Erectile dysfunction Flashcards by Melicia Sanchez

Erectile dysfunction is likely a result of…

concurrent medical conditions that impair systems necessary for penile erection

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Loss of libido may indicate?

androgen deficiency

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Loss of erections may result from?

arterial/venous, neurogenic, hormonal, or psychogenic causes

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What are Risk factors for erectile dysfunction

HTN
Hyperlipidemia
DM
metabolic syndrome
smoking
chronic ethanol abuse
psychological etiologies

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Which medications can lead to erectile dysfunction?

anticholinergic agents
dopamine antagonists
estrogens, antiandrogens
cns depressants
agents that decrease penile blood flow
BPH tx (finasteride, dutasteride)
HLD tx (gemfibrozil)
opiods

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What are types of sexual dysfunction in men?

increased/decreased libido
erectile dysfunction
delayed ejaculation
retrograde ejactulation
infertility

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Role of PNS and SNS in stimulation of the penis?

“point and shoot”

Parasympathetic - erection
Sympathetic - ejaculate

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specific tx is first initiated with…

the least invasive forms of tx

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Goal of tx for ED

restore the quality of the erection and satisfy the pt/partner

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how do Vacuum erection devices work and who are they most effective for?

have slow onset of action (30 mins) and are not discreet

couple in a stable relationship

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What are oral agents used in ED?

PDE inhibitors: 
Sildenafil (Viagra)
Tadalafil (Cialis)
Vardenafil (Levitra)
Avanafil (Stendra)

Yohimbine (Aphrodyne, Yocon, tree bark) - available OTC
Trazodone (Desyrel)

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ADE’s of Yohibine (Aphrodyne, Yocon, Yohimex, tree bark)

anxiety, insomnia, tachycardia, hypertension

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Which drugs are convenient and effective regardless of the etiology of erectile dysfunction?

phosphodiesterase inhibitors

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phosphodiesterase inhibitors fail in which % of pts??

30-40%

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Contraindications for phosphodiesterase inhibitors

in pt’s taking any dosage formulation of nitrate

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FYI: cGMP is involved in which 2 systems and which drugs work

lungs (bronchodilation)
mass cell degradation

anticholinergics (atrovent, ipotroprium)

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How does phosphodiesterase isoenzyme Type 5 work and where is it found?

decreases catabolism of cGMP

genital tissue
also, peripheral vascular tissue, tracheal smooth muscle, platelets

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where is PDE isoenzyme type 6 found? MC side effects and drug assoc. w/?

Rods and cones of the eye
blurred vision and cyanopsia (tinted blue)
MC w/ Sildenafil

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Where is phosphodiesterase isoenzyme type 11 found and which drug is MC?

striated muscle

Tadalafil

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PDE isoenzyme type 11 is assoc. with?

myalgia and muscle pain

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PDE 5 Dosing instructions for Sildenafil (viagra) and vardenafil (levitra)

food decreases absorption by 1 hour

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PDE 5 Dosing instructions for Tadalafil (cialis)

food does not affect rate or extent of drug absorption,

when taken w/ large amount of ethanol may cause orthostatic hypotension

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PDE 5 Dosing instructions for Avanafil (stendra)

may be taken with food, when taken w/ large amount of ethanol may cause orthostatic hypotension

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Which drug is not recommended in ED for a pt with severe hepatic impairment?

Tadalafil (cialis)

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Eating a fatty meal decreases rate of oral absorption of which 2 PDE inhibitors?

Sildenafil (viagra) | vardenafil (levitra/staxyn)

Which drugs interact with Sildenafil, vardenafil, and tadalafil by causing a rise in serum levels unless you reduce the dose?

any potent cytochrome P450 34A inhibitor | ie. Cimetidine, erythromycin, clarithromycin, ketoconzaole, itraconazole, ritonavir, and saquinavir

