Sexual Dysfunction

vascular, neurologic, hormonal

causes of ED in 80% of patients

hypertension, dyslipidemia, obesity, diabetes, BPH, thyroid, age, PAD, prostatectomy, chemo, spinal cord injuries, hypogonadism, alcohol/tobacco/meds

risk factors for ED

anticholinergic, antidepressant, antihypertensive, antipsychotic, BPH agents, chemo, CNS depressants, diuretics, dopamine antagonists, hormones, recreational drugs

medications that may cause ED

cardiovascular

Older patients at intermediate or high risk for _________ disease should undergo assessment before starting pharmacologic therapy

weight loss/exercise; nicotine cessation; avoid alcohol/illicit drugs; control over chronic diseases; vacuum constriction device

nonpharmacologic treatment for ED

yohimbe, L-arginine, panax ginseng

natural products that are not proven to work for ED treatment

testosterone

first line treatment option for male hypogonadism

PDE-5 inhibitors

first line treatment option for ED

alprostadil

second line treatment for ED

sildenafil, tadalafil, vardenafil, avenafil

PDE-5 inhibitors

sildenafil, tadalafil

PDE5 inhibitors that are FDA-approved for the management of pulmonary arterial hypertension (PAH)

sildenafil

PDE5 inhibitor that is FDA-approved for the management of BPH

vasodilator of cavernosal arteries

pharmacologic effect of PDE5 inhibitors

concomitant CYP3A4 inhibitor; hepatic impairment; renal impairment (sildenafil and tadalafil); age >65 (sildenafil, vardenafil)

indications for a lower dose of PDE5 inhibitor

30-60 minutes

onset of action for sildenafil, vardenafil, and avanafil

2-6 hours

onset of action for tadalafil

4 hours

duration of action for sildenafil, vardenafil, and avenafil

24-36 hours

duration of action for tadalafil

avanafil, tadalafil

which PDE5 inhibitors have an increased risk of hypotension with alcohol use?

CYP3A4

how are PDE5 inhibitors metaboliszed?

empty stomach

how should sildenafil and vardenafil (not ODT) be administered?

with or without food (no effect)

how should avanafil and tadalafil be administered?

24 hours

how long should nitrates be avoided after sildenafil or vardenafil use

12 hours

how long should nitrates be avoided after avanafil use?

48 hours

how long should nitrates be avoided after tadalafil use?

nitrates

main DDI for PDE5 inhibitors that can cause fatal hypotension

history of nonarthritic anterior ischemic optic neuropathy; concomitant nitrate use

contraindications for PDE5 inhibitors

uroselective

if alpha-1 antagonists must be used concomitantly, a ______________ a1 antagonist at the lowest dose possible should be used and separated by 4 hours

QT prolongation

PDE5 inhibitor with risk of QTc prolongation

headache/flushing, rhinitis, dyspepsia, hypotension, back/limb pain (tadalafil only)

common side effects of PDE5 inhibitors

sudden hearing loss, vision changes (blue/green color discrimination with sildenafil or vardenafil)

rare side effects of PDE5 inhibitors and should discontinue immediately

alprostadil

most beneficial with psychogenic or neurogenic ED

5 minutes

onset of action for alprostadil

15-45 minutes

duration of action for alprostadil

penile pain,

intracavernosal: hematoma/bruising or fibrosis;

intraurethral: injured urethra, (female partners may experience vaginal burning)

adverse effects of alprostadil

priapism

erection lasting longer than 4 hours; medical emergency due to potential for clotting

alprostadil injection (4%)

which ED treatment has the highest risk for priapism?

4 weeks

follow up period for ED

flibanserin, bremelanotide

indicated for female hypoactive sexual desire disorder

hypotension

BBW for flibanserin

drowsiness, dizziness, nausea

adverse effects of flibanserin

melanocortin receptor agonist

MOA of bremelanotide

8

patients should not receive more than _______ bremelanotide doses per month

uncontrolled HTN, CVD

contraindications for bremelanotide

flushing, headache, nausea, injection site reaction, skin hyperpigmentation

adverse effects of bremelanotide

8 weeks

discontinue flibanserin or bremelanotide after ___________ if improvements have not occured