Term
| For a patient complaining of sexual dysfunction, a history of sexual activity and erectile/sexual dysfunction of the past 4-6 months should be obtained such as: |
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Definition
nature of symptoms and onset
frequency, duration, and quality of erections
morning vs. nocturnal erections
ability to achieve sexual satisfaction |
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Term
| For a patient complaining of sexual dysfunction, important psychosocal history includes: |
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Definition
cigarette smoking, EtOH use, drug use
performance anxiety, depression |
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Term
| For a patient complaining of sexual dysfunction, important lab findings include: |
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Definition
these will help to determine underlying or contributing causes to ED
serum testosterone if signs of hypogonadism/decreased libido or in men that are 50 yrs and older
PSA if enlarged prostate on digital rectal exam
fasting glucose
A1c
fasting lipid panel |
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Term
| For a patient complaining of sexual dysfunction, important physical exam findings include: |
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Definition
evaluate for signs of hypogonadism such as small testes, gynecomastia, or decreased body hair
abnormal penile structure
injury to penis/testes
femoral pulse, other lower extremity pulses
not present or reduced in strength may be a sign of CV disease that could be contributing to how well blood is flowing through their body
anal sphincter tone/reflexes
digital rectal exam (only men that are 50 yrs and older) |
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Term
| common disease states/conditions that can contribute to ED |
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Definition
hypertension
artherosclerosis
peripheral vascular disease
stroke
spinal cord injury
cigarette smoking
excessive ethanol intake
diabetes
hypogonadism
depression/anxiety
Alzheimer's disease
hypothyroidism
chronic renal failure
pituitary tumors |
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Term
| modifiable risk factors for ED |
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Definition
diabetes
hypertension
smoking
BPH
hypogonadism
hypothyroid
depression/anxiety
alcohol abuse
illicit drug abuse
drug-induced
obesity |
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Term
| non-modifiable risk factors for ED |
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Definition
CAD/stroke
PVD/artherosclerosis
increasing age
vascular/prostate surgery
trauma or surgery to pelvis/spine
Peyronie's disease
sickle cell anemia
Alzheimer's disease
CHF
muscular dystrophy |
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Term
| common medications that can cause ED |
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Definition
ANTICHOLINERGIC AGENTS:
antihistamines
1st gen > 2nd gen
antiparkinsonian agents
cholinesterase inhibitors - benztropine, trihexyphenidyl
levodopa
tricyclic antidepressants
3rd gen (amitriptyline, doxepine, clomipramine, imipramine) > 2nd gen
phenothiazines
clozapine, 1st generation antipsychotics, promethazine, thoridazine, chlorpromazine
verapamil, clonidine
DOPAMINE RECEPTOR ANTAGONISTS
metoclopramide
phenothiazines
ESTROGENS, ANTIANDROGENS
LH-releasing hormone agonists
digoxin
spironolactone
ketoconazole
cimetidine
CNS DEPRESSANTS
barbiturates
narcotics
benzodiazepines
excessive alcohol consumption, short-term
AGENTS THAT DECREASE PENILE BLOOD FLOW
diuretics
peripheral beta-adrenergic antagonists
central sympatholytics - methyldopa, clonidine |
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Term
| explain how anticholinergics agents, dopamine antagonists, estrogens and antiandrogens, CNS depressants, and medications that decrease penile blood flow cause drug induced ED |
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Definition
ANTICHOLINERGIC AGENTS
anticholinergic effects
DOPAMINE ANTAGONISTS
inhibit prolactin inhibitory factor, increase serum prolactin, decrease serum testosterone concentration, or antiandrogen effects
ESTROGENS AND ANTIANDROGENS
suppress testosterone mediated stimulation of libido
CNS DEPRESSANTS
suppress perception of psychogenic stimulation
MEDICATIONS THAT DECREASE PENILE BLOOD FLOW
beta-2 antagonism: decrease sympathetic outflow, impairment of vasodilation
central alpha-2 agonism: decreased sympathetic outflow
fluid depletion: diruetics |
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Term
medication that contributes to ED:
beta-2 antagonists, central alpha-2 agonism, fluid depletion agents
ALTERNATIVES: |
