TREATMENT OF ERECTILE DYSFUNCTION

Gregory HarochawRobin Coulter

Tache Pharmacy400 Tache Avenue

Winnipeg, MB R2H 3C3Phone: (204) 233-3469

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

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

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

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

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)

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.

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

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

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

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.

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

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

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

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

MEDICATIONS ASSOCIATED

WITH ED

ALTERNATE SOLUTIONS

MEDICATIONS ASSOCIATED

WITH ED

ALTERNATE SOLUTIONS

Cardiovascular AntidepressantsBetablockers Hydralazine Methyldopa Alpha-blockers

ACE inhibitorsACE II inhibitorsCa++ channel blockers

SSRITricyclic antidepressantMAOI

BuproprionMirtazapine

Diuretics Antipsychotic agentsThiazide diureticsSpironolactone

Furosemide (loop diurectics)

Conventional neurolepticsRisperidone

QuetiapineOlanzapine

Hormone agents Gastroesophageal reflux & ulcersAnti-androgens (e.g. cyproterone)Corticosteroids

Varies depending on indication

Cimetidine Other H2 antagonist or PPI

Antiparkinsonian agents AnticonvulsantsLevodopa 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.

Treatment Options1. PDE5 Inhibitors

a) Sildenafil - Viagra®b) Varedenafil - Levitra®c) Tadalafil - Cialis®

2. Intraurethral suppositoriesa) Alprostadil - MUSE®

3. Intraurethal gel4. Penile injections5. Vacuum devices

Autonomic spinal erection center

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

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®

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

MUSE® Injector

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

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

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

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

Caverject

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

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

Price ComparisonMedication Cost Per Dose

Viagra 100mg/Generic $16.69/$12.79MUSE 1000µg $40.76Intraurethral 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

BD Inject-Ease

Will inject needle into the skin but you still need to push the plunger to dispense injection

$45.00

Autoject 2

Does a complete injection

$69.95

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

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

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

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

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

Osbon ErecaidCLASSIC OTC $395.00 AUTOMATIC $495.00

30 day Warranty5 Year Warranty

Vacuum Devices Bonro Medical

Vacurect® Retails $195.00

Osbon ErecaidConstriction Rings

PINK = FIRM FIT BEIGE = REGULAR FIT

Each colour comes in 2 sizes small and large

Actis

Adjustable constriction loop

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

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

Neo40 DailyDepleted or Low Normal

Neo40 Daily Dose 2 lozenges daily 1 lozenge dailyTesting schedule 2 – 3 times per week Once per weekGoal Maintain Normal

reading for 2 weeksMaintain 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