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Minyak Lintah Kalimantan | Jual Minyak Lintah | Minyak Lintah Asli

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Minyak Lintah Kalimantan memang banyak yang menjual tapi apakah anda tahu mana yang betul betul asli. Baiklah untuk memudahkan anda mencari produk yang benar benar asli Silahkan kunjungi …

Minyak Lintah Kalimantan memang banyak yang menjual tapi apakah anda tahu mana yang betul betul asli. Baiklah untuk memudahkan anda mencari produk yang benar benar asli Silahkan kunjungi http://JualMinyakLintahAsli.com (copy paste alamat ini ke browser kesukaan anda) Atau Hub 081348428286

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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 3/8/2013 Sari IP UGM 2
  • 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% 3/8/2013 Sari IP UGM 4
  • 5. 3/8/2013 Sari IP UGM 5
  • 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 3/8/2013 Sari IP UGM 6
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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 3/8/2013 Sari IP UGM 10
  • 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. 3/8/2013 Sari IP UGM 11
  • 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 3/8/2013 Sari IP UGM 12
  • 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 3/8/2013 Depression, anxiety, social stressor Cigaret, alcohol Sari IP UGM 13
  • 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 3/8/2013 Sari IP UGM 14
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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 3/8/2013 Sari IP UGM 20
  • 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 3/8/2013 Sari IP UGM 26
  • 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 3/8/2013 Sari IP UGM 27
  • 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%)
  • 41. 3/8/2013 Sari IP UGM 41
  • 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
  • 46. 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
  • 47. Penile Prosthesis Indications:  Patients who have failed other therapies  Peyronie’s disease  Severe vasculogenic disease Disadvantages: Surgery Expensive Possible mechanical failure
  • 48. 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
  • 49. 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
  • 50. 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