First & second line treatments for ED AZARIPOUR ARASH MD

A 55 years old diabetic man with 1 year of moderate ED & low libido with gradual onset treated with sildenafil 50 mg with no good response. He has a history of HTN & LUTS treated with atenolole & tamsulosin. He is interested in bicycle riding. He is in a stable relationship with his wife. Genital physical exam is within normal range.

LDL: 175 mg/dl Hct : 48% PSA : 1.5 ng/ml FBS: 175 mg /dl Total Testosterone: 2.8 ng/ml, Free Testosterone: 4 ng/dl, Prolactin: 16 ng/ml, LH: 25 mIU/ml

with chronic ED should be considered a potential Each man > 40 years with chronic ED should be considered a potential cardiovascular risk patient and investigated accordingly.

Low sexual desire Rubio Auricles E, Bivalacqua TJ. Standard operational procedures for low sexual desire in men. J Sex Med. 2013 Jan;10(1):94-107

Hypogonadism & ED Porst H, et Al. SOP conservative treatment of erectile dysfunction. J Sex Med. 2013 Jan;10(1):130-71

T-replacement therapy in hypogonadal men with sexual disorders should start first. Recovery of sexual functions takes usually 4-12 weeks. Evaluate the patient 3 to 6 months after initiation of treatment and then annually. (response, adverse effects, testosterone level, HCT, PSA/DRE)

Approved regimens for testosterone replacement therapy Bhasin S, et Al. Testosterone therapy in men with androgen deficiency syndromes : An endocrine society clinical practice guideline :J Clinc Endocrinol Metab. 2010 Jun;95(6):2536-59

Pseudo-nonresponders to PDE5 inhibitors The use of at least four tablets with highest dose of any PDE5 inhibitor at four different occasions under optimal conditions (appropriate sexual stimulation and appropriate interval between intake and sexual activity).

Salvage pseudo-nonresponders Recounseling of the couples: up to 60% salvage Optimal treatment of concomitant diseases Treatment of concomitant hypogonadism Overdose therapy: 24% salvage rate Shifting to another PDE5 Inh. : 5-8% salvage rate OAD treatment: 50% salvage rate

EDSWT Included in EAU Guideline but current data are still limited and clear recommendations cannot be given.

The main indications for MUSE® are patients who are nonresponders to PDE5 inhibitors due to damage of the autonomic penile nerve supply (radical prostatectomy, cystectomy, and trauma) or in combination with PDE5 inhibitors in the so-called poor responders to oral therapy. –Johnny Appleseed

PGE1 (alprostadil) monotherapy is considered the standard vasoactive agent. VIP/phentolamine and Bimix (papaverine/phentolamjne) are approved in Europe. Papaverine/chlorpromazine somwhere Trimix is more effective than PGE1 monotherapy. Indicated in patients with cavernous insufficiency. Papaverine monotherapy is not recommended.

Combination treatments Level 1: weight loss & Rx of risk factors + PDE5 Level 1: hormone therapy + PDE5 Level 3: PDE5 + MUSE or ICI Level 4: VED + PDE5 or MUSE or ICI Level 5: PDE5 + L-arginine Level 5: OAD Tadalafil + prn PDE5

Porst H, Burnett A, Brock G, Ghanem H, Giuliano F, Glina S, Hellstrom W, Martin-Morales A, Salonia A, Sharlip I, and the ISSM Standards Committee for Sexual Medicine. SOP conservative (medical and mechanical) treatment of erectile dysfunction. J Sex Med 2013;10:130–171.