2. Dr. Anmar Nassir, FRCS(C) Canadian board in General Urology Fellowship in Andrology (U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ) Assisstent Prof Umm Al-Qura Consultant Urology King Faisal Specialist Hospital

3. MANAGEMENT OF ERECTILE DYSFUNCTION

4. NONSURGICAL MANAGEMENT OF ERECTILE DYSFUNCTION  Lifestyle Change  Medication Change  Herbal Supplements  Pelvic Floor Muscle Exercises  Psychosexual Therapy  Hormonal Therapy  Pharmacologic Therapy

6. SildenafilVardenafilTadalafil Cmax (ng/mL) 45020.9378 Tmax (hr) 0.80.7-0.92 Onset of action 15 min to 1 hr 15 min to 2 hr Half-life 3-5 hr 4-5 hr 17.5 hr Bioavailability40%15% Not tested Fatty food Reduced absorption No effect Recommended dosage 25, 50, 100 mg 5, 10, 20 mg

7. SildenafilVardenafilTadalafil Side effects  Headache, dyspepsia, facial flushing YesYesYes  Backache, myalgia RareRareYes  Blurred/blue vision YesRareRare Precaution with antiarrhythmics NoYesNo Contraindication with nitrates YesYesYes

8. Adverse events: PDE5 inhibitors Adverse event Sildenafil (flexible dose) Tadalafil (20 mg) Vardenafil (flexible dose) Headache161515 Flushing10311 Nasopharyngitis/rhinitis/ nasal congestion 439 Dyspepsia784 Abnormal vision 3 Sinusitis 3 Flu syndrome 3 Diarrhea3 Myalgia 3

9. NAION  Nonarteritic Anterior Ischemic Optic Neuropathy  Reported in men using sildenafil, vardenafil, and tadalafil n= 38, 1, and 4, respectively / total of 30 million users of PDE-5  Many of those affected had risk factors such as:  hypertension, diabetes, or hyperlipidemia,  Some men showed causal relationship with recurrence of NAION after rechallenge with PDE-5 inhibitors.

10. WARNINGS All three PDE-5 inhibitors warn against the use in patients with:  Myocardial infarction within the previous 90 days  Unstable angina or angina occurring during sexual intercourse  New York Heart Association class II or greater heart failure in the previous 6 months  Uncontrolled arrhythmias,  Hypotension (>90/50 mm Hg)  Uncontrolled hypertension (>170/100 mm Hg)  Stroke within the previous 6 months  hereditary degenerative retinal disorders,  retinitis pigmentosa  Tendency to develop priapism (e.g., sickle cell anemia, leukemia)

11. Intracavernosal injection ICI

12. Common Intracavernous Agents DrugDose rangeAdvantagesSide Effects Papaverine7.5-60 mgLow cost; Stable at room temp Fibrosis, priapism; Elevation of liver enzymes Alprostadil1-60 μgMetabolized in penis; Priapism rare Painful erection; Requires refrigeration; Relatively expensive Papaverine + phentolamine + alprostadil 0.1-1.0 mLMost potentRequires refrigeration

13. Combination of papaverine and phentolamine Papaverine (30 mg) and phentolamine (0.5 mg)  An erection sufficient for sexual intercourse was achieved in 115 (72%) as follows:  vasculogenic (48%),  psychogenic (93%),  neurogenic (92%),  diabetic (68%),  idiopathic (63%),  traumatic (60%),  alcohol-related (80%),  drug-related (75%).  After a mean follow-up period of 14.1 months,  55 (48%) were still successfully using intracavernous therapy.  A total of 22 episodes of priapism occurred in 16 patients  One patient developed corporeal fibrosis.

14. Trimix  Three mixture containing:  2.5 mL papaverine (30 mg/mL),  0.5 mL phentolamine (5 mg/mL),  0.05 mL alprostadil (500 μg/mL)  74% of patients were maintained at a dose of less than 0.25 mL per injection,averaging 3.1 uses per month.  65% were continuing injection therapy and of these,  89% were satisfied with the drug combination.  5.6% prolonged erections of more than 3 hours.  No patient developed fibrosis or nodules.

15. Suppository use Pellet Muse Pellet

16. Therapeutic Algorithm in ED