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Definition
ACE-inhibitors
ARBs
CCBs (dihydropyridines)
direct rennin inhibitor
selective alpha-1 antagonists |
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Term
medication that contributes to ED: verapamil
ALTERNATIVES: |
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Definition
diltiazem
dihydropyridines (amlodipine, nifedipine, felodipine) |
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Term
medication that contributes to ED:
TCAs
ALTERNATIVES: |
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Definition
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Term
medication that contributes to ED: diphenhydramine
ALTERNATIVES: |
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Definition
| 2nd generation antihistamine (loratadine, cetirizine) |
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Term
medication that contributes to ED: phenothiazines
ALTERNATIVES: |
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Definition
|
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Term
medication that contributes to ED:
metoclopramide
ALTERNATIVES |
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Definition
|
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Term
medication that contributes to ED: cimetidine
ALTERNATIVES |
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Definition
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Term
| determine if a patient is appropriate for use of a phosphodiesterase-5 (PDE-5) inhibitor based on the recommendations of the Second Princeton Consensus Conference |
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Definition
LOW CV RISK = CAN USE PDE-INHIBITORS
asymptomatic/undiagnosed CV disease, < 3 risk factors for CV disease
well controlled HTN
mild, stable angina
mild CHF (NYHA class I)
mild valvular heart disease
myocardial infarction > 6 weeks ago
INTERMEDIATE CV RISK = NEEDS COMPLETE CV WORKUP AND TREADMILL STRESS TEST
3 or more risk factors for CV disease
moderate, stable angina
moderate CHF (NYHA class II)
MI or stroke 6 weeks or less ago
HIGH CV RISK = PDE-INHIBITORS CONTRAINDICATED; SEXUAL INTERCOURSE NOT RECOMMENDED
unstable or symptomatic angina
uncontrolled HTN
severe CHF (NYHA class III/IV)
MI or stroke 2 weeks or less ago
moderate/severe valvular heart disease
high risk cardiac arrhythmia
obstructive hypertrophic cardiomyopathy
*risk factors for CV disease: age, HTN, cigarette smoking, DM, dyslipidemia, sedentary lifestyle, family history of premature coronary disease
NYHA Classification:
I: no limitation of physical activity, physical activity does not cause fatigue, palpitation, or shortness of breath
II: slight limitation of physical activity, comfortable at rest, but physical activity results in fatigue, palpitations, or shortness of breath
III-A: limitation of physical activity; comfortable at rest, but ordinary activity causes fatigue, palpitations, or shortness of breath
III-B: significant limitation of physical activity; comfortable at rest, but minimal activity causes fatigue, palpitations, or shortness of breath
IV: unable to carry on any physical activity without discomfort; symptoms of heart failure at rest |
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Term
PDE-5 inhibitors:
MOA, contraindications, precautions, drug interactions, ADRs |
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Definition
MOA
inhibition of phosphodiesterase (PDE) isoenzyme 5
this allows for longer circulating levels of cGMP and enhanced vasodilatory effects in genital tissue
PDE-5 is present is vascular tissue, smooth muscle, and platelets
CONTRAINDICATIONS:
high CV risk
nitrates - increased serum concentration of NO potentially exacerbating vasodilatory effects of PDE-inhibitors; do not administer nitrates within 24 hours of sildenafil/vardenafil and 48 hours of tadalafil use
PRECAUTIONS:
alpha-1 adrenergic antagonists - may cause hypotension
ethanol - may cause hypotension
DRUG INTERACTIONS
contraindicated in patients taking nitrates
CYP3A4 - increased concentrations with potent 3A4 inhibitors (erythromycin, cimetidine, saquinavir, ketoconazole, protease inhibitors, grapefruit juice); decreased concentrations with 3A4 inducers (rifampin, phenobarbital)
alpha blockers - hypotension; when adding, use lowest dose of PDE-inhibitor; use uroselective alpha blockers if possible; separate PDE-inhibitor from alpha blocker by 4 hours
ADRs:
due to inherent risk of cardiovascular disease with sexual activity, all patients with risk for CV disease should be assessed
common ADRs - headache, facial flushing, dizziness, dyspepsia, nasal congestion, lower back/limb pain (tadalafil)
