Phosphodiesterase type 5 inhibitor (PDE5Is) are first line treatment for erectile dysfunction (ED). Sildenafil, tadalafil, vardenafil, and avanafil. Myocardial infarction, stroke, or life-threatening arrhythmia within the last six months Angina with sexual intercourse Hypotension (blood pressure < 90/50 mmHg Hypertension (blood pressure > 170/100 mmHg Congestive heart failure Class IV Nitrates including nitroglycerine, and isosorbide use All PDE5Is may result in orthostatic hypotension with α-blockers. Drugs that inhibit the CYP34A pathway, like ketoconazole will inhibit the metabolic breakdown of PDE5Is, thus increasing PDE5Is blood levels. Drugs that induce CYP3A4 pathway, like phenobarbital, enhance the breakdown of PDE5Is, so that higher doses of PDE5Is are required.
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Vacuum Erection Devices
First-line therapy in older patients with infrequent sexual intercourse and comorbidity.
Bleeding disorders or anticoagulant therapy
Intraurethral Alprostadil
An alternative to intracavernous injections.
Less-invasive but Less effective than injections.
Testosterone Supplementation
PDE5Is may be more effective if combined with testosterone therapy if there is testosterone deficiency.
Contraindications:
Untreated prostate cancer
Unstable cardiac disease
Cautions:
PSA should be measured in men over 40 years of age prior to starting testosterone therapy.
Testosterone should not be started for a period of three to six months in patients with a history of a cardiovascular events. Testosterone should not be given to men who are currently trying to conceive.
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Alprostadil Injection
Contraindications:
History of hypersensitivity to alprostadil
Risk of priapism
Bleeding disorders.
Papaverine, phentolamine and alprostadil triple injection
Fibrosis is more common because of papaverine and happens in 5-10% of patients.
Penile prostheses
Options:
Inflatable (2- and 3-piece) devices
Semi-rigid devices (malleable)
Complications:
Mechanical failure
Infection
Contraindications:
Urinary tract infection.
Cutaneous infection
Systemic infection
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