L’erezione è una complessa risposta fisiologica che dipende da una perfetta integrazione dei numerosi meccanismi psicologici, vascolari, endocrini e neurologici implicati. Fino a qualche anno fa si pensava che circa il 90% dei deficit erettivi fosse di origine psicologica, ma recenti studi hanno dimostrato la presenza di un’eziologia organica in circa il 50% dei casi di deficit dell’erezione.
Tadalafil is a phosphodiesterase type 5 inhibitor used to treat erectile dysfunction. It has a longer duration of action than other PDE5 inhibitors like sildenafil and vardenafil, remaining effective for 36 hours after dosing. Studies show tadalafil significantly improves erectile function in men with diabetes and may provide additional benefits like improved beta-cell function and metabolic syndrome. Tadalafil is also being investigated for treating conditions like pulmonary arterial hypertension.
Tadalista (Tadalafil Tablets) which belongs to a class of drugs called phosphodiesterase-5 (PDE5) inhibitors, is an oral medicine that is used for treating impotence (the inability to attain or maintain a penile erection) and benign prostatic hyperplasia (BPH). Tadalista tablets have a very long 17.5 hours half-life as compared with only 4 hours for Sildenafil Citrate.
E’ difficile definire che cosa è una eiaculazione precoce; molto dipende dalla soggettività dei due partner.
Ciò che è troppo breve per qualcuno può essere assolutamente normale per un altro. In alcuni casi però l’eiaculazione avviene addirittura prima dell’introduzione del pene in vagina o dopo pochi secondi. Il fatto è che, quando ci si sente eiaculatori precoci, possono nascere insicurezze e timori che condizionano la vita sentimentale e relazionale. Consultate un andrologo che può escludere che vi sia una causa organica (infiammatoria o neurologica) e impostare una terapia corretta. Anche quando non si riesce a trovare, una causa specifica è, in alcuni casi possibile intraprendere una terapia farmacologica specifica che migliora il sintomo.
Sul fronte farmacologico si annunciano importanti novità; è in arrivo una nuova molecola: la Dapoxetina. E’ questa una sostanza che agisce a livello del sistema nervoso centrale alzando i livelli di serotonina, un importante “freno naturale” dell’eiaculazione. L’assunzione è al bisogno , con tutte le problematiche psicologiche che questo può scatenare, almeno un’ora prima del rapporto. Gli effetti collaterali sono riferiti a problemi gastro-intestinali e lo scatenarsi un’occasionale di nausea e senso di vomito.
Tadalafil Dapoxetine Tablets to treat Erectile Dysfunction and Premature Eja...The Swiss Pharmacy
Tadalafil and Dapoxetine Combination medication is a combination containing Tadalafil 20mg and Dapoxetine 60mg in a single tablet.
Tadalafil Dapoxetine Tablets are used for the treatment of male erectile dysfunction as well as treatment of premature ejaculation in men at the same time.
This document discusses the physiology of male sexual function and erectile dysfunction (ED). It notes that normal sexual function requires interactions among vascular, neurologic, hormonal, and psychological systems. Erections can be psychogenic, reflexive, or nocturnal. Nitric oxide plays a key role in achieving erections by relaxing blood vessels. Common causes of ED include reduced blood flow, low nitric oxide levels (from smoking, diabetes, low testosterone), and medications like SSRIs. Testosterone and nitric oxide are important for libido and erections. Sexual function generally declines with age due to various physiological changes. Management of antidepressant-induced sexual dysfunction may include lowering the dose, switching medications, adding phosphodi
L’erezione è una complessa risposta fisiologica che dipende da una perfetta integrazione dei numerosi meccanismi psicologici, vascolari, endocrini e neurologici implicati. Fino a qualche anno fa si pensava che circa il 90% dei deficit erettivi fosse di origine psicologica, ma recenti studi hanno dimostrato la presenza di un’eziologia organica in circa il 50% dei casi di deficit dell’erezione.
Tadalafil is a phosphodiesterase type 5 inhibitor used to treat erectile dysfunction. It has a longer duration of action than other PDE5 inhibitors like sildenafil and vardenafil, remaining effective for 36 hours after dosing. Studies show tadalafil significantly improves erectile function in men with diabetes and may provide additional benefits like improved beta-cell function and metabolic syndrome. Tadalafil is also being investigated for treating conditions like pulmonary arterial hypertension.
