Erectile Dysfunction Flashcards
Sildenafil side effects 9
Headache Nasal congestion Dyspepsia Flushing Rash
Headache Flushing Dyspepsia Abnormal vision Nasal congestion Back pain Myalgia Dizziness/nausea Rash
Epistaxis
Insomnia
Erythema
Diarrhea
When to treat low testosterone
treat when T less than 8nmol/L and with symptoms
recheck when less than 12 nmol/L
normal range 10-30 nmol/L
SHIM
score no ED, severe ED
total score
5 questions
out of 25
22-25 no ED
1-7 severe ED
12-16 mild to mod ED
5 questions
in last 6 months
how would you rate your confidence that you could get and keep an erection
how often hard enough penetration
how often maintain ereciton after penetration
how difficult maintain until completion intercourse
how often satisfied with sexual intercourse
action of NO and cGMP
cavernosal nerve
releases NO from endothelium
SM relaxation, dilates arterioles
initiates erection
NO stimulates production cGMP this activates protein kinase G opens K channels, closes Ca channels low intracellular ca causes SM relaxation SM contracts when cGMP degraded by PDE
how to take IC injection
max dose
time between doses
caverjet alprostadil starting dose
max 3 times a week 24 hours between doses caverjet starting dose 2.5mcg usual dose 5-20 mcg max dose 60mcg
cream alprostadil
cream vitaros
pellet alprostadil
MUSE
response rate to PDE5i after RARP
35-75% after nerve sparing
0-15% after non nerve sparing
how to take sildenafil
most efficacious 50mg 1 hour before sexual activity no heavy meals onset 30 mins to 1 hour half life 3 hours lasts up to 12 hours in blood stream
tadalafil
most well tolerated 5mg dose, other doses 10mg, 20mg 30 mins before sex peak 30 mins c max 2 hours t1/2 17.5 hours lasts up to 36 hours NOt affected by food
vardenafil
10mg initial dose 5mg dose if on alpha blocker, up to max 20mg usual dose 10mg 25-60 mins before sex effective 30 mins half life 4 hours affected by food, avoid fatty meal
action of alprostadil
Vasodilatation by increasing levels of cAMP
side effects of alprostadil
penile pain
long erections 5%
priapism 1%
fibrosis 2%
assessment ED history nature sexual PMH Drug Other
nature of complaint PE? ejaculatory? which context? morning and nightime rigidity curvature
chronology
primary / secondary
gradual or suddent onset
sexual relationship, frequency, who is partner
causes of ED groups
arteriogenic neurogenic penile hormonal drugs other
arteriogenic causes
htn pvd metabolic syndrome smoking pelvic dxr diabetes
neurogenic causes
MS SCI peripheral neuropathy pelvic surgery stroke cauda equina
hormonal
hypogondism
prolactin, pit tumour
hypopit
hypo or hyperthyroid
mixed causes
renal or liver disease
OSA
drugs causes
anti hypertensives anti depressants anti psychotics anti androgens recreational
which antihypertensives cause more ED
which improves ED
beta blockers
thiazide
ARB may improve
alpha blocker may improve
ca channel no great effect
ACE i neutral
mechanism of erection
3 things caernosal nerve NO stimulates guanylyl cyclase in SM cell, which converts GTP to cGMP which stimulates protein kinase G stimulates K channel and inhibits Ca channel decreases IC calcium stop Ca coming in increases K going out SM relaxation
EAU focused examination -4
penile deformities
prostatic disease
signs of hypogonadism
cardiovascular and neurological status
EAU investigation
testosterone early morning
lipid
blood glucose
if above 2 not done in last 6 months
definition diabetes
if fasting blood glucose 7 or more
or HBA1C more than 6.5%
lipid profile
total cholesterol more than 4
LDL cholesterol more than 2 mmol/L
hypertension definition
BP more than 140/80
low testosterone what to do if under 12
repeat total T measure albumin nad SHBG calculate free T LH and FSH PSA lipids FBC, LFT
free T treatment threshold
0.225 nmol/l
if total T less than 8 extra tests
check LH and FSH check prolactin check PSA FBC LFT Lipids
symptoms of prolactinoma
ED
gynaecomastia
galactorrhoea
colour doppler result
PSV peak systolic velocity should be more than 30 cm /sec
initial management ED
EAU
identify and treat curable causes
lifestyle changes and risk factor modifications
provide education to patient and partner
BP tablets
lose weight
lipid and BP management
education
efficacy of PDE5i
generally 2/3 will respond
avanafil not as effective
frequency of headache flushing indigestion stuffy nose blue vision backache
headache 10-20% flushing 10-20% indigestion 5-10% stuffy nose 3-5% blue vision sildenafil rare backahe tadalafil 5%
cmax and half life of sildenafil vs tadalafil
sildenafil
cmax 1.6 hours, half life 4 hours
tadalafil
cmax is 2 hours, half life 17.5 hours
action of CYP34A and PDE5i
inhibitors increase levels of PDE5i
ketoconazole, protease ihibitors
inducers decrease levels of PDE5i
rifampicin, phenytoin, carbamazepine
contradindication PDE5i
taking nitrates hereditary retinal degeneration non arterior ION avoid if SBP <90 recent unstable angina
cautions sildenafil
peptic ulcer autonomic dysfunction bleeding anatomical deformity priapism risk SCD multiple myeloma leukaemia
cons of injection therapy
expensive lack sponaneity pain, fibrosis, priapism high drop out invasive
CI to injection
priapism risk
SCD
can use in PD but not in original trial
can use with anticoagulation but not in licence
size of needle with IC injection
28G needle
side effects alprostadil
1/3 will get burning pain in penis
1% priapism
2% fibrosis risk
golden rules of alprostadil
read information
4 hour rule
max 3 times a week - risk fibrosis
as small a dose as possible
instructions MUSE
pass urine put pellet in urethra massage walk around constriction ring
response to MUSE
30-50% in those not tried tablets before
side effects MUSE
pain 3%
urethral bleeding rare
can get syncope which is not effect of injections
dose of MUSE
1000mcg
larger dose vs injection 20 mcg
cons of vacuum device
erection only to ring blue appearance, cool quality of erection pivoting discolouration bruising blocks ejaculation needs manual dexterity
names of penile prosthesis
malleable
2 piece
3 piece
malleable tactra from Boston 2 piece AMS Ambicor 3 piece AMS 700 Boston Coloplast Titan
malleable
pros 4
cons 3
pros easy insertion easy use low mechanical failure moudable
cons
always rigid
lower rigidity
maybe higher erosion rate
IPP
pros 3
cons 3
best rigidity
increase girth and maybe length
best flaccidity
cons
mechanical failure
hard to insert
manual dexterity
couselling for IPP
see with partner see twice last resort irreversible expectations of erection
GIRTH good, increased LENGTH - not as same as normal erection, will only be as long as SPL RIGIDITY - good but no engorgement SENSATION and ejaculation normal GLANS - none
risks IPP
perioperative
injury organs structures 1/50 to 1/250
coroporal rupture
early haematoma infection 1-3 % in virgin case revision complex 6-10% pain - within 4-6 weeks may be subclinical infection wrong size - concord deformity 2-10%
late mechanical failure within 10 years can result in uncontrolled self inflation 5% lasts 10-15 years erosion <5% auto inflation
virgin IPP vs complex IPP infection rate
1-2% vs 6-10%
complex meaning revision or fibrosis or priapism
