erectile dysfunction

what is ED a red flag for

CV screening

ED is often thought to be a part of aging, but is more likely to be due to ________

concurrent medical conditions or meds

abnormality of which systems can cause ED

nervous (ex: spinal injury)

vascular (ex; atherosclerosis)

hormonal (ex: hypogonadism)

**Can also result if pt doesn’t respond to psychogenic stimulis (malaise, alzheimers disease, performance anxiety)

what meds can cause ED

anticholinergics (antihistimanes, antiparkinsonion agents, TCAs, SSRIs, antipsychotics)

dopamine antagonists (metaclopramide, antipsychotics)

estrogens

antifungals

antiandrogens (digoxin, H2 antagonists (cimetidine), spirinolactone)

antihypertensives

CNS depressants (benzos, barbiturates, narcotics, anticonvulsants, alcohol, cannibas)

surgery, radiation, hormonal treatments used to treat prostate cancer

medical conditions/lifestyle which cause ED

reduction in blood flow to corpora

• PVD

• arteriosclerosis

• cig smoking

• sedentary lifestyle

• penile trauma or surgery

nerve conduction disorders

• spinal cord injury

• stroke

• diabetes

• MS

• dementia

• penile trauma or surgery

endocrine disorders

• hypogonadism

• hypo/hyper thyroidism

• prolactinoma

psychosocial factors causing ED

mental health disorders

insecurity

stress

performance anxiety

relationship quality

diagnosis of ED

often made by primary care physician; specialist when 1st line therapy

detailed sexual history: onset, duration, progression and severity of problem

questionnaire: international index for erectile sexual dysfunction (IIEF-5)

detailed medical history: screen for comorbid conditions, meds, recreational drugs

physical exam: appearance (Peyronie’s Disease, circulation, secondary sexual characteristics, testicular atrophy), sensation testing

lab testing- fasting glucose + HgBA1C, TSH, lipid profile, BP measurement, testosterone levels

non pharm therapy

lifestyle interventions (encourage smoking cessation, weight loss, avoidance of recreational drugs, stress management, exercise)

address any sexual avoidance (couples should be reminded reinstating sexual intimacy can be difficult, priority should be placed on spending more time together and discussing perception of relationship and sexual activity)

address lack of sexual arousal

vacuum erection devices

1st line pharm Tx for ED

PDE5i

why should individuals without ED not use PDEi

risk of priapism

available PDE5i

sildenafil, vardenafil, tadalafil

how to take sildenafil and vardenafil (film coated tablet)

taken 30-60min prior to sexual activity on an empty stomach (avoid fatty meals)

how to take tadalafil

taken 1hr prior to sexual activity without regard to food

how long does sildenafil/vardenafil last

4hr but can be as high as 12hr

how long does tadalafil last

36hr

adverse effects of ALL PDE5i

facial flushing, headache, dyspepsia, nasal congestion, dizziness

decrease BP up to 10mmHg systolic and 6mmHg diastolic (symptomatic hypotension noted with alpha blocker use)

rare- hearing loss and priaprism

sildenafil and vardeafil unique ae

blue vision

vardenafil only unique ae

QT prolongation

tadalafil only unique ae

myalgia and back pain

drug int of PDE5i

metabolized by CYP3A4- be careful with 3A4 inducers/inhibitors

CI with nitrates- extreme hypotension risk. avoid nitrates within 24hr of sildenafil and vardenafil, within 48hr of tadalafil

cautious with alpha blockers- seperate by 4hr if possible (tamsulosin least likely)

alcohol- orthostatic hypo, delays absorption

which PDE5i does food decrease Cmax

sildenafil, vardenafil

how to take vardenafil ODT

dissolve on tongue 45-90min prior to sexual activity

advantages of vacuum erection devices

quite effective (60-80%), non invasive

disadvantages of vacuum erection devices

not discrete, pts may fail to ejaculate, caution in pts taking anticoagulants

what line of treatment is vacuum erection devices

2nd

what line of treatment is intracavernosal injections (alprostadil)

2nd or 3rd line

how fast do intracavernosal injections work and how long do they last

produces erection in 5-15min, can last up to 1hr

who are intracavernosal injections good for

people who have problems with nerve conduction

ae of intracavernosal injections

typically local effects:

most common is penile pain, fibrosis, hematoma

priaprism

rare- infections

how many times per week can intracavernosal injections be used

no more than 3 times weekly

urethral insert pros

moderately effective, less invasive than intercavernosal injections

ae of urethral inserts

typically local

most common- urethral pain, urethral injury

priaprism

vaginal burning and itch can occur in partner

when to insert urethral inserts

10-30min prior to sexual activity

onset and duration of action of urethral inserts

onset 5-10min, duration 30-60min

how often can you insert urethral inserts

no more than 1 administration in 24hr

how to store urethral inserts

store in refrigerator, stable at RT for 14 days