serious or rare ADRs - sensitivity to light (sildenafil, vardenafil), blurred vision (sildenafil, vardenafil), loss of blue-green color discrimination (sildenafil, vardenafil), nonarteritic anterior ischemic optic neuropathy (NAION) (sildenafil, vardenafil) - evaluation by an ophthalmologist is recommended for patients with glaucoma, macular degeneration, diabetic retinopathy, and/or eye surgery or trauma due to rsk of NAION; if sudden loss of vision occurs with PDE-5 inhibitors use, patients should also be referred for evaluation by an ophthalmologist for NAION; priapism |
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Term
alprostadil:
MOA, contraindications, ADRs |
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Definition
intraurethral suppository (MUSE), intracavernosal injection (Caverject)
MOA:
prostaglandin E1
stimulates adenylyl cyclase which increases levels of cAMP
this stimulates smooth muscle relaxation and enhances blood flow in penile sinuses
CONTRAINDICATION:
intracavernosal injection - avoid in patients taking anticoagulants
ADRs:
common - penile/urethral pain, injection site complications (bruising, scarring, infection), vaginal itching, burning, pain in partner (intraurethral route)
serious/rare ADRs - priapism (dose related), dizziness/hypotension (dose related) |
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Term
testosterone replacement products:
MOA, contraindications, ADRs, patient education |
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Definition
MOA:
exogenous supplement to help restore serum testosterone to normal levels
testosterone may be related to sexual dysfunction due to its potential actions on androgen receptors in the CNS that affect sexual drive and ability to stimulate NO synthase which increases NO levels in the body
CONTRAINDICATIONS/PRECAUTIONS
active prostate cancer
BPH
hepatic disease
peripheral edema
polycythemia (high RBC count)
ADRS
common - mood swings, weight gain, edema, contact dermatitis (patches only, gel has lower incidence), sodium retention, dyslipidemia, gynecomastia, prostate/urinary disorder, decreased HDL, increased cholesterol, increased LFTs, increased PSA, increased HCT/Hgb
serious/rare ADRs - gynecomastia, hepatotoxicity (PO/alkylated formulations)
PATIENT EDUCATION - KNOW FOR THE TEST!
serum testosterone levels need to be taken in the morning, prior to use of any testosterone product
ANDRODERM AND TESTODERM PATCHES SHOULD BE APPLIED JUST PRIOR TO BED and can be placed to the arms, back, or buttocks, preferable in non-hairy areas (androderm can also be applied to the thighs)
ANDRODERM GEL SHOULD BE APPLIED IN THE MORNING and can be applied to skin of the shoulders, upper arms, or abdomen, preferably in non-hairy areas. do not shower within 5-6 hours of administration and wash hands well after applying to skin |
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Term
vacuum erection devices:
MOA, contraindications, ADRs |
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Definition
MOA:
plastic cylinder placed over penis
air pumped OUT of cylinder
negative pressure draws blood into penis
rubber ring at base of penis secures blood
ring worn for maximum of 30 minutes
penis may appear cyanotic and cool
CONTRAINDICATIONS
sickle-cell patients (high risk of priapism)
PRECAUTIONS:
use cautiously in patients taking warfarin (risk of priapism)
COMMON ADRS:
primaryADRs are penis is cool/numb to touch and/or discolored appearance (bluish)
penile bruising
delayed ejaculation or ejaculation blockade |
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Term
| mechanism of drug-drug interaction between PDE-5 inhibitors and nitrates |
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Definition
increased serum concentration of NO potentially exacerbating vasodilatory effects of PDE-inhibitors
do not administer nitrates within 24 hours of sildenafil/vardenafifl and 48 hours of tadalafil use |
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Term
| PDE-5 inhibitors: administration |
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Definition
time to peak onset:
sildenafil = 0.5-1 hour
vardenafil = 0.7-0.9 hour
tadalafil = 2 hours
mean plasma t1/2:
sildenafil = 4 hours
vardenafil = 4-5 hours
tadalafil = 18 hours
absorption decreased by fatty meal:
sildenafil = YES
vardenafil = YES
tadalafil = NO
all are metabolized by CYP3A4. doasage reductions recommended if taken concurrently with other potent CYP3A4 inhibitors
requires foreplay in order for medication to work
take at least 30-60 minutes prior to anticipated sexual activity (2 hours for tadalafil)
take sildenafil on an empty stomach
do not take more than one dose in 24 hours (time between doses may be extended for tadalafil)
no recommended for use with other ED therapies |
