​Kembara Xtra - Medicine - Erectile Dysfunction

​Kembara Xtra - Medicine - Erectile Dysfunction 
Introduction 
erectile dysfunction (ED) is the constant or recurrent inability to develop or keep an erection of sufficient hardness and duration for sexual intercourse. erectile dysfunction can affect both men and women.
In the past, erectile dysfunction (ED) in men was thought to be a symptom of the aging process in men; however, it is more commonly the result of concurrent medical conditions of the patient or from medications that patients may be taking to treat those conditions. ED is common among older men and has a negative impact on their quality of life; however, they rarely discuss their sexual problems with their physicians.
● Synonym(s): impotence

Epidemiology Incidence
It is anticipated that over 600,000 new instances of ED will be identified each year in the United States; however, it is possible that this figure is an underestimate of the true incidence of ED because of the widespread underreporting of the condition.
Prevalence
In terms of the overall prevalence of ED in some form:
52% of men between the ages of 40 and 70
An increase in risk associated with aging that ranges from 12.4% in males aged 40 to 49 years to 46.6% in males aged 50 to 69 years

Causes and effects: etiology and pathophysiology 
● Erections are neurovascular events.
– Nitrous oxide is released as a result of stimulation, which results in an increase in the creation of cyclic guanosine 3',5'-monophosphate (cGMP).
– Because of this, the cavernous smooth muscle is able to relax, which results in an increase in blood flow to the penis.
– An erection is the result of a decrease in venous outflow, which is caused by the cavernosal sinusoids becoming enlarged as a result of the blood flowing through them. This is accomplished through the passive compression of the subtunical veins.
ED can occur as a result of a change in any one of these occurrences.

Problems with the systems that are necessary for a proper penile erection might lead to erectile dysfunction (ED).
- Vascular: disorders that prevent blood from flowing properly Peripheral vascular disease, diabetes, arteriosclerosis, essential hypertension, and several drugs that treat hypertension
– Neurologic disorders are those that interfere with nerve conduction to the brain or the penile vasculature. – Spinal cord injuries, strokes, and diabetes are examples of neurologic diseases.
- Endocrine illnesses include those that are related with changes in testosterone, luteinizing hormone, and prolactin levels.
- Structural conditions such as phimosis, congenital curvature, and lichen sclerosis
- Patients who are suffering from malaise, despair, or performance anxiety due to psychological factors
ED can be caused by social habits like smoking and excessive alcohol consumption, as well as by some medications.
Therapy for prostate cancer Trauma or injury to the structure (caused by a bicycle accident)
Genetics
Almost seldom associated with chromosomal abnormalities.


Increasing age, cardiovascular disease, diabetes mellitus, metabolic syndrome, sedentary lifestyle, smoking cigarettes, pelvic surgery, radiation, trauma or injury to the pelvic area or spinal cord, medications that induce erectile dysfunction (SSRIs, -blockers, clonidine, digoxin, spironolactone, antiandrogens, corticosteroids, H2 blockers, anticonvulsants), and central neurologic and endocrinologic conditions
Abuse of substances (alcohol, cocaine, opioids, or marijuana) Abuse of psychological conditions (stress, anxiety, or depression, sexual abuse, or relationship issues) Abuse of psychological conditions (sexual abuse, or relationship problems)

Prevention 

The following are the two most effective methods for preventing ED:
Choosing to live a healthy lifestyle by going to the gym on a regular basis, eating meals that are rich in a variety of nutrients, drinking alcohol in moderation, and not smoking.
Managing diabetes, cardiovascular disease, and any other chronic conditions along with your patients, in addition to treating any pre-existing health conditions
WARNING: becoming older in and of itself is not a cause.

Conditions That Often Occur Together 
Cardiovascular disease: - When compared to men who do not have ED, men who do have ED have a higher risk of suffering from cardiovascular conditions such as angina, myocardial infarction, stroke, transient ischemic attack, congestive heart failure, or cardiac arrhythmia.

Psychiatric problems Diabetes Neurological conditions Metabolic syndrome Psychiatric disorders


Diagnosis 
Incapacity to achieve or sustain an erection that is satisfactory for sexual activity.

Providing a History Identify concurrent medical conditions or surgical procedures, history of trauma, and a list of current drugs (for example, hypertension meds). Also provide a history of any previous injuries.
Detailed sexual history is important to rule out premature ejaculation, which is frequently confused with erectile dysfunction (ED). The International Index of Erectile Function (IIEF) patient questionnaire is a useful tool in the clinica.

