Managing the Patient with Erectile Dysfunction: What Would You Do?

Transcription

1 Managing the Patient with Erectile Dysfunction: What Would You Do? Florida A & M University College of Pharmacy and Pharmaceutical Sciences 42 nd Annual Clinical Symposium Wayne A. Sampson, M.D. Cross Creek Medical Tallahassee, FL

2 Learning Objectives: Identify medical conditions and medications associated with the development of erectile dysfunction Recognize safe and appropriate use of the phosphodiesterase inhibitors Define the role of medications, other than the phosphodiesterase inhibitors, and non-medication treatments used in the treatment of erectile dysfunction Recall adverse effects, important drug interactions, and patient counseling pearls for patients treated with medications for erectile dysfunction

3 Erectile Dysfunction (ED) Definition: The inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse It is estimated to affect million men in the United States

4 Penile Erection Neurovascular event subject to psychological and hormonal modulation Upon sexual stimulation nerve impulses release neurotransmitters from the cavernous nerve terminals and relaxing factors from the endothelial cells in the penis

5 Penile Erection Several fold increase in blood flow to penis venous plexus located between the sinusoids & the rigid tunic covering the penis are compressed resulting in almost total occlusion of venous outflow Traps blood within the corpora cavernosa & raises the penis from flaccid to erect position Nitrous oxide releases from the nonadrenergic neurotransmitter & the endothelium is likely the principal neurotransmitter for penile erection

6 Sildenafil, Vardenafil, and Tadalafil are drugs currently FDA approved for treatment of ED and they work by blocking phosphodiesterase enzyme activity

7 Causes of ED Psychological Organic Neurogenic Hormonal Arterial Venous Cavernosal Drug Induced

8 Common Mixed Etiologies of ED Psychogenic Performance Anxiety Strained Relationships Lack of Sexual Arousability Overt Psychiatric Disorders Depression Schizophrenia Neurological Disorders Parkinson s Disease Alzheimer s Dementia Stroke Spinal Cord Injury

9 Common Mixed Etiologies of ED Androgen Deficiency Decrease Nocturnal Erections Decreased Libido Hormonal Erection in response to visual stimulation is preserved in patients with hypogonadism suggesting androgen is not essential for erection

10 Hormonal Hyperprolactinemia of any cause results in both reproductive and sexual dysfunction due to the inhibitory action of prolactin on gonadotropins releasing hormone secretion resulting in hypogonadotrophic hypogonadism

11 Vascular Deficiencies: Arterial Insufficiency Risk Factors Hypertension Hyperlipidemia Cigarette Smoking Diabetes Pelvic Irradiation Focal stenosis of common penile artery often occurs in men who have sustained blunt trauma to the perineum

12 Erectile Dysfunction Poor venous occlusion during erection can result an ED Degenerative Changes Peyronie s Disease Aging Diabtes Mellitus

13 Medications Associated with ED: Central neurotransmitter pathways (serotonergic, noradrenergic and dopaminergic) involved in sexual function may be disrupted by psychotropics and centrally acting antihypertensives. Beta-Blockers* Thiazide Diuretics Spironolactone** Cigarettes Alcohol

14 Erectile Dysfunction: Diagnosis Medical, Sexual, & Psychological History Physical Examination of: Breasts Hair Distribution Penis Testis Palpitation of Femoral & Pedal Pulses Testing of Genital & Perineal Sensation Appropriate Labs UA CBC FBG Testosterone Lipids

15 Erectile Dysfunction: Evaluation Evaluate for underlying CVD Diabetes Mellitus Hyperlipidemia Hypertension

16 Erectile Dysfunction: Prevalence In men with new onset of ED there was an estimated 25% increase risk of MI, strokes, angina and TIAs compared to men without ED ED is as important a risk factor for CVD as is smoking or a family history of heart disease Previous results showed that among patients that seek help for ED, nearly 20% had undiagnosed high blood pressure 15% had diabetes mellitus and 5% already had significant coronary artery disease

17 Erectile Dysfunction: Treatment Lifestyle Changes Quit Smoking Lose Weight Increase Physical Activity D/C Drugs with harmful Side Effects Psychotherapy Pharmaceutical Therapy

18 Erectile Dysfunction: Treatment Oral FDA approved Sildenafil (Viagra) in 1998 first oral therapy Multiple additional Phosphodiasterase 5-Inhibitors (PDE) inhibitors have been approved Taken prior to sexual activity

19 ED Treatment: Phosphodiasterase 5-Inhibitors PDE inhibitors work by enhancing the effects of Nitrous Oxide relaxing penile smooth muscle during sexual stimulation and allows increased blood flow First Line Therapy PDE inhibitors should not be used more than once daily Contraindicated with concomitant use of nitrates or alpha blockers hypotension

20 ED Treatment: Yohimbine Dopamine & Serotonin Agonists Trazodone may be effective but studies are inconsistent IM Testosterone

21 ED Treatment: Intracavernosal injections with drugs such as papaverine, phentolamine, and alprostadil modulate endothelial function and induce and maintain erection Intraurethral Injections Pumps: Vacuum Erection Devices Penile (implant) surgery

22 References 1.Andersson KE. Mechanisms of penile erection and basis for pharmacological treatment of erectile dysfunction. Pharmacol Rev. 2011;63(4): Symonds T. The erection hardness score and its relationship to successful sexual intercourse. J Sex Med. 2008;5(10): Kovac JR. A critical analysis of the 2014 CUA guidelines for erectile dysfunction: is there more that can be done? Can Urol Assoc J. 2015;9(1-2): Chou NH, Huang YJ, Jiann BP. The impact of illicit use of amphetamine on male sexual functions. J Sex Med. 2015;12(8): Cao S, Yin X, Wang Y, Zhou H, Song F, Lu Z. Smoking and risk of erectile dysfunction: systematic review of observational studies with meta-analysis. PLoS One. 2013;8(4):e Wu C, Zhang H, Gao Y, et al. The association of smoking and erectile dysfunction: results from the Fangchenggang Area Male Health and Examination Survey (FAMHES). J Androl. 2012;33(1): Shamloul R, Bella AJ. Impact of cannabis use on male sexual health. J Sex Med. 2011;8(4): Bang-Ping J. Sexual dysfunction in men who abuse illicit drugs: a preliminary report. J Sex Med. 2009;6(4): Corona G, Rastrelli G, Monami M, et al. Body weight loss reverts obesity-associated hypogonadotropic hypogonadism: a systematic review and meta-analysis. Eur J Endocrinol. 2013;168(6):