1. Dr P A Nathan Hollybrook Medical Centre

2. How common? 50% of men between 40-70yrs 70% of men aged 70yrs

3. History Key Points Difficulty getting and maintaining erection Premature ejaculation Psychosocial

4. Causes IHD,hypertension, High cholesterol Diabetes Neurological problems Low testosterone – previous head injury Nerve damage – pelvis Drugs Alcohol Cycling Psychological or mental health

5. Risk factors Smoking High blood pressure Weight Inactivity Diet Alcohol Diabetes

6. Investigations Bloods MSU Bp ECG

7. Prescribing When was viagra available? What classification of drug? Which neurotransmitter is involved? What contra-indications are there to oral medication? What is important about alpha-blockers? How successful is this treatment? Who is at risk of prolonged erections? How is prescription endorsed?

8. 1 July 1999

9. NHS criteria Diabetes, MS, Parkinson’s disease Poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, spinal cord injury Dialysis for renal failure Radical pelvic surgery, prostatectomy, renal transplant Were receiving other treatments on 14.9.1998 Suffering severe stress (specialist centre)

10. Severe stress Significant disruption to normal social and occupational activities Marked effect on mood, behaviour, social and environmental awareness Marked effect on interpersonal relationships

11. Side effects Dyspepsia, Vomiting Headaches Flushing Dizziness, myalgia, visual disturbances Raised intra-ocular pressure Nasal congestion hypersensitivity reasctions Priapism, Painful red eyes

12. More prescribing Which agent? How many? Where can I get it from? Interactions

13. Comparison SildenafilTadalafilvardenafil Time for onset15 mins30 mins60 mins Duration5 hrs36 hrs4 hrs Dose Range25-100mg10-20 mg5-20 mg Main side effectsHeadache, flushing Muscle, back, stomach pain Hypotension, MI, Stroke Dose frequency24 hrs24 hrs (not recommended) 24 hrs Cost£2.34-7.25£5.85-6.45£2.87-7.63 Brand nameViagraCialisLevitra Daily dose2.5-5mg

14. £7.85

15. What other agents can you use? Apomorphine (uprima) Alprostadil Caverject Virdal duo MUSE

16. Herbal alternatives? What herbal treatments are available for treating erectile dysfunction? Yohimbe – African tree bark Chinese horny goat weed Ginko Biloba Red ginseng (natural source of sildenafil)

17. Other treatments Treat underlying condition Psychosexual counselling

18. When to refer? Vaccum devices Penile prosthesis