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PR3152 Study Deck - Pharmacotherapeutics > Erectile Dysfunction > Flashcards

Erectile Dysfunction Flashcards

1
Q

Define erectile dysfunction.

A

Persistent (at least 6 months) inability to achieve / maintain an erection of sufficient duration and firmness to complete satisfactory intercourse

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2
Q

Describe the physiology behind an erection
HINT: Blood flow, smooth muscle, parasympathetic system and functional hormonal system

A

Arterial blood flow into penis increases while venous blood flow out of penis decrease

Upon erection, smooth muscle relax to allow the corpora cavernosa to fill up with blood. Swelling occurs and thus, the compression of venules against the tunica albuginea

Parasympathetic system is activated due to ACh. Increase nitric oxide lead to increase in activity of GMP and hence cGMP. Furthermore, ACH and prostaglandin E also increasea adenyl cyclase and cAMP. Therefore, smooth muscle vasodilation occurs, increasing blood flow

The production of testosterone also encourages libido

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3
Q

Describe what happens after an erection when the penis is flaccid.

A

Deactivation of parasympathetic system occurs when cGMP is deactivated by PDE5

Activation of sympathetic system occurs when alpha 2 adrenergic receptors are induced causing smooth muscle contraction and reducing blood flow

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4
Q

What are the subgroups of organic etiology behind ED? In each subgroup, name an example.

A

Vascular: Arteriosclerosis, peripheral vascular disease, hypertension, diabetes

Hormonal: Hypogonadism, hyper-prolactinemia (suppress testosterone production)

Nervous system:
- Central: stroke, CNS trauma, spinal cord injuries
- Peripheral: Diabetes, Neuropathy and urethral surgery

Medication induced: too many

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5
Q

Name the medications associated with ED and their mode of action.
NOTE: To refer to notes for alternatives to consider

A

Clonidine, methyldopa, beta blockers (except nebivolol), thiazide diuretics
- Decrease penile blood flow

Anticholinergics: decrease ACh activity

Dopamine antagonist (e.g. metaclopramide): decreases dopamine

Selective serotonin reuptake inhibitors : decrease serotonin and testosterone

5ARI: Finasteride, Dutasteride : decrease testosterone

CNS depressants (e.g. benzodiazepam, anticonvulsants): suppress psychic stimulus

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6
Q

What are some psychogenic etiology of ED

A

Malaise
Loss of attraction
Stress
Performance anxiety
Mental disorders
Sedation

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7
Q

What are other etiology of ED?

A

Smoking
Obesity
Alcohol
Illicit drug use

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8
Q

What are the signs and symptoms of ED besides the inability to achieve an erection?

A

Loss of interest in sexual activity
Depression
Performance anxiety
Embarrassment
Anger
Low self esteem
Disharmony in a relationship

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9
Q

How is an erectile dysfunction diagnosed?

A

Assess patient sign and symptoms
Use sexual health inventory for men scoring system
Identify underlying cause of erectile dysfunction by checking medical. social and surgical history
Conduct any labs if needed (blood; lipid; testosterone)

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10
Q

What does the score in SHIM mean?

A

Mild / no ED: 17-21
Moderate to severe: < 11

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11
Q

Why is a CV evaluation needed for all patients with erectile dysfunction?

A

Sexual activity causes sympathetic activation. Increase BP and HR. Increasing the risk of myocardial infarction

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12
Q

What should I do for patients who come back with high risk of CVD from their CV evaluation?

A

Cardiac rehabilitation
Regular exercise

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13
Q

What are some nonpharmacological advice to give patients with ED?

A

Address the modifiable risk factors such as smoking cessation, weight control, control glucose, BP and lipids; exercise and decrease alcohol intake

Psychotherapy

VED

Surgery

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14
Q

What are some pharmacological agents to consider giving patients?

A

PDE5 inhibitors
Testosterone replacement
Alprostadil

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15
Q

What is the mechanism of action of PDE5 inhibitors?

A
  1. Inhibit PDE5 enzyme
  2. Induce catabolism of cGMP
  3. Enhance cGMP activity
  4. Induce smooth muscle relaxation
  5. Erection
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16
Q

What are the 4 agents of PDE5 inhibitors used in ED?

