1 ED many factors vascular neurologic hormonal psychological Increase venous outflow or decrease arterial inflow of blood a Organic factors vascular hormonal anatomic neurogenic Main cause of ED 80 i Vascular disease atherosclerosis plaque build up in penis affects coronary arteries AND penile vasculature Can present up to 3 years before CAD symptoms RF ii Neurogenic DM alc drug disorders Alzheimer Parkinson MS iii Hormonal hypo hyper thryoidism addison s cushing s hypogonadism affects amount testosterone made hyperprolactemia SSRI iv Meds analgesics antianxoilyics anticonvulsants antidepressants antihistamine antipharkinson antipyschotics diuretics hormones illicit drugs b Psychological all non organic depression performance anxiety relationship status 2 Treatment 1 lifesytle changes PHE5 inhib testosterone replacement decrease test decrease libido 2 Alt PO meds Caverject Vacuum pump last line inflatable penile prosthesis screen of CV disease a TLC increase exercise decrease BP help blood fow same shit as HTN and CAD decrease weight BMI 30 limit alc intake smoking cessation All men with ED should be assessed for CV disease b c we need to treat b PDE inihibitors when horny increase NO then guanine cyclase then cGMP PDE5 converts cGMP to GMP not wanted Therefore if block increase cGMP reduce conc of Ca SM relaxation increase inflow of blood into penis then erection i Sildenafil Viagra 100mg Tadalafil Cialis 20mg Vardenafil Levitra 20mg Avanafil Stendra 200mg Well tolerated CI in pts taking nitrates isosorbide nitroglycerin Cialis possible low dose for prophylaxis Also good for the weekend 1 Ade HA dizziness flushing and rhinitis all due to vasodilation in periphery Caustion in pts on antihypertensives caution decrease BP Esp alpha blockers and orthostatic hypo Verdenafil ass with higher qtc prolongation Visual disburbances rare side effect of blindness in verdinafil And sildenafil Esp in CAD 2 Pros effective easy to use discreet works well in pts with ED caused by DM spinal cord injury 2nd of antidepressants Cons expensive side effects from vasodilation drug interactiosn with p450 3a4 warning with alpha blocker does not work for decrease libido ii Testosterone replacement therapy only effectve ED secondary to hypogondaism Increase libido and sex satisfaction If PDE5 failed ADE erthryosytosis elevated LFTs BPH acne aggravations and prostate cancer If man have prostate breast cancer DNU Avoid contact w women and children Use applicator and wash hands after put under arms Not recommended in men with normal test levels decrease testes size infertility side effects risk of cancer iii Alprostdil effective PGE1 analog SM relaxation Intracavernosal Caverject more effective than intrarthral Muse ADE penile pain hematoma plaques and priarim hypotension Good add on therapy for penile pump and PDE5 inhibitor For suppository insert and massage to dissolve Hold for 5 min and usually takes 20 min to work Penile plaques can bend penis or change to hourglass shape iv Trazodone antidepressants anxiolytic Can cause priaprism Not recommendatd v Vacuum erection device VED least invasive decrease efficacy over time May cause penile injury More effective when combined w alprostdil CI in men with RBC disorder or taking anticoagulants vi Penile Prosethsis invasive surgery last line 3 Priaprism ischemic more common medical emergency Should be resolved ASAP Stepwise matter intracavernouse injection of phenylephrine vasoldilator aspiration of blood out of penis repeat 1 and 2 as needed q2 3 min place shunt if aspiration fails If 4 hours emergency non ischemic cause by high unregulated aterial inflow Results in laceration of cavernouse artery