Clincial Apprach To Male Sexual Dysfucntion

Question 1

Types of ejactulation disorders

Answer 1

Premature
- most common and affects 20-30% of males

Delayed

Anejaculation

Anorgasmia

Question 2

Causes of low libido

Answer 2

Medications
- most common

Alcoholic and recreational drug overuse

Depression

Relationship psychological issues

Low testosterone

Sexual aversion disorders

Systemic chronic illnesses

Question 3

Erectile dysfunction

Answer 3

Most common type of sexual dysfunctional

Affects 30% of all males and increases with age

• 20% = 50-59
• 37% = > 70 yr old men

Presents with significant sexual stigmata

• suicidal and depressive ideologies
• emotional disturbances
• decreased QOL

Most common etiologies = vascular based

• DM (increases risk by 800%)
• CAD
• chronic HTN
• Peripheral vascular disease
• also anxiety

Risk factors:

• use of thiazides and beta blockers for HTN treatment
• use of SSRIs and SNRIs
• use of sexual enhancers that aren’t FDA approved
• nicotine use (smoking )and alcohol

Also not having enough sex (less than once per week) increases risks by 200% over time

Question 4

Work up for erectile dysfunction

Answer 4

Rectal and prostate Exams

Doppler ultrasound to look for obstructions and leakages
- GOLD standard

CBC and LFTs

If you want to check for neurogenic causes = nighttime penile tumesence study (NPT)

Also consider testosterone level measurements

Occasionally get a penile specific angiography
- if you suspect occlusion of arteries/claudication

Question 5

Treatment for erectile dysfunction

Answer 5

Usually start on a phosphodiesterase inhbitor (slidenafil) and treat underlying morbidities more tightly if present

DONT revascularization unless they are all of the following

• young
• non smoker
• healthy (no morbidities and not overweight)
• focal occlusion

Can also supplement with a penile vacuum pump

Second line (refractory only) = injections of alprostadil (prostaglandin E1 analog which induces Vasodilation)

Question 6

PDE5 inhibitors

Answer 6

Sildenafil = best safety track record

Tadalafil = longest duration of action
- is more preferred actually

Avanavil = newest with shortest onset

all work to increase cGMP levels in corpora cavernous by blocking enzymes used to decrease cGMP levels

• *NEVER use nitrates in combo = life threatening hypotension**
• also be careful in cAD patients (can cause MI)

Question 7

What testosterone level suggests erectile dysfunction

Answer 7

<225 ng/dL

Question 8

What are common second line refractory mixtures used for erectile dysfunction

Answer 8

1) phentolamine + papaverine = (Bimix)

2) Bimix + alprostadil = (trimix)

Question 9

Priapism

Answer 9

Is an erection lasting > 4hrs and is a medical emergency
- will ischemia to the penis and treatment requires evacuation of the corpora cavernous

Chance to occur in all erectile dysfucntion medications as well as other medications

Question 10

Stuff about intraurethral deposition of alprostadil (other PDE-5s)

Answer 10

Less invasive than intrapenile and is successful 70% of time

Also low systemic effects

ADRs:

• penile pain
• Contraindicated in sickle cell and significant PVD and CAD (can lead to priapism)

Question 11

Premature ejaculation definition

Answer 11

Contains all the following

• 1) brief latency (< 1-2 minutes)
• 2) loss of control
• 3) psychological distress in partner or patient

Treatment:

1) first line = SSRIs, topical anesthetics and psychotherapy
2) second line = PDE-5 inhibitors
3) third line = tramadol

Question 12

What is the most helpful test in diagnosing vasculogenic ED?

Answer 12

Direct injection with PGE1

- if no conclusion of vessels = erection in minutes

Question 13

What si the worst surgical approach to ED?

Answer 13

Self-contained inflatable implant