Ika Puspita Sari
Bag. Farmakologi & Farmasi Klinik Fakultas Farmasi UGM
Ika.puspitasari@gmail.com
The inability of a man to achieve or maintain an
erection sufficient for his sexual needs or the needs
of his partner.
The...
Incidence
 20-30 million American men suffer ED
 Age dependent
 2% men age <40 years
 25% men age 65
 75% men >75 yea...
ERECTILE DYSFUNCTION
Impotence
 As many as 30 million men in North America suffer

from some degree of erectile dysfuncti...
3/8/2013

Sari IP UGM

5
The International Index of Erectile Function (IIEF-5) Questionnaire
Reprinted by permission from Macmillan Publishers Ltd:...
3/8/2013

Sari IP UGM

7
3/8/2013

Sari IP UGM

8
3/8/2013

Sari IP UGM

9
Erectile dysfunction is divided into two etiologic categories:
psychogenic and organic. Most causes of erectile dysfunctio...
The severity of erectile dysfunction is often described as mild,
moderate or complete, although these terms have not been
...
ERECTILE DYSFUNCTION
Risk Factors
 Age (Biggest Risk)*
 Diabetes*
 Hypertension*
 Elevated Total or Low HDL Cholestero...
Conditions Associated with Erectile Dysfunction
Aging
Chronic diseases

DM, CHD,
Hypertension,Lipid, Liver,
Renal. Vascula...
Diabetic Control vs ED
 The better the diabetes control, the better the erections
 Hemoblobin A1c(blood test that measur...
3/8/2013

Sari IP UGM

15
Causes of ED
Other risk Factors ²
 Diabetes
 Chronic renal failure
 Hepatic failure

27% - 59%
40%
25% - 70%

 Multipl...
Causes of ED
Risk Factors
Massachusetts Male Aging Study¹

 Treated heart disease

39%

 Treated diabetes

28%

 Treate...
Causes of ED







Spinal cord injuries: 5% - 80%
Pelvic and urogenital surgery and radiation
Substance abuse
Alcoh...
Causes of ED
Medication:
 Most common cause of ED in men >50

 Many men are polymedicated
 Also have co-morbid conditio...
Medication
Antihypertensive medications
Diuretics

Type of sexual dysfunction*

Thiazides
Spironolactone (Aldactone)

Erec...
A Practical Evaluation of Men with ED
Sexual History
 Premature ejaculation
 Retarded ejaculation
 Painful intercourse
...
A Practical Evaluation of Men with ED
Differentiating Psychogenic from Organic ED
Organic ED:
 Gradual deterioration
 De...
A Practical Evaluation of Men with ED
Differentiating Psychogenic from Organic ED
Psychogenic Impotence:
 Younger patient...
3/8/2013

Sari IP UGM

24
3/8/2013

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25
Sexual Function and Related History
Description of erectile dysfunction
Age at onset and duration
Association with specifi...
The cardiovascular examination should include assessment of vital
signs (especially blood pressure and pulse) and signs of...
Treatment Options
 Nonpharmacologic
 Non-invasive
 Minimally invasive
 Invasive

 Counseling and/or sex therapy
Treatment Options
 Oral medications - Viagra, Levitra, Cialis
 Urethral suppositories (MUSE)
 Injection therapy - Caver...
Counseling and/or Sex Therapy
 Rule out depression
 Try oral medication in patient with psychogenic

impotence
 Refer t...
Ideal Medication for Treatment of ED
 Effective
 Available on demand
 Free of toxicity and side effects
 Easy to admin...
Medication
(PDE Inhibitors)
Indications:
 Psychogenic ED
 Mild vasculogenic ED
 Neurogenic ED
 Side effects from medic...
3/8/2013

Sari IP UGM

33
3/8/2013

Sari IP UGM

34
3/8/2013

Sari IP UGM

35
3/8/2013

Sari IP UGM

36
Medication
(PDE Inhibitors)
Side effects:
 Headache
 Flushing
 Dyspepsia
 Nasal congestion
 Visual disturbances
 Pri...
Medication
(PDE Inhibitors)
Contraindications:
 Organic Nitrites:
 Oral
 Sublingual

 Severe cardiac disease
 Obtain ...
Medication
(Yohimbine, Yocon, Erex, Yohimex)
 Alpha 2 andrenoreceptor antagonist
 Dose: 5.4 mg TID
 Results: ~20% (same...
Transurethral Therapy
Alprostadil - MUSE








