Dr. Anmar Nassir, FRCS(C)

Canadian board in General UrologyFellowship in Andrology (U of Ottawa)Fellowship in EndoUrology and Laparoscopy (McMaster Univ)

Assisstent Prof Umm Al-QuraConsultant Urology King Faisal Specialist Hospital

MANAGEMENT OF ERECTILE DYSFUNCTION

NONSURGICAL MANAGEMENT OF ERECTILE DYSFUNCTION

Lifestyle Change Medication Change Herbal Supplements Pelvic Floor Muscle Exercises Psychosexual Therapy Hormonal Therapy Pharmacologic Therapy

      SildenafilSildenafil VardenafilVardenafil TadalafilTadalafilCmax (ng/mL)Cmax (ng/mL) 450450 20.920.9 378378

Tmax (hr)Tmax (hr) 0.80.8 0.7-0.90.7-0.9 22

Onset of actionOnset of action 15 min to 1 hr15 min to 1 hr 15 min to 1 hr15 min to 1 hr 15 min to 2 hr15 min to 2 hr

Half-lifeHalf-life 3-5 hr3-5 hr 4-5 hr4-5 hr 17.5 hr17.5 hr

BioavailabilityBioavailability 40%40% 15%15% Not testedNot tested

Fatty foodFatty food Reduced absorptionReduced absorption Reduced absorptionReduced absorption No effectNo effect

Recommended Recommended dosagedosage

25, 50, 100 mg25, 50, 100 mg 5, 10, 20 mg5, 10, 20 mg 5, 10, 20 mg5, 10, 20 mg

      SildenafilSildenafil VardenafilVardenafil TadalafilTadalafilSide effectsSide effects         

   Headache, dyspepsia, Headache, dyspepsia, facial flushingfacial flushing

YesYes YesYes YesYes

   Backache, myalgiaBackache, myalgia RareRare RareRare YesYes

   Blurred/blue visionBlurred/blue vision YesYes RareRare RareRare

Precaution with Precaution with antiarrhythmicsantiarrhythmics

NoNo YesYes NoNo

Contraindication with nitratesContraindication with nitrates YesYes YesYes YesYes

Adverse events: PDE5 inhibitors

Adverse eventAdverse eventSildenafil Sildenafil (flexible dose)(flexible dose)

Tadalafil Tadalafil (20 mg)(20 mg)

Vardenafil Vardenafil (flexible dose)(flexible dose)

HeadacheHeadache 1616 1515 1515

FlushingFlushing 1010 33 1111

Nasopharyngitis/Nasopharyngitis/rhinitis/nasal congestionrhinitis/nasal congestion

44 33 99

DyspepsiaDyspepsia 77 88 44

Abnormal visionAbnormal vision 33      

SinusitisSinusitis       33

Flu syndromeFlu syndrome       33

DiarrheaDiarrhea 33      

MyalgiaMyalgia    33   

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.

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)

Intracavernosal injectionIntracavernosal injection

ICI

Common Intracavernous Agents

Drug Dose range Advantages Side Effects

Papaverine 7.5-60 mg Low cost; Stable at room temp

Fibrosis, priapism; Elevation of liver enzymes

Alprostadil 1-60 μg Metabolized in penis; Priapism rare

Painful erection; Requires refrigeration; Relatively expensive

Papaverine + phentolamine + alprostadil

0.1-1.0 mL Most potent Requires refrigeration

Combination of papaverine and phentolaminePapaverine (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.

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.

Suppository use

Pellet

Muse

Pellet

Therapeutic Algorithm in ED

Treat

Yes

C ontinue

Satisfied

C ontinue

Satisfied

C ontinue

Satisfied

C ontinue

Satisfied

Prosthesis

N one

C om bination

N one

IC

N one

intraurethra l

none

O ral

N O

H x & Exam .BS, PR L, Testosterone