ED Flashcards
Men presenting with ED should undergo:
GUIDELINE STATMENT 1
A thorough medical, sexual, and psychosocial hx, a PE, and selective laboratory testing
risk factors include: age, comorbid medical and psych condition, prior sx, medication, fhx of vascular dz, personal hx vascular dz, substance abuse, tobacco, neuro dz, endocrinopathies, meds, psychosocial
What is recommended to quantify and qualify a man’s sxs with ED?
GUIDELINE STATEMENT 2
validated questionnaire
(bother, satisfaction, relationship impact)
IIEF, SHIM
What health concerns can ED be a warning sign of?
GUIDELINE STATEMENT 3
CVD
(endothelial dysfunction and inflammation)
What initial lab tests for ED should be performed?
GUIDELINE STATEMENT 4
testosterone
2 am values (do not measure during acute illness)
(< 300 ng/DL low)
What instances may warranted specialized testing? What does this testing include?
GUIDELINE STATEMENT 5
some men warrant specialized testing may guide treatment
young
have strong fhx CVD
hx of pelvic trauma
failed prior ED tx
strong likelihood of primary psychogenic
concomitant PD
lifelong ED
Tests:
**Nocturnal penile tumescence (shaft gauge during sleep)
**ICI (in office: prostaglandin E1, paparavine, and/or phentolamine)
**Penile duplex US (7-10 Hz transducer, 5-10 minutes after ICI → vascular eval: PSV < 30 → arterial insufficiency, EDV > 5 veno-occlusive dz; RI (EDV/PSV >0.80 → normal)
**Caversonometry (quantify pressure after ICI), selective internal pudendal angiography
**Pudendal arteriography (young men with suspected arterial insufficiency)
For ED, referral to whom after initial evaluation SHOULD be considered? How will this help?
GUIDELINE STATEMENT 6
Mental health professions
to promote treatment adherence, reduce performance anxiety, and integrate tx into sexual relationship
What should clinicians counsel men with ED about lifestyle?
GUIDELINE STATEMENT 7
comorbidities negatively affect ED
lifestyle modifications, including changes in diet, increased physical activity, will improve overall health and improve erectile function
What is an FDA approved initial treatment option for ED? What should be discussed?
GUIDELINE STATEMENT 8
PDE5i (phosphodiesterase type 5 inhibitor)
inhibit breakdown of cGMP → increase smooth muscle relaxation in corpus cavernosum → increased erection hardness
discuss benefits, risks, efficacy
contraindications: nitrates (hypotension), amyl nitrate (poppers) other interactions: antidepressants, anti-fungal, anti-hypertensives, HIV/AIDS drugs
*patients should be stable on alpha blocker prior to initiating PDE5i (some interaction for hypotension)
- PDE5i, particularly sildenafil, tadalafil, and vardenafil, appear to have similar efficacy for general population
- Dose-response effects across PDE5i meds are small and non-linear (i.e. doubling dose not double effect)
- On- demand dosing vs. daily for tadalafil appears to have same level of efficacy
Most common a/e of PDE5i
dyspepsia
headache
flushing
back pain
nasal congestion
myalgia
visual disturbance
dizziness
Detail instruction to maximize efficacy for PDE5i
GUIDELINE STATEMENT 9
Dosing of PDE5i should be:
GUIDELINE STATEMENT 10
titrated to provide optimal efficacy
Patients who try PDE5i without efficacy, what should be considered?
Incorrect usage
black market products
require sexual stimulation
waiting and adequate amount of time
fatty meals (sildenafil and vardenafil, tadalafil is unaffected by food)
How are PDE5i metabolized:
cytochrome CYP4A system
*dose reduction may be necessary with CYP450 i (ketoconazole, erythromycin, ritonavir, indinivir, grapefruit juice)
Others may enhance: rifampin, phenobarbital, phenytoin, carbamazepine
**Men with severe hepatic or renal dysfunction (GVR < 30) should be stared on lowest dose
How do you follow men on PDE5i
Recheck at 3 mo for BPH and efficacy/adverse effects
If satisfactory, q 6-12 mo for same
ask for changes in meds (nitrates, addition of alpha blocker, etc)
What should patients be informed about penile rehab after RP or RT?
GUIDELINE STATEMENT 11
men who desire preservation o f erectile function after treatment for prostate cancer by radical prostatectomy or radiotherapy should be informed that early use of PDE5i post-treatment may not improve spontaneous, unassisted erectile function