5 - ED Flashcards
Erections are results of?
Neurovascular event
Neurotransmitters
What does the neurovascular event of ED include?
- Intact autonomic and somatic nerve supply to penis
- arterial blood flow supplied by the paired cavernosal arteries
- smooth and striated musculature of the corpora cavernosa and pelvic floor
What neuortransmitters are involved in an erection?
Nitric oxide (primary)
Others
- acetylocholine, prostaglandins and vasoactive intestinal peptide
Flow chart of erection?
Slide 8
Blood flow and muscle action w erection?
Increase arterial flow
Relaxtion of smooth muscles in corpora cavernosa
Increase venous resistance
Contraction of bulbocavernosa and ischiocavernous muscles -> further rigidity of penis
Definition of ED?
Consistent inability to attain or maintain a sufficiently rigid penile erection for sexual performance
Etiology of ED?
Organic
Psychogenic
Can be an overlap
Describe psychogenic ED
Young men
+ nocturnal/morning erection
Situational ED
Types of psychogenic ED?
Generalized
- unresponsive
Situational
- partner related
- performance related
- psychological distress or adjustment related
Types of organic ED?
Neurogenic Hormonal Arterial Venous Drug-induced
How to differentiate psychogenic and organic ED?
“Do you get nocturnal erections?”
Yes - psycogenic
No - organic
Dont know - there is a monitor for that
Diseases related to ED?
Slide 15
Risk factors for ED?
- men >40
- DM
- dyslipidemia
- HTN
- psych probs (depression)
- neurologic disease
- CKD
- cardiac/peripheral disease
- previous prostate cancer
- pelvic trauma/surgery/irradiation
- endocrine d/o
- tobacco
- alcohol
- drugs
- obesity
History q’s for ED?
Other sex dysfunction
- loss of libido (androgen)
- anejaculation (many diseases)
- anorgasmia
- premature ejaculation
Is ED chroinic, occasional, situational
Is problem attaining or maintaining
Diseases
Trauma
Drug, etoh, tobacco
Questionnaire for ED?
International index of erectile function (IIEF)
Common meds that cause ED
Antihypertensive - B blocker - thiazide - spironolactone - clonidine Antidepressants Opioids Prostate agents - doxazosin - terazosin
Rapid onset ED is prob?
Psychogenic Genitourinary trauma (prostatectomy)
Nonsustained erection is prob?
Anxiety
Venous leak
Complete loss of nocturnal ED is prob?
Vascular or neurologic disease
Physical exam
Note secondary sex characteristics \+ gynecomastia Peripheral vascular exam Focused neurosensory exam GU exam - scarring, plaques - testicular size/masses Prostate exam
Lab for ED?
Lipids Glucose Testosterone Prolactin TSH
What arethe special test?
- Nocturnal penile tumescence testing
- trial of oral PDE-5
- direct injection of vasoactive substances into penis (test blood flow)
- penile duplex doppler
- penile cavernosography
- pudendal arteriography
Tx for ED?
Lifestyle - bla - bla - bla They want pills not exercise
PDE-5 inhibitors
Adverse effects of PDE-5 inhibitors
HOTN
- esp w alpha blockers
Priapism (rare)
Contraindications for PDE-5?
Contraindicated w nitroglycerine or nitrates
Relative
- active corinary ischemia
- heart failure
- borderline HOTN
- multi HTN meds
- CYP450-3A4 (erythromycin, cimetidine, ketaconazole)
How to take sildenafil (viagra)?
1-4 hrs before sex
Empty stomach
- high fat meal delays absorption
Stimulation is required for erection
When do you need to take verdenafil or tadalafil, avanafil?
Vardenafil (levitra)
- 1 hr prior
- max 1 day
Tadalafil (cialis)
- 1 hr prior
- no more than 1 every 2 days
- last 36hrs
Avanafil (stendra)
- 15 min before
Non PDE-5 meds for ED?
Vasoactive therapy
- alprostadil (prostaglandin E2)
(injection or urethral suppository)
- hormonal replacement
Before hormone replacement you should?
Rule out prostate cancer
Adjunct devices for ED?
Vacuum erection device
Inflatable penile implant
Flexible rod penile implant
Vascular disorder ED treatment?
- Trauma-induced focal arterial occulsion
- congenital venous occlusion
High failure rate
You should know how to recognize the signs of ED,
Its not hard…