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Term
| effectiveness of PDE-5 inhibitors |
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Definition
1st line agents for most patients with ED
similar efficacy rates between agents (50-80%)
patients with nerve damage (DM, radial prostatectomy) may have lower response rates
insufficient clinical evidence to conclude if there is any benefit in switching between agents
dosage adjustments is recommended for elderly, severe renal dysfunction, and severe hepatic dysfunction (tadalafil not recommended in severe hepatic dysfunction) for all patients
patients having minimal therapeutic effects with an adequate trial of a PDE-inhibitor may benefit from daily dosing. currently there is limited clinical evidence and is not recommended as a routine treatment approach. tadalafil is only product with FDA approval for daily use for ED |
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Term
| medication monitoring parameters for PDE-5 inhibitors |
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Definition
continue to take for a minimum trial of 5-8 doses
if after an adequate trial of the medication, contact health care professional as dose titrations are often needed |
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Term
| administration of alprostadil |
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Definition
take just prior to anticipated sexual activity
both administration forms require good visual ability and manual dexterity. intracavernosal route additionally requires aspetic technique and comfort with injections
do not use more than 1 intracavernosal injection per day or 3 injections per week, no more than 2 doses of intraurethral pellets per day
intraurethral suppository (MUSE):
empty bladder
gently massage after insertion so the medication will dissolve into corpora cavernosa
intracavernosal injection (Caverject):
administration at a 90 degree angle LATERALLY (avoid posterior and anterior); want the delivery of the medication to be in the corpora cavernosa |
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Term
| effectiveness of alprostadil |
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Definition
continue to take for a minimum trial of 5-8 doses
2nd-3rd line agents due to more invasive administration
intracavernosal injections may be preferred for patients with DM on insulin/injection therapy or with peripheral neuropathy
efficacy of intracavernosal route is much greater than intraurethral route due to greater dose of drug reaching corpus cavernosa. much higher dose often needed with intraurethral route
with intracavernosal route, there is a dose-dependent response in producing an erection and length of an erection. no development of tolerance occurs with this route of administration
vacuum erectile devices have been used in combination with intracavernosal route and may be considered with treatment failure. a penile constriction band is often combined with intraurethral route to enhance efficacy |
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Term
| testosterone replacement therapy products |
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Definition
fluoxymesterone - oral supplement
testosterone patch (Testoderm, Androderm) - transdermal
testosterone gel (AndroGel, Testim) - transdermal
testosterone buccal (Striant)
testosterone cypionate (Deop-Testosterone) - IM injection
testosterone enanthate (Delatestryl) - IM injection
testosterone implant (Testopel) - subcutaneous implant |
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Term
| administration of the testosterone patch, gel and buccal products |
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Definition
testosterone patch:
APPLIED AT BEDTIME
testosterone gel:
APPLIED IN MORNING
buccal testosterone:
push curved side against upper gum, hold in place through lip for 30 seconds, leave in place for 12 hours, rotate side of mouth for new application |
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Term
| effectiveness of testosterone products |
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Definition
only indicated for ED in patients with low testosterone levels (primary or secondary hypogonadism) and decreased libido
effects of supplementation may be seen within days to weeks of initiating drug therapy
testosterone replacement will only improve mood and sexual drive. they do not have any overall effects on penile erections
an IDEAL TESTOSTERONE REPLACEMENT PRODUCT mimics the normal circadian pattern of endogenous testosterone, produces testosterone levels within the normal physiiologic range, produces dihydrotestosterone and estradiol (metabolites of testosterone) near usual physiologic levels an patterns, and have minimal adverse effects.
