Erectile Dysfunction Flashcards
Medication Causes of ED
- Diuretics
- Opiates
- Dopamine antagonists
- Finasteride
- Gemfibrozil
- Spironolactone
What is the least invasive treatment for ED
Vacuum erection device
What is often the first line treatment for ED
oral phosphodiesterase inhibitor
Goal of treatment of ED must consider what?
satisfaction of both the patient and the partner
Vacuum erection Devices (VED) who is this most appropriate for?
Since these are not discreet and can take 30 minutes to work, this is best for couple in a stable relationship
Yohimbine (oral tree bark supplement)
- reduces peripheral alpha adrenergic tone
- so, permits cholinergic tone
When are PDEs contraindicated
if patient is taking nitrate
What is a side effect of PDE isoenzyme type 6?
cyanopsia (seeing with blue tint)
**most common with sildenafil (Viagra)
What is the side effect associated with PDE Isoenzyme type 11?
myalgia and muscle pain
**most common with tadalafil (Cialis)
What is the difference in regards to food and absorption with sildenafil and Tadalafil?
Sildenafil has decreased absorption with food
Tadalafil (Cialis) absorption is not affected by food
Which PDE is not recommended in severe hepatic impairment?
Tadalafil (Cialis)
Which PDE doesn’t have an active metabolite?
Tadalafil (Cialis)
Discuss differences in PDE inhibitors and the cytochrome P450 3A4 system
Sidenafil should be decreased with any potent inhibitor
Tadalafil should be reduced only with the MOST potent (ex. ketozonazole, ritonavir)
What are the 2 most common adverse effects of PDE?
headache
facial flushing
dyspepsia*
nasal congestion*
What is the most concerning ADE for PDEs?
Nonarteritic anterior ischemic optic neuropathy
-sudden, unilateral, painless blindness, which may be irreversible
Who is at risk for NAION - nonarteritic anterior ischemic optic neuropathy?
- smokers*
- 50+
What is the most concerning ADE for Vardenafil (Levitra)
QT prolongation
What most often is the cause for priapism?
excessive dosing
Priaprism Treatment
- Ice packs on perineum and penis
- Walk up stairs
- Oral pseudophedrine (alpha-agonist effect)
- Aspiration of corpus cavernosum
- injection of alpha-adrenergic agent (phenylephrine, epinephrine, or methylene blue into the corpus cavernosa)
Third Princeton consensus conference for cardiovascular risk stratification: Low risk
- asymptomatic cardiovascular disease with <3 risk factors
- Well controlled HTN
- Mild CHF
- Mild valvular disease
- MI >8 weeks ago
Can a low risk patient be started on a phosphodiesterase inhibitor?
yes
Third Princeton consensus conference for cardiovascular risk stratification: Intermediate risk
- > 3 CV risk factors
- Mild/Moderate stable angina
- Recent stroke in past 2-8 weeks
- Moderate CHF
- History of stroke, TIA, or PAD
Can an intermediate risk patient be started on phosphodiesterase inhibitor?
complete CV workup with treadmill stress test to see if they are healthy enough for sexual activity (then, reclassify as low or high risk)
Third Princeton consensus conference for cardiovascular risk stratification: High risk
- Unstable angina
- Uncontrolled HTN
- Severe CHF
- Recent MI in past 2 weeks
- Moderate to severe valvular disease
- High-risk for arrhythmias
- obstructive hypertrophic cardiomyopathy
Who is testosterone indicated for?
- Decreased libido**
- Confirmed low serum testosterone
Best time to measure testosterone?
early morning (8am)
What other lab value needs to be assessed with testosterone?
lutenizing hormone (LH) to distinguish primary versus secondary hypogonadism
Testosterone contraindications
- If normal serum testosterone
- asymptomatic with hypogonadism
- isolated erectile dysfunction
Why are (oral testosterones) methyltestosterone and Fluoxymesterone not recommended?
- extensive first pass hepatic catabolism
- associated with hepatotoxicity**
What is important to consider about buccal testosterone supplements?
remove before every morning and evening toothbrushing
What is important to remember about IM testosterone?
ADEs:
- Mood swings*
- Gynecomastia (excess testosterone is converted to estradiol)
- Polycythemia
- Hyperlipidemia
Where should transdermal testosterone supplements be placed?
- upper arm
- Back
- Abdomen
- thigh
How long should you avoid swimming, showering, or washing administration site after placing transdermal testosterone?
3 hours after application
Where is the testosterone transdermal spray placed?
front and inner thighs
Where should Testosterone transdermal solution (Axiron) be applied?
- Axilla
- Apply testosterone AFTER deodorant is in place
How long does it take the subcutaneous implant pellet form of testosterone to work?
Takes 3-4 months to work
must be given by trained health professional
Which testosterone formulations put serum testosterone in normal range, produce normal circadian pattern of serum testosterone and produce normal pattern of serum concentrations of androgen metabolites?
- Transdermal patch
2. Transdermal gel
Which testosterone formulations only give normal serum testosterone concentrations but not normal cicadian pattern and normal androgen metabolites?
- IM
- Subcutaneous implant
- Buccal system
What is the name of the intracavernosal injections?
Alprostadil (Caverject)
What is the name of the intraurethral medication for ED?
Alprostadil (MUSE)
What does Alprostadil (Prostaglandin E1) stimulate?
adenylcyclase which leads to increased production of cAMP–>smooth muscle relaxation of the arterial blood vessels and sinusoidal tissues (enhanced blood flow)
Why does MUSE (intraurethral alprostadil) have minimal systemic absorption?
most is removed by first pass through the lungs!
