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TREATMENT OF ED • Multiple effective therapeutic options are available (see next slide) • Treatment should be individualized • Choice should be based on: Cause Personal preference Partner issues Cost and practicality Interventions Life style Regular erections for prevention Non pharm. Vacuum constrictive devices medications • Diet (a low-fat, low-cholesterol, plant-based diet) • weight management, regular cardiovascular exercise, and smoking cessation. Life style • Stop or modify drugs increasing ED as possible • Beneficial drugs for ED eg: ACEI , CCBlockers and doxazocin medications • For prevention of ED • The risk of ED was inversely related to intercourse frequency. • Further research is needed in this area. Regular erection ED TREATMENT OPTIONS • Phosphodiesterase-5 (PDE-5) inhibitor • Vacuum tumescence device (external) • Vasoactive drug (injected) • MUSE (intraurethral) • Testosterone (injected or topical) • Surgery ORAL PDE-5 INHIBITORS • Potentiate the penile response to sexual stimulation • Improve the rigidity and duration of erection • Effective for neurogenic conditions • Taken 1 hr prior to sexual activity; last 4–36 hr • No effect until sexual stimulation occurs ORAL PDE-5 INHIBITORS Sildenafil Vardenafil Tadalafil Onset of action 60 min 45 min 45–60 min Duration of action 4 hours 4 hours 24–36 hours CAUTIONS WITH PDE-5 INHIBITORS • Potential side effects Rhinitis Headache Flushing Dyspepsia Transient visual disturbance (sildenafil) • Contraindicated for concomitant use with nitrate drugs, since the combination can produce profound and fatal hypotension • Also contraindicated with α-blocker use Failure of response WITH PDE-5 INHIBITORS • Arteriogenic or venogenic cause • Inadequate dose of vasoactive agent Penile brachial pressure index to assess arteriogenic ED – – – – – – hormonal abnormalities, food or drug interactions, timing and frequency of dosing, lack of adequate sexual stimulation, heavy alcohol use, the patient's relationship with his partner VACUUM TUMESCENCE DEVICES • External device to create negative pressure • Constriction ring placed at base of penis • Effective for neurogenic, venogenic, and psychogenic dysfunction • Requires manual dexterity • Can cause local pain, swelling, bruising, painful ejaculation • Must remove constriction ring after 30 min Vacuum Constriction Devices. INTRACAVERNOUS INJECTION OF VASOACTIVE DRUGS • Alprostadil FDA-approved Erections last 40 to 60 minutes • Phentolamine: used in combination with alprostadil or papaverine, or both • Potential adverse events: bruising, hematoma, local pain, fibrosis, and priapism Alprostadil Intraurethral Suppositories and Intracavernosal Injections. MUSE (Medicated Urethral System for Erection) • Small pellet of alprostadil placed within urethra • Produces erection in 10 to 15 minutes • Possible side effects: Penile pain Urethral burning Throbbing sensation in perineum TESTOSTERONE • Increases libido and may improve ED in men with true hypogonadism • Available as IM injection; transdermal patch, gel • Possible side effects: Polycythemia Increased prostate size Gynecomastia Fluid retention CAUTIONS WITH TESTOSTERONE • Before starting therapy, perform digital rectal exam to assess prostate size and measure baseline prostate-specific antigen (PSA) • Check PSA and hematocrit every 3 months during first year, then every 12 months SURGICAL TREATMENTS FOR ED • Implanted penile prosthesis For neurogenic, arteriogenic, and venogenic erectile failure May result in infection, device erosion, fibrosis • Penile revascularization surgery has had limited success Managing ED in the Presence of Cardiovascular Disease • Guidelines for managing ED in patients with cardiovascular disease developed by the Princeton Consensus Panel recommend assigning patients to one of three risk levels (high, intermediate, and low) based on their cardiovascular risk factors. – High-risk patients are defined as those with unstable or refractory angina; uncontrolled hypertension; congestive heart failure (CHF; New York Heart Association class III, IV); MI or a cardiovascular accident within the previous 2 weeks; high-risk arrhythmias; hypertrophic obstructive and other cardiomyopathies; or moderate-to-severe valvular disease. The document states that patients at high risk should not receive treatment for sexual dysfunction until their cardiac condition has stabilized. – Patients at low risk may be considered for all first-line therapies. The majority of patients treated for ED are in the low-risk category defined as those who have asymptomatic coronary artery disease and less than three risk factors for coronary artery disease (excluding gender); controlled hypertension; mild, stable angina; a successful coronary revascularization; uncomplicated past MI; mild valvular disease; or CHF (left ventricular dysfunction and/or New York Heart Association class I). – Patients whose risk is indeterminate should undergo further evaluation by a cardiologist before receiving therapies for sexual dysfunction. Post Radical Prostatectomy ED • PDE5Is are the first-line choice of oral pharmacotherapy for post-RP ED in patients who have undergone nerve-sparing (NS) surgery. The choice of PDE5Is as first-line treatment is controversial because the experience (surgical volume) of the surgeon is a key factor in preserving postoperative erectile function, in addition to patient age and NS technique. In fact, PDE5Is are most effective in patients who have undergone a rigorous NS procedure √ Early use of high-dose sildenafil after RP has been suggested Definition The penile erection Phases of erection Erectile function in elderly Causes of erectile dysfunction • • • • • Organic – Psychological – Mixed – Diagnosis of ED • History Questionaire Examination Laboratory tests – – – – ED intervention • Non pharmacological – pharmacological –