erectile dysfunction Flashcards
interpersonal relationship among 2 people in romantic relationship, who may or may not be actively engaged in sexual relations
intimacy
experience of pleasure from one’s senses leading to an increased awareness of an appreciation for one’s own body
sensuality
any combination of sexual behaviour, sensual activity, emotional intimacy, or sense of sexual identity (a bio-psyco-social process + cultural and interpersonal factors)
sexuality
consistent or recurrent inability of male to attain and maintain an erection of the penis sufficient to permit satisfactory sexual intercourse
ED
inability of male to perform sexual act
impotence
dick changes with aging
Arousal becomes delayed, less rigidity in erection
Weaker, shorter orgasms
Prolonged plateau and diminished urge to ejaculate
More rapid detumescence with a prolonged refractory period
physiology of a flaccid penis
SNS
arterial and smooth muscle contracted
physiology of an erect penis
PNS
NO primary mediator
vasodilation + decrease in peripheral vascular resistance
pulmonary RF for ED
COPD, OSA
endocrine RF for ED
hypogonadism (meh), DM, obesity
CV RF for ED
HPTN, hypercholesterolemia, vascular disease, strole
why is a man with ED a cardiac pt until proven otherwise
endothelial dysfunction leads to ED leads to early death
lfiestyle RF for ED
obesity
sedetary lifestyle
bike riding
smoking, alcohol
shift work
poor diet
COVID can cause ED through mechs like
endothelial dysfxn, psyc distress, impaired pulmonary hemodynamics, exacerbation of CV diseases, impact on T levels, sensory loss
what Anti-HPTN drugs worsen ED? which would be chosen instead
worsen: BB, thiazides, aldosterone antagonists, centrally acting
better: CCB, ARB, ACEi
what hormone affecting drugs worsen/ cause ED
antiandrogens: spironolactone, cimetidine
CS, E, P, GnRH agonists, 5alpha reductase inhibitors
which psyc meds worsen ED
SSRIs, SNRIs, TCAs, MAOi, 1st gen neuroleptics, risperidone
which psyc meds are preferred for ED
buproprion, mirtazapine, quetiapine, olanzapine, aripiprazole
list 3 assessment tools for ED
SQoL assessment, self esteem and relationship questionnaire (SEAR), erectile dysfunction inventory of tx satisfaction (EDITS), # of events (penetration, attempts), international index of erectile function (IIEF)
what are first line ED tx
PDE5i, psychotherapy
what are second line ED tx
IV inj, intraurethral suppositories, vacuum erection device
nonpharm ED tx
Counseling of both partners
Lifestyle: smoking cessation, avoid EtOH, substance misuse, healthy diet, exercise, adequate sleep
pharm classes for ED
PDE1
prostaglandin E1
MUSE
injections
trazodone
PDEi response for ED is ____ in diabetics
lower
PDEi response is ______ dependent
dose
PDEi SEs
flushing, headache, dyspepsia, nasal congestion, visual disturbances (more with sildenafil)
PDE5i may increase risk of
malignant malenoma or basal cell carcinoma
PDEi eye safety
nonarteritic anterior ischemic optic neuropathy (NAION)
new/ worsening glaucoma
change in colour perception
how do PDEi change colour perception
PDE6 interacts with sildenafil in retina for blue tinged vision
what is NAION
Non-arteritic anterior ischemic optic neuropathy (NAION): acute ischemia of optic nerve, infarct may result, visual field defect or vision loss may occur
Counsel pt to inform MD if experiencing vision loss
what is an absolute contraindication for PDE5i
nitrates
CV effects of sildenafil may be potentially hazardous in include (5)
active coronary ischemia (not on nitrateS)
CHF and boarderline low BP
boarderline low volume status
complicated, multidrug AHA regimen
meds that can prolong half life (P450 3A4i, 2C9i)
PDEi should monitor for dizziness with
alpha antagonists
how long to trial PDEi
4 mths
what is the only PDEi you can use on demand
tadalafil 20mg
how long before sex to take sildenafil
30min-4hrs
how long before sex to take tadalafil
stat = 20mg (max 3x/wk)
15min-36h if 5mg daily
how long before sex should you take vardenafil
15min-4hrs
which PDEi have their Cmax decreased with high fat meal
sildenafil, verdenafil
which PDEi is most associated with visual disturbances
sildenafil
prostaglandin E MOA
↑ cAMP = SM relaxation, vaso occlusion, erection (endogenous NO not required)
how long before sex to inject Prostaglandin E1
<1hr, erection can occur within 5min
max usage of sildenafil
1dose/d
max use of vardenafil
1dose/day
max use of tadalafil
3 on demand 20mg doses/ week
one 5mg/day
max use of PGE1
1 dose/24h, 3 doses/wk
when are PGE1s used
when systemic therapies are CI
- inject into area instead
PGE1 AEs
penile pain, priapism
PGE1 contraindications
any condition that increases the risk of priapism (sick cell anemia, multiple myeloma, leukemia, anatomical penile deformity)
MUSE is
alprostadil- a PGE1
what should you use for ED pts who refuse injections + failed on PDEi
MUSE
aloprostil AEs (MUSE)
penile pain, urethral burring, vaginal irritation for partner
which meds are used for ED injections
papaverine
phentolamine
PGE1
what is triple therapy for ED
papaverine
phentolamine
PGE1
papaverine is a _____ with MOA ______
nonspec PDEi
↑cAMP and cGMP in penile erectile tissue
papaverine SEs
penile fibrosis, potential hepatotoxicity
phentolamine is a ___________ and blocks ___________
alpha 1,2 selective antagonist
blocks sympathetic receptors that controls tone
drawbacks of injections for ED include
nonspontaneous, manual dexterity, eyesight, priapism, fibrosis, dropout/ adherence
trazodone MOA for ED
facilitates 5HT and DA pathways
trazodone SEs
priapism, sedation
which NHPs are used for ED
yohimbine
panax gingseng
butea superba
L-arginine
Yohimbine MOA
a2-antagonist, acts at brain center to control libido, penile erection
yohimbine is used for ____ ED with evidence of ____
psychogenic ED
mixed evidence but superior to placebo
panex gingseng MOA
increase cGMP + relaxation of corpus cavernosum
role of panax ginseng
psyc ED
which NHP is not recommended rn for ED
1. yohimbine
2. panax ginseng
3. butea superba
4. L0arginine
3
L-arginine MO for ED
NO production
role of L arginine in ED
use with PDE5i if resistant
most effective tx for ED
1. PDEi
2. penile devices
3. penile prosthesis
4. NHPs like yohimbine
2
how to monitor for efficacy of ED tx
dose required, number and quality of erections after taking meds
internationl index of erectile function
secual encounter profile
what is classified as priapism
Unwanted erection lasting >4hrs + not associated with sexual desire
what is the danger with priapism
if >36hrs = permanent ED
better chances if restoring normal fxn if ER fast
what is the most common type of priapism
low flow
tx of priapism
early stage = ice packs and cold showers
analgesia
decompression (remove at least 5ml)
intracavernosaal sympathomimetics
oral sympathomimetics
shunt surgery
what re some Intracavernosal sympathomimetics you can use in priapism
phenylephrine for rapid vasoconstriction
what oral sympathomimetics can be given for priapism
terbutaline po 5-10mg, pseudoephedrine po
caution CV risk