The Patient's Clinical Examination 
gynecomastia, small testicles, and decreased body hair are some of the signs and symptoms of hypogonadism. a detailed assessment of the cardiovascular, neurologic, and genitourinary systems is also necessary.
Check the femoral and lower extremity pulses to evaluate the vascular supply to the genitals. Take the patient's blood pressure, measure their waist circumference, and calculate their body mass index. Examine the tone of the anal sphincter as well as the genital reflexes, particularly the cremasterics and the bulbocavernosus.

Differential Diagnosis Premature ejaculation Decreased libido Anorgasmia Sudden versus chronic ED Premature ejaculation Decreased libido Anorgasmia


Results From the Laboratory 
There are some patients who might benefit from a vascular and/or neurologic assessment and monitoring of their nocturnal erections, but this is not something that should be done as part of a routine workup.

Initial Tests (laboratory, imaging) — HbA1c, lipid panel, CBC, BMP, TSH, morning total and free testosterone level — Doppler, angiography, and cavernosogram are available radiologic modalities but are not indicated in regular practice for the diagnosis of erectile dysfunction (ED).


Additional Assessments, as well as Other Important Factors

Other hormone tests, such as prolactin, should only be conducted when there is a strong clinical suspicion that a particular endocrinopathy is present.
The severity of ED can be evaluated using a variety of diagnostic procedures and other questionnaires, such as the International Index of Erectile Function (IIEF) and its approved and more readily administered shortened version, the Sexual Health Inventory for Men (SHIM).


Management 

The first-line treatment for erectile dysfunction (ED) consists of making changes to one's lifestyle and taking steps to manage any drugs that may be a contributing factor. First try the treatment that is the least invasive, and save more extreme measures for those who don't improve.
It is suggested that men diagnosed with vasculogenic undergo cardiovascular risk stratification as well as management of risk factors.
Phosphodiesterase type 5 (PDE-5) inhibitors are the first-line treatment for erectile dysfunction (ED). Current smoking has been shown to have a substantial association with erectile dysfunction (ED), and quitting smoking has been shown to have a positive influence on the restoration of erectile function.


The Standard Procedure 
It is possible that men whose erectile dysfunction (ED) is caused by depression or anxiety will benefit from psychosexual therapy, either on its own or in combination with psychoactive medicines.

• A reduction in body mass and an increase in the amount of physical exercise for obese men who suffer from ED. Men who have metabolic syndrome should be encouraged to make changes to their lifestyles in order to lower their risk of cardiovascular events and erectile dysfunction (ED).


The First Line Of Defense Is Medication
PDE-5 inhibitors are a successful treatment for erectile dysfunction (ED) in many men, including those who have diabetes mellitus or a spinal cord injury, as well as those whose sexual dysfunction is caused by antidepressants. The patient's preferences on cost, ease of use, and unwanted effects should guide the choice of treatment. There is an insufficient amount of evidence to warrant choosing one agent above the others:
Sildenafil (Viagra): the typical daily on-demand dose is between 50 and 100 milligrams, and it should be taken at least one hour and up to four hours before sexual activity.
Vardenafil (Levitra): the typical daily on-demand dose is 5 to 20 milligrams, and it should be taken at least one hour and no more than five hours before sexual activity.
Vardenafil (Staxyn): (oral-dissolving tablet) the typical daily on-demand dose is 10 mg within at least 1 hour and up to 5 hours before engaging in sexual activity.
 Tadalafil (Cialis): the recommended daily dosage is 2.5 to 5.0 mg, which should be taken independently of the activity level, or 5 to 20 mg, which should be taken at least 30 minutes and up to 36 hours before engaging in sexual activity.
Avanafil (Stendra): the typical daily on-demand dose is between 50 and 200 milligrams, and it should be taken at least 15 to 30 minutes and up to 4 hours before sexual activity.
– Some of the unwanted side effects of PDE-5 inhibitors include headache, face flushing, dyspepsia, nasal congestion, dizziness, hypotension, increased sensitivity to light (with sildenafil and vardenafil), visual abnormalities, lower back discomfort (with tadalafil), and priapism (with excessive doses).
– In order to have the best possible results, sildenafil and vardenafil should be taken on an empty stomach.
Considerations Regarding the Aged
When treating senior patients, use doses that are on the lower end of the dosing range, and conduct an exercise tolerance test before writing a prescription.
● Sildenafil 25 mg daily
● Vardenafil 5 mg daily
Two-Thirds Line
Injectable medications that are delivered intraurethrally or intracavernosally are considered effective second-line treatments that should be given to patients based on their individual preferences. Suppositories used via the intraurethral route are a less intrusive therapeutic alternative than injections administered via the intracavernosal route; nevertheless, they are not as effective. Relaxation of the smooth muscle in the arterial blood arteries and sinusoidal tissues in the corpora is caused by alprostadil, which is also known by its chemical name, prostaglandin E1.

