Erectile Dysfunction

Question 1

1. Which of the following distinguishes the PDE-5 inhibitor tadalafil from avanafil,
   vardenafil, and sildenafil?
   A. Efficacy
   B. Safety
   C. Speed of onset
   D. Duration of action
   E. All of the above

Answer 1

D

Question 2

2. Which of the following is/are contraindications to the use of PDE-5 inhibitors?
   A. History of a myocardial infarction 6 months ago
   B. Mild, stable angina
   C. NYHA Class I heart failure
   D. Nitrate use
   E. All of the above are contraindications to the use of PDE-5 inhibitors

Answer 2

D

Question 3

3. Which of the following statements regarding the management of ED is most accurate?
   A. Avanafil has been proven to offer superior efficacy vs sildenafil
   B. Intracavernosal injections are ideal for younger men in new relationships
   C. Penile prosthesis insertion is considered when less invasive options have failed
   D. Intraurethral alprostadil is more effective than intracavernosal alprostadil
   injections
   E. PDE inhibitors may worsen hypertension

Answer 3

C

Question 4

4. Which of the following medication regimens is most likely to promote ED in a patient with hypertension, gastroesophageal reflux, and dyslipidemia?
   A. Losartan, aluminum hydroxide, and fenofibrate
   B. Lisinopril, calcium carbonate, and niacin
   C. Diltiazem, lisinopril, and ranitidine
   D. Amlodipine, calcium carbonate, and fenofibrate
   E. Metoprolol, spironolactone, and gemfibrozil

Answer 4

E

Question 5

5. Which of the following statements is correct regarding PDE inhibitor use for ED?

A. Tadalafil may be taken with a high-fat meal
B. Sildenafil has a significant drug interaction with antiarrhythmic medications
C. Vardenafil’s time to onset of effect is within 10 minutes
D. All are contraindicated in patients taking oral anticoagulants
E. All are considered second-line therapy options in patients with diabetes

Answer 5

A

Question 6

6. A 55-year-old man with ED has recently been prescribed 50 mg of sildenafil for organic ED. He returns upset that it did not work and would like to switch to something else. Which of the following could have led to the failed response?

A. He took the sildenafil on an empty stomach.
B. The dose of sildenafil was taken an hour prior to attempting intercourse.
C. After taking the sildenafil, he waited for a response before approaching his
partner.
D. He attempted multiple times with this dose before returning to his provider.

Answer 6

C

Question 7

7. Which of the following describes how ED should be managed in a patient with CV disease assessed to have high risk according to the Princeton Consensus Conference?

A. Low-dose PDE inhibitor
B. Penile prosthesis
C. Low-dose intraurethral alprostadil
D. VED
E. Patient must be stable and in low to moderate risk to initiate treatment

Answer 7

E

Question 8

8. Which formulation of testosterone replacement is associated with wide swings of serum testosterone concentrations?

A. Daily transdermal testosterone gel
B. Daily transdermal testosterone patch
C. Twice daily buccal testosterone
D. Every two week intramuscular (IM) testosterone cypionate

Answer 8

D

Question 9

9. Which of the following statements are correct regarding VEDs?

A. They are an appropriate first line therapy for young men in new relationships
B. The constriction band may be left on up to 90 minutes
C. They are contraindicated in men taking nitrates
D. Adverse effects include painful ejaculation or inability to ejaculate
E. They should never be combined with other ED therapies

Answer 9

D

Question 10

10. A 68-year-old patient presents to the clinic after initiation of avanafil 200 mg 3 months ago. He continues to be unsuccessful with intercourse despite correct use and appropriate
    expectations. What would be the best approach to his ED treatment at this time?

A. Increase avanafil dose to 300 mg as needed
B. Draw serum testosterone concentrations to assess for hypogonadism
C. Switch to sildenafil 25 mg as needed
D. Combine avanafil at current dose with an α-blocker
E. Initiate spironolactone for treatment of his hypertension

Answer 10

B

Question 11

11. A patient in his 40s presents with complaints of some erections, but not sufficient for intercourse with his new sexual partner. When questioned, he states that he recently ended his marriage, takes no chronic medications, and has excellent past physical and mental health. Which of the following interventions would you suggest first?

