Please enable JavaScript.
Coggle requires JavaScript to display documents.
Erectile Dysfunction (Treatment (Vacuum Erection Device (Noninvasive…
Erectile Dysfunction
Treatment
Vacuum Erection Device
Noninvasive medical device, it can be used repeatedly
Works by drawing arterial blood into the corpora cavernosa
Onset of actions is 3-20 minutes
Not discrete, works best in older patients who are married or who have stable sexual relationships
Contraindicated in patients with sickle cells disease or patients with history of prolonged erections. Use cautiously by patients taking warfarin
Second line therapy in patients who do not respond to PDE-5 inhibitors or those who do not respond to injectable drug treatments
use in combination with PDE-5 inhibitors or other agents can make VEDs more effective
PDE-5 Inhibitors
first-line
Effectiveness is dose-related
AVOID
combination with other therapy for ED
people pre-disposed to priapism: sickle cell anemia, leukemia, multiple myeloma
combination with nitrates= severe hypotension
Interactions
all are hepatically catabolized by CYP3A4
DDIs with CYP3A4 inhibitors
Sildenafil has an active metabolite, excreted in urine
Sildenafil & tadalafil should be dose reduced in renal impairment
Dosing
Sildenafil, vardenafil, avanafil should be dosed 30-60min before intercourse
Tadalafil takes at least 2hr
in those who dont respond to on-demand dosing, may take daily low dose
Adverse Effects
mild or moderate, self-limiting and tolerance develops with use
headache, facial flushing, dyspepsia, nasal congestion, dizziness
use with caution in patients with CV disease
Testosterone Replacement Therapy
Supply exogenous testosterone and restore serum testosterone levels to normal range of 300-1,100 ng/dL
Correct hypogonadism
May stimulate nitric oxide synthase, thus increasing NO
ONLY use in patients who are symptomatic with primary, secondary, or mixed hypogonadism with serum testosterone that are less than 250-350 ng/dL
Does NOT directly correct ED, but improves libido, thereby correcting secondary ED
Serum levels may correct within days; clinical improvement generally observed within days or weeks after initiation
Formulations
Oral
Hepatotoxicity
Buccal
BID dosing and $$
Patches
should be reserved for patients refusing injections
increase level within 2-6hr
produce a "natural" hormone level pattern
gel
IM
no bioavailability problems
effective
dosing every 2-4wks
Dosing
produce serum concentrations in the normal range
mimic the circadian rhythm
3-6months is considered adequate trial
Recommend target serum level 450-600 ng/dL
alprostadil (prostaglandin E1)
stimluates adenyl cyclase, increasing production of cAMP
available as intracavernosal (Caverject/Edex) and intraurethral insert (MUSE)
intracavernosal more effective than intraurethral
intracavernosal
about 70-90% effective
usually lasts 12-44 minutes
onset in 5-15 minutes
no more than once per 24 hours, no more than 3 times per week
use aseptic technique, massage penis to help distribute drug, rotate injection sites
intraurethral
medication pellet inside a prefilled applicator
void first to moisten urethra
insert 0.5 inches into urethra
push plunger, massage penis
Penile Prostheses
Most invasive
Reserved for pts who do not respond to less invasive medical treatment
Need anesthesia & skilled urologist
Two types: malleable & inflatable
Malleable: two bendable rods inserted into the corpora cavernosa
Inflatable: several mechanical parts, including a pump, reservoir, and fillable cyclinders
Provide penile rigidity suitable for vaginal intercourse
90% patient satisfaction (highest)
Surgical success rate is 82-98%
AE: infection, mechanical failure, erosion of the rods through the penis, late-onset infeciton
Alt. Agents:
Yohimbine
Paperverine
Phenotolamine
Diagnosis
Severity of ED
International Index of Erectile Function
quality of sexual intercourse for the past 4wks- 6 months
Complete medical, psychosocial, surgical hx
Check for hypogonadism
abnormal penile curvature
genital reflexes to check nerve supply
digital rectal exam in >50yrs to rule out BPH
Fasting Serum blood glucose
Lipid profile
Serum testosterone in >50yrs & those who complain of decreased libido and ED
