gregory harochaw robin coulter tache pharmacy 400 tache avenue winnipeg, mb r2h 3c3 phone: (204)...
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TREATMENT OF ERECTILE DYSFUNCTION
Gregory HarochawRobin Coulter
Tache Pharmacy400 Tache Avenue
Winnipeg, MB R2H 3C3Phone: (204) 233-3469
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What is Erectile Dysfunction?
The persistent or recurrent inability to obtain or maintain an erection sufficient for sexual activity1
o > 50% of men aged 40 – 70 will have fairly marked erectile problems2,3
o Incidence is on the rise due to aging population & and prevalence of conditions that are the root of the problem (i.e. diabetes, cardiovascular disease)2
1. Hatzimouratidis K, and Hatzichristou D. Sexual dysfunctions: Classifications and definitions. Journal of Sexual Medicine 2007;4:241-250.
2. Fazio L, Brock G. Erectile dysfunction: management update. CMAJ 2004;170(9):1429-1437
3. Feldman HA, Goldstein I, Hatzichristou D, et al. Impotence and its medical and psychosocialcorrelates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61
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Men With ED
ED can have a major impact on the quality of life and self-esteem of men who suffer from it
Men often draw a link between their masculinity and their ability to have an erection
Some men with ED may begin to think that they are no longer a “real” man
This can lead also to affected relationships with partners
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Pathophysiology: Mechanism of an erection
A normal erection relies on the coordination: Vascular Neurological Hormonal Psychological
An erection can occur following direct genital stimulation or auditory or visual stimulation, aspects that contribute to the influx of blood to the penis
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Pathophysiology: Mechanism of an erection
An erection occurs when the amount of blood rushing to the penis is greater than the amount of blood flowing from it
A massive influx of blood accumulates in the sinusoidal spaces due to relaxation of smooth muscle & dilatation of arteries corpora cavernosa to swell (tumescence)
Tumescence compresses the veins that normally drain the penis prevents blood outflow & maintains penile rigidity
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Pathophysiology: Mechanism of an erection
Usually following ejaculation: A reduction in arterial inflow due to
contraction of the smooth muscle cells Combination of increased venous return loss of erection (detumescence)
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Erectile Dysfunction
ED is most often an organic origin (up to 80%)
Can also have psychogenic causes In several cases, it is both
organic/psychogenic in origin mixed-type ED
Anatomy and physiology of erection: pathophysiology of erectile dysfunction.Int J Impot Res 2003;15 Suppl 7:S5-S8.
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Main Organic Causes
Vascular Roughly 40% of cases of ED in men over 50 Vascular problems can impede arterial blood
flow into the penis Examples: diabetes, cardiovascular disease
(hypertension ,dyslipidemia), Peyronie’s disease, smoking, and trauma affecting blood circulation
Feldman HA, Goldstein I, Hatzichristou D, et al. Impotence and its medical and psychosocial
correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61
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Main Organic Causes
Neurological conditions Can lead to interruption in nerve impulse
transmission or the failure to conduct nerve impulses
Examples: diabetic or alcoholic neuropathy, MS, stroke, trauma or surgical procedures involving the spinal cord or pelvis
Brock G. Issues in the assessment and treatment of erectile dysfunction: Individualizingand optimizing treatment for the “silent majority”.
www.medscape.com/viewprogram/1826Accessed January 20, 2009
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Main Organic Causes
Hormone disorders ED that is hormonal in origin can be related to
low circulation blood levels of testosterone (hypogonadism), hyperprolactinemia (drug-related or non-drug related), hypothyroidism, adrenal insufficiency or glucocorticoid excess
Brock G. Issues in the assessment and treatment of erectile dysfunction: Individualizing
and optimizing treatment for the “silent majority”. www.medscape.com/viewprogram/1826
Accessed January 20, 2009
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Psychogenic Origin
Can be cause by: Anxiety Depression or psychosis Possibly with a loss of self-esteem
If causes of erectile dysfunction are completely psychological, the patient will continue to have nocturnal erections
Men with psychogenic ED often lose interest in sex
Anatomy and physiology of erection: pathophysiology of erectile dysfunction.Int J Impot Res 2003;15 Suppl 7:S5-S8.
