Pharmacotherapy of _Erectile Dysfunction_______________



Pharmacotherapy of _Erectile Dysfunction_______________

Barry VanDenHeuvel, PharmD Candidate 2007

|Epidemiology |The incidence of erectile dysfunction is low in men younger than 40 years of age, but increases as men age. |

| |The Massachusetts Male Aging Study reported an overall prevalence of 52% for any degree of erectile dysfunction in men aged 40 to 70. |

| |More recently, the Health Professional Follow Up Study of more than 31,000 male health professionals aged 53 to 90 reported a prevalence of|

| |erectile dysfunction as 33%. |

| |Erectile dysfunction is not caused by age, but rather by other concurrent conditions or from medications usage. |

| |Up to 50% of patients with Diabetes Mellitus develop erectile dysfunction. |

| |A study of misuse reported that of the 41 patients entering a rehabilitation center for “sexually compulsitivity,” 48.8% reported current |

| |use of prescription ED medication. Half of those patients had prescriptions; the rest obtained them by other means. |

|Disease State |The National Institutes of Health (NIH) Consensus Development Conference on Impotence (December 7-9, 1992) defined impotence as "male |

|Definition |erectile dysfunction, that is, the inability to achieve or maintain an erection sufficient for satisfactory sexual performance." ED is the |

| |more precise term, especially given the fact that sexual desire and the ability to have an orgasm and ejaculate may well be intact despite |

| |the inability to achieve or maintain an erection. |

| | |

| |The Index Patient is defined as a man with no evidence of hypogonadism or hyperprolactinemia who develops, after a well-established period |

| |of normal erectile function, ED that is primarily organic in nature. |

|Patho-physiology |Erectile dysfunction can result from any single abnormality or combination of abnormalities of the four systems necessary for a normal |

| |penile erection. Vascular, neurologic, or hormonal etiologies of erectile dysfunction are collectively referred to as organic erectile |

| |dysfunction. About 80% of patients with erectile dysfunction have organic type. Patients who fail to respond to psychogenic stimuli have |

| |psychogenic erectile dysfunction. |

| | |

| |Erectile dysfunction can be the result of many diseases. Disease that compromise vascular flow to the corpora cavernosum, such as |

| |peripheral vascular disease, arteriosclerosis, and essential hypertension, are associated with an increased incidence of erectile |

| |dysfunction. Diseases that impair nerve conduction to the brain, such as spinal cord injury or stroke, or conditions that impair |

| |peripheral nerve conduction to the penile vasculature, such as diabetes mellitus, can result in erectile dysfunction. Diseased associated |

| |with hypogonadism result in lower levels of testosterone, which can diminish sexual drive and lead to secondary erectile dysfunction. |

| | |

| |Finally, patients must be in the proper mental frame of mind to be receptive to sexual stimuli. Patients who are depressed, have |

| |performance anxiety, are sedated, have Alzheimer’s disease, or have mental disorders often complain of erectile dysfunction. |

| | |

| |Lastly, approximately 10% to 25% of the cases of erectile dysfunction are caused by medications. |

|Clinical Presentation |General |

| |Patient will usually show no physical signs or symptoms. Erectile dysfunction is usually a symptom of another disease or treatment. |

| |Physical exam: |

| |Penis evaluated for diseases of curvature, Femoral and lower extremity pulses checked for proper blood flow, anal sphincter and other |

| |genital reflexes checked to indicated integrity of nerve supply to penis. |

| |Laboratory Tests (usually for diagnosing comorbities): |

| |Serum blood glucose, lipid profile, thyroxine level, and serum testosterone level. |

| |Mental/Emotional: |

| |Affects men emotionally in many different ways, such as depression, performance anxiety, or embarrassment. Marital difficulties and |

| |avoidance of sexual intimacy are common. In fact, patients are often brought to a physician by their mates. Often there is nonadherence |

| |to medications that the patient believes are causing erectile dysfunction. |

| |Other diagnostic tests: |

| |International Index of Erectile Dysfunction questionnaire. |

|Risk Factors |Risk factors include hypertension, diabetes mellitus, chronic ethanol abuse, smoking, pelvic, perineal, or penile trauma or surgery, |

