1. First & second line treatments for ED
AZARIPOUR ARASH MD

2. 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.

3. 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

4. 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.

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

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

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

8. 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 Jun;95(6):

9. 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).

10. 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

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

12. 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

13. 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.

14. 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

15. 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.