1.  A normal erection relies on the coordination:  Vascular  Neurological  Hormonal  Psychological  An erection can occur following direct genital stimulation or auditory or visual stimulation, aspects that contribute to the influx of blood to the penis

4. About 35 – 75% of men with diabetes will experience at least some degree of ED (impotence) during their lifetime Men with diabetes develop ED 10 – 15 years earlier than men without diabetes Often 1 st symptom men notice even before they are diagnosed as a diabetic Above age of 50, the likelihood of having difficulties with an erection occurs in approximately 50 – 60% of men Above the age of 70, there is a 95% likelihood of having some difficulty with erection function www.WebMD.com

5.  To get an erection, men need healthy:  Blood vessels  Nerves  Muscle function  Desire to be sexually stimulated  Elevated blood glucose levels can cause damage to blood vessels & nerves to the penis  Men with coronary artery disease (CAD) & diabetes will be 9 times more likely to develop ED than men with just diabetes www.diabetes..about.com

6.  Longer a man has diabetes with poor blood glucose levels, complications of accompanying heart disease such as high blood pressure & high cholesterol can also affect ED  Diabetic men who smoke also have increased risk of developing ED www.diabetes..about.com

7. MEDICATIONS ASSOCIATED WITH ED ALTERNATE SOLUTIONS MEDICATIONS ASSOCIATED WITH ED ALTERNATE SOLUTIONS CardiovascularAntidepressants Betablockers Hydralazine Methyldopa Alpha-blockers ACE inhibitors ACE II inhibitors Ca ++ channel blockers SSRI Tricyclic antidepressant MAOI Buproprion Mirtazapine Diuretics Antipsychotic agents Thiazide diuretics Spironolactone Furosemide (loop diurectics) Conventional neuroleptics Risperidone Quetiapine Olanzapine Hormone agentsGastroesophageal reflux & ulcers Anti-androgens (e.g. cyproterone) Corticosteroids Varies depending on indication CimetidineOther H2 antagonist or PPI Antiparkinsonian agentsAnticonvulsants LevodopaAt the neurologist’s discretion Carbamazepine Phenytoin At the neurologist’s discretion Miscellaneous: Phenothiazine antiemetics, opioids (chronic use), digoxin, ketoconazole, lithium Drug-induced male sexual dysfunction.Pharmacist’s Letter/Prescriber’s Letter 2006; 22(9):220907.

8. 1. PDE5 Inhibitors a) Sildenafil - Viagra® b) Varedenafil - Levitra® c) Tadalafil - Cialis® 2. Intraurethral suppositories a) Alprostadil - MUSE® 3. Intraurethal gel 4. Penile injections 5. Vacuum devices

9. Autonomic spinal erection center

11. DrugStrengthQuantityPrice Viagra®/Generic25mg4$50.82/$47.51 Viagra®/Generic50mg4$53.27/$49.74 Viagra®/Generic100mg4$54.83/$51.16 Levitra®5mg4$62.35 Levitra®10mg4$67.12 Levitra®20mg4$70.32 Cialis®10mg4$70.32 Cialis®20mg4$73.57 Cialis®2.5mg28$131.39 ($18.77/4) Cialis®5mg28$136.59 ($19.51/4)

12.  MUSE®  250ug, 500ug, 1000ug  Medicated Urethral System for Erection  A choice for people:  Who do not respond to oral pills  Are afraid of injections  Suppository (about the size of a grain of rice) which is placed about 1” inside the urethra using a special applicator

13.  Fool proof and low incidence of SE’s  Gives an erection similar to penile injection therapy  Gives the most normal looking erection. The head of the penis doesn’t swell in penile injections/PDE5 inhibitors but does with MUSE®

14.  50 – 75% of men don’t respond well  50- 60% of men don’t respond consistently  May get good erection one time but not the next  May develop a lack of confidence because 1 out of every 2 or 3 uses doesn’t work well  2% of men may have dizziness on 1 st administration with 1000µg strength. May need to do the 1 st dose in the Dr’s office  Not with 250µg or 500µg dose

17. MuseQuantityPrice 250µg1$40.24 500µg1$40.24 1000µg1$40.76

18.  Fool proof and low incidence of SE’s  Gives an erection similar to penile injection therapy  Possibly stronger than using MUSE®  Must be kept in the fridge and has a 30 day expiry date

19.  Many combinations  Dispense in 0.2ml single use syringes  Expiry date 30 days  Dose 0.2 intraurethrally 10 – 15 minutes prior to sexual intercourse  Hold penis upright for 30 seconds to allow medication to absorb  Rub any excess cream over the forehead of the penis

21. QuantityPrice Alp 240/Pap 24/Phe 1.2 / 0.2ml6 Dose$136.90 Alp 240/Pap 24/Phe 1.2 / 0.2ml1 Dose*$22.81 Muse 1000µg1$40.76 If 1 single dose ordered the price would be higher

