Alprostadil Does Not Need to Be Held Prior to Anesthesia
Alprostadil used for erectile dysfunction does not require discontinuation before anesthesia, as there are no guideline recommendations or evidence supporting perioperative withdrawal of this medication. The drug is administered on an as-needed basis for sexual activity and is not a chronic daily medication that would require perioperative management decisions.
Context and Clinical Reasoning
Alprostadil for Erectile Dysfunction
- Alprostadil is a synthetic prostaglandin E1 used as intracavernosal injection, intraurethral suppository, or topical cream for erectile dysfunction 1
- The medication is administered on-demand before sexual activity, not as a scheduled daily therapy 1, 2
- Patients typically use alprostadil up to 2 times per week, with no more than once per 24-hour period 3, 4
Perioperative Medication Management Guidelines
The 2014 ESC/ESA guidelines on non-cardiac surgery provide comprehensive recommendations for perioperative medication management but make no mention of holding alprostadil or other erectile dysfunction therapies 5. The guidelines specifically address:
- Continuation of pulmonary arterial hypertension (PAH)-specific therapies perioperatively, including prostaglandin analogs used for PAH 5
- Management of antihypertensive medications, with specific guidance on ACE inhibitors, ARBs, and beta blockers 5
- No recommendations exist for holding erectile dysfunction medications 5
Key Distinction: PAH vs. Erectile Dysfunction
- For patients receiving alprostadil for pulmonary arterial hypertension, the ESC/ESA explicitly recommends that "patients receiving PAH-specific treatment continue this in the pre-, peri-, and post-operative period without interruption" 5
- For erectile dysfunction, alprostadil is not a continuous therapy and would simply not be administered during the perioperative period when sexual activity is not occurring 1, 2
Safety Profile Supporting Perioperative Use
Minimal Systemic Effects
- Intraurethral alprostadil demonstrates "no typical systemic effects observed with oral ED pharmacological treatments" 6
- The most common adverse effects are localized: application site burning (12.2%), meatal pain (4.4%), with only 0.4% experiencing prolonged erection ≥4 hours 4
- Hypotension occurred in only 3.3% of men in clinic settings and was uncommon at home 2
No Priapism Risk in Perioperative Setting
- The AUA guidelines note that "men treated with alprostadil alone are less prone to progress to ischemic priapism compared to those treated with papaverine and phentolamine" 5
- No cases of priapism or penile fibrosis were reported in the largest clinical trial of 1,511 men 2
Practical Clinical Approach
Simply instruct patients not to use alprostadil on the day of surgery or during the postoperative recovery period when sexual activity would not occur. This is a matter of common sense rather than a formal medication hold:
- Document that the patient uses alprostadil for erectile dysfunction in the medication history 1
- No formal "hold" order is necessary since it's not a scheduled medication 1, 2
- Resume use when the patient has recovered sufficiently to engage in sexual activity postoperatively 5
Common Pitfall to Avoid
Do not confuse alprostadil for erectile dysfunction with continuous prostaglandin therapy for PAH or neonatal ductus arteriosus—these are entirely different clinical scenarios with different perioperative management 5.