Tadalista (Tadalafil Tablets) which belongs to a class of drugs called phosphodiesterase-5 (PDE5) inhibitors, is an oral medicine that is used for treating impotence (the inability to attain or maintain a penile erection) and benign prostatic hyperplasia (BPH). Tadalista tablets have a very long 17.5 hours half-life as compared with only 4 hours for Sildenafil Citrate.
E’ difficile definire che cosa è una eiaculazione precoce; molto dipende dalla soggettività dei due partner.
Ciò che è troppo breve per qualcuno può essere assolutamente normale per un altro. In alcuni casi però l’eiaculazione avviene addirittura prima dell’introduzione del pene in vagina o dopo pochi secondi. Il fatto è che, quando ci si sente eiaculatori precoci, possono nascere insicurezze e timori che condizionano la vita sentimentale e relazionale. Consultate un andrologo che può escludere che vi sia una causa organica (infiammatoria o neurologica) e impostare una terapia corretta. Anche quando non si riesce a trovare, una causa specifica è, in alcuni casi possibile intraprendere una terapia farmacologica specifica che migliora il sintomo.
Sul fronte farmacologico si annunciano importanti novità; è in arrivo una nuova molecola: la Dapoxetina. E’ questa una sostanza che agisce a livello del sistema nervoso centrale alzando i livelli di serotonina, un importante “freno naturale” dell’eiaculazione. L’assunzione è al bisogno , con tutte le problematiche psicologiche che questo può scatenare, almeno un’ora prima del rapporto. Gli effetti collaterali sono riferiti a problemi gastro-intestinali e lo scatenarsi un’occasionale di nausea e senso di vomito.
Tadalafil Dapoxetine Tablets to treat Erectile Dysfunction and Premature Eja...The Swiss Pharmacy
Tadalafil and Dapoxetine Combination medication is a combination containing Tadalafil 20mg and Dapoxetine 60mg in a single tablet.
Tadalafil Dapoxetine Tablets are used for the treatment of male erectile dysfunction as well as treatment of premature ejaculation in men at the same time.
This document discusses the physiology of male sexual function and erectile dysfunction (ED). It notes that normal sexual function requires interactions among vascular, neurologic, hormonal, and psychological systems. Erections can be psychogenic, reflexive, or nocturnal. Nitric oxide plays a key role in achieving erections by relaxing blood vessels. Common causes of ED include reduced blood flow, low nitric oxide levels (from smoking, diabetes, low testosterone), and medications like SSRIs. Testosterone and nitric oxide are important for libido and erections. Sexual function generally declines with age due to various physiological changes. Management of antidepressant-induced sexual dysfunction may include lowering the dose, switching medications, adding phosphodi
Vidalista (Generic Tadalafil Tablets) is an oral medicine that is used for treating impotence (the inability to attain or maintain a penile erection). You can choose to take it on an as needed basis or take a low dose version everyday, so that you can be ready anytime.
For proper dosage of the medicine it is best to consult a doctor. Buy Tadarise 20 mg is taken when needed, approximately one hour before intercourse, preferably on an empty stomach. The maximum allowed dosage is one pill within a 36-hour period.
If you are taking tadarise 20 to treat erectile dysfunction, you should know that it does not cure erectile dysfunction or increase sexual desire. Tadarise does not prevent pregnancy or the spread of sexually transmitted diseases such as human immunodeficiency virus (HIV).
Este documento es una partitura musical para clarinete en si bemol menor titulada "Brasileirinho". La pieza musical está compuesta en las tonalidades de sol mayor y re menor y contiene dos secciones musicales, cada una repetida dos veces.
This document summarizes a presentation on male hypogonadism and testosterone replacement. It covers testosterone synthesis in the body and effects on health. It discusses how testosterone levels decline with age and guidelines for testosterone replacement therapy. Key points include confirming low testosterone levels through morning blood tests, assessing for underlying causes of low testosterone, discussing risks and benefits of treatment, and monitoring patients on therapy through repeated assessments of symptoms, hematocrit and PSA levels.
Compositor - Pixinguinha / Benedito Lacerda
Arranjo - Antônio Carlos Carrasqueira / Edmilson Capelupi
Estilo - Choro
Formação - Partitura Solo(Trompete)
We are an ISO 9001:2015 certified pharma company working with 800+ associates and our all products are CGMP/WHO certified promoting through Allopathic PCD Pharma franchise Business.
