Transcript Document


A normal erection relies on the coordination:
Vascular
 Neurological
 Hormonal
 Psychological


An erection can occur following direct genital
stimulation or auditory or visual stimulation,
aspects that contribute to the influx of blood to
the penis


About 35 – 75% of men with diabetes will experience
at least some degree of ED (impotence) during their
lifetime
Men with diabetes develop ED 10 – 15 years earlier
than men without diabetes



Often 1st symptom men notice even before they are
diagnosed as a diabetic
Above age of 50, the likelihood of having difficulties
with an erection occurs in approximately 50 – 60% of
men
Above the age of 70, there is a 95% likelihood of
having some difficulty with erection function
www.WebMD.com

To get an erection, men need healthy:
Blood vessels
 Nerves
 Muscle function
 Desire to be sexually stimulated



Elevated blood glucose levels can cause
damage to blood vessels & nerves to the penis
Men with coronary artery disease (CAD) &
diabetes will be 9 times more likely to develop
ED than men with just diabetes
www.diabetes..about.com


Longer a man has diabetes with poor blood
glucose levels, complications of accompanying
heart disease such as high blood pressure &
high cholesterol can also affect ED
Diabetic men who smoke also have increased
risk of developing ED
www.diabetes..about.com
MEDICATIONS
ASSOCIATED
WITH ED
ALTERNATE
SOLUTIONS
Cardiovascular
Betablockers
Hydralazine
Methyldopa
Alpha-blockers
ALTERNATE
SOLUTIONS
Antidepressants
ACE inhibitors
ACE II inhibitors
Ca++ channel
blockers
SSRI
Tricyclic
antidepressant
MAOI
Buproprion
Mirtazapine
Antipsychotic agents
Diuretics
Thiazide diuretics
Spironolactone
MEDICATIONS
ASSOCIATED
WITH ED
Furosemide
(loop diurectics)
Conventional
neuroleptics
Risperidone
Quetiapine
Olanzapine
Hormone agents
Gastroesophageal reflux & ulcers
Anti-androgens (e.g. Varies depending
cyproterone)
on indication
Corticosteroids
Cimetidine
Antiparkinsonian agents
Anticonvulsants
Levodopa
Carbamazepine
Phenytoin
At the neurologist’s
discretion
Other H2 antagonist
or PPI
At the neurologist’s
discretion
Miscellaneous:
Phenothiazine antiemetics, opioids (chronic use), digoxin, ketoconazole, lithium
Drug-induced male sexual dysfunction.Pharmacist’s Letter/Prescriber’s Letter 2006; 22(9):220907.
PDE5 Inhibitors
1.
a)
b)
c)
2.
Intraurethral suppositories
a)
3.
4.
5.
Sildenafil - Viagra®
Varedenafil - Levitra®
Tadalafil - Cialis®
Alprostadil - MUSE®
Intraurethal gel
Penile injections
Vacuum devices
Autonomic spinal erection center
Drug
Strength
Quantity
Price
Viagra®/Generic
25mg
4
$50.82/$47.51
Viagra®/Generic
50mg
4
$53.27/$49.74
Viagra®/Generic
100mg
4
$54.83/$51.16
Levitra®
5mg
4
$62.35
Levitra®
10mg
4
$67.12
Levitra®
20mg
4
$70.32
Cialis®
10mg
4
$70.32
Cialis®
20mg
4
$73.57
Cialis®
2.5mg
28
$131.39 ($18.77/4)
Cialis®
5mg
28
$136.59 ($19.51/4)

MUSE®



250ug, 500ug, 1000ug
Medicated Urethral System for Erection
A choice for people:
 Who do not respond to oral pills
 Are afraid of injections

Suppository (about the size of a grain of rice) which
is placed about 1” inside the urethra using a special
applicator



Fool proof and low incidence of SE’s
Gives an erection similar to penile injection
therapy
Gives the most normal looking erection. The
head of the penis doesn’t swell in penile
injections/PDE5 inhibitors but does with
MUSE®


50 – 75% of men don’t respond well
50- 60% of men don’t respond consistently



May get good erection one time but not the next
May develop a lack of confidence because 1
out of every 2 or 3 uses doesn’t work well
2% of men may have dizziness on 1st
administration with 1000µg strength. May
need to do the 1st dose in the Dr’s office

Not with 250µg or 500µg dose
Muse
Quantity
Price
250µg
1
$40.24
500µg
1
$40.24
1000µg
1
$40.76




Fool proof and low incidence of SE’s
Gives an erection similar to penile injection
therapy
Possibly stronger than using MUSE®
Must be kept in the fridge and has a 30 day
expiry date

Many combinations
Dispense in 0.2ml single use syringes
 Expiry date 30 days
 Dose 0.2 intraurethrally 10 – 15 minutes
prior to sexual intercourse
 Hold penis upright for 30 seconds to
allow medication to absorb
 Rub any excess cream over the forehead
of the penis

Quantity
Price
Alp 240/Pap 24/Phe 1.2/0.2ml
6 Dose
$136.90
Alp 240/Pap 24/Phe 1.2/0.2ml
1 Dose*
$22.81
Muse 1000µg
1
$40.76
If 1 single dose ordered the price would be higher

Intracavernosal injection therapy


Very safe & highly effective
Around since 1983.


