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1. Ika Puspita Sari
Bag. Farmakologi & Farmasi Klinik Fakultas Farmasi UGM
Ika.puspitasari@gmail.com

2. The inability of a man to achieve or maintain an
erection sufficient for his sexual needs or the needs
of his partner.
The inability to attain or sustain an erection adequate for
sexual stimulation
Most men experience this at some point in their lives,
usually by age 40
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3. Incidence
 20-30 million American men suffer ED
 Age dependent
 2% men age <40 years
 25% men age 65
 75% men >75 years
 Not a necessary occurrence of the aging process

4. ERECTILE DYSFUNCTION
Impotence
 As many as 30 million men in North America suffer
from some degree of erectile dysfunction
 The probability of a man between 40 and 70 years of
age having some degree of erectile dysfunction is 52%
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6. The International Index of Erectile Function (IIEF-5) Questionnaire
Reprinted by permission from Macmillan Publishers Ltd: Rosen RC, Cappelleri
JC, Smith MD, et al. Development and evaluation of an abridged, 5-item version
of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for
erectile dysfunction. Int J Impot Res. 1999 Dec;11(6):319-26. © 1999
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10. Erectile dysfunction is divided into two etiologic categories:
psychogenic and organic. Most causes of erectile dysfunction
were once considered to be psychogenic, but current
evidence suggests that up to 80 percent of cases have an
organic cause
NIH Consensus Conference on
Impotence. JAMA. 1993;270:83–90.
Organic causes are :vasculogenic, neurogenic and hormonal
etiologies
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11. The severity of erectile dysfunction is often described as mild,
moderate or complete, although these terms have not been
precisely defined.
The male sexual response cycle consists of four major phases:
(1) desire, (2) arousal (erectile ability), (3) orgasm and (4)
relaxation.
Disorders and dysfunction may occur in one or more of these
phases,6 and the clinician evaluating sexual function
problems must clarify which phase is primarily responsible for
the patient's symptoms.
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12. ERECTILE DYSFUNCTION
Risk Factors
 Age (Biggest Risk)*
 Diabetes*
 Hypertension*
 Elevated Total or Low HDL Cholesterol*
 Medicines (hypoglycemic agents, vasodilators, antihypertensives,
antidepressants)*
 Smoking**
 Depression
 Obesity
* Massachusetts Male Aging Study
** Mannino et. al. Am. J. Epidemiol. 140(11):1003-8
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13. Conditions Associated with Erectile Dysfunction
Aging
Chronic diseases
DM, CHD,
Hypertension,Lipid, Liver,
Renal. Vascular
Endocrine abnormalities
Hypogonad, Hyper Prl,
Hypo/hyper Tiroid
Neurogenic
Spinal cord, multiple scl,
herniated disc
Trauma/injury (pelvic,
penile)
Peyronie's disease, priapism
Pelvic radiation
Psychologic issues
Life style, Medication
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Depression, anxiety, social
stressor
Cigaret, alcohol
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14. Diabetic Control vs ED
 The better the diabetes control, the better the erections
 Hemoblobin A1c(blood test that measures diabetes control)
 Diabetic Neuropathy (pain or numbness in hands and feet)
 Control weight
 Improve exercise level
Romeo, J.H, et.al. J. Urol. 163(3), 2000
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16. Causes of ED
Other risk Factors ²
 Diabetes
 Chronic renal failure
 Hepatic failure
27% - 59%
40%
25% - 70%
 Multiple Sclerosis
 Severe depression
71%
90%
 Other (vascular disease, low HDL, high cholesterol)
²Benet et al. Urol Clinic North Am. 1995; 151:54-61

17. Causes of ED
Risk Factors
Massachusetts Male Aging Study¹
 Treated heart disease
39%
 Treated diabetes
28%
 Treated hypertension
15%
¹Feldman Ha, J Urol 1994; 151:54-61

