1. Treatment of Erectile Dysfunction
Gregory Harochaw
Robin Coulter
Tache Pharmacy
400 Tache Avenue
Winnipeg, MB R2H 3C3
Phone: (204)

2. What is Erectile Dysfunction?
The persistent or recurrent inability to obtain or maintain an erection sufficient for sexual activity1
> 50% of men aged 40 – 70 will have fairly marked erectile problems2,3
Incidence is on the rise due to aging population & and  prevalence of conditions that are the root of the problem (i.e. diabetes, cardiovascular disease)2
Hatzimouratidis K, and Hatzichristou D. Sexual dysfunctions: Classifications and definitions. Journal of Sexual Medicine 2007;4:
Fazio L, Brock G. Erectile dysfunction: management update. CMAJ 2004;170(9):
Feldman HA, Goldstein I, Hatzichristou D, et al. Impotence and its medical and psychosocialcorrelates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61

3. Men With ED
ED can have a major impact on the quality of life and self-esteem of men who suffer from it
Men often draw a link between their masculinity and their ability to have an erection
Some men with ED may begin to think that they are no longer a “real” man
This can lead also to affected relationships with partners

4. Pathophysiology: Mechanism of an erection
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

5. Pathophysiology: Mechanism of an erection
An erection occurs when the amount of blood rushing to the penis is greater than the amount of blood flowing from it
A massive influx of blood accumulates in the sinusoidal spaces due to relaxation of smooth muscle & dilatation of arteries  corpora cavernosa to swell (tumescence)
Tumescence compresses the veins that normally drain the penis  prevents blood outflow & maintains penile rigidity

7. Pathophysiology: Mechanism of an erection
Usually following ejaculation:
A reduction in arterial inflow due to contraction of the smooth muscle cells
Combination of increased venous return
loss of erection (detumescence)

8. Erectile Dysfunction ED is most often an organic origin (up to 80%)
Can also have psychogenic causes
In several cases, it is both organic/psychogenic in origin  mixed-type ED
Anatomy and physiology of erection: pathophysiology of erectile dysfunction.
Int J Impot Res 2003;15 Suppl 7:S5-S8.

9. Main Organic Causes Vascular Roughly 40% of cases of ED in men over 50
Vascular problems can impede arterial blood flow into the penis
Examples: diabetes, cardiovascular disease (hypertension ,dyslipidemia), Peyronie’s disease, smoking, and trauma affecting blood circulation
Feldman HA, Goldstein I, Hatzichristou D, et al. Impotence and its medical and psychosocial
correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61

10. Main Organic Causes Neurological conditions
Can lead to interruption in nerve impulse transmission or the failure to conduct nerve impulses
Examples: diabetic or alcoholic neuropathy, MS, stroke, trauma or surgical procedures involving the spinal cord or pelvis
Brock G. Issues in the assessment and treatment of erectile dysfunction: Individualizing
and optimizing treatment for the “silent majority”.
Accessed January 20, 2009

11. Main Organic Causes Hormone disorders
ED that is hormonal in origin can be related to low circulation blood levels of testosterone (hypogonadism), hyperprolactinemia (drug-related or non-drug related), hypothyroidism, adrenal insufficiency or glucocorticoid excess
Brock G. Issues in the assessment and treatment of erectile dysfunction: Individualizing
and optimizing treatment for the “silent majority”.
Accessed January 20, 2009

12. Psychogenic Origin Can be cause by:
Anxiety
Depression or psychosis
Possibly with a loss of self-esteem
If causes of erectile dysfunction are completely psychological, the patient will continue to have nocturnal erections
Men with psychogenic ED often lose interest in sex
Anatomy and physiology of erection: pathophysiology of erectile dysfunction.
Int J Impot Res 2003;15 Suppl 7:S5-S8.

13. Risk Factors1,2,3 Aging Diabetes (vascular or neurological problems)
Cardiovascular disease (vascular issues)
Stress, anxiety & depression (low libido or self-esteem)
Medications or illicit substances
Prostatectomy (neurological problems)
Smoking (exacerbates vascular problem)
Hatzimouratidis K, and Hatzichristou D. Sexual dysfunctions: Classifications and definitions. Journal of Sexual Medicine 2007;4:
Fazio L, Brock G. Erectile dysfunction: management update. CMAJ 2004;170(9):
Feldman HA, Goldstein I, Hatzichristou D, et al. Impotence and its medical and psychosocialcorrelates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54-61

15. Diabetes ED
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 1st 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

