Our topic is erectile dysfunction, an important topic. You need to figure out as to what the
underlying disease is. Let’s take a look at our few differentials. Maybe perhaps the erectile
dysfunction is being caused by Peyronie. Be careful. The reason I say that if there’s fibrosis
taking place with the penis, that there’s every possibility that you might find abnormal curvature,
maybe priapism or ultimately because it’s a dysfunction resulting in erectile dysfunction.
Keep in mind that with Peyronie that also you may have a patient that may have contraction
of the hand. That manifestation of the hand is called Dupuytren. That’s also fibrosis, superficial
type by the way. Trauma. Nervous system. The nerves itself may not be working properly
secondary to something like diabetic neuropathy. Remember, you need your sympathetic and
parasympathetic for proper erection. Other causes. There’s a condition known as Leriche's
syndrome or aortoiliac occlusive disease. So, what happens here is the fact there’s improper
or lack of blood supply to the penis in the corpus cavernosum. The impotence associated with
triad of aching claudication so think about where you are now, there is going to be occlusion
taking place in a major artery. If it’s claudication then you’re thinking about the leg,
hip, buttocks, and thighs, all these in the area of the aortoiliac area, region. Along with this,
there might be erectile dysfunction as well. If it’s diabetes mellitus then diabetes could result
in two possible issues. It could be atherosclerosis, therefore lack of blood supply. In addition,
it could also be diabetic neuropathy. Important, important sign is the erectile dysfunction,
isn’t it? Hypogonadism, maybe perhaps your patient is suffering from primary or secondary
hypogonadism resulting in erectile dysfunction. Important differentials from henceforth,
it is not always just going to be Viagra that’s going to help your patient. You need to make
sure you come down to or understand the underlying disease. Other important etiologies.
Psychogenic disorders especially young men and if there’s sudden, abrupt onset of impotence.
Medications: Beta blockers, anti-depressants, antipsychotics, any of these that may then bring
about hypogonadism and substance abuse. Management: Underlying cause. Is it atherosclerosis?
Is it a neuropathic change? Is it medication? Is it Peyronie? Underlying cause always with erectile
dysfunction. We have done a lot of issues and a lot of signs and symptoms in a patient in which
you have to come to the underlying disease. This is just one of them. Management: maybe
perhaps it is Viagra that you’re recommending which is a phosphodiesterase 5 inhibitor.
Look at the suffix. We have afil, afil, afil, vardenafil, sildenafil, tadalafil. The adverse
effects include well, cardiovascular is huge even to this day especially if your patient is taking
nitrates. So if you’re thinking about maybe atherosclerosis, it had really two type of disease.
Every single blood vessel could possibly be affected. Cerebrovascular accident, now the heart,
coronary artery disease. Initially, maybe perhaps 70% of the coronary artery in fact has been
occluded. Therefore upon exertion, you can only imagine, there will be inadequate blood supply
to the heart. A lack of oxygenation of the heart will result in (ouch) chest pain upon exertion.
Rest makes the pain go away referring to stable angina. What are you going to give this patient?
Sublingual nitroglycerin. What may happen as well is the fact that when you give nitrate and in
addition, you give phosphodiesterase 5 inhibitor, the combination of the two is absolutely
contraindicated. There’s another one called your riociguat. It may result in pulmonary hypertension.
Important, important adverse effects you definitely want to know in the cardiovascular system
with Viagra. You’ve heard of Cialis, everything that you’ve seen on your commercials.
Cardiovascular system, nitrates are contraindicated in pulmonary hypertension with riociguat.
Adverse effects of your phosphodiesterase inhibitors. “Blue vision” caused by cross-reaction
of phosphodiesterase 6 inhibitor naturally found in the retina lasting two to three hours
and more or less your ion. We’ll talk more about this in a little bit but at this point, at least
know that blue vision is due to the fact that the ever phosphodiesterase 5 inhibitor will then
cross-react with the 6 inhibitor. You’ve heard of cross-reaction all the time. There’s every
possibility. Penicillins and cephalosporins are always going to cross-react, right?
Other side effects. Sudden hearing loss. Reduce the dose with CYP3A4 inhibitors big time.
In pharmacology, you’ve learned about those drugs including clarithromycin, big time drug
being used in H. pylori eradication. Ketoconazole, antifungal, protease inhibitors, maybe
perhaps you’re thinking about HIV treatment, heart, and grapefruit juice. Don’t forget this nutrition.
All of these would inhibit CYP3A4. What does that mean? If these are drugs that inhibit
cytochrome P450 specifically 3A4, now what happens? You’re not able to properly metabolize
your drug, thus, you would have increased activity of the drug resulting in (uh-oh) increased
side effects in these patients. Big time important. Make sure you know about 3A4 inhibitors please.
Other options include, there’s something called Alprostadil which is a prostaglandin E1.
Now in general, when you think prostaglandin, remember this is erectile dysfunction. You're
trying to restore the blood supply perhaps, right? Earlier, we just talked about phosphodiesterase
5 inhibitor or you could use prostaglandin. What do you know about prostaglandins especially E1?
Vasodilation. Welcome to Alprostadil. You can have intrapenile or intraurethral or suppository,
different methods of administration. You can have vacuum-assisted erection, devices used
or recommended at times or perhaps even penile prosthesis. Things that you want to keep in mind
and other options for erectile dysfunction. Bottom line is make sure that you take a look at the
underlying disease and address it appropriately. Peyronie Disease in greater detail.
Puckering, what does puckering mean? Contraction, why? Notice the title. It’s a fibrotic plaque.
Cause flexion, contracture. Look for abnormal curvature of the penis. And fourth and fifth digits,
pinkie, ring finger contract. We’re in two different places, right? Penile contraction, Peyronie.
Hence, we definitely call this Dupuytren. It does not involve deep structure. That’s very important.
So therefore, the type of fibrosis that you see here is superficial. What do you mean?
Why is this important, Dr. Raj? Because you might have heard of Gardner syndrome. In Gardner
syndrome, you have familial adenomatous polyposis and you have a desmoid tumor which is a
deep type of fibrosis, completely different, desmoid. This is Peyronie, superficial.
It maybe caused by fibrogenic cytokines. What they are exactly? Well at this point,
I haven’t got enough feedback to go into greater detail but it should make sense to you
that there is pathologic increased activity of fibrogenic cytokines.