El simposio presentará tres charlas sobre temas relacionados con la diabetes mellitus tipo 2. La primera charla discutirá el uso de la terapia con inhibidores de SGLT2 para tratar el riesgo cardiovascular-renal-metabólico en pacientes con DM2. La segunda charla analizará los beneficios de los inhibidores de SGLT2 más allá del control glucémico. La tercera charla explorará el enfoque del cardiólogo para tratar a pacientes con DM2.
Erectile dysfunction is common in men with diabetes and tends to be more severe than in non-diabetic men. Screening for ED should be conducted annually as part of diabetes reviews. Asking direct questions such as "Are your erections hard enough for penetration?" can help identify cases of ED. Phosphodiesterase type 5 inhibitors are usually first-line treatment but some men may require additional options or a dose change if initial treatment is not effective. Testosterone deficiency can also contribute to ED in diabetic men.
An Update On Dpp 4 Inhibitors In The Management Of Type 2 DiabetesPk Doctors
The document discusses DPP-4 inhibitors, including sitagliptin and vildagliptin, for the treatment of type 2 diabetes. It summarizes that DPP-4 inhibitors work by inhibiting the DPP-4 enzyme, increasing active incretin levels like GLP-1 and GIP, and improving glucose control. Studies showed that both sitagliptin and vildagliptin improved glycemic measures like HbA1c and fasting glucose when used as monotherapy or add-on therapy to other diabetes medications like metformin. The document concludes that DPP-4 inhibitors are a promising new treatment option for type 2 diabetes.
ueda2012 do we still need high doses-d.mohammedueda2015
This document discusses hypertension and the need for high doses of antihypertensive medications. It provides data showing that over half of adults with hypertension still have uncontrolled blood pressure despite improvements. It also summarizes trials showing residual cardiovascular risk even when blood pressure is controlled. The document advocates for early use of combination antihypertensive therapy, especially those targeting the renin-angiotensin-aldosterone system, to improve control and reduce organ damage. It highlights valsartan specifically as a well-studied angiotensin receptor blocker with strong evidence from numerous trials across cardiovascular conditions.
Diabetes is associated with sexual dysfunction in both men and women. In men, erectile dysfunction is much more common, with a threefold increased risk. The risk increases with age. In women, female sexual dysfunction is also more prevalent among those with diabetes. Risk factors include poor glycemic control, cardiovascular disease, and psychological issues. Treatment involves lifestyle modifications, medication management, and counseling or therapy.
This document discusses the clinical profile and efficacy of the combination drug GLYXAMBI, which contains empagliflozin and linagliptin. It summarizes clinical trial results showing that GLYXAMBI provides significant reductions in HbA1c and body weight compared to the individual components alone in patients with type 2 diabetes. Guidelines from major diabetes organizations have been updated to recommend SGLT2 inhibitors like empagliflozin and GLP-1 receptor agonists to reduce cardiovascular risk based on positive cardiovascular outcomes trial results.
This document discusses the rational for using the combination of amlodipine and valsartan to treat hypertensive diabetic patients. It notes that hypertension is present in 20-60% of diabetic patients and substantially increases their risk of complications. While guidelines recommend tight control of both blood pressure and blood glucose, many patients require multiple medications to achieve targets. The combination of amlodipine, a calcium channel blocker, and valsartan, an angiotensin receptor blocker, provides complementary mechanisms of action that allow for more effective blood pressure control with fewer side effects compared to monotherapies. Clinical trials demonstrate the amlodipine/valsartan combination is well-tolerated and effective at reducing blood pressure
Phosphodiesterase enzymes (PDEs) regulate intracellular levels of cyclic nucleotides and cell function. There are 11 PDE families with over 50 isoforms. PDE inhibitors prevent degradation of cAMP and cGMP to modulate signal transduction. PDE5 inhibitors like sildenafil, tadalafil, and vardenafil are used to treat erectile dysfunction by prolonging cGMP signaling. They may have other uses such as for pulmonary hypertension, heart failure, and female sexual dysfunction. PDE5 inhibitors are contraindicated with nitrates due to risk of hypotension and require monitoring for potential side effects and drug interactions.