A

Sildenafil
Vardenafil
Tadalafil
Avanafil

17
Q

Can PDE5 inhibitors work immeadiately?

A

No. Requires sexual stimulation to enhance erection and hence adviced to take it before sex

18
Q

Which PDE5 inhibitors require hepatic dose adjustment?

A

Sildenafil, Vardenafil and Tadalafil

19
Q

Which PDE5 inhibitors require renal dose adjustment?

A

Sildenafil and Tadalafil

20
Q

Which PDE5 inhibitors must be taken on an empty stomach?

A

Sildenafil
Vardenafil

21
Q

What group of patients should a lower initial dose be considered?

A

Patients > 65y
Those on alpha blockers
Those with renal failure
Those taking CYP3A4 inhibitors

22
Q

What are the general adverse effects of PDE5 inhibitors?

A

Headache
Rhinitis
Backache
Flushing
Muscle and back pain
Dizziness
Hypotension

23
Q

What are some major adverse events to look out for those on PDE5i?

A

Prolonged erection: to seek ED if > 4h

Sudden hearing loss

QTc prolongation : Vardenafil

Muscle pain due to tadalafil high PDE 2 affinity

24
Q

What is a red flag seen in sildenafil and vardenafil and why does this occur?

A

Ocular problems such as color discrimination, sensitive to light, norarteritic anterior ischemic optic neuropathy (NAION)

Both agents have increased affinity to PDE6 in the retina

25
Q

What are some risk factors of NAION? Why does it occur?

A

Risk factors: DM, smoking, HTN, CVD, Dyslipidemia, more than 50 years

Happens when blood flow to optic nerve is blocked

26
Q

What are potential drug drug interactions to consider for those on PDE5 inhibitors?

A

Nitrates
Antihypertensives
Alcohol
CYP3A4 inhibitors: Increase PDE5 inhibitor concentration

27
Q

How should safety be monitored for those on PDE5 inhibitors?

A

Check for BP, side effects, DDI and cardiac health status

28
Q

What should you check for in the event of a failure upon initiation of PDE5 inhibitors? If not, what should be done?

A

Check if the PDE5i was
- Administered with food
- timing and frequency of dosing
- Lack of adequate sexual stimuli
- Titrated to max dose

Change to a different class or consider invasive therapy

29
Q

What is the purpose of testosterone?

A

Restore serum testosterone to normal range

30
Q

What are the indications of using testosterone for ED?

A

Symptomatic hypogonadism which is confirmed by low libido and serum testosterone concentration

31
Q

What are the adverse drug reactions of testosterone therapy for ED?

A

Irritability
Aggressive behavior
Undesirable hair growth
High BP
Hepatotoxicity
Dyslipidemia
Polycythemia
Prostatic hyperplasia

32
Q

Who is contraindicated for use of testosterone?

A

Those with prostate cancer

33
Q

What are the monitoring parameters for testosterone in ED? How often should they be monitored?

A

Serum testosterone within 1-3 months and 6-12 months

Discontinue if no improvement after 3 months

34
Q

Describe the mechanism of action for alprostadil.

A

Stimulates adenyl cyclase and increase cAMP
Induce smooth muscle relaxation causing an erection

35
Q

What is DDI to avoid with use of alprostadil?

A

PDE5 inhibitors

36
Q

What are the routes of administration for alprostadil?

A

Intraurethral and intracavernosal (preferred)

37
Q

What is the ADR associated with intraurethral alprostadil?

A

Pain
Warmth / burning sensation
Voiding difficulties
Bleeding / spotting priapism
Partners may experience vaginal burn / itch

38
Q

What are the advantages and disadvantages of using alprostadil intracavernosal?

A

Advantage: High efficacy
Disadvantages
- Invasive
- May lack spontaneity as need to be done before sex
- Great risk of ADR such as priapism, bleeding, hematoma and fibrosis
- Fear of needles
- Complicated administration

PR3152 Study Deck - Pharmacotherapeutics (10 decks)

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