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

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

www.WebMD.com

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 diabeteswww.diabetes..about.com

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

www.diabetes..about.com

MEDICATIONS ASSOCIATED

WITH ED

ALTERNATE SOLUTIONS

MEDICATIONS ASSOCIATED

WITH ED

ALTERNATE SOLUTIONS

Cardiovascular Antidepressants

Betablockers Hydralazine Methyldopa Alpha-blockers

ACE inhibitorsACE II inhibitorsCa++ channel blockers

SSRITricyclic antidepressantMAOI

BuproprionMirtazapine

Diuretics Antipsychotic agents

Thiazide diureticsSpironolactone

Furosemide (loop diurectics)

Conventional neurolepticsRisperidone

QuetiapineOlanzapine

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

CarbamazepinePhenytoin

At the neurologist’s discretion

Miscellaneous:Phenothiazine antiemetics, opioids (chronic use), digoxin, ketoconazole, lithiumDrug-induced male sexual dysfunction.Pharmacist’s Letter/Prescriber’s Letter 2006; 22(9):220907.

Treatment Options

1. PDE5 Inhibitorsa) Sildenafil - Viagra®b) Varedenafil - Levitra®c) Tadalafil - Cialis®

2. Intraurethral suppositoriesa) Alprostadil - MUSE®

3. Intraurethal gel4. Penile injections5. Vacuum devices

Autonomic spinal erection center

Tache PharmacyPrice PDE5 InhibitorsDrug Strength Quantity Price

Viagra®/Generic

25mg 4 $50.82/$47.51

Viagra®/Generic

50mg 4 $53.27/$49.74

Viagra®/Generic

100mg 4 $54.83/$51.16

Levitra® 5mg 4 $62.35

Levitra® 10mg 4 $67.12

Levitra® 20mg 4 $70.32

Cialis® 10mg 4 $70.32

Cialis® 20mg 4 $73.57

Cialis® 2.5mg 28 $131.39 ($18.77/4)

Cialis® 5mg 28 $136.59 ($19.51/4)

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

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®

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

MUSE® Injector

Tache Pharmacy MUSE® Prices

Muse Quantity Price

250µg 1 $40.24

500µg 1 $40.24

1000µg 1 $40.76

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

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

Tache Pharmacy PricesIntraurethral Gel

Quantity Price

Alp 240/Pap 24/Phe 1.2/0.2ml 6 Dose $136.90

Alp 240/Pap 24/Phe 1.2/0.2ml 1 Dose* $22.81

Muse 1000µg 1 $40.76

If 1 single dose ordered the price would be higher

Penile Injections

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

Caverject

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

Caverject

Penile Injections 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

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

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

BD Inject-Ease

Will inject needle into the skin but you still need to push the plunger to dispense injection

$45.00

Autoject 2

Does a complete injection

$69.95

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

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

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

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

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

Automatic Vacuum Pumps

ANDROVACUUM PREMIUMNO WARRANTY - $295.00 Osbon ErecAid Esteem

5 Year Warranty - $495.0030 day money back

guarantee

Vacuum Devices Bonro Medical

Vacurect® Retails $245.00

Osbon ErecaidConstriction Rings

PINK = FIRM FIT BEIGE = REGULAR FIT

Each colour comes in 2 sizes small and large

Actis

Adjustable constriction loop

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

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

Neo40 Daily

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