty assigning level of risk to any specific amount of alcohol consumption. This is in part due to doubt over the existence and
Alcohol ranks 6th in risk factors for burden of disease in Australia
Alcohol-attributable hospitalisations and deaths did not decline between 2004-2015 Alcohol contributes 6% of disease burden for men compared with 2.8% for women
Men have markedly higher rates of alcoholattributable hospitalisation (1.6-fold) and alcoholattributable death (2-fold) compared with women 3
Table 2
>50% of harm attributable to alcohol in Australia is from harm to others 4
magnitude of any cardioprotective effect of alcohol. Further, alcohol is known to cause cancer in humans (Group 1 carcinogen). Evidence from systematic reviews suggest alcohol consumption as low as one standard drink per day is associated with increased risk of breast and gastrointestinal cancers. Finally, the 2009 guidelines are old and updated guidelines should be released in 2020. It hoped that a brief summary of the new information available for screening, assessing and treating men with alcohol use issues will be ready soon.
– References available on request Author competing interests – nil relevant disclosures.
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