Erectile Dysfunction Flashcards
1
Q
Terminology
A
- Intimacy: Quality of the interpersonal relationship among two
people in a romantic relationship, who may or may not be
actively engaged in sexual relations. - Sensuality: The experience of pleasure from one’s senses
leading to an increased awareness of an appreciation for one’s
own body. - Sexuality: Any combination of sexual behavior, sensual activity,
emotional intimacy, or sense of sexual identity. - A complex bio-psycho-social process
- Physiological aspects must be understood in the context
of interpersonal and cultural factors - Erectile Dysfunction: The consistent or recurrent inability of
the male to attain and maintain an erection of the penis
sufficient to permit satisfactory sexual intercourse. - Impotence: Inability of the male to perform the sexual act
2
Q
Epidemiology
A
Of all risk factors, age is
the strongest
association
30-39 2.3%
40-49 0 – 9.5%
50-59 2 – 30.8%
60-69 11 – 55.1%
70-79 15 – 53.4%
80+ 64 - 76%
3
Q
Changes with Aging
A
- Arousal
- Delayed
- Less rigidity
- Plateau
- Prolonged
- Urge to ejaculate is
diminished
*Orgasm - Weaker, shorter
*Detumescence - More rapid
- Prolonged refractory
period
4
Q
Pathophysiology
A
Flaccid
* Sympathetic system
* Arterial and smooth
muscle contracted
Erect
* Parasympathetic
system
* Vasodilation, decrease
in peripheral vascular
resistance (PVR)
* Nitric oxide primary
mediator
5
Q
risk factors
A
diabetes
CV CKD
environmental facotrs, lifestyle
see slide 11
Lifestyle
* Cigarette smoking –> damage to vessels
* Sedentary lifestyle
* EtOH use –> excessive can lead to hypogonadism
* Variable but never protective
* Bicycle riding > 3 hours a week or more
* Shift work –> testosterone fluctuations, impotence situation
* Diet
* reduced risk (protective) with Mediterranean diet
◼ Psychological
◼ Stress
◼ Performance anxiety
◼ Partner conflict
◼ Misinformation
6
Q
Risk Factors - Disease
A
- Periodontitis (chronic)
- HIV infection
- Trauma
- Irradiation
- Renal failure
- Hepatic failure
- LUTS (OR = 2.2 – 9.0)
- Pulmonary
- COPD
- OSA
- Endocrine
- DM (OR = 1.5 – 3.6)
- Hypogonadism
- Obesity (OR = 1.5 – 3.0)
- CV
- HTN (OR = 1.3 – 1.8)
- Vascular disease/CAD (OR = 1.3 – 2.2)
- Hypercholesterolemia (OR = 1.2 – 2.3)
- Stroke (OR = 1.3)
- Neurology/Psychiatry
- Depression (1.7-1.8)
- MS
- Alzheimer Disease
- Parkinson Disease
- Spinal cord injury
7
Q
Risk Factors - Disease
* Organ systems
A
- CV
- “A man with ED, even with no cardiac symptoms, is a cardiac
patient until proven otherwise. Perhaps we could say that the 3
‘EDs’ are related: endothelial dysfunction leads to erectile
dysfunction leads to early death.” - Diameter
- Penile artery = 1-2 mm
- Proximal LAD = 3-4 mm
- Meta-analysis
- All cause mortality
- RR 1.24 (CI95, 1.11-1.39)
8
Q
Risk Factors
– COVID
A
Mechanisms * Endothelial dysfunction * Psychological distress * Impaired pulmonary
hemodynamics
* Exacerbation of CV disease * Impact on T levels * Sensory loss (anosmia,
ageusia)
9
Q
Risk Factors - Medication
A
- Antihypertensives
- centrally acting, β blockers, thiazides, aldosterone antagonists
- ACE-I, ARB, CCB generally preferred in ED patients to treat HTN
- Anti-androgens
- spironolactone, cimetidine
- Hormone therapy
- corticosteroids, estrogens, progestins, Gn-RH agonists
- 5-alpha reductase inhibitors
- Psychotropic medications
- Antidepressants (SSRI, SNRI, TCA, MOAI)
- Bupropion, mirtazapine preferred
- Neuroleptics (1st generation, risperidone)
- Second generation preferred (quetiapine, olanzapine, aripirazole)
- Drugs associated with SUD
- tobacco, heroin, cocaine, ethanol
- Analgesia
- NSAIDs (chronic use, high dose)
- Opioids
Antihypertensives –> vascular
- Unsure why thiazidescause it
Spironolactone: gynecomasic, breast pain, estrogenic effect
Cimetdine at high doses
Most antidepressents
10
Q
Assessment/Diagnosis
A
- History
- Sexual function (e.g. onset, duration)
- Medical history (e.g. CV conditions)
- Drug use (e.g. steroids, OTC, prescription)
- Psychosocial (e.g. partner conflict, hx of abuse)
- Physical exam (e.g. urologic, CV)
- Laboratory tests (e.g. T, prolactin, lipids))
- Additional tests (e.g. Dopper U/S, relationship
evaluation)
11
Q
Assessment Tools
A
- SQoL assessment
- Self-esteem and relationship questionnaire (SEAR)
- Erectile dysfunction inventory of treatment satisfaction
(EDITS) - # of events (penetration, attempts)
- International Index of Erectile Function (IIEF)
- 15 questions, 5 domains
- Domains include:
A. Erectile Function
B. Orgasmic Function
C. Sexual Desire
D. Intercourse Satisfaction
E. Overall Satisfaction
12
Q
Goals
A
- How broad are the goals of treatment?