A. Initiate a PDE-5 inhibitor
B. Vacuum erection device
C. Counseling and reassurance
D. Penile prosthesis
E. Intracavernosal injections of alprostadil

Answer 11

C

Question 12

12. Which of the following are risk factors for the development of organic ED?
    A. Psychiatric disorders
    B. Neurologic disorders (eg, Parkinson disease)
    C. Diabetes mellitus
    D. Cardiovascular diseases
    E. All of the above

Answer 12

E

Question 13

13. Which of the following statements regarding intracavernosal injections for ED are correct?
    A. Medication should be injected into each cavernosa separately.
    B. Dose titration should occur in the prescriber’s office.
    C. Dose should be titrated to achieve an erection lasting 4 hours.
    D. Patients may use injections daily if desired.
    E. A common side effect is a difficulty discriminating blue from green

Answer 13

B

Question 14

14. The usual dose of sildenafil should be reduced in which of the following situations?
    A. Elderly
    B. Hepatic impairment
    C. Renal impairment
    D. Concomitant use of an α-blocker
    E. All of the above

Answer 14

D

Question 15

15. Which of the following is not a desired characteristic of a therapy for ED?
    A. Lead to an erection lasting more than 4 hours
    B. Minimal side effects
    C. Convenient administration
    D. Quick onset of action
    E. Few drug interactions

Answer 15

A

Question 16

1. A 75-year-old patient presents with new-onset hypogonadism and erectile dysfunction. The serum testosterone concentration has been found to be low and supplementation is initiated using a testosterone gel. Patient education for this type of product includes:
   Select ALL that apply.
   A. Avoid swimming or showering for 2 to 3 hours after application.
   B. Gel should be applied every 2 to 3 weeks.
   C. Use care to prevent the transfer of the gel to children or other adults.
   D. Allow the site to dry

Answer 16

A,C,D,E

Answer: A, C, D, E
Option A: Correct. Water at the site of application should be avoided to prevent washing off
Option B: Incorrect. Testosterone gels are applied once daily (except nasal which is three times
daily)
Option C: Correct. Testosterone transfer to others is a significant problem
Option D: Correct. Allowing to dry and covering reduces the risk of transfer to others
Option E: Correct. Washing hands also reduces the risk of transfer to others

Question 17

2. Which of the following statements are true regarding VEDs?
   A. The device should not be combined with other therapies due to adverse effects.
   B. The device is highly effective for treating ED.
   C. The device allows for a high degree of spontaneity.
   D. The device is contraindicated with nitrate use.

Answer 17

B

Option A: Incorrect. VEDs can be combined with other therapies, which may increase
effectiveness.
Option B: Correct. VEDs are very effective when used by older patients in stable relationships.
Option C: Incorrect. VEDs do not allow for much spontaneity due to the need to pump just before sexual activity.
Option D: Incorrect. Nitrates are contraindicated with PDE-5 inhibitors not VEDs.

Question 18

3. Sexual stimulation leads to the release of ________, which enhances the production of
   __________________ to induce an erection.

A. cGMP, NO
B. NO, ATP
C. NO, cGMP
D. Epinephrine, NO

Answer 18

C

Question 19

4. A 65-year-old man with a prostatectomy history has tried monotherapy with tadalafil, a VED, and alprostadil intracavernosal injections in addition to combination therapy. The patient
   continues to be unsuccessful with intercourse despite correct use and appropriate expectations. What would be the best approach to ED treatment at this time?

A. Switch to lower dose but once-daily tadalafil.
B. Referral for prosthesis.
C. Double the past doses of PDE5 inhibitor and alprostadil injections.
D. Counseling with partner in attendance as we have exhausted all effective options.

Answer 19

B

Option A: Incorrect. Daily tadalafil has not been shown to be more effective than the as-needed dosing.
Option B: Correct. When patients have tried most other options of therapy, prosthesis is the next in line. It is very effective, but the most invasive; so, it is typically the last option.
Option C: Incorrect. Doubling doses would only be effective if the patient was on a
subtherapeutic dose to begin with and would possibly lead to worsening adverse effects.
Option D: Incorrect. Patient should be given the option for a prosthesis before determining nothing is effective.

Question 20

5. Which of the following statements regarding the management of ED is most accurate?

A. Avanafil has been proven to offer superior efficacy versus sildenafil.
B. Intracavernosal injections are ideal for younger men in new relationships.
C. Penile prosthesis insertion is considered when less invasive options have failed.
D. Intraurethral alprostadil is more effective than intracavernosal alprostadil injections.