Este documento es el himno a la bandera nacional de Brasil. Consta de cuatro estrofas donde se expresa el amor y respeto por la bandera del país, símbolo de la patria brasileña. Se describe a la bandera como representante de la naturaleza y belleza de Brasil, y se la contempla para comprender el deber hacia la nación.
Marcellus Simadibrata Kolopaking MD PhD
Department of Medical Education
Division Gastroenterology Department of Internal Medicine
Faculty of Medicine University Indonesia
Dr.Cipto Mangunkusumo Hospital Jakarta
Relazione presentata dal Prof. Enrico Paciaroni (AN) Primario Emerito, INRCA Ancona, componente del Comitato di Indirizzo e Verifica dell’Istituto. Convegno Timidezza d'amore e ansia sessuale, Ancona 20 Novembre 2010
1. O documento discute as diferenças na sexualidade entre homens e mulheres e como elas podem gerar conflitos.
2. As mulheres tendem a se preocupar mais com sentimentos e personalidade, enquanto homens se excitam mais facilmente com estímulos visuais.
3. Apesar das diferenças naturais, a cultura também influencia a sexualidade e a noção de que homens são infiéis por natureza é questionada.
Vidalista (Generic Tadalafil Tablets) is an oral medicine that is used for treating impotence (the inability to attain or maintain a penile erection). You can choose to take it on an as needed basis or take a low dose version everyday, so that you can be ready anytime.
For proper dosage of the medicine it is best to consult a doctor. Buy Tadarise 20 mg is taken when needed, approximately one hour before intercourse, preferably on an empty stomach. The maximum allowed dosage is one pill within a 36-hour period.
If you are taking tadarise 20 to treat erectile dysfunction, you should know that it does not cure erectile dysfunction or increase sexual desire. Tadarise does not prevent pregnancy or the spread of sexually transmitted diseases such as human immunodeficiency virus (HIV).
Este documento es una partitura musical para clarinete en si bemol menor titulada "Brasileirinho". La pieza musical está compuesta en las tonalidades de sol mayor y re menor y contiene dos secciones musicales, cada una repetida dos veces.
This document summarizes a presentation on male hypogonadism and testosterone replacement. It covers testosterone synthesis in the body and effects on health. It discusses how testosterone levels decline with age and guidelines for testosterone replacement therapy. Key points include confirming low testosterone levels through morning blood tests, assessing for underlying causes of low testosterone, discussing risks and benefits of treatment, and monitoring patients on therapy through repeated assessments of symptoms, hematocrit and PSA levels.
Compositor - Pixinguinha / Benedito Lacerda
Arranjo - Antônio Carlos Carrasqueira / Edmilson Capelupi
Estilo - Choro
Formação - Partitura Solo(Trompete)
We are an ISO 9001:2015 certified pharma company working with 800+ associates and our all products are CGMP/WHO certified promoting through Allopathic PCD Pharma franchise Business.
El simposio presentará tres charlas sobre temas relacionados con la diabetes mellitus tipo 2. La primera charla discutirá el uso de la terapia con inhibidores de SGLT2 para tratar el riesgo cardiovascular-renal-metabólico en pacientes con DM2. La segunda charla analizará los beneficios de los inhibidores de SGLT2 más allá del control glucémico. La tercera charla explorará el enfoque del cardiólogo para tratar a pacientes con DM2.
Erectile dysfunction is common in men with diabetes and tends to be more severe than in non-diabetic men. Screening for ED should be conducted annually as part of diabetes reviews. Asking direct questions such as "Are your erections hard enough for penetration?" can help identify cases of ED. Phosphodiesterase type 5 inhibitors are usually first-line treatment but some men may require additional options or a dose change if initial treatment is not effective. Testosterone deficiency can also contribute to ED in diabetic men.
An Update On Dpp 4 Inhibitors In The Management Of Type 2 DiabetesPk Doctors
The document discusses DPP-4 inhibitors, including sitagliptin and vildagliptin, for the treatment of type 2 diabetes. It summarizes that DPP-4 inhibitors work by inhibiting the DPP-4 enzyme, increasing active incretin levels like GLP-1 and GIP, and improving glucose control. Studies showed that both sitagliptin and vildagliptin improved glycemic measures like HbA1c and fasting glucose when used as monotherapy or add-on therapy to other diabetes medications like metformin. The document concludes that DPP-4 inhibitors are a promising new treatment option for type 2 diabetes.
ueda2012 do we still need high doses-d.mohammedueda2015
This document discusses hypertension and the need for high doses of antihypertensive medications. It provides data showing that over half of adults with hypertension still have uncontrolled blood pressure despite improvements. It also summarizes trials showing residual cardiovascular risk even when blood pressure is controlled. The document advocates for early use of combination antihypertensive therapy, especially those targeting the renin-angiotensin-aldosterone system, to improve control and reduce organ damage. It highlights valsartan specifically as a well-studied angiotensin receptor blocker with strong evidence from numerous trials across cardiovascular conditions.