In 1982, a French surgeon injected a vasodilator into
the pelvic artery & the patient obtained an erection
Shortly after, a British physician injected a drug
directly into the penis

Alprostadil 20µg/0.5ml
 Prefilled syringe
 Dosage range 5 – 20µg

Works in 60% with all men with ED


Will work better with milder erection problems
Can cause an aching or burning penile pain in some
men with cavernous nerve injury

Alprostadil



Papaverine




Blocks -adrenergic receptors in penile blood vessels 
relaxation of trabecular cavernous smooth muscles & dilatation
of the penile arteries
Weak erectile-promoting effect when used alone.
Potentiates the effect of papaverine or PGE-1
Atropine


Inhibits phosphodiesterase in smooth muscle cells, which 
cAMP & cGMP  relaxation of vascular smooth muscles
Phentolamine


Prostaglandin E -1  cAMP
Vasodilator & muscle relaxant of corpus cavernosum &
trabecular smooth muscle
Smooth muscle relaxation
Chlorpromazine


 blocker activity
1:1 mg interchangeability with phentolamine

Products require refrigeration


Caverject® is kept at room temperature
After 18 months of radical prostatectomy more
than 70% of people will  the dose of their
injection

Duration of injection will be a sign for this
i.e. 30 minutes  45 minutes  60 minutes
Medication
Viagra 100mg/Generic
Cost Per Dose
$16.69/$12.79
MUSE 1000µg
Intraurethral Gel
$40.76
$22.82***
Caverject 20ug
$40.17*
Tri-Mix
$4.10**
*Caverject is a single use vial so product. Manufacturer
recommends once mixed product to be discarded
regardless what dose is used
** Tri-Mix dose used here is 40 units (0.4ml). In a 10.6ml
vial a person would get 24 doses
***Need to order 6 doses to get this price
Will inject needle into the skin but you still need
to push the plunger to dispense injection
$45.00
Does a complete injection
$69.95

Have been used for more than a century






1874 by Dr. John King
1917 Dr. Otto Lederer developed constriction rings
for maintenance of erections
1960’s Geddings Osborn developed his version of
vacuum device
1974 Osborn’s product became commercially
available
1976 FDA withdrew it’s approval
1982 FDA reapproved product

Erect penis (especially Caucasian) appears blue
or grey



50% of blood from arteries oxygenated
50% of blood from veins  non-oxygenated
Arterial blood is warmer than venous blood


Penis may not be as warm (1º-2º F lower)
Most common complaint of partners
 Touch penis
 Upon penetration



Takes 2-10 minutes to obtain a functional
erection
Take on average 4 attempts to use pumps to
become proficient
Need to place constriction ring as close as
possible to base of penis. Penis will be hard on
one side of ring and soft on the other side

Only wear for maximum 30 minutes

80-90%of men can obtain an erection


Overall patient satisfaction 60-80%
In order to achieve enough pressure in the
vacuum device, gel will have to be applied to
the open end of the device

Some men will also have to trim the pubic hair to
maximize seal

Certain groups of men should avoid using
these devices

Blood thinners or history of bleeding disorders
 Coumadin® - Warfarin
 Plavix® - Clopidogrel




Diminshed penile sensation
Spinal cord injury
Significant penile curvature
History of priapism
Not ASA 81mg
ANDROVACUUM PREMIUM
NO WARRANTY - $295.00
Osbon ErecAid Esteem
5 Year Warranty - $495.00
30 day money back guarantee

Bonro Medical

Vacurect® Retails $245.00
PINK = FIRM FIT
BEIGE = REGULAR FIT
Each colour comes in
2 sizes small and large
Adjustable constriction loop


Acronym for “Power to Empty Every
time while Never Urinating Too
Soon”
Contains:



Vitamin C, E, B6, Selenium, Zinc,
Echinacea, Glycine, Alanine, Glutamic
Acid, Saw Palmetto (Beta-Sitosterol),
Pygrum, Pumpkin Seed, Nettle, Garlic &
Ginkgo Biloba
Antioxidants, antiinflammatories, betasitosterol & immune boosters
 EPS & WBC & improved PSA

ED is may be an early warning sign of CVD



80% of men who had ED in beginning of a study
were more likely to develop CVD by the end of the
10 year study
Neo40 Daily helps restore nitric oxide (NO)
levels
Safer and more effective than L-arginine
Depleted or Low
Normal
Neo40 Daily Dose
2 lozenges daily
1 lozenge daily
Testing schedule
2 – 3 times per week
Once per week
Goal
Maintain Normal
reading for 2 weeks
Maintain Normal
reading every other day
Dose after reaching goal
Reduce to 1 lozenge per
day
Reduce to 1 lozenge
every other day
Testing Schedule after
reaching goal
Test 2 – 3 times per week
until restoration is stable
at Normal
Test once a week to
confirm restoration is
stable at Normal
1 Box (30 lozenges/2 test strips) $59.99TAX
1 Container (10 strips) $13.35TAX