- What can these drug therapies address?
- Consider feasible goals:
- Increased number of erections
- Improved quality of erections
- Restore self-esteem for both partners
- Restore sexual relationship with partner
- Improve QOL
13
Q
Non-Pharmacologic Intervention
A
- Counseling of both partners
- Advantages/Disadvantages
- Lifestyle
- Smoking cessation
- Avoid EtOH, substance misuse
- Healthy diet
- Exercise
- Adequate sleep
14
Q
PDE5 Inhibitors
A
- Response rate:
- 60-80% response (dose dependent)
- 50-55% response in patients with diabetes
Dose (sildenafil) Response rate (%)
25 mg 72
50 mg 80
100 mg 85
15
Q
PDE5 Inhibitors - Safety
A
- Side effects
- Flushing
- Headache
- Dyspepsia
- Nasal congestion
- Visual disturbances (more with sildenafil)
- Safety
- Signal PDE5-I may increase risk of malignant melanoma
or basal cell carcinoma
16
Q
PDE5 Inhibitors –
Ophthalmic Safety
A
- Non-arteritic anterior ischemic optic neuropathy
(NAION) - Acute ischemia of the optic nerve
- Infarction may result
- Visual field defect or vision loss may occur
- Patient counseling: inform MD if experiencing vision loss
- Glaucoma
- Case reports of worsening or new onset glaucoma
- Change in colour perception
- PDE6 interaction with sildenafil in the retina
- Blue tinged vision
not enough blood perfuson for eye,blood being pulled away
17
Q
ACC/AHA Risk
A
- Absolute contraindication:
- Use of PDE-5 inhibitors and concurrent use of nitrates
- Cardiovascular effects of sildenafil may be potentially
hazardous in: - Patients with active coronary ischemia (not on nitrates)
- Patients with CHF and borderline low BP
- Patients with borderline low volume status
- Patients on complicated, multi-drug, antihypertensive regimen
- Patients taking medications that can prolong t1/2 (P450 3A4 inhibitors;
2C9 inhibitors) - Warnings/Precautions
- non-selective alpha-antagonists (e.g. terazosin, doxazosin)
- Black-box warning in USA
- selective alpha-antagonists (e.g. tamsulosin)
18
Q
PDE5 Inhibitors – Treatment
Failure
A
- Rx renewal
- 4 months = 60%
- 12 months = 30%
- Reasons for failure
- People
- Health professional issues
- Patient
- Partner
- Condition
- ED, comorbidities
- Treatment
- Drug (choice, dose)
19
Q
Prostaglandin E1
A
- MOA: Increases cAMP, leading to smooth muscle
relaxation, veno-occlusion, and erection - Note: endogenous NO not required
- Response rate = 70-90%
- Role: local therapy used when systemic therapy
contraindicated - Dose
- start 1.25 mcg
- Usual dose = 10 mcg
- Given <1 hr prior to sexual activity
- Erection can occur within 5 min
- Max = 1 dose/24 h
- Max = 3 doses/week
- Inject into corpus cavernosum, on sides of penis
20
Q
Prostaglandin E1
* Side effects
conta
A
- penile pain (tx 37% vs placebo 2%)
- Priapism (4%)
- Contraindications
- Any condition that increases risk of priapism
- sickle cell anemia, multiple myeloma, leukemia, anatomical
deformity of the penis
Do not inject on top of penis
IV injection of vasodilator and can pass outt
only have to inject one sidie and both sides will become erect
21
Q
MUSE
A
- MOA: As per prostaglandin E1
- 30-50% response rate
- Role: local therapy for patients who refuse injection
- Dose: 15-30 min prior to intercourse
- Starting dose = 125 mcg
- Max = 2 doses/24 hr
- Caution if partner is pregnant
- AE: penile pain (32%), urethral burning (12%)
vaginal irritation (partner)
22
Q
Triple Therapy
A
- PAPAVERINE
- Nonspecific phosphodiesterase inhibitor
- Increases cAMP and cGMP in penile erectile tissue
- Dose: 5-45 mg intracavernosal injection