Tadalafil doses are reduced only when the drug is used w/

most potent cytochrome P450 3A4 inhibitors | ie. Ketoconazole, Ritonavir

MC ADE's for PDE 5 inhibitors?

``` Headache facial flushing dyspepsia nasal congestion dizziness ```

What is the most worrisome ADE for PDE Inhibitors?

Nonarteritic anterior ischemic optic neuropathy | - sudden, unilateral, painless blindness, which may be irreversible

Which pt's are at risk for Nonarteritic anterior ischemic optic neuropathy

glaucoma, macular degeneration, DM retinopathy HTN undergone eye surgery or have experienced eye trauma pts age 50 y/o or greater smokers

Low back pain is unique to which PDE Inhibitor?

Tadalafil (cialis)

Which ADE is unique to vardenafil?

prolongation of the QT interval

Which 2 drugs have a shorter plasma half live making it more assoc. w/ priapism?

Sildenafil and vardenafil

Tx for priapism

1. oral pseudoephedrine 60-120mg orally 2. aspiration of the corpus cavernosum and intracavernous injection of alpha-andrenergic agents or methylene blue 3. phenylephrine, epi, or methylene blue may be instilled into the corpus cavernosa

Which drugs interact with PDE and what can it cause?

organic nitrates severe hypotension increase tissue levels of cGMP also angina tx (CCB, morphine, adrenergic antagonist)

Serum testosterone levels decrease starting at what age and rate?

40y/o ~10% per decade after

Symptoms of decreased testosterone?

decreased libido, ED, gynecomastia, small testes, reduced growth of body hair and beard, decreased muscle mass, increased body fat

untreated decreased testosterone may cause -->

anemia and osteoporosis

What time of day should you collect serum testosterone concentrations and what should you order with it?

8am | serum luteinizing hormone (LH)

T or F: Testosterone replacement regimens directly correct erectile dysfunction?

FALSE. improves libido therby correcting 2ndary ED

Testosterone replacement regimens should never be administered to..

men with normal serum levels pts asxs w/hypogonadism pts w /isolated ED as only sign hypogonadism

Oral testosterone supplements (Methyltestosterone and fluoxymesterone) are not recommended for use in...

pt's with hepatotoxicity

What is important about dosing testosterone buccal system (striant)

time the dose so that buccal system is removed before every am and evening toothbrushing do NOT chew or swallow

Testosterone cypionate IM injection (depo-testosterone) Contraindicated in...

pts w/severe hepatic or renal impairment

Testosterone cypionate IM injection (depo-testosterone) side effects

mood swings

What pt. education should you give pt on testosterone transdermal patch (androderm)

avoid swimming, showering, or washing administration site for 3 hrs after patch application

Where should you apply the transdermal testosterone supplement - androgel 1.6%?

to shoulders and upper arms

Where should you apply the transdermal testosterone spray (fortesta)?

front and inner thighs

Pt education for Testosterone transdermal solution (axiron)?

limit application to axilla | apply antiperspirant or deodorant before axiron

Who should administer testosterone subQ implant pellet (testopel)

trained health professional

Pt education for testosterone subQ implant pellet (testopel)

clinical onset is delayed for 3-4 months after initial dose

ADE's of oral testosterone?

hyperlipidemia sodium retention *NOT a good choice!!

ADE's of oral alkylated androgens?

hyperlipidemia sodium retention *Hepatoxicity

Intramuscular testosterone cypionate or enanthate ADE's

mood swings, gynecomastia, polycythemia, hyperlipidemia

What is the only testosterone replacement regimen that does not achieve serum testosterone concentrations in normal range?

Oral testosterone

Testosterone subcutaneous implant ADE's

pellet can be extruded accidentally (loss of drug effect)

Buccal system ADE's?

gum irritation, bitter taste

Which testosterone replacement regiment achieves normal range of serum testosterone, circadian pattern, and androgen metabolites?

Transdermal gel

T or F: Alprostadil intracavernosal injections and intraurethral pellets are effective independent of etiology of erectile dysfunction? How many fail tx?

Trueee 1/3 of pt's

Who administers Alprostadil?

the pt. | intracavernosal injection and intraurethral pellets

What is an example of an intraurethral drug?

Alprostadil (MUSE)

What are examples of intracavernosal agents?

Alprostadil (Caverject and Edex) Papaverine Phentolamine

MOA of Alprostadil -- Prostaglandin E1 (Caverject and Edex intracavernosal?

causes smooth muscle relaxation of the arterial blood vessels and sinusoidal tissues in the corpora --> enhanced blood flow to and blood filling of the corpora

How long does the erection last with Alprostadil -- Prostaglandin E1 (Caverject and Edex intracavernosal?

no longer than 1 hour directly related to the dose

What is the efficacy of Alprostadil -- Prostaglandin E1 (Caverject and Edex intracavernosal?

70-90%

T or F: Intraurethral Alprostadil (MUSE) can be combined with VED?

trueeee

Pt education of Intraurethral Alprostadil (MUSE)

administer 5-10 mins before sexual intercourse | empty bladder beforehand, voiding completely

what is Penile prothesis?

surgical insertion of a prothesis is most invasive tx of ED

Which PDE lasts 24-36 hours and inhibits PDE-11?

Tadalafil (Cialis)

Which PDE does not have an active metabolite?

Tadalafil (Cialis)