Diabetes is associated with sexual dysfunction in both men and women. In men, erectile dysfunction is much more common, with a threefold increased risk. The risk increases with age. In women, female sexual dysfunction is also more prevalent among those with diabetes. Risk factors include poor glycemic control, cardiovascular disease, and psychological issues. Treatment involves lifestyle modifications, medication management, and counseling or therapy.
This document discusses the clinical profile and efficacy of the combination drug GLYXAMBI, which contains empagliflozin and linagliptin. It summarizes clinical trial results showing that GLYXAMBI provides significant reductions in HbA1c and body weight compared to the individual components alone in patients with type 2 diabetes. Guidelines from major diabetes organizations have been updated to recommend SGLT2 inhibitors like empagliflozin and GLP-1 receptor agonists to reduce cardiovascular risk based on positive cardiovascular outcomes trial results.
This document discusses the rational for using the combination of amlodipine and valsartan to treat hypertensive diabetic patients. It notes that hypertension is present in 20-60% of diabetic patients and substantially increases their risk of complications. While guidelines recommend tight control of both blood pressure and blood glucose, many patients require multiple medications to achieve targets. The combination of amlodipine, a calcium channel blocker, and valsartan, an angiotensin receptor blocker, provides complementary mechanisms of action that allow for more effective blood pressure control with fewer side effects compared to monotherapies. Clinical trials demonstrate the amlodipine/valsartan combination is well-tolerated and effective at reducing blood pressure
Phosphodiesterase enzymes (PDEs) regulate intracellular levels of cyclic nucleotides and cell function. There are 11 PDE families with over 50 isoforms. PDE inhibitors prevent degradation of cAMP and cGMP to modulate signal transduction. PDE5 inhibitors like sildenafil, tadalafil, and vardenafil are used to treat erectile dysfunction by prolonging cGMP signaling. They may have other uses such as for pulmonary hypertension, heart failure, and female sexual dysfunction. PDE5 inhibitors are contraindicated with nitrates due to risk of hypotension and require monitoring for potential side effects and drug interactions.
Este documento es el himno a la bandera nacional de Brasil. Consta de cuatro estrofas donde se expresa el amor y respeto por la bandera del país, símbolo de la patria brasileña. Se describe a la bandera como representante de la naturaleza y belleza de Brasil, y se la contempla para comprender el deber hacia la nación.
Marcellus Simadibrata Kolopaking MD PhD
Department of Medical Education
Division Gastroenterology Department of Internal Medicine
Faculty of Medicine University Indonesia
Dr.Cipto Mangunkusumo Hospital Jakarta
Relazione presentata dal Prof. Enrico Paciaroni (AN) Primario Emerito, INRCA Ancona, componente del Comitato di Indirizzo e Verifica dell’Istituto. Convegno Timidezza d'amore e ansia sessuale, Ancona 20 Novembre 2010
1. O documento discute as diferenças na sexualidade entre homens e mulheres e como elas podem gerar conflitos.
2. As mulheres tendem a se preocupar mais com sentimentos e personalidade, enquanto homens se excitam mais facilmente com estímulos visuais.
3. Apesar das diferenças naturais, a cultura também influencia a sexualidade e a noção de que homens são infiéis por natureza é questionada.
MST - Malattie sessualmente trasmesse - Piccolo Manuale - Provincia di Romavideo_roma
Un magazine rivolto agli studenti delle superiori per dare informazioni sull' Aids e le malattie sessualmente trasmesse e per dare spunti di riflessione per una sessualità consapevole.
Este documento presenta un calendario de Playboy, advirtiendo a los menores de 18 años que se abstengan de verlo. Incluye fotos de modelos recientes del calendario y fue editado y montado por Emilio Gil, un jubilado que mantiene un blog sobre temas varios.