Pathophysiology/Etiology
Normal erection physiology
vascular
arterial flow is enhanced by acetylcholine which works along with cGMP/cAMP/nitric oxide to relax smoot muscle and produce vasodilation
Swollen corpora compres the veins to reduce venous outflow and maintain the erection
nervous/psychogenic
sexual sensory stimuli are carried thru cholinergic nerves to the corpora
detumenescence results from norepinephrine
hormonal
testosterone stimulates libido (and maybe plays a role in nitric oxide and cGMP production)
organic erectile dysfunction
any disturbance of vascular, neurologic, or hormonal etiologies of a normal erection
most commonly disruption of vascular flow to corpora (peripiheral vacular disease, arteriosclerosis, essential HTN)
psychogenic erectile dysfunction
Malaise, reactive depression, performance anxiety, sedation, Alzheimer's disease, hypothyroidism, mental disorders
Social Habits
Cigarette smoking: vasoconstrictor effect can compromise blood flow to the corpora and decrease cavernosal filling
Excessive ethanol intake: androgen deficiency, peripheral neuropathy, chronic liver disease
Clinical Presentation
Sx
erectile dysfunction or inability to have sexual intercourse
may or may not be associated with decreased libido and ejaculatory disorders
Signs
IIEF survey
Concurrent medication use
Concurrent medical illnesses or past surgical procedures
PE can reveal signs of hypogonadism
Labs
Serum testosterone concentration if patient exhibits signs of hypogonadism
Blood sample for prostate specific antigens if enlarged prostate
Monitoring
Phosphodiesterase Inhibitor
Sildenafil
visual complaints, loss of vision, hearing loss, BP, pulse, clinical sx of ED
vardenafil
visual complaints, loss of vision, hearing loss, BP, pulse, clinical sx of ED, palpitations or dizziness
tadalafil
visual complaints, loss of vision, hearing loss, BP, pulse, clinical sx of ED, palpitations or dizziness, myalgia
avanafil
clinical sx of ED, visual complaints, loss of vision, BP, pulse, palpitations or dizziness, hearing loss
Prostaglandin E1
alprostadil, intracavernosal
clinical sx of ED, presence of hematoma or fibrotic nodules, BP, pulse
alprostadil, intraurethral
clinical sx of ED, urethral injury as evidenced by pain, bleeding, or tissue damage, BP, pulse
Testosterone Supplements
methyltestosterone
clinical sx of ED, PE for edema, BP, serum lipids, hematocrit, hepatic transaminases, prostate specific antigen, serum testosterone
fluoxymesterone
clinical sx of ED, PE for edema, BP, serum lipids, hematocrit, hepatic transaminases, prostate-specific antigen, serum testosterone
testosterone buccal system
clinical sx of ED, PE for edema, BP, serum lipids, hematocrit, hepatic transaminases, prostate-specific antigen, serum testosterone
testosterone cypionate or enanthate
clinical sx of ED, PE for edema, BP, serum lipids, hematocrit, hepatic transaminases, prostate-specific antigen
testosterone patch
clinical sx of ED, PE for edema, BP, serum lipids, hematocrit, hepatic transaminases, prostate-specific antigen, serum testosterone
testosterone gel/spray/axillary solution
clinical sx of ED, PE for edema, BP, serum lipids, hematocrit, hepatic transaminases, prostate-specific antigen, serum testosterone
testosterone subQ implant
clinical sx of ED, PE for edema, BP, serum lipids, hematocrit, hepatic transaminases, prostate-specific antigen, serum testosterone
testosterone undecanoate
clinical sx of ED, PE for edema, cough, SOB, BP, serum lipids, hematocrit, hepatic transaminases, prostate-specific antigen
Risk Factors
HTN
diabetes
coronary artery disease
dyslipidemia
smoking
chronic alcohol abuse
Medications can cause/increase risk
Anticholinergic agents
Antiparkinsonian Agents
TCAs
Phenothiazines
Dopamine antagonists (increase prolactin levels so decreased testosterone production)
estrogens or drugs w/ antiandrogenic effects
CNS depressants
agents that decrease penile blood flow (diuretics, peripheral beta-adrenergic antagonists, central sympatholytics)
Also finasteride, dutasteride, lithium carbonate, gemfibrozile, MOAs, opiates
Goals of therapy
Improve the quantity and quality of penile erection suitable or intercourse and is satisfactory.