Erectile Dysfunction Flashcards by Mason Truong

Erectile dysfunction is defined as…

Persistent/recurrent inability to achieve/maintain an erection of sufficient rigidity to perimit satisfactory sexual activity for at least 3 months

Sexual dysfunction is more encompassing but may include ED

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Recall that an erection occurs via complex interaction between…

Vascular, hormonal, neurological, and psychological systems

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The neurological pathway of erection physiology focuses on…

ACh increasing levels of cGMP, cAMP, and nitric oxide - resulting in smooth muscle relaxation that increases arterial blood flow.

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ED may occur via any abnormality in…

Vascular, hormonal, neurologic, or psychogenic systems

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Up to 25% of ED cases are ____

Medication-induced

Notably with temporal timing

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Major risk factors for ED include…

Older age
Lifestyle factors (tobacco, obesity, sedentary)
Medical conditions
Medications

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Vascular causes of ED are mostly centered around…

Disease states that compromise vascular flow to corpora cavernosum - most common cause of ED

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Associated medical conditions that cause vascular ED include….

Diabetes
Atherosclerosis
HTN
Renal or liver disease
Cigarette smoking
Radiation

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ED in healthy men with no other symptoms may be associated with…

Early (subclinical) signs of CAD

Both ED and CAD are linked - both consequences of endothelial dysfunction, leading to restrictions in blood flow

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If a person presents with ED they should have these checked…

BP, BG, cholesterol

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ED is more prevalent in those with diabetes, compared to those without. This is due to…

Vascular and neurogenic mechanisms

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Risk of ED associated with diabetes is related to…

Duration and degree of glycemic control

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ED often occurs ____ than in those without diabetes, and may be…

Earlier - may be the presenting symptom

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Response to PDE5 inhibitors seems to be ____ in patients with diabetes, therefore…

Lower - higher doses are frequently needed

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Regarding the neurological system of ED, sexual arousal causes nerve impulses to travel from the brain, via spinal cord to the genital region:
Conditions that impair nerve conduction to the brain include…

Spinal cord injury
Stroke
Pelvic trauma
Prostate surgery

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Parkinson’s
Alzheimer’s
MS
Epilepsy
Diabetic or alcoholic neuropathy

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Regarding the hormonal aspect of ED, this is the main hormone involved…

Testosterone

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Testosterone levels ____ with age, which could contribute to…

Decline = Decreased libido - secondary ED

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Common causes of ED that may be psychogenic include…

Stress
Performance anxiety, fear, relationship issues
Depression, other mental disorders

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To help with psychogenic-related ED, this could be tried…

Psychotherapy as monotherapy or as adjunct to pharmacologic treatment - typically see greater response compared to organic (vascular) disease

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Diagnosis of ED usually involves the following…

Analysis of sexual, medical, social, and medication history - can use standardized questionnaires
Physical exam (pulses, hypogonadism)

Lab tests sometimes

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Goals of therapy for ED treatment include…

Improving sexual satisfaction + intimacy
Improving sexual quality of life
Improve overall quality of life

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Non-pharmacologic treatment for ED include…

Study These Flashcards

Improve diet + exercise
Smoking cessation
Limit alcohol + recreational drug use
Psychotherapy

Efficacy of non-pharm treatment is…

Study These Flashcards

A good recommendation to improve overall health - may be sufficient alone in some cases

May improve effectiveness of treatment

Usually recommended in adjunction to drug therapy

1st line therapy for ED is...

PDE5 inhibitors

PDE5 inhibitors include these 3 drugs...

Sildenafil Vardenafil Tadalafil ## Footnote They have different PK profiles

Phosphodiesterases is an enzyme that inactivates ____, which function is to...

cGMP - helps with smooth muscle relaxation + inflow of blood into corpora

The phosphodiesterase that is most prominent in the corpora cavernosa is...

Type 5

MOA of PDE5 inhibitors is to...

Inhibit PDE5 enzyme that degrades cGMP in corpora cavernosa. Facilitates erection by prolonging action of cGMP, enhancing nitric oxide-induced smooth muscle relaxation and vasodilation

When using PDE5 inhibitors, ____ is still required to achieve erection.

Sexual stimulation

Efficacy of PDE5 inhibitors are... | Any differences between the 3 in the class? What improves it?