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Risk Factors1,2,3
Aging Diabetes (vascular or neurological
problems) Cardiovascular disease (vascular issues) Stress, anxiety & depression (low libido or
self-esteem) Medications or illicit substances Prostatectomy (neurological problems) Smoking (exacerbates vascular problem)1. Hatzimouratidis K, and Hatzichristou D. Sexual dysfunctions: Classifications and
definitions. Journal of Sexual Medicine 2007;4:241-250.2. Fazio L, Brock G. Erectile dysfunction: management update. CMAJ 2004;170(9):1429-
14373. Feldman HA, Goldstein I, Hatzichristou D, et al. Impotence and its medical and
psychosocialcorrelates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61
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Diabetes ED About 35 – 75% of men with diabetes will
experience at least some degree of ED (impotence) during their lifetime
Men with diabetes develop ED 10 – 15 years earlier than men without diabetes Often 1st symptom men notice even before they are
diagnosed as a diabetic Above age of 50, the likelihood of having
difficulties with an erection occurs in approximately 50 – 60% of men
Above the age of 70, there is a 95% likelihood of having some difficulty with erection function
www.WebMD.com
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Diabetes ED
To get an erection, men need healthy: Blood vessels Nerves Muscle function Desire to be sexually stimulated
Elevated blood glucose levels can cause damage to blood vessels & nerves to the penis
Men with coronary artery disease (CAD) & diabetes will be 9 times more likely to develop ED than men with just diabeteswww.diabetes..about.com
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Diabetes ED
Longer a man has diabetes with poor blood glucose levels, complications of accompanying heart disease such as high blood pressure & high cholesterol can also affect ED
Diabetic men who smoke also have increased risk of developing ED
www.diabetes..about.com
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MEDICATIONS ASSOCIATED
WITH ED
ALTERNATE SOLUTIONS
MEDICATIONS ASSOCIATED
WITH ED
ALTERNATE SOLUTIONS
Cardiovascular Antidepressants
Betablockers Hydralazine Methyldopa Alpha-blockers
ACE inhibitorsACE II inhibitorsCa++ channel blockers
SSRITricyclic antidepressantMAOI
BuproprionMirtazapine
Diuretics Antipsychotic agents
Thiazide diureticsSpironolactone
Furosemide (loop diurectics)
Conventional neurolepticsRisperidone
QuetiapineOlanzapine
Hormone agents Gastroesophageal reflux & ulcers
Anti-androgens (e.g. cyproterone)Corticosteroids
Varies depending on indication
Cimetidine Other H2 antagonist or PPI
Antiparkinsonian agents Anticonvulsants
Levodopa At the neurologist’s discretion
CarbamazepinePhenytoin
At the neurologist’s discretion
Miscellaneous:Phenothiazine antiemetics, opioids (chronic use), digoxin, ketoconazole, lithiumDrug-induced male sexual dysfunction.Pharmacist’s Letter/Prescriber’s Letter 2006; 22(9):220907.
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Treatment Options
1. PDE5 Inhibitorsa) Sildenafil - Viagra®b) Varedenafil - Levitra®c) Tadalafil - Cialis®
2. Intraurethral suppositoriesa) Alprostadil - MUSE®
3. Intraurethal gel4. Penile injections5. Vacuum devices
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Autonomic spinal erection center
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Intraurethral Suppository
MUSE® 250ug, 500ug, 1000ug Medicated Urethral System for Erection A choice for people:
Who do not respond to oral pills Are afraid of injections
Suppository (about the size of a grain of rice) which is placed about 1” inside the urethra using a special applicator
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Advantages with MUSE®
Fool proof and low incidence of SE’s Gives an erection similar to penile
injection therapy Gives the most normal looking erection.
The head of the penis doesn’t swell in penile injections/PDE5 inhibitors but does with MUSE®
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Disadvantages with MUSE® 50 – 75% of men don’t respond well 50- 60% of men don’t respond consistently
May get good erection one time but not the next May develop a lack of confidence because 1
out of every 2 or 3 uses doesn’t work well 2% of men may have dizziness on 1st
administration with 1000µg strength. May need to do the 1st dose in the Dr’s office Not with 250µg or 500µg dose
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MUSE® Injector
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Intraurethal Gels
Fool proof and low incidence of SE’s Gives an erection similar to penile
injection therapy Possibly stronger than using MUSE® Must be kept in the fridge and has a 30
day expiry date
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Intraurethral Gels Many combinations
Dispense in 0.2ml single use syringes
Expiry date 30 days Dose 0.2 intraurethrally 10 – 15
minutes prior to sexual intercourse Hold penis upright for 30 seconds to
allow medication to absorb Rub any excess cream over the
forehead of the penis
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Penile Injections
Intracavernosal injection therapy Very safe & highly effective
Around since 1983. In 1982, a French surgeon injected a
vasodilator into the pelvic artery & the patient obtained an erection
Shortly after, a British physician injected a drug directly into the penis
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Caverject
Alprostadil 20µg/0.5ml Prefilled syringe Dosage range 5 – 20µg