 Alprostadil administered intraurethrally (Muse):
— Pellets of 125, 250, 500, and 1,000 micrograms for intraurethral suppository administration. Administer between 5 and 50 minutes before engaging in sexual activity.
It is not recommended to take more than two dosages in twenty-four hours.
● Intracavernosal alprostadil (available in 2 formulations):
– The recommended dosage of Alprostadil (Caverject) is 10 to 20 g, with a maximum dose of 60 g. Using a needle that is 0.5 inches long and either 27 or 30 gauges in diameter, the injection should be given at a right angle into one of the lateral surfaces of the proximal third of the penis. Do not use more than three times per week or more than once per twenty-four hours.
It is also possible to combine alprostadil with papaverine (Bimix), phentolamine (Trimix), and atropine (QuadMix).
Vacuum erection device, often known as a VED, is a noninvasive solution that can be purchased without a prescription.
Artificial penile implantation


Caution 

It is recommended that the first trial dosage of second-line medicines be given under the supervision of a specialist or a primary care physician who is knowledgeable in these treatments.
If the patient's erection continues for more than four hours, the physician needs to be notified immediately.
In men who have sickle cell anemia or blood dyscrasias, you should not use vacuum equipment. Taking testosterone supplements can improve erectile dysfunction and libido in men who have hypogonadism (6) [B]. Oral therapy, injectable depots, transdermal patches and gels, subcutaneous pellets, and other delivery methods are among the available formulations.
Do not provide testosterone to males with erectile dysfunction who already have normal testosterone levels. This is a recommendation from best practices in urology.

 Warning Signs And Symptoms:
- Phosphodiesterase inhibitors with nitroglycerin (or other nitrates): a risk of hypotension so severe that it could prove fatal
- Precautions/side effects:
○ Testosterone: precautions: Because exogenous testosterone lowers sperm count, it should not be administered to patients who wish to maintain their fertility; adverse effects include acne and sodium retention.
 Local penile pain, bleeding from the urethra, disorientation, and increased urination caused by intraurethral suppository
○ Intracavernosal injection: penile discomfort, edema and hematoma, visible nodules or plaques, and priapism
Sildenafil causes hypotension (patients using nitrates should exercise caution), and PDE-5 inhibitors cause impotence. Caution is advised in patients with congenital extended QT syndrome, patients taking class Ia or II antiarrhythmics, patients taking nitroglycerin, patients taking beta-blockers (such as terazosin, tamsulosin), patients with retinal illness, patients with unstable cardiac disease, patients with liver failure, and patients with renal failure. Significant potential interactions may occur.
○ PDE-5 inhibitor concentration is affected by CYP3A4
inhibitors (e.g., erythromycin, indinavir,
ketoconazole, ritonavir, amiodarone, cimetidine,
clarithromycin, delavirdine, diltiazem, fluoxetine,
fluvoxamine, grapefruit juice, itraconazole,
nefazodone, nevirapine, saquinavir, and verapamil).
There is a possibility that serum concentrations and/or toxicity will be raised. When treating these patients, lower initial doses should be utilized.
Rifampin and phenytoin have the potential to lessen the amount of PDE-5 inhibitor in the blood.

Further Methods of Treatment 

Men who struggled in their romantic relationships and were treated with counseling in addition to sildenafil had more effective sexual encounters than those who received only sildenafil.


Surgical Methods and Operations 
Patients who are not eligible for first- or second-line therapy or who have tried other treatments without success should not be considered for penile prosthesis.


Medication That Is Complementary 
Because they have not been shown to be effective in clinical trials, trazodone, yohimbine, and herbal treatments are not advised for the treatment of erectile dysfunction (ED). The use of low-intensity shock waves as a treatment for erectile dysfunction is not currently approved by the FDA; nonetheless, a number of studies have demonstrated that it can be effective, particularly in individuals who are younger, do not have diabetes, and whose cases of ED are less severe. There is a need for additional investigation.


Continued Patient Observation and Monitoring
Treatment should be evaluated not only at the beginning of the process but also after the patient has finished at least one to three weeks of a particular treatment: Keep an eye on the patient's level of enjoyment as well as the quality and quantity of his penile erections.
DIET
It is recommended that you make changes to your diet and get more exercise in order to achieve a normal body mass index.

The prognosis is that there is no difference in the efficacy of any of the PDE-5 inhibitors that are now available on the market. They have a success rate of between 55% and 80% when sexual stimulation is present.
– Patients with diabetes mellitus and radical prostatectomy who also suffer from erectile dysfunction have a lower success rate overall.
The overall efficiency of intracavernosal alprostadil ranges from 70–90%, while the effectiveness of intraurethral alprostadil ranges from 43–60%. Penile prosthesis are connected with a patient satisfaction percentage that ranges between 85 and 90 percent.

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