Similar between the 3 PDE5 inhibitors Improved with education Are dose related (80% at low dose, further 20% at high dose)

The 1st dose of a PDE5 inhibitor can be efficacious, but...

Will likely see improved success, with successive doses

A PDE5 inhibitor should be tried ____ times before judging success

6-8 times

Non-response is determined by a trial of ____ tries under ____ at max dose.

4-6 tries under optimal conditions at max dose

If a patient has non-response to a PDE5 inhibitor, does that mean they cannot use the other drugs in the class?

No - failure with one PDE5 inhibitor does not rule out a trial of another one.

Peak onset of PDE5 inhibitors are ____, therefore, patients should take them...

60 minutes (120 minutes for tadalafil) - take 30-60 minutes prior to intercourse

Duration of PDE5 inhibitors are... | Which one is unique?

About 4 hours, and can be up to 10-12 hours. Tadalafil duration is up to 36 hours | Tadalafil = "weekend drug"

All PDE5 inhibitors are metabolized via...

CYP 3A4 Sildenafil + vardenafil = 2C9 ## Footnote Double check dosing in hepatic impairment

THe PDE5 inhibitors that need renal dose adjustments are...

Sildenafil + tadalafil

Most common AE's with PDE5 inhibitors include...

Vasodilation - headache, flushing, dyspepsia Dizziness, rash, rhinitis

Other possible AE's asides from vasodilatory effects from PDE5 inhibitors include...

Back and muscle pain (tadalafil) Hypotension (sildenafil + vardenafil > tadalafil) Color visual changes, blurred vision, increased light sensitivity

These are contraindicated with PDE5 inhibitors, because...

Nitrates - vasodilator action of nitrates are amplified and may be fatal

How long should nitrates and PDE5 inhibitors be spaced out?

Sildenafil + vardenafil - 24 hours Tadalafil - 48 hours

Other notable DI's with PDE5 inhibitors include...

CYP3A4 inducers + inhibitors - may have to adjust dose Non-selective alpha1 blockers - possibility of further hypotensive effects Other antihypertensives are fine as long as BP is OK

Serious AE's with PDE5 inhibitors include...

Priapism (long, painful erection lasting 4+ hours) Chest pain Sudden, unilateral hearing or vision loss Possibility of QT prolongation with vardenafil

Sexual activity increases possibility of experiencing ____ - therefore, we should avoid use of PDE5 inhibitors in those at high risk of...

Ischemic events and MI - avoid in those with high risk of CV events (unstable angina, severe HF, recent stroke/MI, high risk arrythmia, uncontrolled HTN)

For those 65+ we should start PDE5 inhibitors at...

The lowest possible dosing first, for CV safety

Alprostadil is another medication for ED that works by...

Stimulating increased production of cAMP, causes smooth muscle relaxation of tissues in corpora to restrict venous outflow

Alprostadil is available as...

Intracavernosal injection Intraurethral insert

Which alprostadil formulation showed better efficacy?

Intracavernosal However note that onset (¬10 minutes) and duration (¬1 hour) is still similar between both

Notable AE's with alprostadil include...

Pain (IC - penile fibrosis, IU - urethral pain, burning sensation in partner) Vasodilatory effects similar to PDE5 - headache, hypotension, dizziness Rare - priapism; but more common compared to PDE5

Papaverine is another ____ injection that works by...

Intracavernosal injection - inhibits cavernosal phosphodiesterase, inhibiting breakdown of cAMP causing smooth muscle relaxation

Papaverine is typically used in lower doses combined with other intracavernosal injections because of...

Dose-limiting AE's | Priapism, corporal fibrosis, hypotension, hepatotoxicity

Phentolamine is another ____ injection that works by...

Intracavernosal injection - non-selective alpha blocker that increases cholinergic tone, improving cavernosal filling

Similar to papaverine, phentolamine is also used in combination with other intracavernosal injections to...

Minimize AE's while maintaing efficacy

Vacuum erection devices work by...

Using a pump that is activated to produce vacuum pressure, drawing arteriolar blood into the corpora cavernosa ## Footnote Non-invasive and good efficacy in stable mature relationships

With female sexual dysfunction, ____ are not effective. If vaginal symptoms are an issue, we could try...

PDE5 inhibitors - vaginal symptoms = topical estrogen to help enhance lubrication, decrease dyspareunia

Erectile Dysfunction Flashcards

(57 cards)