ED

Question 1

What is ED

Answer 1

persistent (>/= 3 mths) of failure to achieve OR maintain an erection
—- can be an incomplete ability to have one or inconsistent ability to have one OR not being able to maintain one for long enough

Question 2

What is the prevalence of ED

Answer 2

50% of men have bw age of 40-70
—- increases with age

Question 3

T or F: ED can be a marker for CV disease

Answer 3

T: could indicate something more severe is happening —- athero, DM , poor peripheral perfusion
——- may need some looking into see if something else happening

Question 4

Ethologies of ED

Answer 4

Psychogenic: trauma, anxiety, performance anxiety related

Organic

Question 5

What are examples of organic causes of ED

Answer 5

Vascular: HTN, smoking, CAD. DM (impact BF )

Neurological: SC injury, brain injury, stroke

Hormonal: low test, hypo/hyper thyroid, high prolactin

Local penile factors: fracture, Peyronie’s disease

Drug induced

Question 6

What types of drugs can cause ED

Answer 6

antidepressants: SSRIs, MOAIs, TCAs
antihypertensive agents: BB
other cardiac agents: digoxin
diuretics: thiazide or spiro
hormones
H2RAs
recreational drugs

Question 7

T or F: for an erection to occur need 3 systems working: vascular/BF, neurological + hormonal

Answer 7

T

Question 8

Differences in vascular flow during an erection vs not

Answer 8

limp boi: arterial BF in + out corpora cavernosa

erection: decrease venous outflow + increase arterial inflow via ACH mediated vasodilation (PNS) + cGMP/cAMP

Question 9

Nervous system input into erection

Answer 9

Sacral nerve reflex
— external stimuli integrated into hypo
—- PNS: dopamine —- pro erection
—- SNS (alpha): anti-erection

Question 10

Impact of test on Erection

Answer 10

Test stimulate sex drive
— AR on penile arteries + may increase NO + cGMP levels
—- help maintain erection (vasodilation of arterial BVs)

Question 11

T or F: 80% of ED are caused by organic causes

Answer 11

T
- generally originate from 1 or multiple causes

Question 12

What percentage of ED are drug induced

Answer 12

10-20%

Question 13

SS of ED

Answer 13

no erection + decreased libido or other sexual disorders
- low satisfaction

Question 14

ED RF

Answer 14

signs of hypogonadism
weird/abnormal dick
decreases pulses in pelvic region (less BF)
decreased anal sphincter tone

Question 15

T or F: to have ED your test levels need to be low

Answer 15

F- may be low

Question 16

T or F: using the standardized survey (SHIM), a low number indicates more severe ED

Answer 16

T- can use SHIM to get an idea of severity, onset, duration of ED (sexual history)

Question 17

When would DRE be indicated when someone comes to you with ED

Answer 17

If > 50

Question 18

What test levels can be looked at if someone has ED

Answer 18

FBG, A1c, lipids —- worried about something CV
serum T if > 50 OR if younger + decreased libido

Question 19

What is the first treatment option for ED

Answer 19

PDE5 inhibitors

Question 20

Other than PDE5i, what can be used to treat ED

Answer 20

• test if documented hypogonadism
• sexual counselling
• local therapy: intracavernous or intraurethral agents
• vacuum
• surgery

Question 21

MoA of PDE5i

Answer 21

Vasodilator by preventing the breakdown of cGMP to breakdown products
- cGMP: helps cause SM relaxation in BV in CC

Question 22

What is the general onset of the PDE5i

Answer 22

30-60 mins after taking

— avoid taking with fatty meals (delay onset) except T

Question 23

Duration of PDE5i

Answer 23

S+V: 12 hours
T: 36hours

Question 24

For PDE5i to work, what do you still need

Answer 24

Sexual stimulation —- need that release of NO to cause cGMP to be produced

Question 25

What percentage of people respond to PDE5i

Answer 25

70% - if DM: 50-70% — if not working: look into how taking etc

Question 26

What PDE5i can be dosed daily + what is the dose

Answer 26

T: 2.5-5mg daily

Question 27

PRN dose of tadalafil

Answer 27

10-20mg PRN

Question 28

PRN dosing of sildenafil + Vardenafil

Answer 28

S- 50-100mg PRN V: 10-20mg PRN (same as T)

Question 29

What other indications do both sildenafil + tadalafil have?

Answer 29

PAH

Question 30

General AEs of PDE5i

Answer 30

nasal congestion, headache, hearing loss, priapism, NAION

Question 31

Impact of CYP 3A4 inducers of PDE5i

Answer 31

increase their metabolism —- might need higher dose to be effective ex// erythromycin or ketoconazole

Question 32

CYP3A inhibitors + PDE5i

Answer 32

decrease their metabolism —- may need to decrease doses to avoid SEs

Question 33

What are the CI of PDE5i

Answer 33

Nitrates of any form history of priapism

Question 34

What are the visual anomalies that can occur with PDE5i

Answer 34

light sensitivity, blurred vision, impairment of blue-green colour discrimination - dose related + transient - likely associated with weak PDE-6 inhibition (highest with Sildenafil)

Question 35

What is NAION

Answer 35

Nonarteritic anterior ischemic optic neuropathy —- no BF to optic nerve sudden unilateral painless blindness — rare but 2X more likely in those on PDE5i - if happens, stop taking right away - use PDE5i cautiously in those with ocular history (macular degeneration, glaucoma, DM retinopathy ) as well as HTN, dyslipidemia

Question 36

T or F: hearing loss is a SE of PDE5i

Answer 36

T- sudden + normally unilateral —— if occurs, occurs with 1st dose —- goes away once stop taking med ( for 1/3 of pts)

Question 37

What is priapism

Answer 37

persistent erection lasting > 4 hours that is not associated with sexual stimulation or desire — higher risk with S+V> T - categorized as ischemic (urological emergency) or non-ischemic (SL)

Question 38

What pts would be at higher CV risk and require referral to MD for ED rx

Answer 38

moderate stable angina/unstable angina uncontrolled HTN recent MI 2-6 wks stroke non-cardiac sequelae of atherosclerotic disease (stroke PVD)

Question 39

What type of interaction occurs bw nitrates + PDE5i

Answer 39

PD interaction - both cause increase in cGMP —- huge drop in BP — increase risk of MI, CV death etc

Question 40

T or F: don’t administer nitrates within 48 hours AFTER taking S or V

Answer 40

F- after 24 hours —- don’t administer within 48 hours after if taken T

Question 41

What is Alprostadil—- Caverject

Answer 41

Prostaglandin E1 agent - intercavernosal injection (70-90% effective) - causes vasodilation —- inject 5-10 mins before + should get erection within 5-20mins

Question 42

Max use of Alprostadil- Caverject

Answer 42

Max of once daily or 3/week