Management of ED 3.2.2 Flashcards
Treatment aim for ED?
Achieve erection adequate for sexual intercourse
Non-pharmacological considerations for ED?
- Diet, exercise, associated weight loss (metabolic)
- Smoking cessation
- Counsellingm, lifestyle changes (psychogenic)
- Modifying drug therapy causing ED
- Addressing substance abuse
What 1st to 4th line for ED treatment options after establishing cardiac fitness for sexual activity
1st line = PDE5 inhibitors
2nd line = Intracavernosal alprostadil and vacuum erection device
3rd line = Intracavernosal combinations (alprostadil, papaverine, phentolamine (SAS))
4th line = Penile implant
Why are PDE 5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) first line drugs? What are their A/Es? Max dose per day?
- Drugs of choice: convenience (oral administration), effectiveness, onset of effect: 30-60 minutes
A/Es: headache (>10%), flushing, dizziness, dyspepsia, nasal congestion/rhinitis
- Avanafil perhaps better tolerated (but less effective)
- Visual effects (sildenafil), back pain (tadalafil), QT prolongation (vardenafil)
NO more than ONE dose per day
Why are PDE5 inhibitors contraindicated with nitrates? How to use if required for nitrates?
Risk of profound hypotension or MI.
- If nitrate needed, allow at least 24 hours (12 hours with avanafil, 48 hours with tadalafil) after a dose of PDE5 inhibitor. Longer if PDE5 inhibitor elimination delayed.
How long to separate dose of PDE5I and alpha blockers by?
4 hours (6 hours with vardenafil)
When are PDE-5 inhibitors CI?
- CI in men in whom sexual intercourse not recommended due to CV risk
- CI with in non-arteritic anterior ischaemic optic neuropathy (NAION) –> avoid when vision loss in one eye = increased risk
What to do if no response to PDE-5 inhibitors?
- Trial max dose on 6 diffreent days 2 hours after meal (avanafil, sildenafil, vardenafil)
- Trial alternative PDE5 inhibitor
- Exclude hypogonadism
What are some considerations for alprostadil (prostaglandin E1)? Can be combined with PDE-5? AE? CI?
Intracarvesonal injection
2nd line when PDE5 inhibitors ineffective C/I (monotherapy)
- Max 1 injection in 24 hours (upto 3/week)
- Dose titration and training in self injection
Combination with PDE 5 = high risk of AE
A/Es: local pain, bruising, haematoma, priapism, cavernosal fibrosis
C/I: genitourinary (e.g. penile implant) when sexual intercourse inadvisable
Papaverine considerations? What is it used with?
- Used alone or in combo with alprostadil
- Intracavernosal injection
- Genitourinary and CV CI/s
What is phentolamine only used with?
Only used with papaverine and or alprostadil injection (SAS)
> higher chances of priapism
Considerations for
A) vacuum erection devices
B) penile implants
C) testosterone therapy
A)
- require dexterity
- generally safe, one-off cost
B)
- last line of treatment
- high success rate
- expensive, requires surgery, implant foreign materials and destroy the cavernosal tissue
C)
- if deficiency diagnosed
What is priapism? Which PDE-5 inhibitor may it occur in and why?
Abnormally prolonged erection
- persistent and painful
- not caused by sexual desire/stimulation
MEDICAL EMERGENCYYY
> result in permamanent damage to cavernosal tissue
- 5-10% of those using alprostadil will experience this during dose titration
What medications cause priapism?
Intracavernosal therapy for ED (most common), PDE5 inhibitors (infrequent with vardenafil), chlorpromazine, corticosteroids, some antihypertensives (prazosin)
What are some physical causes for priapism?
spine/pelvis tumour, sickle cell diseas, leukaemia, blood clots, prostatitis, urethritis, cystitis