Works in 60% with all men with ED Will work better with milder erection problems Can cause an aching or burning penile pain in
some men with cavernous nerve injury
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Caverject
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Penile Injections Alprostadil
Prostaglandin E -1 cAMP Vasodilator & muscle relaxant of corpus cavernosum &
trabecular smooth muscle Papaverine
Inhibits phosphodiesterase in smooth muscle cells, which cAMP & cGMP relaxation of vascular smooth muscles
Phentolamine Blocks -adrenergic receptors in penile blood vessels
relaxation of trabecular cavernous smooth muscles & dilatation of the penile arteries
Weak erectile-promoting effect when used alone. Potentiates the effect of papaverine or PGE-1
Atropine Smooth muscle relaxation
Chlorpromazine blocker activity 1:1 mg interchangeability with phentolamine
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Penile Injections
Products require refrigeration Caverject® is kept at room temperature
After 18 months of radical prostatectomy more than 70% of people will the dose of their injection Duration of injection will be a sign for this
i.e. 30 minutes 45 minutes 60 minutes
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Price Comparison
Medication Cost Per Dose
Viagra 100mg/Generic $16.69/$12.79
MUSE 1000µg $40.76
Intraurethral Gel $22.82***
Caverject 20ug $40.17*
Tri-Mix $4.10**
*Caverject is a single use vial so product. Manufacturer recommends once mixed product to be discarded regardless what dose is used
** Tri-Mix dose used here is 40 units (0.4ml). In a 10.6ml vial a person would get 24 doses
***Need to order 6 doses to get this price
Prices January 2013
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BD Inject-Ease
Will inject needle into the skin but you still need to push the plunger to dispense injection
$45.00
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Autoject 2
Does a complete injection
$69.95
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Vacuum Devices Have been used for more than a century
1874 by Dr. John King 1917 Dr. Otto Lederer developed constriction
rings for maintenance of erections 1960’s Geddings Osborn developed his version
of vacuum device 1974 Osborn’s product became commercially
available 1976 FDA withdrew it’s approval 1982 FDA reapproved product
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Vacuum Devices
Erect penis (especially Caucasian) appears blue or grey 50% of blood from arteries oxygenated 50% of blood from veins non-oxygenated
Arterial blood is warmer than venous blood Penis may not be as warm (1º-2º F lower) Most common complaint of partners
Touch penis Upon penetration
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Vacuum Devices
Takes 2-10 minutes to obtain a functional erection
Take on average 4 attempts to use pumps to become proficient
Need to place constriction ring as close as possible to base of penis. Penis will be hard on one side of ring and soft on the other side Only wear for maximum 30 minutes
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Vacuum Pumps
80-90%of men can obtain an erection Overall patient satisfaction 60-80%
In order to achieve enough pressure in the vacuum device, gel will have to be applied to the open end of the device Some men will also have to trim the pubic hair
to maximize seal
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Vacuum Devices
Certain groups of men should avoid using these devices Blood thinners or history of bleeding disorders
Coumadin® - Warfarin Plavix® - Clopidogrel
Diminshed penile sensation Spinal cord injury Significant penile curvature History of priapism
Not ASA 81mg
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Osbon ErecaidCLASSIC OTC $395.00 AUTOMATIC $495.00
30 day Warranty5 Year Warranty
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Vacuum Devices Bonro Medical
Vacurect® Retails $195.00
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Osbon ErecaidConstriction Rings
PINK = FIRM FIT BEIGE = REGULAR FIT
Each colour comes in 2 sizes small and large
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Actis
Adjustable constriction loop
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Peenuts® Acronym for “Power to Empty
Every time while Never Urinating Too Soon”
Contains: Vitamin C, E, B6, Selenium, Zinc,
Echinacea, Glycine, Alanine, Glutamic Acid, Saw Palmetto (Beta-Sitosterol), Pygrum, Pumpkin Seed, Nettle, Garlic & Ginkgo Biloba
Antioxidants, antiinflammatories, beta-sitosterol & immune boosters
EPS & WBC & improved PSA
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Neo 40 Daily
ED is may be an early warning sign of CVD 80% of men who had ED in beginning of a
study were more likely to develop CVD by the end of the 10 year study
Neo40 Daily helps restore nitric oxide (NO) levels
Safer and more effective than L-arginine
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Neo40 Daily
Depleted or Low Normal
Neo40 Daily Dose 2 lozenges daily 1 lozenge daily
Testing schedule 2 – 3 times per week Once per week
Goal Maintain Normal reading for 2 weeks
Maintain Normal reading every other
day
Dose after reaching goal
Reduce to 1 lozenge per day
Reduce to 1 lozenge every other day
Testing Schedule after reaching goal
Test 2 – 3 times per week until restoration
is stable at Normal
Test once a week to confirm restoration is
stable at Normal
1 Box (30 lozenges/2 test strips) $59.99TAX
1 Container (10 strips) $13.35TAX