Pharmacotherapy of Erectile Dysfunction

Question 1

Define Erectile Dysfunction

Answer 1

Inability to maintain penile erection sufficient for penetration to permit satisfactory sexual intercouse

Question 2

Psychogenic Causes of ED

Answer 2

Generalized unresponsiveness or inhibition
Situational (performance)
Psychological (mood, stress)

Question 3

Organic Causes of ED

Answer 3

Neurogenic (stroke, parkinson’s, DM, ETOH, Spinal cord injury)
Vascular (PVD, arteriosclerosis, HTN, trauma)
Hormonal (decreased T, hyperprolactinemia, hypothyroidism, hyperthyroidism)
Medication induced

Question 4

Drugs that Induce ED

Answer 4

Anticholinergics
Antidepressants
Antipsychotics
Dopamine antagonists
Estrogens
Antiandrogens
CNS depressants
Antihypertensives
Cigarette and alcohol use

Question 5

Diagnosis

Answer 5

Severity
Complete medical and surgical history
Review of meds
PE
Labs

Question 6

International Index of Erectile Function

Answer 6

15 objective questions (erectile function, orgasmic function, sexual desire, intercourse satisfaction, overall satisfaction
5 categories of severity

Question 7

PDE5 Inhibitors

Answer 7

First line therapy

Effective, PO, low side effect, discreet

Question 8

PDE5 Inhibitor MOA

Answer 8

Normally PDE5 breaks down cGMP which increase calcium which causes SM contraction which decreases blood flow leading to flaccid penis
Inhibitors block this

Question 9

***PDE6 Side Effects

Answer 9

Photoreceptor in the retine leading to increase sensitivity to light, blurred vision, loss of blue green differentiation

Question 10

PDE11 Selective (Tadalafil) Side Effect

Answer 10

Skeletal muscle leading to back and muscle pain

Question 11

PDE5 Inhibitor COntraindication

Answer 11

Nitrate use (hypotension)

Question 12

PDE5 Inhibitor Precautions

Answer 12

Erection > 4 hours can lead to necrosis bc of lack of blood flow
CAD possibility (R vs B)
Hypotension and fluid depletion may be potentiated

Question 13

PDE5 SE

Answer 13

Headache, dizzy, flushing dyspepsia
Priapism (erection > 4 hrs)
Hearing impairment
Visual disturbances
Back pain
Nonarteritic anterior ischemic optic neuropathy

Question 14

Nonarteritic anterior ischemic optic neuropathy

Answer 14

Blood flow blocked to the optic nerve

Rapid onset of painless unilateral vision loss

Question 15

NAION RF

Answer 15

Other visual problems

Longer PDE5 Inhibitor use

Question 16

PDE5 Inhibitor Interactions

Answer 16

CYP 3A4 inhibitors
Antihypertensives
Alcohol

Question 17

Avanafil is good because

Answer 17

It avoids PDE6/11 inhibition

Question 18

Viagra inhibits

Answer 18

PDE5/6 not 11

Question 19

Levitra and staxyn inhibit

Answer 19

PDE5

6 minimally and not 11

Question 20

Cialis inhibits

Answer 20

PDE 5 and 11 NOT 6

Question 21

PDE5 Inhibitors Counseling

Answer 21

Engage in foreplay
Take on empty stomach
Avoid alcohol

Question 22

Alprostadil MOA

Answer 22

Synthetic PGE1

Increase cAMP which causes SM relaxation and increase blood flow leading to prolong erection

Question 23

Alprostadil Pros

Answer 23

Works on Multiple ED etiologies

Pretty good efficacy

Question 24

Alprostadil Cons

Answer 24

Inconvenience (injection into penis/suppository)
Unnatural erection
Cost!!!

Question 25

Alprostadil Contraindications

Answer 25

Anatomical deformity of the penis or predisposure ot priapism

Question 26

Alprostadil Precautions

Answer 26

Bleeding disorder Use of vasoactive agents (hypotension) Cardiac health

Question 27

Alprostadil Side Effects

Answer 27

Penile pain, cavernosal scarring, priapism, bleeding | Dizzy, hypotension

Question 28

Alprostadil Injection Counseling

Answer 28

Room temp Reconstitute prior to use Inject 5-10 minutes before desire erection (last 1 hr)

Question 29

Alprostadil Injections

Answer 29

Side of the penis so it gets to cavernosum (not head or tip) and change the side each time injecting

Question 30

Alprostadil Suppository Counseling

Answer 30

Refrigerator Empy bladder before use Walk around to help erection develop (5-10 minutes) - last 1 hr

Question 31

Vacuum Erection Devices (VED)

Answer 31

``` 3 Parts (pump, cylinder, and tubing) Vacuum draws blood into the corpora cavernosa 30 minutes to start working First line in monogamous relationships Best in conjuntion with alprostadil ```

Question 32

Hypogonadism

Answer 32

Low T in AM (<300) | Decreased libido, muscle strength, depression

Question 33

Supplemental testosterone

Answer 33

Does not directly treat ED but improves libido (secondary ED)

Question 34

Ideal testosterone replacement

Answer 34

achieve normal testosterone serum, circadian rhythm pattern (peak in AM) and androgen metabolites Minimal side effects

Question 35

Testosterone come in what formulas?

Answer 35

``` PO IM Transdermal Gels Implants ```

Question 36

Testosterone should be caused in?

Answer 36

BPH and prostate cancer Liver toxicity Stop if no improvement in 3 months

Question 37

Testosterone common side effects

Answer 37

Cardio CNS (aggression) Derm (acne) Endocrine (wt gain, hypoglycemia)

Question 38

IM Testosterone has

Answer 38

less frequent dosing but increased side effects

Question 39

Topical patches

Answer 39

Good absorptions | Applied at night

Question 40

Topical Gels

Answer 40

Shoulder upper arms ab NOT genitals | Apply in AM and let dry

Question 41

Yohimbine

Answer 41

Herbal Widely used aphrodisiac Central alpha 2 antagonists (causes vasodilation) NOT RECOMMENDED!!