18. Causes of ED






Spinal cord injuries: 5% - 80%
Pelvic and urogenital surgery and radiation
Substance abuse
Alcohol: >600ml/wk
Smoking amplifies other risk factors
Medications may be responsible for ~25% of cases of
ED
 Bicycle riding

19. Causes of ED
Medication:
 Most common cause of ED in men >50
 Many men are polymedicated
 Also have co-morbid conditions

20. Medication
Antihypertensive medications
Diuretics
Type of sexual dysfunction*
Thiazides
Spironolactone (Aldactone)
Erectile dysfunction, decreased libido
Erectile dysfunction, decreased libido
Central agents (methyldopa [Aldomet],
clonidine [Catapres])
Peripheral agents (reserpine
[Serpasil])
Alpha blockers
Erectile dysfunction, decreased libido
Sympatholytics
Beta blockers (particularly nonselective agents)
Psychiatric medications
Antipsychotic agents
Antidepressants
Erectile dysfunction, ejaculatory
dysfunction
Erectile dysfunction, ejaculatory
dysfunction
Erectile dysfunction, decreased libido
Multiple phases of sexual function
Tricyclic antidepressants
Decreased libido, erectile dysfunction
Monoamine oxidase inhibitors
Multiple phases of sexual function
Selective serotonin reuptake inhibitors Ejaculatory dysfunction, erectile
dysfunction
Anxiolytic agents
Benzodiazepines
Decreased libido
Antiandrogenic
Digoxin (Lanoxin)
Histamine H2-receptor blockers
Decreased libido, erectile dysfunction
Decreased libido, erectile dysfunction
Others
Alcohol (long-term heavy use)
Ketoconazole (Nizoral)
Niacin (Nicolar)
Phenobarbital
Phenytoin (Dilantin)
Decreased libido, erectile dysfunction
Decreased libido, erectile dysfunction
Decreased libido
Decreased libido, erectile dysfunction
Decreased libido, erectile dysfunction
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21. A Practical Evaluation of Men with ED
Sexual History
 Premature ejaculation
 Retarded ejaculation
 Painful intercourse
 Anorgasmia
 Decreased Libido
 Dissatisfaction with sex life

22. A Practical Evaluation of Men with ED
Differentiating Psychogenic from Organic ED
Organic ED:
 Gradual deterioration
 Decrease in morning erections and nocturnal
erections
 No erections with masturbation
 No loss of libido
 Presence of co-morbid conditions

23. A Practical Evaluation of Men with ED
Differentiating Psychogenic from Organic ED
Psychogenic Impotence:
 Younger patient (<40)
 Preservation of morning erections and nocturnal
erections
 Achieve erection with masturbation
 May be partner-specific
 Often sudden onset

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26. Sexual Function and Related History
Description of erectile dysfunction
Age at onset and duration
Association with specific event
Progression (rapid vs. gradual) of dysfunction
Quality of erections
Partial, unable to sustain
Frequency of dysfunction
Mild (occasional), moderate
(often), complete absence
Setting of erectile dysfunction
Presence or absence of
nocturnal erections
Presence or absence of
dysfunction with different
partners
Presence or absence of
dysfunction with self pleasuring
Other sexual problems (loss of libido, ejaculation problems)
Presence of chronic disease
Use of prescription, over-the-counter, or recreational drugs
Cigarette smoking
Social issues
Relationships
Life stressors
Expectations of patient and partner
Knowledge of sexual function
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27. The cardiovascular examination should include assessment of vital
signs (especially blood pressure and pulse) and signs of hypertensive
or ischemic heart disease.
The patient's demeanor, dress, speech and overall appearance should be
noted for signs suggestive of anxiety or depressive disorders.
Several reflexes can be tested to evaluate sacral cord function
The genital evaluation should assess for local abnormalities, such
as hypospadias or phimosis, and evidence of hypogonadism
The prostate gland should be assessed for size, consistency and
symmetry
A complete blood count, urinalysis, renal function, lipid
profile, fasting blood sugar, and thyroid function.
The basic screen consists of serum testosterone and prolactin
measurements
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28. Treatment Options
 Nonpharmacologic
 Non-invasive
 Minimally invasive
 Invasive
 Counseling and/or sex therapy

