Module 3.2.2 (Management of ED) 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 (specifically prazosin) by?
4 hours (6 hours with vardenafil)
> because of hypotension
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?
> lower dose may be needed if got side effects
- Trial max dose on 6 different 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 ED treatment 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
treatment for priapism if
A) if present for 2 hours
B) if not subsided in 4 hours
C) >6 hours
A)
- Hot shower and pseudoephedrine 120mg orally (single dose)
> pseudoephedrine = Alpha receptor-mediated vasoconstriction within the corpora cavernosa. Pseudoephedrine is an alpha1-selective adrenergic agonist with no indirect neurotransmitter-releasing action.
B)
- Repeat above, contact doctor or afrter hours/ED
C)
- Aspiration of blood from corpora cavernosa
Treatemnt for premature ejaculation?
- treat underlying cause first e.g. ED
- behavioural therapy (stop and start technique)
> difficult to maintain
- counselling on issues to address anxiety or psychogenic cause
topical
- lignocaine 2.5% + prilocaine 2.5% cream
- apply thinly 10-20min prior to intercourse
- residual cream should be washed off before contact with partner
SSRI
- prn dosing –> less AE such as anorexia, reduced libido or anejuclation, but risk of withdrawal
> dapoxetine 1-3 hours before intercourse (1 dose/ 24 hours)
> sertraline 3-5 hours before intercourse
> paroxetine 3-5 hours before intercourse
- daily dosing = preferred
> paroxetine and sertraline
What CAM possibly effective for ED?
Panax ginseng
1400-2700mg daily has improved sexual function in men with ED
What CAM possibly effective for PE?
Multi-ingredient cream containing Panax ginseng (SS Cream) –> applied to the glans penis 1 hour prior to, and washed off immediately before intercourse
