Sexual dysfunction Flashcards

explain the path after sexual stimulation

ACH increase NO production → increase guanylate cyclase activity → increase cGMP → decrease Ca levels → smooth muscle relaxation → erection

List the Ed pathophysiology

1. ______
   - disease that compromise blood flow to corpora cavernosum (PVD, HTN, ateriosclerosis)

2. ____
   - disease that impair nerve conduction to brain (stroke, spinal cord injury)
   - condition that impair nerve conduction to penile vasculature

3. _____
   - hypogonadism (small testicals, diminished sex drive, gynecomastia, decreased body hair)

vascular, neurologic, hormonal

list the risk factors for ED

smoking, drinking, depression, marital problems, performance anxiety, medication

A medication that can cause ED

• MOA: anticholinergic activity

  • second gen will cause less ED

  • SSRI less vs TCA (fluoxetine, sertraline, paroxetine can cause more ED)

anticholinergics (TCAs, antiparkinsonian, antihistamine)

A medication that can cause ED

• MOA: inhibit prolactin inhibitory factor = increase prolactin levels

  • high prolactin levels will inhibit testosterone production and decrease libido

dopamine antagonists (metoclopramide, phenothiazines)

A medication that can cause ED

• MOA: suppress testosterone mediated stimulation of libido

• ED will develop secondary to decreased sex drive

antiandrogens (spironolactone)

A medication that can cause ED

• MOA: suppress perception of psychogenic stimuli

• lack of psychogenic stimuli (attractive partner, sweet smell, touch, etc)

CNS depressant (ETOH, narcotics, barbituates, anticonvulsants)

A medication that can cause ED

• MOA: reduced arterial flow to corpora 

• diuretics will decrease intravascular volume = decreased arteriolar flow

• ACEIs, CCBs, ARBs, terazosin/doxazosin are better to use 

BP meds (diuretics, peripheral adrenergic antagonists, central sympatholytics such as methyldopa, clonidine)

serum testosterone test best done during

morning

treatment for ED

1. oral phosphodiesterase inhibitors (PDE)

2. VED, intracavernosal injection or intraurethral prostaglandin insert

3. surgery

list the phosphodiesterase-5 inhibitors (PDE)

sildenafil (viagra), vardenafil (levitra), tadalafil (cialis), vardenafil ODT (staxyn), avanafil (stendra)

what is MOA of PDE

inhibits catabolism of cGMP

list the drug that has longest DOA

tadalafil (cialis)

List sildenafil (viagra) starting dose and max dose

50 mg to 100 mg

List vardenafil (Levitra) starting dose and max dose

10 mg to 20 mg

List tadalafil (Cialis) starting dose and max dose

10 mg to 20 mg or QD 2.5 mg to 5-10 mg

List avanafil (stendra) starting dose and max dose

100 mg to 200 mgL

List the PDE drug that has DOA of 4-6+ hours

sildenafil (Viagra), vardenafil (levitra)

List the PDE drug that has DOA of 36+ hours

tadalafil (Cialis)

List the PDE drug that has DOA of 5-10 hours

avanafil (Stendra)

PDE interactions

• delayed absorption with fatty meals→ take 2 hours before or after fatty meal

sildenafil (viagra) and vardenafil (Levitra)

PDE interactions

• can be taken with or without food (has no effect on rate of absorption)

Tadalafil (cialis) and avanafil (Stendra)

PDE interactions

• needs to be taken on empty stomach

sildenafil (viagra)

PDE adverse effects for sildenafil (viagra)

HA, flushing, dizziness, nasal congestion, dyspepsia, visual effect, myalgia

PDE adverse effects for vardenafil (levitra)

sildenafil (viagra) SE + qt interval prolongation, BP reduction, HR increase

PDE adverse effects for tadalafil (cialis)

sildenafil (viagra) SE + visual disturbances and flushing, but mostly back pain and myalgia

PDE contraindication/precaution

• avoid ____ because of dangerous drop in BP (increase risk of stroke, passing out, or brain bleed)

nitrates

when avoiding PDE+ nitrate, wait how long between the two dose?

24 hr for sildenafil (viagra) and vardenafil (levitra); 48 hours for tadalafil (Cialis)

PDE contraindication/precaution

• avoid using PDE in combination with _____ because of additive effects on lowering BP

alphablockers such as terazosin (hytrin), prazosin (Minipress), doxazosin (Cardura), tamsulosin(Flomax), alfuzosin (uroxatral)

PDE contraindication/precaution

• when seeing sudden decrease or loss of hearing and/or vision

immediate stop PDE

PDE contraindication/precaution

• when seeing blue/green vision change, stop if they dont go away after several hours

  • ____ should avoid taking PDE because of this side effects due to inhibition of pde 6 in photoreceptor cell sin retinal rods and cones

pilots

_________ occurs when erection lasts longer than 4 hours 

priapism

• 3 parts

  • pump (generate negative vacuum pressure)

  • cylinder (closed one end and penis inserted in other end

  • tubing (connects pump to cylinder)

• vacuum pressure from pump draws arteriolar blood to corpora cavernosa

• constriction bands/tension rings can be placed at base of penis to prolong erection

  • keeps arteriolar blood in and decrease venous outflow from penis

• 30 min onset 

• manual or battery operated → recc Rx only 

Vacuum erection device (VEDs)

intracavernosal injection such as caverject and Edex and intraurethral insert such as MUSE 

alprostadil aka prostaglandin 

list the prostaglandin (alprostadil) pathway

stimulates adenyl cyclase → increase cAMP production → decrease Ca → smooth muscle relaxation → enhanced blood flow

what are the two intracavernosal injection alprostadil

• administer 5-10 mins before intercourse

• DOA: 1 hr

• PENINJECT for manual dexterity issue, needle phobia, or poor vision

caverject and edex

what are the intraurethral insert alprostadil

MUSE

what are some side effects of alprostadil (caverject)

plaques/fibrosis, priapism, hematoma and bruising 

what are some side effects of alprostadil (muse)

urethral pain, female partner may have vaginal irritation

_____ can also be used for ED 

• injected

• inexpensive, convenient, and no issue with bioavailability or hepatotoxic adverse effect 

• other adverse effect:  ____

testosterone; NA retention and gynecomastia 

3 line ED treatment

1. malleable or semi rigid = permanent erection bc of 2 bendable rods inserted

2. inflated = more natural

infection/mechanical failure are side effects

penile prostheses

female ED medication

• not approved in post menopausal women

flibanserin (addyi)

what is VERY IMPORTANT to tell pt on flibanserin (addyi)

take one daily AT BEDTIME to reduce hypotension risk

what to tell pt on flibanserin (addyi) about alcohol to prevent severe hypotension

stop drinking 2 hours before dose or skip evening dose; dont drink after evening dose until morning

pt taking flibanserin (addyi) should avoid ____ because of Hypotension risk

fluconazole (diflucan)