B8.071 Male Sexual Dysfunction Flashcards
classification of male sexual dysfunction
- libido
- erectile function
- impotence
- priapism - disorders of ejaculation
libido
sexual drive or desire to engage in sexual activity
factors that affect libidom
T levels (most important)
chronic disease
depression
fatigue
evaluation of libido
AM T level (free T level in select cases)
general medical/physical evaluation
psychological evaulation
treatment of libido dysfunction
replace T if indicated and safe
treat other illness or depression
definition of erectile dysfunction
consistent or recurrent inability to attain or maintain penile erection sufficient for sexual satisfaction
prevalence of ED
30 mil men in US
52% of men between 40-70
-% correlates with decade (40% of men in 40s, 50% of men in 50s)
basic physiology of erection
more blood going into penis than coming out
- parasympathetics
- cause vasodilation which results in erection
- fibers come from the pelvic plexus and run along the side of the prostate - sympathetics
- responsible for ejaculation
- cause detumescence by vasoconstriction
- fibers from T12-L3 from hypogastric plexus run alongside of prostate
types of ED
arteriogenic/vasculogenic
neurologic
venous outflow
pscyhogenic
risk factors for ED
HTN surgery diabetes trauma dyslipidemia meds depression smoking obesity peripheral vascular disease CVD sedentary lifestyle
if a young-ish patient comes in with ED, what should you do in addition to treating the ED?
refer for a cardio workup
CVD issues commonly coexist
relationship between ED and diabetes
20-85% of diabetics will suffer from ED 10-15 years earlier than general population predictors of ED in diabetics -peripheral neuropathy -glycemic control
mechanism of ED in diabetics
small vessel disease affects inflow to penis
small vessel disease to the cavernosal nerves affects sympathetic input
classic signs of a diabetic who might have ED
peripheral neuropathy
diabetic retinopathy
renal insufficiency
number 1 cause of ED
arteriogenic/vasculogenic disease
hardening of arteries > can’t provide sufficient blood flow to penis
trauma and ED
may effect inflow or outflow
abnormal venous outflow termed “venous leak”
surgical causes of ED
radical prostatectomy
colon surgery
bladder surgery
may effect the cavernosal nerves which signal the blood vessels to dilate
pathophys of post prostatectomy ED
neurological
-endothelial and smooth muscle changes result from loss of innervation
-neural factors may play a role
arterial insufficiency
-preservation of the pudendals or accessory obturators
veno-occlusive dysfunction
-venous leak results
anatomical/structural changes
hormonal
-number of pts appear to be hypogonadal after
psychogenic
psychological components of ED
depression, stress, matrimonial discord
**rarely is ED completely psychogenic, over 90% have an underlying organic cause
illicit drugs that can cause ED
alcohol
marijuana
cocaine
cigs
steps in diagnosis of ED
- H&P
- rarely do anything other than this
- usually just try a treatment and see if it helps - US of penile arteries
- penile arterial velocity >30 cm after injection with vasoactive agent - xray tests of veins looking for venous leak
- invasive
- leak can be repaired by IT or surgical ligation
lab eval of ED
T may be associated with decreased libido
-normally don’t check this unless pt complains of low libido, most men with low T maintain erectile function
270-900 is normal
oral meds for ED
PDE5 inhibitors -sildenafil, vardenafil, tadalafil testostozine, "the ropes", yohimbine -never been proven to more apomorphine (central acting) -associated with nausea and vomiting
sildenafil
first PDE5 on the market
25, 50, and 100 mg doses
4 hr half life
side effects of sildenafil
headache
flushing
blue vision
dyspepsia
contraindications for sildenafil
nitrates
unstable angina
recent MI or stroke (<2 wks)
retinitis pigmentosa
tadalifil
most recent PDE5 inhibitor on the market
5, 10, 20 mg doses
17.5 hr half life
side effects of tadalifil
headache
dyspepsia
myalgias
contraindications for tadalifil
a blockers (except tamsulosin) nitrates unstable angina recent MI or stroke reduce dose in pts with renal insufficiency (5 mg) and hepatic impairment (10 mg) alcohol? maybe?
vardenafil
2.5, 5, 10, 20 mg doses
4-5 hr half life
side effects of vardenafil
headache
flushing
rhinitis
contraindications for vardenafil
drugs that prolong the QT interval (amiodarone, sotalol) nitrates unstable angina recent MI or stroke hepatic/renal impairment
what is NAION
non-arteritic anterior ischemic optic neuropathy
can cause permanent loss of vision
-precaution for all PDE5 inhibitors
-only occurred in patients with multiple risk factors including DM, smoking, CVD, HTN, hyperlipidemia, low cup to disc ratio
may have several episodes of decreased vision before permanent loss occurs
vacuum erection device
pros: safe, effective
cons: cumbersome, hinge effect, requires manual dexterity, cold penis
muse
intraurethral alprostadil suppository
only effective in 30% of men
may cause vaginal irritation in female partner
intracorporal injection therapy
very effective
pros: one of the most effective treatments, results in natural erection
cons: may cause burning or curvature, risk of priapism, expensive, requires manual dexterity
penile prosthesis
infection risk
looks rough for a week
will lose some girth and length of the penis (set realistic expectations)
work well tho
priapism
persistent erection which lasts for 4 or more hours
- low flow
- high flow
characteristics of low flow priapism
painful
glans is soft
may “stutter”
causes of low flow priapism
incorrect use of intracavernosal agents sickle cell disease trazodone TPN neoplastic processes
treatment of low flow priapism
oral doesnt work irrigation -saline -phenylepherine shunts
how to diagnose low flow priapsim
pO2 on blood gas
-super low O2
blood is thick, black, clotting
characteristics of high flow priapism
non painful
not a full erection
glans full as well
causes of high flow priapism
trauma resulting in AV fistula
treatment of high flow priapism
embolization
premature ejaculation
ejaculation which occurs prior to coitus or before the patient would like common in younger men -treat with SSRI may be a sign of ED -treat with PDE5 inhibitor
retrograde ejaculation
semen goes into the good ol bladder
- diabetes
- neurologic conditions
- surgical procedures
- meds
anejaculation
disruption of sympathetic outflow
- neuro conditions
- after retroperitoneal surgery