| |neurologic disease, endocrinopathy, obesity, pelvic radiation therapy, Peyronie's disease, and prescription or recreational drug use. |

| | |

|Diagnosis |The typical initial evaluation of a man complaining of ED is conducted in person and includes sexual, medical, and psychosocial histories |

| |as well as laboratory tests thorough enough to identify comorbid conditions that may predispose the patient to ED and that may |

| |contraindicate certain therapies. History may reveal causes or comorbidities such as cardiovascular disease (including hypertension, |

| |atherosclerosis, or hyperlipidemia), diabetes mellitus, depression, and alcoholism. Related dysfunctions such as premature ejaculation, |

| |increased latency time associated with age, and psychosexual relationship problems may also be uncovered. Most importantly, a history can |

| |reveal specific contraindications for drug therapy. |

| |Attention is given to defining the problem, clearly distinguishing ED from complaints about ejaculation and/or orgasm, and establishing the|

| |chronology and severity of symptoms. An assessment of patient/partner needs and expectations of therapy is equally important. |

| |A focused physical examination evaluating the abdomen, penis, testicles, secondary sexual characteristics and lower extremity pulses is |

| |usually performed. Established patients with a new complaint of ED typically are not re-examined. According to the AUA Prostate-specific |

| |Antigen (PSA) Best Practice Policy on early detection of prostate cancer, both digital rectal examination of the prostate and serum PSA |

| |measurement should be offered annually in all men over 50 with an estimated life expectancy of more than 10 years.5 Prostate-specific |

| |antigen measurement and rectal examination may assume additional significance when considering the use of testosterone in the management of|

| |male sexual dysfunctions. Additional testing, such as testosterone level measurement, vascular and/or neurological assessment, and |

| |monitoring of nocturnal erections, may be indicated in select patients. |

| | |

|Desired Therapeutic |The goal of treatment is an improvement in the quantity and quality of penile erections suitable for intercourse. Health care providers |

|Outcomes* |need to ensure that the patient has reasonable expectations. Furthermore, only patients with erectile dysfunction should be treated. |

| | |

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| | |

|*Reference of |American Urological Association, Management of Erectile Dysfunction ('05/Updated '06) |

|Guidelines Used | |

|Treatment Options** |The management of erectile dysfunction begins with the identification of organic comorbidities and psychosexual dysfunctions; both should |

| |be appropriately treated or their care triaged. The currently available therapies that should be considered for the treatment of erectile |

|(Non-drug and Drug |dysfunction include the following: oral phosphodiesterase type 5 [PDE5] inhibitors, intra-urethral alprostadil, intracavernous vasoactive |

|Therapy – include all |drug injection, vacuum constriction devices, and penile prosthesis implantation. These appropriate treatment options should be applied in a|

|therapeutic |stepwise fashion with increasing invasiveness and risk balanced against the likelihood of efficacy. |

|classes/agents | |

|available and |Generally no treatment for erectile dysfunction is ideal. Treatment should be chosen in order of least invasive. |

|preferences per | |

|treatment guidelines) |Oral phosphodiesterase type 5 inhibitors, unless contraindicated, should be offered as a first-line of therapy for erectile dysfunction. |

| | |

| |For patients with psychogenic erectile dysfunction, psychotherapy may be used as monotherapy, or as an adjunct to specific treatments for |

| |the disorder. This psychotherapy will generally include the patient and his partner. |

| | |

| |For patients with hypogonadism, testosterone replacement therapy is indicated. |

| | |

|**See Treatment Options|Other unapproved agents that have been used for erectile dysfunction are trazadone, yohimbine, papaverine, and phentolamine. |

|Table | |

| |Surgical insertion of a penile prosthesis is the most invasive treatment and is reserved for patients who fail to respond to or are not |

| |candidates for less invasive oral or injectable treatments. |

| | |

| |Most insurance companies will not pay for treatment, so cost is very important to patients. |

|Monitoring |Efficacy: |

| |Quantity and quality of penile erections suitable for intercourse’ |

|(Efficacy and Toxicity |Reduction in mental anguish. |

|Parameters) |International Index of Erectile Dysfunction questionnaire |

| | |

| | |

| |Toxicity: |

| |Headache, dyspepsia |

| |Penile pain |

| |Blood pressure (Phospodiesterase inhibitors) |

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