410.3 🩺 內科專科考前版

410.3.0.1 📌 一頁重點

22E updates: ED window to CV disease; PDE5 daily for BPH + ED dual benefit; flibanserin / bremelanotide for HSDD; testosterone for postmeno HSDD (controversial); collagenase for Peyronie’s
Taiwan: 健保 sildenafil + tadalafil 條件; 健保 alprostadil intracavernosal; 健保 prosthesis surgery 條件; flibanserin / bremelanotide 自費; 健保 cabergoline; 健保 sex therapy referral

410.3.0.2 🌟 Pearls (10)

ED is window to CV disease: precedes MI by 3-5 yr; consider cardiac eval in ED workup
Tadalafil daily 2.5-5 mg: dual benefit ED + BPH/LUTS
PDE5 + α-blocker combination: hypotension; titrate carefully
PDE5 in heart failure: useful in selected (improves exercise + ED)
Sildenafil for pulmonary hypertension (Revatio formulation)
NAION (non-arteritic ischemic optic neuropathy): rare PDE5 SE; warning if eye symptoms
Priapism > 4 hr = urological emergency
Flibanserin alcohol contraindication: severe hypotension + syncope
Bremelanotide melanocortin SE: nausea, BP elevation, focal hyperpigmentation
Testosterone for postmenopausal HSDD: off-label; lower dose; monitor virilization

410.3.0.3 📍 Taiwan + 健保

健保 sildenafil + tadalafil (limited per ED severity, post-prostatectomy 條件)
健保 vardenafil, avanafil 自費多
健保 alprostadil intracavernosal
健保 vacuum erection device 條件
健保 penile prosthesis 條件
健保 paroxetine for PE (off-label)
Dapoxetine 自費
Flibanserin (Addyi) 自費 / 部分非上市
Bremelanotide (Vyleesi) 未上市 Taiwan
健保 vaginal estrogen + ospemifene (條件)
健保 cabergoline + bromocriptine
Collagenase (Xiaflex) 自費多

410.3.0.4 🎓 內專必懂 (10)

Sexual dysfunction comprehensive workup
ED + CV disease relationship
PDE5 inhibitor + drug interactions (nitrate, α-blocker)
PDE5 daily for ED + BPH dual
Female sexual dysfunction 4 categories
Flibanserin + bremelanotide (premenop HSDD)
Postmenopausal sexual dysfunction (GSM + libido)
PE treatment ladder + behavioral
Drug-induced sexual dysfunction recognition
22E: collagenase Peyronie’s, daily PDE5 for BPH+ED, sildenafil pulm HTN

410.3.0.5 ⚙️ ED Workup (內專)

History:
- Onset, severity, situational vs all
- Nocturnal erections (psychogenic if intact)
- Comorbidity (DM, CV, neuro)
- Drug review
- Sexual history + relationship
- Trauma / surgery (prostatectomy, pelvic)

Examination:
- General
- Genital + neurologic + vascular pulses

Lab:
- AM total T (consider free if obese)
- Glucose + HbA1c
- Lipid panel
- TSH if low libido
- Prolactin if low libido + low T

Cardiac evaluation:
- Risk stratification (Framingham, ASCVD)
- Stress test if high risk + new ED + CV risk factors
- ED is risk equivalent for CV in some patients

Treatment selection:
- Optimize comorbidity
- PDE5 1st (consider daily tadalafil if BPH coexisting)
- Switch SE drugs if drug-induced
- Combination if partial response
- Intracavernosal alprostadil (high efficacy)
- Vacuum device
- Surgery if refractory

410.3.0.6 ⚙️ Female Sexual Dysfunction Workflow

Step 1 — History (sensitive):
- Onset, severity, distress
- Lifelong vs acquired
- Generalized vs situational
- Component (desire, arousal, orgasm, pain)
- Relationship + mental health
- Trauma history (consider PTSD)
- Drug review

Step 2 — Lab + Hormone:
- Estradiol + FSH (menopause)
- Testosterone (free)
- Prolactin
- TSH
- Glucose, lipid (CV / DM)

Step 3 — Address Underlying:
- Menopausal: vaginal estrogen, HRT if symptomatic + no CI
- Hyperprolactinemia: cabergoline
- Hypothyroid: T4
- Drug-induced: switch (SSRI → bupropion, mirtazapine)
- Depression: treat
- Pain: address (endometriosis, vulvodynia)

Step 4 — Specific Treatment:
- HSDD premenop: flibanserin (nightly), bremelanotide (on-demand)
- HSDD postmenop: low-dose testosterone (off-label, controversial)
- Vaginal dryness/GSM: lubricant, moisturizer, vaginal estrogen, ospemifene, DHEA
- Vaginismus: pelvic floor PT, dilators, sex therapy
- Anorgasmia: vibrator, sex therapy
- Drug-induced anorgasmia: switch

Step 5 — Multimodal:
- Sex therapy / CBT
- Couple counseling
- Relationship work
- Mental health support

⚠️ AI 草稿。