H para Hombres - Agosto 2015 - Alejandra RiveraJack 007
La pandemia de COVID-19 ha tenido un impacto significativo en la economía mundial y las vidas de las personas. Muchos países han impuesto medidas de confinamiento que han cerrado negocios y escuelas, y han pedido a la gente que se quede en casa tanto como sea posible para frenar la propagación del virus. A medida que los países comienzan a reabrir gradualmente, existen esperanzas de que la economía pueda recuperarse, pero el camino a seguir sigue siendo incierto.
This document discusses modern lifestyle trends and their impact on infertility. It notes that delaying childbearing and fertility treatment, smoking, obesity, stress, and certain environmental toxins can negatively influence fertility. Certain foods (like lentils, garlic, honey), a Mediterranean diet, olive oil, and vitamins may help fertility. The document provides recommendations around lifestyle changes like not delaying childbearing or IVF past age 38, limiting but not eliminating caffeine and alcohol, and quitting smoking to improve fertility outcomes. It emphasizes the importance of lifestyle choices in both reducing infertility and improving the success of fertility treatments.
The document discusses lifestyle factors that can impact fertility, including delaying childbearing, smoking, obesity, stress, and diet. It provides recommendations for improving fertility by not delaying treatment, quitting smoking, losing weight if obese, limiting stress, and eating a healthy diet. The document also discusses vitamins and foods that can support fertility, like lentils, garlic, honey, olive oil, and a Mediterranean-style diet.
Modern lifestyles can negatively impact fertility through factors like delayed childbearing, smoking, obesity, stress, and diet/nutrition. The document recommends several practical steps people can take to support fertility, such as not delaying childbearing past age 38, quitting smoking, losing weight if overweight, limiting caffeine/alcohol, addressing psychological stress, and following a healthy Mediterranean-style diet. The key message is that lifestyle choices have consequences for fertility and people should be aware that small adjustments could make a meaningful difference in their chances of conceiving.
2. Definizione di Disfunzione Erettile
Significativa o ricorrente inabilità dell’uomo
nell’ottenere e/o mantenere l’erezione,
fino al termine del rapporto sessuale
NHI Consensus Development Panel on Impotence.
NHI Consensus Conference. Impotence. JAMA 1993
5. “International Index of Erectile
Function”(IIEF)
Questionario 15 domande
– autosomministrato
– non invasivo
– discreto
6. Classificazione DE: IIEF
PUNTEGGIO DELLA FUNZIONE CLASSIFICAZIONE DELLA
ERETTILE DISFUNZIONE ERETTILE
1-10 Completa
11-16 Moderata
17-25 Lieve
26-30 Non DE
7.
8.
9.
10. sistema
circolatorio
sistema sistema
nervoso endocrino
EREZIONE
11. Organic Causes of E.D.:
Percentage Distribution
Adapted with permission from Goldstein I and the Working Group for the Study of Central
Mechanisms
in Erectile Dysfunction. Sci Am. August 2000;70-75.
13. Fattore di Rischio:
Malattie Neurologiche
• Malattie demielinizzanti predispongono alla
DE
– Sclerosi multipla
• 70 - 80% degli uomini con Sc.Mult. è affetto da DE
• Epilessia
• Accidenti cerebrovascolari
• Atrofia multisistemica (Parkinson)
14. Fattore di Rischio:
Interventi Chirurgici
• Procedure chirurgiche
– lesioni di nervi
– vasi sanguigni
• Resezione transuretrale della prostata
(TURP)
• Basso addome
– ileostomia
– colostomia
• Radioterapia (circa 70%)
15. Fattore di Rischio:
Cause Endocrine
La DE dovuta a endocrinopatia non è
comune (5%):
• iperprolattinemia
• ipertiroidismo
• ipotiroidismo
• ipogonadismo
16. ESAMI DI LABORATORIO
(Il 5% delle D.E. è di origine endocrina )
• TESTOSTERONE TOTALE
• FREE TESTOSTERONE
• PROLATTINA
• PROFILO GLICEMICO
• ASSETTO LIPIDICO
• FSH E LH ( SE
TESTOSTERONE BASSO )
• (ORMONI TIROIDEI)
17. Condizioni particolari: diabete mellito
50% dei diabetici: DE Fattori neurogeni
Talvolta sintomo di Neuropatia
disautonomica
esordio
Neuropatia periferica
Antidiabetici orali = insulina
Arteriosi
Controllo glicemia +++
Rischio aterosclerosi
Microangiopatia
> latenza
Endoteliali
< intensità orgasmo
Alterato rilasc. mlt
< vol. eiaculato
Miogeni
Alterata fx mlt
24. ECOCOLOR DOPPLER
PENIENO DINAMICO
COSA CI PUO’ DIRE ?
