1 / 51

Treatment of Erectile Dysfunction

Treatment of Erectile Dysfunction. Gregory Harochaw Robin Coulter Tache Pharmacy 400 Tache Avenue Winnipeg, MB R2H 3C3 Phone: (204) 233-3469. What is Erectile Dysfunction?. The persistent or recurrent inability to obtain or maintain an erection sufficient for sexual activity 1

evania
Download Presentation

Treatment of Erectile Dysfunction

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Treatment of Erectile Dysfunction Gregory Harochaw Robin Coulter Tache Pharmacy 400 Tache Avenue Winnipeg, MB R2H 3C3 Phone: (204) 233-3469

  2. What is Erectile Dysfunction? • The persistent or recurrent inability to obtain or maintain an erection sufficient for sexual activity1 • > 50% of men aged 40 – 70 will have fairly marked erectile problems2,3 • 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 • Hatzimouratidis K, and Hatzichristou D. Sexual dysfunctions: Classifications and definitions. Journal of Sexual Medicine 2007;4:241-250. • Fazio L, Brock G. Erectile dysfunction: management update. CMAJ 2004;170(9):1429-1437 • 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

  3. 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

  4. 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

  5. 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

  6. 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)

  7. 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.

  8. 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

  9. 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: Individualizing and optimizing treatment for the “silent majority”. www.medscape.com/viewprogram/1826 Accessed January 20, 2009

  10. 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

  11. 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.

  12. 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) • Hatzimouratidis K, and Hatzichristou D. Sexual dysfunctions: Classifications and definitions. Journal of Sexual Medicine 2007;4:241-250. • Fazio L, Brock G. Erectile dysfunction: management update. CMAJ 2004;170(9):1429-1437 • 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

  13. 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

  14. 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 diabetes www.diabetes..about.com

  15. 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

  16. Drug-induced male sexual dysfunction.Pharmacist’s Letter/Prescriber’s Letter 2006; 22(9):220907.

  17. Treatment Options • PDE5 Inhibitors • Sildenafil - Viagra® • Varedenafil - Levitra® • Tadalafil - Cialis® • Intraurethral suppositories • Alprostadil - MUSE® • Intraurethal gel • Penile injections • Vacuum devices

  18. Autonomic spinal erection center

  19. 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

  20. 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®

  21. 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

  22. MUSE® Injector

  23. 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

  24. 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

  25. 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

  26. 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

  27. Caverject

  28. 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

  29. 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

  30. Price Comparison Prices January 2013

  31. BD Inject-Ease Will inject needle into the skin but you still need to push the plunger to dispense injection $45.00

  32. Autoject 2 Does a complete injection $69.95

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. Automatic $495.00 OsbonErecaid Classic OTC $395.00 5 Year Warranty 30 day Warranty

  39. Vacuum Devices • Bonro Medical • Vacurect® Retails $195.00

  40. Beige = Regular fit OsbonErecaidConstriction Rings Pink = firm fit Each colour comes in 2 sizes small and large

  41. Actis Adjustable constriction loop

  42. 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

  43. 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

More Related