Mechanism of Action: vasodilator
Administration: 125, 250, 500. 10...
3/8/2013

Sari IP UGM

41
Penile Injection Therapy
Caverject, Edex, Tri/Bi-Mix







Mechanism of action: smooth muscle vasodilator
Administr...
Androgen Replacement Therapy
 Indications: hypogonadism (<285ng/dl)
 Avoid oral estrogens-increase LFTs
 Injectable – 2...
Androgen Replacement Therapy
 Avoid in patients with prostate or breast cancer
 Slight increase risk of BPH
 Monitor al...
Vacuum Constriction Device
 Erection limited to 30 minutes
 Results: 80%-90%
 Contraindications: bleeding disorders, si...
Vacuum Constriction Device
 Was previously first-line treatment for ED
 Seldom used now that oral therapy is available
...
Penile Prosthesis
Indications:
 Patients who have failed other therapies
 Peyronie’s disease
 Severe vasculogenic disea...
Penile Prosthesis
Advantages:
 Low-morbidity
 Low-mortality surgery
 Low complication rates
 High success rates – 5% m...
Penile Prosthesis
Advantages (cont.)
 Good rigidity
 Freedom from medications
 Outpatient/24HR surgery
 Resume sexual ...
Refer Patients to a Urologist
 Patients who fail medical management
 Patients with Peyronie’s disease
 Patients with se...
Minyak Lintah Kalimantan | Jual Minyak Lintah | Minyak Lintah Asli
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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 http://JualMinyakLintahAsli.com (copy paste alamat ini ke browser kesukaan anda) Atau Hub 081348428286

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Minyak Lintah Kalimantan | Jual Minyak Lintah | Minyak Lintah Asli

  1. 1. Ika Puspita Sari Bag. Farmakologi & Farmasi Klinik Fakultas Farmasi UGM Ika.puspitasari@gmail.com
  2. 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. 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. 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. 5. 3/8/2013 Sari IP UGM 5
  6. 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
  7. 7. 3/8/2013 Sari IP UGM 7
  8. 8. 3/8/2013 Sari IP UGM 8
  9. 9. 3/8/2013 Sari IP UGM 9
  10. 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. 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. 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. 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. 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
  15. 15. 3/8/2013 Sari IP UGM 15
  16. 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. 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. 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. 19. Causes of ED Medication:  Most common cause of ED in men >50  Many men are polymedicated  Also have co-morbid conditions
  20. 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. 21. A Practical Evaluation of Men with ED Sexual History  Premature ejaculation  Retarded ejaculation  Painful intercourse  Anorgasmia  Decreased Libido  Dissatisfaction with sex life
  22. 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. 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
  24. 24. 3/8/2013 Sari IP UGM 24
  25. 25. 3/8/2013 Sari IP UGM 25
  26. 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. 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. 28. Treatment Options  Nonpharmacologic  Non-invasive  Minimally invasive  Invasive  Counseling and/or sex therapy
  29. 29. Treatment Options  Oral medications - Viagra, Levitra, Cialis  Urethral suppositories (MUSE)  Injection therapy - Caverject, Trimix, Bimix  Vacuum constriction device  Surgery  Sex therapy
  30. 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. 31. Ideal Medication for Treatment of ED  Effective  Available on demand  Free of toxicity and side effects  Easy to administer  Inexpensive
  32. 32. Medication (PDE Inhibitors) Indications:  Psychogenic ED  Mild vasculogenic ED  Neurogenic ED  Side effects from medication(s) patient is already taking
  33. 33. 3/8/2013 Sari IP UGM 33
  34. 34. 3/8/2013 Sari IP UGM 34
  35. 35. 3/8/2013 Sari IP UGM 35
  36. 36. 3/8/2013 Sari IP UGM 36
  37. 37. Medication (PDE Inhibitors) Side effects:  Headache  Flushing  Dyspepsia  Nasal congestion  Visual disturbances  Priapism
  38. 38. Medication (PDE Inhibitors) Contraindications:  Organic Nitrites:  Oral  Sublingual  Severe cardiac disease  Obtain stress testing
  39. 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. 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. 41. 3/8/2013 Sari IP UGM 41
  42. 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. 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. 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. 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. 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. 47. Penile Prosthesis Indications:  Patients who have failed other therapies  Peyronie’s disease  Severe vasculogenic disease Disadvantages: Surgery Expensive Possible mechanical failure
  48. 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. 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. 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

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