• Se ci sono alterazioni
strutturali dei corpi
cavernosi (fibrosi, placche)
• Se c’è una alterazione
dell’inflow arterioso penieno
• Se c’è una alterazione del
meccanismo veno-occlusivo
penieno
25. IL PERCORSO
TERAPEUTICO DELLA
DISFUNZIONE ERETTILE
26. Opzioni terapeutiche
Intervento
sui fattori di rischio
modificabili
Educazione e
terapia sessuale
Farmaci
per uso
orale
Terapie
locali Terapia
chirurgica
1st International Consultation on Erectile Dysfunction, Parigi, luglio 1999
27. FARMACI ATTIVI PER
SOMMINISTRAZIONE ORALE
Testosterone
Yohimbine
Apomorfina sublinguale
Inibitori delle PDEs-5
28. TESTOSTERONE
Terapia sostitutiva ormonale maschile (male
HRT)
Male HRT: INDICAZIONI
ADAM (Androgen Decline in the Aging Male)
PADAM (Partial Androgen Deficiency of Aging Male)
Sono entrambi ipogonadismi secondari correlati
all’invecchiamento e caratterizzati da sintomi e/o
manifestazioni cliniche dovute a ridotta disponibilità di T
La diagnosi obiettiva e clinica può essere o meno suffragata da
tests biochimici che confermino l’ipogonadismo (T e Tlib.)
Morales A, Heaton JPW. Urol Clin NA 2001; 28:279
29. TESTOSTERONE
Terapia sostitutiva ormonale maschile (male
HRT)
Correlazioni tra riduzione del T e patologie cardio-vascolari
• Malattia cardiovascolare – IMA – Ictus ischemico
Lovejoy JC et al. J Clin Endocrinol Metab 1996; 81: 2198-203
Rosano G et al.G It Andrologia, 2002;1
Conseguenze della riduzione del T sulla sessualità
• Riduzione della libido
• Degenerazione della cellule mm. liscie dei corpi cavernosi ed aumento
del connettivo
• Deficit della NOS neuronale
• Riduzione dell’afflusso arterioso e dell’efficacia del meccanismo
veno-occlusivo
• Aumentata sensibilità all’effetto contrattile degli alfa-adrenergici
• Deficit di rilascio di NO durante la fase eccitatoria per probabile
regolazione diretta degli androgeni sull’attività della PDE-5
30. TESTOSTERONE
Terapia sostitutiva ormonale maschile (male
HRT)
Effetti collaterali e controindicazioni
Controindicazioni assolute
- cancro della prostata
- carcinoma mammario
- apnee notturne
- presenza di apnee notturne (Sleep Apnea)
- Ipertrofia Prostatica Benigna con sintomatologia
ostruttiva
Controindicazioni relative
- Ipertrofia Prostatica Benigna con sintomatologia
ostruttiva assente o minima
- aumento dell’ematocrito e dei livelli di emoglobina
31. LE TERAPIE ORALI
PRIMO LIVELLO TERAPEUTICO
Farmaci ad azione
periferica
Sildenafil – Tadalafil –
Vardenafil
Farmaci ad azione centrale
Apomorfina
34. La famiglia delle Fosfodiesterasi
12 Gruppi di PDE (PDE 1 – 12) - 21 Sottogruppi - 53 Varianti distinte
PDE1 SNC, miocardio, muscolatura liscia e striata …
PDE2 Corteccia surrenalica, C.C., cuore, mm.liscia visceri,
SNC
PDE3 C.C., cuore, piastrine, mm. liscia vasi e visceri
PDE4 Putamen, n. caudato, testis, tiroide …
PDE5 C.C., muscolatura liscia vascolare e viscerale, piastrine
PDE6 Retina
PDE7 Muscolatura striata, miocardio, linfociti …
PDE8 Ubiquitario (testis, ovaie, colon, tenue) …
PDE9 Ubiquitario (milza, tenue, SNC) …
PDE10 Putamen, n. caudato, testis, tiroide
PDE11 Ubiquitario (muscolatura liscia e striata, testis, fegato, rene) …
35. Gli inibitori della PDE-5
O CH3
HN N
O O N O CH
S 3
N N
N O HN
O N
H3 C O
S N
CH3 N N
Sildenafi CH3
l H C
3
N
O
O
H CH
C H3 Vardenafi CH3
3
N
l
N
N
H H
O
O
O
Tadalafil
36. Quali sono i motivi che scoraggiano
l’uso della terapia orale?