Answer 20

C

Option A: Incorrect. PDE5 inhibitors all have similar efficacy.
Option B: Incorrect. Intracavernosal injections are ideal for older patients in stable relationships.
Option C: Correct. Prostheses are last line when less invasive options have failed as they are invasive.
Option D: Incorrect. Intraurethral alprostadil (MUSE) is LESS effective than intracavernosal
alprostadil.

Question 21

6. Medication classes associated with erectile dysfunction exacerbations include:
   A. α 1 -Blockers
   B. Opioids
   C. Metformin
   D. Testosterone

Answer 21

B

Option A: Incorrect. α 1 -Blockers are less likely to worsen ED than other antihypertensives.
Option B: Correct. Opioids worsen ED.
Option C: Incorrect. Metformin does not worsen ED and may lead to benefit if it improves
glucose control.
Option D: Incorrect. Testosterone could be beneficial if patient has low serum testosterone.

Question 22

7. A 62-year-old man has been using avanafil 50 mg as needed for 3 months without satisfactory results. With no significant cardiovascular history, drug interactions, or concomitant disease
   states to limit treatment options, which of the following would be the most appropriate next step?
   A. Switch to sildenafil 50 mg as needed.
   B. Increase the dose of avanafil to 100 mg.
   C. Initiate intracavernosal alprostadil injections.
   D. Combine VED and avanafil at current dose.

Answer 22

B

Option A: Incorrect. Efficacy is similar for agents and switching at a similar dose will not increase efficacy.
Option B: Correct. Patient is using low dose avanafil. First step is to increase the dose.
Option C: Incorrect. Intracavernosal injections are not the best choice when the dose of avanafil may be increased and then add or substitute VED if desired.
Option D: Incorrect. Combining VED and PDE5 does increase efficacy, but a dose increase alone is warranted first.

Question 23

8. When prescribing intraurethral alprostadil for ED, which of the following are correct statements?

A. Medication should be injected into the cavernosa.
B. Patient will require training on proper intraurethral administration education.
C. Dose should be titrated to achieve an erection lasting up to 4 hours.
D. Onset of action is 60 to 90 minutes.

Answer 23

B

Option A: Incorrect. Medication is not injected, but is an intraurethral pellet.
Option B: Correct. Patient should receive education on proper administration.
Option C: Incorrect. The dose must be titrated to ensure erection sufficient for intercourse but does not last longer than 1 hour.
Option D: Incorrect. Onset of action is 5–10 minutes.

Question 24

9. Which of the following medications is administered as an intercavernosal injection?
   A. Aveed
   B. Muse
   C. Natesto
   D. Caverject

Answer 24

D

Option A: Incorrect. Aveed given as an intramuscular injection.
Option B: Incorrect. Muse is given as an intraurethral pellet.
Option C: Incorrect. Natesto is an intranasal testosterone gel.
Option D: Correct. Caverject is an intracavernosal alprostadil injection.

Question 25

10. Which situation would necessitate a reduction in the usual starting dose of a PDE-5 inhibitor? A. Combined use with a VED B. Past medical history of hypertension C. Concomitant use of a CYP3A4 inhibitor D. History of a prostatectomy

Answer 25

C Option A: Incorrect. Usual dose is appropriate in combination Option B: Incorrect. Past medical history of hypertension would not necessitate a lower dose. Option C: Correct. CYP3A4 inhibitors would necessitate a lower dose due to reduction in metabolism. Option D: Incorrect. Prostatectomy history may lead to reduced benefit, not a reduction in starting dose.

Question 26

11. RF is a 68-year-old man in the clinic for lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). While discussing treatment options, it is also mentioned that they have been struggling with achieving erections for the past year. Past medical history includes hypertension, GERD, and hypothyroidism. Labs include testosterone at the low end of normal; cholesterol, TSH, lipid profile, prostate specific antigen, and CMP are all within normal limits. Current medications include lisinopril, levothyroxine, and omeprazole. Which of the following are correct statements regarding initial treatment of this patient? A. Initiate tadalafil daily with the possible addition of a selective α 1 -blocker in the future. B. Drug interactions preclude the use of PDE5 inhibitors. C. VED is the best option as PDE5 inhibitors have a low efficacy rate in patients with BPH. D. Initiate doxazosin now for LUTS and add a PDE5 inhibitor in 3 months for treatment of ED.