16. Diabetes ED 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

17. Diabetes ED
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

18. MEDICATIONS ASSOCIATED WITH ED
ALTERNATE SOLUTIONS
Cardiovascular
Antidepressants
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 agents
Gastroesophageal reflux & ulcers
Anti-androgens (e.g. cyproterone)
Corticosteroids
Varies depending on indication
Cimetidine
Other H2 antagonist or PPI
Antiparkinsonian agents
Anticonvulsants
Levodopa
At the neurologist’s discretion
Carbamazepine
Phenytoin
Miscellaneous:
Phenothiazine antiemetics, opioids (chronic use), digoxin, ketoconazole, lithium
Drug-induced male sexual dysfunction.Pharmacist’s Letter/Prescriber’s Letter 2006; 22(9):

19. Treatment Options PDE5 Inhibitors Intraurethral suppositories
Sildenafil - Viagra®
Varedenafil - Levitra®
Tadalafil - Cialis®
Intraurethral suppositories
Alprostadil - MUSE®
Intraurethal gel
Penile injections
Vacuum devices

20. Autonomic spinal erection center
The increase in arterial inflow to the penis is dependent upon the autonomic spinal erection center, which
sends parasympathetic and sympathetic impulses to the arteries and smooth muscles of the corpora
cavernosa. High concentrations of nitric oxide (NO) are released through neural pathways into the smooth
muscles of the corpora cavernosa (Figure 2). Nitric oxide activates cyclic guanosine monophosphate
(cGMP), resulting in a reduction in cytosolic calcium levels and relaxation of the smooth muscles.
Phosphodiesterase type 5 (PDE-5) is responsible for the breakdown of cGMP into an inactive form,
5+cGMP4, which inhibits the effect of NO.

21. Presence of fatty foods can double the absorption time of Sildenafil and Vardenafil from 1 hour to 2 hours. Absorption is reduced from 20-50%. Take these at 5PM and say dinner is at 7PM then these products will continue to work 8-12 hours later.
If taken after meals then people should wait at least 2 hours prior to activity.
For diabetics, stomach emptying time is very much delayed so they should take these for sure before meals to get a response.
For tadalfil because reponse is 2-4 hours people should take 1st dose at least 4 hours prior to activity to ensure this works for them.
Side effects come on with minutes of taking the pill and last minutes. These are usually mild and disappear after a while.
Visual disturbances: sildenafil/vardenafil cross react with an enzyme in the retina known as PDE6, thus causes blurred vision, double vision or loss of colour vision. Not dangerous and does not cause night blindness.
Tadalfil can cause pooling of blood in major muscles in the body particularly back buttock’s and leg. 10% discontinuation.

22. Intraurethral Suppository
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

23. Advantages with MUSE® 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®

24. Disadvantages with MUSE®
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 1st administration with 1000µg strength. May need to do the 1st dose in the Dr’s office
Not with 250µg or 500µg dose

25. MUSE® Injector

27. Intraurethal Gels 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

28. Intraurethral Gels 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

30. Penile Injections Intracavernosal injection therapy Around since 1983.
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

31. Caverject Alprostadil 20µg/0.5ml Works in 60% with all men with ED
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

32. Caverject

34. Penile Injections Alprostadil Papaverine Phentolamine Atropine
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

35. Penile Injections 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

36. Price Comparison Medication Cost 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
Prices January 2013

37. BD Inject-Ease
Will inject needle into the skin but you still need
to push the plunger to dispense injection
$45.00

38. Autoject 2
Does a complete injection
$69.95

39. Vacuum Devices 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

40. Vacuum Devices 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

42. Vacuum Devices 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

43. Vacuum Pumps 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

44. Vacuum Devices 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

45. Osbon Erecaid Classic OTC $395.00 Automatic $495.00 5 Year Warranty
30 day Warranty

46. Vacuum Devices
Bonro Medical
Vacurect® Retails $195.00

47. Osbon Erecaid Constriction Rings
Pink = firm fit
Beige = Regular fit
Each colour comes in
2 sizes small and large

48. Actis
Adjustable constriction loop

49. Peenuts®
Acronym for “Power to Empty Every time while Never Urinating Too Soon”
Contains:
Vitamin C, E, B6, 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

50. Neo 40 Daily 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

51. Neo40 Daily 1 Box (30 lozenges/2 test strips) $59.99TAX
Depleted or Low
Normal
Neo40 Daily Dose
2 lozenges daily
1 lozenge daily
Testing schedule
2 – 3 times per week
Once per week
Goal
Maintain Normal reading for 2 weeks
Maintain Normal reading every other day
Dose after reaching goal
Reduce 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) $59.99TAX
1 Container (10 strips) $13.35TAX