232. Male Sex Dysfx

Question 1

Erectile Dysfx

• define
• assoc
• prevalence

Answer 1

Persistent inability to achieve/maintain erection firm enough to have sexual intercourse
Usually accompanied by psych sx (performance anxiety)
Prevalence: 1 in 5 men older than 20yo (increases with age)

Question 2

What are the erection centers in the CNS and what is their function?

What are erectogenic and erectolytic NTs?

What disease state is closely associated with erectile dysfx?

Answer 2

PVN: senses arousal, releases oxytocin (pro-erectile)
MPOA: triggers erection, sends signal down SC to penis
PGN: inhibits erection if inappropriate time/setting

Erectogenic: PGE1, cAMP/cGMP, ACh, VIP, DA

Erectolytic: Adrenaline (during stress), GABA

CVD is a predictor of ED: both are endothelial dysfx states, and angioplasty of pelvic vasculature may improve erectile fx

Question 3

What are the 3 categories of ED? Which is most common?

Answer 3

1. Psychogenic/Loss of Confidence (performance anxiety, depression)
2. Organic: Chronic Disease, Meds, Alcohol, Drugs, Neural Disease
3. Mixed: MOST COMMON

Question 4

What are the 6 different ways you can dx ED?

Answer 4

1. HISTORY: Erectile fx hx (truest assessment of natural machienery: nocturnal erections), Psychosexual Hx (social, cultural, religious, education, psychological/interpersonal factors, identify and rule-out psychological + interpersonal factors, ask about partner)
2. PHYSICAL EXAM: BMI, WC (independent of BMI), gynecomastia, signs of hypogonadism, UGR exam, DRE Exam
3. Labs: Early morning total T level
4. Penile duplex doppler US: assess blood inflow and outflow, cavernosography (assess venous leak), pudendal angiography (arterial insufficiency)
5. Nocturnal penile tumescence/rigidity: strain gauge during sleep
6. Biothesiometry: screen for neuropathic changes (vibration sense)

Question 5

ED Tx:

• initial
• phases

Answer 5

Optimize/Correct comorbidities: DM, HTN control, hyperlipidemia, T deficiency, lifestyle (weight loss, stop smoking, more exercise, therapy)
- modify pt meds

I: oral meds (PDE5-i’s) 1ST LINE (contraindicated if taking nitrates, CV risk factors, alpha blocker, HIV med use - prolong CYP)

II: more invasive

• intraurethral suppository (alprostadil PGE: VD)
• Intracavernosal INjection (alprostadil with NO)
• vacuum erection device

III: severe cases

• penile prosthesis
• penile revascularization

Question 6

What are the NTs and hormones of ejaculation?

Answer 6

NTs: ACh (contract seminal vesicles), Oxytocin (contract seminal apparatus), 5HT (expulsion reflex; may delay ejaculation), DA (pro-ejaculatory)

Hormones:

• T - high amounts = PE
• Thyroid hormone: high amounts = PE
• PRL (5HT surrogate): high = DE
• Oxytocin: surges during ejaculation, orgasm, detumescence

Question 7

Premature Ejaculation

• what is it
• prevalence
• mgmt

Answer 7

Poor ejac control with assoc bother (usually <2min penetration)
Prev: 20% prevalence

Mgmt: Behavioral (stop/start, partner required, poor complicance/sustainability)
Transdermal numbing cream (Lidocaine - OTC)
SSRIs (delay ejaculation)

Question 8

Delayed Ejaculation

• causes
• tx
• med causes

Answer 8

• 42% SSRIs, 28% psychogenic, 21% low T, 7% abnormal penile sensation (DM, trauma, iatrogenic)

Tx: Buproprion (block NE, DA reuptake)
Cyproheptadine (antihistamine, raises 5HT due to SSRI)
Amantadine (DA stim)
Yohimbe (alpha2 block)

Med causers: SSRIs, Antipsychotics (block DA, induce hyperPRL - SWITCH to ARIPIPRAZOLE - less orgasm disorders)