1. Treatment of Erectile Dysfunction

2. Erectile Dysfunction
The persistent or recurrent inability to obtain or maintain an erection sufficient for sexual activity
ED can have a major impact on the quality of life and self-esteem of men who suffer from it
Men often draw a link between their masculinity and their ability to have an erection
This can lead also to affected relationships with partners

3. Erectile Dysfunction
> 50% of men aged 40 – 70 will have fairly marked erectile problems
Most often is due to an organic origin (up to 80%)
Can also have psychogenic causes
In several cases, it is both organic/psychogenic in origin  mixed-type ED

4. 1. Main Organic Causes Vascular
Roughly 40% of cases of ED in men over 50
Vascular problems can impede arterial blood flow into the penis, Examples: diabetes, hypertension, dyslipidemia
Neurological conditions
Can lead to interruption in nerve impulse
Examples: diabetic or alcoholic neuropathy
Hormone disorders
ED can be due to low testosterone (hypogonadism), hyperprolactinemia, hypothyroidism, adrenal insufficiency or glucocorticoid excess.

5. 2. Psychogenic Origin Can be cause by: Anxiety Depression or psychosis
Possibly with a loss of self-esteem
If causes of erectile dysfunction are completely psychological, the patient will continue to have nocturnal erections
Men with psychogenic ED often lose interest in sex

6. MEDICATIONS ASSOCIATED WITH ED
Cardiovascular
Antidepressants
Hormone agents
Beta blockers Hydralazine Methyldopa
Alpha-blockers
Digoxin
SSRI
TCA
MAOI
Anti-androgens
Corticosteroids
Diuretics
Antipsychotic agents
GIT
Thiazide diuretics
Spironolactone
Conventional neuroleptics
Risperidone
Cimetidine
Antiemetics,
Antiparkinsonian
Anticonvulsants
Miscellaneous:
Levodopa
Carbamazepine
Phenytoin
lithium
Phenothiazine
opioids (chronic use), ketoconazole

7. Treatment Options PDE5 Inhibitors Sildenafil Varedenafil Tadalafil
Centrally Acting Oral Drugs
Apomorphine
Intraurethral suppositories
Alprostadil
Intraurethal gel
Penile injections

8. 1. PDE5 Inhibitors
NO in the corpus cavernosum of the penis lead to vasodilation
Men who have erectile dysfunction often produce insufficient amounts of NO.
The small amount of cGMP (required for the production of NO) is being broken down at the same rate, so they cannot maintain an erection.

9. Theses drugs work by selectively inhibiting PDE5 (the enzyme that breaks down cGMP).
This prevents the hydrolysis of cGMP, allowing cGMP to accumulate and prolong the vasodilation effect, resulting in a stronger and longer erection.
These drugs work regardless of the cause of ED, but all require sexual stimulation for activation.

10. The figure below shows the mechanism of action of Viagra, and the other PDE5 inhibitors, on the nitric oxide cycle.

11. Adverse effects
Headache, flushing, Severe hypotension,
Dyspepsia, Impaired vision, Priapism
Increased intraocular pressure
Sudden hearing loss
Contraindications:
Hypotension and ischemic heart disease
Since PDE5 inhibitors may cause transiently hypotension, organic nitrates should not be taken for at least 48 hours after taking the last dose.
Using organic nitrates within this timeframe may increase the risk of life-threatening hypotension.

12. Viagra for women…
Due to Viagra’s PDE5 inhibition it may improve vaginal engorgement and lubrication.
Viagra for women is was created in 2003.
84 percent success rate of decreasing symptoms of female sexual dysfunction, but It doesn’t have FDA approval yet.
Befar, the topical alprostadil cream, may be used to treat Female Sexual Arousal Disorder.  It would cause clitoral stimulation by vasodilatation.

13. 2. Centrally Acting Oral Drugs
Apomorphine is a centrally acting drug that improves erectile dysfunction by enhancing the central natural erectile signals that normally occur in the brain during sexual stimulation.
It is a non-selective dopamine receptor agonist and acts mainly on dopamine D2-like receptors in the brain.

14. 3. Intraurethral Suppository
Alprostadil
Prostaglandin E1 analogue which is a vasodilator
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 cm inside the urethra using a special applicator
Advantages
Gives an erection similar to penile injection therapy
The head of the penis swell with Alprostadil suppositories

15. MUSE® Injector

17. 4. Intraurethal Gels
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
Directions of use:
Dispense in 0.2ml single use syringes
Administer 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

18. 5. Penile Injections Intracavernosal injection therapy
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

19. Alprostadil (Caverject)

21. Alprostadil
Prostaglandin E -1  cAMP
Vasodilator & muscle relaxant of corpus cavernosum & trabecular smooth muscle
Prefilled syringe
Works in 60% men with ED
Will work better with milder erection problems
Can cause an aching or burning penile pain in some men
Papaverine
Inhibits phosphodiesterase in smooth muscle cells, which  cAMP & cGMP  relaxation of vascular smooth muscles

22. 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
Chlorpromazine
 blocker activity

23. GOOD LUCK