- SE: Penile fibrosis, Potential hepatoxicity
- PHENTOLAMINE
- -1, -2 selective antagonist
- blocks sympathetic receptors that control tone
- Dose: 0.5 mg (range 0.25 – 1.5 mg) intracavernosal injection
- TRIPLE THERAPY
- Papaverine + Phentolamine + PGE1
23
Q
Drawbacks of Injection Therapy
A
- Non-spontaneous
- Manual dexterity
- Eyesight
- Priapism
- Fibrosis
- Drop-out/Adherence
24
Q
Natural Health Products
* Many products promoted but few have clinical trials
A
- Yohimbine
- MOA: 2-antagonist, acts at brain centre to control libido, penile
erection - Dose: 5.4 mg po TID or 15 mg daily (daily dose often used in
combination) - Evidence: mixed results; superior to placebo
- SE: Mild BP elevation, palpitations, nervousness, irritability
- Role: psychogenic ED
- Panax ginseng
- MOA: increase cGMP; relaxation of corpus cavernosum
- Dose: 600-1000 mg TID
- Evidence: meta-analysis of 7 human trials
- Role: subgroup of psychogenic ED greatest benefit
- Butea superba
- Other names: Kwoa Krua Dang
- MOA: corpus cavenosum relaxation
- Dose: grams of dried plant product
- Evidence: 1 RCT showing benefit; 1 RCT compared to
sildenafil which was negative - Role: not recommended at this time
- L-Arginine
- L-citrulline converted to L-arginine
- MOA: NO production
- Dose: 1500 – 5000 mg QD - TID
- Evidence: few RCT as mono-tx, but multiple RCTs with PDE5I
- Role: combined with PDE5I if resistant
25
Trazodone
* MOA: Facilitates 5HT and DA pathways
* Dose 50-200 mg
* Side effects: priapism, sedation
26
Penile Prostheses
* 95% response rate * Pharmacology * Analgesia * Antibx x1d post-op * Complications: * Require surgery * Infection * Bleeding * Thrombotic risk * Erosions * Mechanical failure
27
Vacuum Devices
* 98% response rate
* Very low acceptance rate
* Complications:
* Penile edema
* Ecchymosis
28
Investigational Therapy
* Pharmacologic
* BTX-A
* Dopamine receptor agonists (apomorphine)
* Melanocortin receptor agonists
* Potassium channel openers
* Rho-kinase inhibitors
* Vascular endothelial growth factor
* NO synthase
* Non-pharmacologic
* Shock wave therapy
* Stents
* Stem cells
* Platelet rich plasma (PRP) injections
* Others
29
Monitoring of ED Treatment
* Efficacy
* Dose required (titration necessary?)
* Number and quality of erections after taking medication
* General question:
* “Has the treatment you have been taking improved your erections?”
* The International Index of Erectile Function (IIEF, or IIEF-5)
* Sexual Encounter Profile (SEP)
* 5-question patient diary (yes/no)
* Were you able to achieve at least some erection (some enlargement of the penis)?
* Were you able to insert your penis into your partner’s vagina?
* Did your erection last long enough for you to have successful intercourse?
* Were you satisfied with the hardness of your erection?
* Were you satisfied with the overall sexual experience?
* Completed by the patient after each sexual encounter
30
Priapism
Unwanted erection
lasting >4 hours
* Not associated with
sexual desire
* Permanent ED at
36h
* Most common type:
low flow
* High flow is rare;
may occur after
trauma or surgery
* Treatment:
* Early stage – ice packs, cold shower
* Analgesia
* Decompression
* Aspiration of blood (at least 5 mL) – resolves approx. 30% of cases
* Intracavernosal sympathomimetics – resolves approx. 80% of
cases
* Phenylephrine
* Start 50-100 mcg into corpus cavernosum q2-5m
* Titrate to detumescence or until 10 mg total given
* Oral sympathomimetics (note CV risks)
* Terbutaline po 5-10 mg
* Pseudoephedrine po
* Shunt surgery
