1. 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

2. Autonomic spinal erection center
The increase in arterial inflow to the penis is dependent upon the autonomic spinal erection center, which
sends parasympathetic and sympathetic impulses to the arteries and smooth muscles of the corpora
cavernosa. High concentrations of nitric oxide (NO) are released through neural pathways into the smooth
muscles of the corpora cavernosa (Figure 2). Nitric oxide activates cyclic guanosine monophosphate
(cGMP), resulting in a reduction in cytosolic calcium levels and relaxation of the smooth muscles.
Phosphodiesterase type 5 (PDE-5) is responsible for the breakdown of cGMP into an inactive form,
5+cGMP4, which inhibits the effect of NO.

6. 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

7. 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

8. 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

9. MEDICATIONS ASSOCIATED WITH ED
ALTERNATE SOLUTIONS
Cardiovascular
Antidepressants
Betablockers Hydralazine Methyldopa Alpha-blockers
ACE inhibitors
ACE II inhibitors
Ca++ channel blockers
SSRI
Tricyclic antidepressant
MAOI
Buproprion
Mirtazapine
Diuretics
Antipsychotic agents
Thiazide diuretics
Spironolactone
Furosemide
(loop diurectics)
Conventional neuroleptics
Risperidone
Quetiapine
Olanzapine
Hormone agents
Gastroesophageal reflux & ulcers
Anti-androgens (e.g. cyproterone)
Corticosteroids
Varies depending on indication
Cimetidine
Other H2 antagonist or PPI
Antiparkinsonian agents
Anticonvulsants
Levodopa
At the neurologist’s discretion
Carbamazepine
Phenytoin
Miscellaneous:
Phenothiazine antiemetics, opioids (chronic use), digoxin, ketoconazole, lithium
Drug-induced male sexual dysfunction.Pharmacist’s Letter/Prescriber’s Letter 2006; 22(9):

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

11. Autonomic spinal erection center
The increase in arterial inflow to the penis is dependent upon the autonomic spinal erection center, which
sends parasympathetic and sympathetic impulses to the arteries and smooth muscles of the corpora
cavernosa. High concentrations of nitric oxide (NO) are released through neural pathways into the smooth
muscles of the corpora cavernosa (Figure 2). Nitric oxide activates cyclic guanosine monophosphate
(cGMP), resulting in a reduction in cytosolic calcium levels and relaxation of the smooth muscles.
Phosphodiesterase type 5 (PDE-5) is responsible for the breakdown of cGMP into an inactive form,
5+cGMP4, which inhibits the effect of NO.

12. Presence of fatty foods can double the absorption time of Sildenafil and Vardenafil from 1 hour to 2 hours. Absorption is reduced from 20-50%. Take these at 5PM and say dinner is at 7PM then these products will continue to work 8-12 hours later.
If taken after meals then people should wait at least 2 hours prior to activity.
For diabetics, stomach emptying time is very much delayed so they should take these for sure before meals to get a response.
For tadalfil because reponse is 2-4 hours people should take 1st dose at least 4 hours prior to activity to ensure this works for them.
Side effects come on with minutes of taking the pill and last minutes. These are usually mild and disappear after a while.
Visual disturbances: sildenafil/vardenafil cross react with an enzyme in the retina known as PDE6, thus causes blurred vision, double vision or loss of colour vision. Not dangerous and does not cause night blindness.
Tadalfil can cause pooling of blood in major muscles in the body particularly back buttock’s and leg. 10% discontinuation.

13. Tache Pharmacy Price PDE5 Inhibitors
Drug
Strength
Quantity
Price
Viagra®/Generic
100mg 4
$54.83/$44.83
Levitra®
20mg
$73.43
Cialis®
$78.32
5mg 28
$ ($20.93/4)

14. 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

15. 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®

16. 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

17. MUSE® Injector

19. Tache Pharmacy MUSE® Prices
Quantity
Price
250µg 1
$48.53
500µg
1000µg

20. 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

21. 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

23. Tache Pharmacy Prices Intraurethral Gel
Quantity
Price
Alp 250/Pap 0.3/Phe 0.2/0.2ml
6 Dose
$149.46
1 Dose*
$24.98
Muse 1000µg 1
$48.53
*If 1 single dose ordered the price would be higher

24. Penile Injections Intracavernosal injection therapy Around since 1983.
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

25. Caverject Alprostadil 20µg/0.5ml Works in 60% with all men with ED
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

26. Caverject

28. Penile Injections Alprostadil Papaverine Phentolamine Atropine
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 Medication Cost Per Dose Viagra 100mg/Generic
$13.70/$11.20
MUSE 1000µg
$48.53
Intraurethral Gel 250/0.3/0.2
$24.98***
Caverject 20ug
$40.56*
Tri-Mix
$3.94**
*Caverject is a single use vial so product. Manufacturer recommends once mixed product to be discarded regardless what dose is used
** Tri-Mix dose used here is 40 units (0.4ml). In a 10ml vial a person would get 24 doses
***Need to order 6 doses to get this price

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

36. 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

37. 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

38. 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

39. Automatic Vacuum Pumps
Androvacuum Premium
No warranty - $295.00
Osbon ErecAid Esteem
5 Year Warranty - $495.00
30 day money back guarantee

40. Vacuum Devices
Bonro Medical
Vacurect® Retails $245.00

41. Osbon Erecaid Constriction Rings
Pink = firm fit
Beige = Regular fit
Each colour comes in
2 sizes small and large

42. Actis
Adjustable constriction loop