29. Treatment Options
 Oral medications - Viagra, Levitra, Cialis
 Urethral suppositories (MUSE)
 Injection therapy - Caverject, Trimix, Bimix
 Vacuum constriction device
 Surgery
 Sex therapy

30. Counseling and/or Sex Therapy
 Rule out depression
 Try oral medication in patient with psychogenic
impotence
 Refer to sex therapist or psychiatrist for sever
psychopathology

31. Ideal Medication for Treatment of ED
 Effective
 Available on demand
 Free of toxicity and side effects
 Easy to administer
 Inexpensive

32. Medication
(PDE Inhibitors)
Indications:
 Psychogenic ED
 Mild vasculogenic ED
 Neurogenic ED
 Side effects from medication(s) patient is already
taking

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37. Medication
(PDE Inhibitors)
Side effects:
 Headache
 Flushing
 Dyspepsia
 Nasal congestion
 Visual disturbances
 Priapism

38. Medication
(PDE Inhibitors)
Contraindications:
 Organic Nitrites:
 Oral
 Sublingual
 Severe cardiac disease
 Obtain stress testing

39. Medication
(Yohimbine, Yocon, Erex, Yohimex)
 Alpha 2 andrenoreceptor antagonist
 Dose: 5.4 mg TID
 Results: ~20% (same as placebo)
 Side effects: increase blood pressure, tachycardia,
anxiety

40. Transurethral Therapy
Alprostadil - MUSE







Mechanism of Action: vasodilator
Administration: 125, 250, 500. 1000ug
Insert in the urethra
Erection occurs 10-15 minutes later
Erection lasts 30-45 minutes
Results: 10-65%
Side effects: Pain, bleeding, priapism (<3%)

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42. Penile Injection Therapy
Caverject, Edex, Tri/Bi-Mix






Mechanism of action: smooth muscle vasodilator
Administration: 10, 20, 40ug
Inject directly into corporeal bodies of the penis
Results: 70%-90%
Dropout rates: 25%-60%
Side effects: pain (36%), priapism (4%), fibrosis

43. Androgen Replacement Therapy
 Indications: hypogonadism (<285ng/dl)
 Avoid oral estrogens-increase LFTs
 Injectable – 200mg testosterone (cypionate, enathate,
propionate), q2-3 weeks
 Transdermal
 Patch
 gel

44. Androgen Replacement Therapy
 Avoid in patients with prostate or breast cancer
 Slight increase risk of BPH
 Monitor all patients with annual DRE and PSA

45. Vacuum Constriction Device
 Erection limited to 30 minutes
 Results: 80%-90%
 Contraindications: bleeding disorders, sickle cell
disease, anticoagulation
 Complications: coolness, petechiae, numbness, pain
with ejaculation
 High drop out rate

47. Vacuum Constriction Device
 Was previously first-line treatment for ED
 Seldom used now that oral therapy is available
 Considered an alternative if patient fails oral therapy
and does not want to proceed with surgery

48. Penile Prosthesis
Indications:
 Patients who have failed other therapies
 Peyronie’s disease
 Severe vasculogenic disease
Disadvantages:
Surgery
Expensive
Possible mechanical failure

49. Penile Prosthesis
Advantages:
 Low-morbidity
 Low-mortality surgery
 Low complication rates
 High success rates – 5% malfunction rate at 5 years
 High satisfaction rate – 87%
 High partner satisfaction rate

50. Penile Prosthesis
Advantages (cont.)
 Good rigidity
 Freedom from medications
 Outpatient/24HR surgery
 Resume sexual activity 4-6 weeks
 No loss of ability to ejaculate or achieve orgasm

51. Refer Patients to a Urologist
 Patients who fail medical management
 Patients with Peyronie’s disease
 Patients with severe vasculogenic ED
 Patients on NTG who are not candidates for oral
medications
 Patients requesting an implant