injectable products are preferred for symptomatic patients over other routes of administration due to being equally effective, decreased risk of toxicity, and inexpensive |
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Term
| medication monitoring for testosterone products |
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Definition
serum testosterone levels: baseline, Q 6-12 months for chronic therapy (if low or high, need a repeated level prior to any dosage titrations)
lipid panel: baseline, Q 6-12 months for chronic therapy
hematocrit: baseline, Q 6-12 months for chronic therapy
liver function tests: baseline (for oral formulations only); IM, transdermal, and buccal preparations avoid first pass metabolism to prevent liver toxicity
PSA: baseline, yearly for chronic therapy (screen for BPH, only indicated for patients 40 years or greater)
digital rectal exam: baseline, yearly for chronic therapy (screen for colon cancer, only indicated for patients 40 years and greater)
injectable testosterone (IM): testosterone levels should be normal just prior to next injection
testosterone patches: measure testosterone 14 days after first use
testosterone gel: measure testosterone 14 days after first use
buccal testosterone: AM serum concentrations should be measured after 4-12 weeks |
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Term
| vacuum erection devices: effectiveness |
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Definition
first line treatments for older adults in stable sexual relationships
second line treatment option in younger patients that fail adequate trails of PDE-5s/alprostadil
constriction bands or tension rings are often used in conjunction with the VED for greater erection duration |
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Term
| compare and contrast the different testosterone replacement products on its ability to achieve ideal characteristics for a testosterone replacement product |
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Definition
PO testosterone:
DOES NOT achieve normal circadian pattern of testosterone
DOES NOT achieve normal pattern and concentration of testosterone metabolites
testosterone patch:
DOES achieve normal circadian pattern of testosterone IF APPLIED AT BEDTIME
DOES achieve normal pattern and concentration of testosterone metabolites
testosterone gel:
DOES achieve normal circadian pattern of testosterone IF APPLIED IN MORNING
DOES achieve normal pattern and concentration of testosterone metabolites
buccal testosterone:
DOES NOT achieve normal circadian pattern of testosterone
DOES achieve normal pattern and concentration of testosterone metabolites
injectable testosterone:
DOES NOT achieve normal circadian pattern of testosterone
DOES NOT achieve normal pattern and concentration of testosterone metabolites
causes supraphysiologic levels of testosterone for several days after injection
testosterone implant:
DOES NOT achieve normal circadian pattern of testosterone
DOES NOT achieve normal pattern and concentration of testosterone metabolites |
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Term
| common non-approved drug therapy options for ED |
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Definition
TRAZODONE:
antagonist effects on peripheral alpha adrenergic receptors
PRIAPISM IS A SIDE EFFECT (NOT RECOMMENDED FOR ED TREATMENT)
PHENTOLAMINE:
RECALLED
PAPAVERINE:
nonspecific PDE inhibitor
YOHIMBINE:
central alpha adrenergic antagonist; decreases peripheral adrenergic tone allowing greater peripheral cholinergic tone
L-ARGININE:
substrate for NO synthase and is converted to NO
DEHYDROEPIANDOSTERONE (DHEA):
an endogenous androgen hormone
CABERGOLINE:
dopamine agonist approved in US for hyperprolactinemic disorders |
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