22.  Intracavernosal injection therapy  Very safe & highly effective  Around since 1983.  In 1982, a French surgeon injected a vasodilator into the pelvic artery & the patient obtained an erection  Shortly after, a British physician injected a drug directly into the penis

23.  Alprostadil 20µg/0.5ml  Prefilled syringe  Dosage range 5 – 20µg  Works in 60% with all men with ED  Will work better with milder erection problems  Can cause an aching or burning penile pain in some men with cavernous nerve injury

26.  Alprostadil  Prostaglandin E -1   cAMP  Vasodilator & muscle relaxant of corpus cavernosum & trabecular smooth muscle  Papaverine  Inhibits phosphodiesterase in smooth muscle cells, which  cAMP & cGMP  relaxation of vascular smooth muscles  Phentolamine  Blocks  -adrenergic receptors in penile blood vessels  relaxation of trabecular cavernous smooth muscles & dilatation of the penile arteries  Weak erectile-promoting effect when used alone.  Potentiates the effect of papaverine or PGE-1  Atropine  Smooth muscle relaxation  Chlorpromazine   blocker activity  1:1 mg interchangeability with phentolamine

27.  Products require refrigeration  Caverject® is kept at room temperature  After 18 months of radical prostatectomy more than 70% of people will  the dose of their injection  Duration of injection will be a sign for this i.e. 30 minutes  45 minutes  60 minutes

28. MedicationCost Per Dose Viagra 100mg/Generic$16.69/$12.79 MUSE 1000µg$40.76 Intraurethral Gel$22.82*** Caverject 20ug$40.17* Tri-Mix$4.10** *Caverject is a single use vial so product. Manufacturer recommends once mixed product to be discarded regardless what dose is used ** Tri-Mix dose used here is 40 units (0.4ml). In a 10.6ml vial a person would get 24 doses ***Need to order 6 doses to get this price

29. Will inject needle into the skin but you still need to push the plunger to dispense injection $45.00

30. Does a complete injection $69.95

31.  Have been used for more than a century  1874 by Dr. John King  1917 Dr. Otto Lederer developed constriction rings for maintenance of erections  1960’s Geddings Osborn developed his version of vacuum device  1974 Osborn’s product became commercially available  1976 FDA withdrew it’s approval  1982 FDA reapproved product

32.  Erect penis (especially Caucasian) appears blue or grey  50% of blood from arteries  oxygenated  50% of blood from veins  non-oxygenated  Arterial blood is warmer than venous blood  Penis may not be as warm (1º-2º F lower)  Most common complaint of partners  Touch penis  Upon penetration

34.  Takes 2-10 minutes to obtain a functional erection  Take on average 4 attempts to use pumps to become proficient  Need to place constriction ring as close as possible to base of penis. Penis will be hard on one side of ring and soft on the other side  Only wear for maximum 30 minutes

35.  80-90%of men can obtain an erection  Overall patient satisfaction 60-80%  In order to achieve enough pressure in the vacuum device, gel will have to be applied to the open end of the device  Some men will also have to trim the pubic hair to maximize seal

36.  Certain groups of men should avoid using these devices  Blood thinners or history of bleeding disorders  Coumadin® - Warfarin  Plavix® - Clopidogrel  Diminshed penile sensation  Spinal cord injury  Significant penile curvature  History of priapism Not ASA 81mg

37. ANDROVACUUM PREMIUM NO WARRANTY - $295.00 Osbon ErecAid Esteem 5 Year Warranty - $495.00 30 day money back guarantee

38.  Bonro Medical  Vacurect® Retails $245.00

39. PINK = FIRM FITBEIGE = REGULAR FIT Each colour comes in 2 sizes small and large

40. Adjustable constriction loop

41.  Acronym for “ P ower to E mpty E very time while N ever U rinating T oo S oon”  Contains:  Vitamin C, E, B 6, Selenium, Zinc, Echinacea, Glycine, Alanine, Glutamic Acid, Saw Palmetto (Beta-Sitosterol), Pygrum, Pumpkin Seed, Nettle, Garlic & Ginkgo Biloba  Antioxidants, antiinflammatories, beta- sitosterol & immune boosters   EPS & WBC & improved PSA

42.  ED is may be an early warning sign of CVD  80% of men who had ED in beginning of a study were more likely to develop CVD by the end of the 10 year study  Neo40 Daily helps restore nitric oxide (NO) levels  Safer and more effective than L-arginine

43. Depleted or LowNormal Neo40 Daily Dose2 lozenges daily1 lozenge daily Testing schedule2 – 3 times per weekOnce per week GoalMaintain Normal reading for 2 weeks Maintain Normal reading every other day Dose after reaching goalReduce to 1 lozenge per day Reduce to 1 lozenge every other day Testing Schedule after reaching goal Test 2 – 3 times per week until restoration is stable at Normal Test once a week to confirm restoration is stable at Normal 1 Box (30 lozenges/2 test strips) $59.99 TAX 1 Container (10 strips) $13.35 TAX