ERECTILE DYSFUNCTION IN CHRONIC KIDNEY DISEASE PATIENTS

Sexual dysfunction is very common in patients with chronic kidney disease. Kidney disease can cause chemical changes in the body affecting circulation, nerve function, hormones and energy level. The condition has been found to be significantly more common in men and women with chronic kidney disease (CKD) than in the general population. Approximately 50% of male predialysis CKD patients and 80% of male dialysis patients have erectile dysfunction. Multiple factors contribute to the frequent occurrence of sexual dysfunction in CKD patients, including hormonal disturbances such as hyperprolactinemia, hypogonadism in males.

Causes of erectile dysfunction in chronic kidney disease:
1. Diabetes 
2. High Blood pressure
3. Men with renal disease may find their hormone levels changing
4. Side effect of medicines, particularly those taken to control blood pressure
5. Symptoms such as breath and body odor, weight gain or unusual facial or body hair may be present
6. A man on hemodialysis may feel self conscious about how his vascular access site looks and feels
7. Men on peritoneal dialysis may worry about the size of their abdomens
8. Some men with kidney disease are afraid sexual activity may be harmful to their condition or harmful to their partners. 
9. Anemia due to kidney disease
10. Chronic kidney disease mineral and bone disorder

Treatment must start with determining and treating the underlying causes. Honest evaluation of alcohol, tobacco, and recreational drugs is essential. Assessment of emotional life, i.e. how well the patient gets along with his partner is vital. He may benefit from a referral to a psychotherapist, or the couple may be advised to seek marriage guidance. For men in whom vascular problem appears to predominate: Doppler studies, pharmacocavernosometry, pharmacocavernosography, dynamic infusion studies, and colour Doppler response studies may be helpful. 

Once erectile dysfunction is diagnosed and psychosexual component is ruled out a review of the drugs, haemoglobulin levels and dialysis adequacy should be corrected. They should have hormonal studies, including testosterone, LH, FSH, and prolactin. Correction of these hormones may not necessarily restore libido. The use of testosterone injections have shown only a small and variable response in erectile function. Using clomiphene in uraemic males may correct the androgen deficiency and increase the sense of well‐being, libido, and potency, similarly to testosterone administration; however, its long‐term use in uraemia is inconclusive.  To treat erectile dysfunction, bromocriptine in doses of 2.5–5 mg has been shown to improve libido and potency; the mechanism, however, remains unclear and it is possible that bromocriptine may influence potency directly as a result of its dopaminergic properties.

http://www.aafp.org/afp/2000/0101/p95.html

Treatment of erectile dysfunction in chronic kidney disease:
1. Your doctor can perform blood work to determine if your lack of interest in sex is due to your changing hormone levels. He may prescribe medicine to bring your levels to a normal range.
2. Talk to your doctor about the blood pressure medications you are taking if you are experiencing impotence. 
3. Phosphodiesterase-5 inhibitors (PDE5i) such as viagra compared with placebo significantly increases sexual performance.
4. Oral zinc supplementation results in a significant increase in plasma testosterone concentration along with an increase in the potency and frequency of intercourse. 
5. Only sparse data are available for vitamin E, bromocriptine, and dihydroxycholecalciferol in CKD patients and no trials assessed intracavernous injections, transurethral injections, mechanical devices, or behavioral therapy in CKD. 

Therapies that have been used to treat sexual dysfunction include phosphodiesterase-5 inhibitors (PDE5i), intracavernosal injections, intraurethral suppositories, hormonal therapy, mechanical devices, and psychotherapy.
Studies have also identified significant associations between sexual dysfunction in chronic kidney disease patients and depression, impaired quality of life, and adverse cardiovascular outcomes. Effective treatment of sexual dysfunction in CKD patients may therefore potentially lead to improvement in these patient-level outcome. There are now many new assessment techniques and treatments. There are encouraging reports in the use of phosphodiestrase 5‐inhibitors use in patients with CKD. A greater awareness of this common problem should be encouraged so that patients and their partners do not feel embarrassed about broaching this subject with their physicians. Although renal transplant may effectively reverse many of the hormonal and psychological changes of chronic renal failure, many patients will remain on a transplant waiting list for a considerable length of time. Patients who develop significant vascular disease may still remain impotent even after a successful transplant.

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