Answer 26

A Option A: Correct. Tadalafil is indicated for treatment of LUTS in patients with BPS and it may be effective for these symptoms as well as ED. A selective α 1 -blocker would then be added if needed for more control without severe hypotension risk. Option B: Incorrect. There are no drug interactions with PDE5 inhibitors in this patient. Option C: Incorrect. PDE5 inhibitors do not have a lower efficacy rate with BPH, but regardless would start with PDE5, increase the dose, and then substitute or add a VED. Option D: Incorrect. Nonselective α 1 -blockers (doxazosin) would treat LUTS but not ED. In addition, nonselective α 1 -blockers combined with PDE5 inhibitors can induce significant hypotension.

Question 27

12. A 50-year-old patient and a new sexual partner are in the clinic for the patient’s yearly wellness examination. The patient uncomfortably asks about treatment for a new-onset “problem with erections.” When questioned, the patient’s marriage recently ended, they take no chronic medications, and have excellent past physical and mental health. The patient is able to achieve partial erections, but not suitable for intercourse. Which of the following interventions would be the best for initial treatment? A. Initiate a PDE5 inhibitor B. Initiate a VED C. Intracavernosal injections D. Counseling and reassurance

Answer 27

D Option A: Incorrect. Most likely psychogenic dysfunction. Counseling and reassurance is treatment of choice. Option B: Incorrect. Most likely psychogenic dysfunction. Counseling and reassurance is treatment of choice. Option C: Incorrect. Most likely psychogenic dysfunction. Counseling and reassurance is treatment of choice. Option D: Correct. With excellent health and no medications, this is most likely psychogenic dysfunction with a new partner and the ending of a marriage. Counseling and reassurance is the best first step. Can add other treatments as needed.

Question 28

13. A 55-year-old man with ED has recently been prescribed 50 mg of sildenafil for organic ED. They return upset that it did not work and would like to try something else. Which of the following could have led to the failed response? A. Sildenafil was taken on an empty stomach. B. The dose of sildenafil was taken an hour prior to attempting intercourse. C. After taking sildenafil, they waited for a response before approaching their partner. D. Intercourse was attempted multiple times with the same dose.

Answer 28

C Option A: Incorrect. High fat meals would delay the onset of sildenafil. It is recommended on an empty stomach. Option B: Incorrect. Sildenafil should be dosed 1 hour prior to anticipated activity. Option C: Correct. PDE5 inhibitors are not initiators of erections. Sexual stimulation is required after dosing to attain an erection. Option D: Incorrect. Patients should attempt six to eight times with a dose before increasing or switching therapies.

Question 29

14. A 68-year-old patient presents to clinic for follow-up on ED, hypogonadism and type 2 diabetes. Since the last visit, they have experienced ankle swelling and burning and tingling toes. Current medications include metformin, dapagliflozin, lisinopril, hydrochlorothiazide, and testosterone gel. Current A1c is 7%, blood pressure 128/78 mm Hg, hematocrit is 54%, liver enzymes are slightly elevated and electrolytes and renal function within normal limits. Which of the following should be considered adverse effects of testosterone supplementation? Select ALL that apply. A. Elevation in liver enzymes B. Burning and tingling in feet C. Increased hematocrit D. Ankle swelling

Answer 29

A,C,D Option A: Correct. Testosterone supplementation can lead to liver enzyme elevations. Option B: Incorrect. Burning and tingling in feet is most likely due to diabetes. Option C: Correct. Testosterone supplementation can lead to polycythemia. Option D: Correct. Testosterone supplementation can lead to sodium retention and edema.

Question 30

15. A patient diagnosed with ED and hypogonadism 6 months ago is in the clinic with complaints of mood swings and “just not feeling themself” throughout the dosing interval. Their ED has improved somewhat, but it is not resolved. Currently using testosterone cypionate 200 mg IM every 3 weeks. What would be the most appropriate change to therapy? A. Increase testosterone cypionate to 300 mg every 3 weeks. B. Increase the testosterone cypionate dosing interval to every 4 weeks. C. Switch testosterone therapy to oral once-daily dosing. D. Switch testosterone therapy to testosterone gel once-daily dosing.

Answer 30

D Option D. Correct. He is experiencing symptoms of the above and then below physiologic concentrations of testosterone produced by IM injections. A gel would provide a more consistent concentration.