Ragioni citate dai pazienti per non aver mai usato inibitori della PDE5 per il
trattamento della DE (risposte multipli possibili).
Preoccupazione per eventi
avversi
Sicurezza
Imbarazzo
Nessun bisogno/nessuna
partner
Diagnosi di DE recente
Costo
Mancanza di efficacia/beneficio
Pazienti (%)
Pereleman & Edwards, ISHM World Congress, Nice 2010
37. I vantaggi di una formulazione
orodispersibile
Anche con altre terapie on demand (es. il trattamento dell’emicrania) la
formulazione orodispersibile viene preferita dai pazienti
Dowson & Charlesworth 2003 Int J Clin Pract
Alcuni pazienti (specialmente tra gli anziani) hanno difficoltà ad ingerire
compresse
Koizumi et al., 1997 Int J Pharm
Difficoltà ad ingerire una compressa se l’acqua non è disponibile
Pereleman & Edwards, ISHM World Congress, Nice 2010
38. Vardenafil Orodispersibile
L’assorbimento e la biodisponibilità di vardenafil orodispersibile
non sono influenzati da un pasto ricco di grassi
AUC Cmax
10 10
0 0 *
5 5
0 0
0 0
pasto pasto
digiuno digiuno
abbondante abbondante
* p < 0.05
Heinig et al. Clin Drug Investig 2011; 31:27-41
39. Controindicazioni agli PDE5-i
Assunzione di nitrati
Infarto miocardico negli ultimi 3 mesi
Angina instabile
Accidente cerebro-vascolare negli ultimi 6 mesi
Insuffi.cardiaca classe 2 NYHA negli ultimi 6 mesi
Retinite pigmentosa
40. E’ assolutamente vietato l’uso
di sildenafil – vardenafil – tadalafil
in pazienti:
In terapia con nitroderivati
Affetti da retinite pigmentosa
41. VACUUM CONSTRICTOR
DEVICE (VCD)
• Il VCD tipico comprende una camera sottovuoto (o
cilindro), una pompa e degli anelli di costrizione
• Il VCD funziona creando del “vuoto” attorno al pene per
parecchi minuti finché la pressione negativa del vuoto
stesso possa attira il sangue nei tessuti del cavernosi; a
questo conseguono la tumescenza e la rigidità peniene
• Un anello di costrizione posto alla base del pene (Max. 30
mmHg di costrizione) consente poi al pene di restare
tumescente e rigido una volta che viene rimosso il cilindro
(Max: 20’)
42. TERAPIA INIETTIVA
• Pazienti che non rispondono alla terapia orale
• Pazienti che non possono usare la terapia orale
• Pazienti con esiti di chirurgia radicale della pelvi
Efficace nella maggior parte dei pazienti
indipendentemente dall’eziologia della
D.E. = 73% di successo
Sicurezza e tollerabilità ben documentate
Utilizzato per la diagnostica
Eventi Avversi:
Priapismo : 1,1% (dose-
dipendente)
Dolore penieno grave : 3,9%
47. GLI INSUCESSI DELLA TERAPIA
ORALE NON HANNO SCELTE
SODDISFACENTI
• FIC 73% DROP OUT 32% COSTI
27% PAURA DELL’AGO
24% NON NATURALE
• VACUUM 75% NON SODDISFACENTE
• MUSE 25% RI - PRESCRIZIONI
49. INDICAZIONI ALLA CHIRURGIA
PROTESICA DELLA D.E
PAZIENTI CON D.E. A PATOGENESI ORGANICA
Pz. non responder alla terapia medica
Controindicazioni all’attuale terapia medica
Fibrosi cavernosa
Malformazioni congenite od acquisite del
pene
Non accettazione o controindicazione al
Vacuum Device
Pz. che preferisce l’opzione protesica ad
altri presidi terapeutici