ࡱ> TVS@ +bjbj "Juu"|||||||8  d$7$9$9$9$9$9$9$$n&R(]$|]$||r$X||7$7$Vg"@||+# ȵTR." K#$0$"x)j)+#||||)|+# Zt^]$]$DPharmacotherapy 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 Definition The National Institutes of Health (NIH) Consensus Development Conference on Impotence (December 7-9, 1992) defined impotence as "male 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 Alzheimers 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 Outcomes* *Reference of Guidelines Used The goal of treatment is an improvement in the quantity and quality of penile erections suitable for intercourse. Health care providers need to ensure that the patient has reasonable expectations. Furthermore, only patients with erectile dysfunction should be treated. American Urological Association, Management of Erectile Dysfunction ('05/Updated '06) http://www.auanet.org/guidelines/edmgmt.cfmTreatment Options** (Non-drug and Drug Therapy include all therapeutic classes/agents available and preferences per treatment guidelines) **See Treatment Options Table 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 dysfunction include the following: oral phosphodiesterase type 5 [PDE5] inhibitors, intra-urethral alprostadil, intracavernous vasoactive drug injection, vacuum constriction devices, and penile prosthesis implantation. These appropriate treatment options should be applied in a stepwise fashion with increasing invasiveness and risk balanced against the likelihood of efficacy. Generally no treatment for erectile dysfunction is ideal. Treatment should be chosen in order of least invasive. 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. Other unapproved agents that have been used for erectile dysfunction are trazadone, yohimbine, papaverine, and phentolamine. 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 and Toxicity Parameters) Efficacy: Quantity and quality of penile erections suitable for intercourse Reduction in mental anguish. International Index of Erectile Dysfunction questionnaire Toxicity: Headache, dyspepsia Penile pain Blood pressure (Phospodiesterase inhibitors) Barry VanDenHeuvel, PharmD Candidate 2007 Pharmacotherapy Presentation Pharmaceutical Care Rotation University of Maryland School of Pharmacy Happy Harrys Pharmacy Patient Care Center, Perryville, MD 78cpu dde{GHUXbcdeotGHQR]_ !ٳٳْh`56CJaJh`5CJaJh`CJOJQJaJh`CJOJQJaJh`CJOJQJ h`aJh`CJaJ h`CJh`CJaJh`5CJaJ h`5h`h`5>*CJaJh`5CJaJ08bcpqrstui  & F$If$If$a$*+ ~~~~~ssm~$If $7$8$H$If$Ifzkd$$Ifl0* $ t0644 la de~~~~~~~~~~~~~$Ifzkd$$Ifl0* $ t0644 laecde{|}~~zkd$$$Ifl0* $ t0644 la$If$. 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