ED Flashcards
Men presenting with ED should undergo:
GUIDELINE STATMENT 1
A thorough medical, sexual, and psychosocial hx, a PE, and selective laboratory testing
risk factors include: age, comorbid medical and psych condition, prior sx, medication, fhx of vascular dz, personal hx vascular dz, substance abuse, tobacco, neuro dz, endocrinopathies, meds, psychosocial
What is recommended to quantify and qualify a man’s sxs with ED?
GUIDELINE STATEMENT 2
validated questionnaire
(bother, satisfaction, relationship impact)
IIEF, SHIM
What health concerns can ED be a warning sign of?
GUIDELINE STATEMENT 3
CVD
(endothelial dysfunction and inflammation)
What initial lab tests for ED should be performed?
GUIDELINE STATEMENT 4
testosterone
2 am values (do not measure during acute illness)
(< 300 ng/DL low)
What instances may warranted specialized testing? What does this testing include?
GUIDELINE STATEMENT 5
some men warrant specialized testing may guide treatment
young
have strong fhx CVD
hx of pelvic trauma
failed prior ED tx
strong likelihood of primary psychogenic
concomitant PD
lifelong ED
Tests:
**Nocturnal penile tumescence (shaft gauge during sleep)
**ICI (in office: prostaglandin E1, paparavine, and/or phentolamine)
**Penile duplex US (7-10 Hz transducer, 5-10 minutes after ICI → vascular eval: PSV < 30 → arterial insufficiency, EDV > 5 veno-occlusive dz; RI (EDV/PSV >0.80 → normal)
**Caversonometry (quantify pressure after ICI), selective internal pudendal angiography
**Pudendal arteriography (young men with suspected arterial insufficiency)
For ED, referral to whom after initial evaluation SHOULD be considered? How will this help?
GUIDELINE STATEMENT 6
Mental health professions
to promote treatment adherence, reduce performance anxiety, and integrate tx into sexual relationship
What should clinicians counsel men with ED about lifestyle?
GUIDELINE STATEMENT 7
comorbidities negatively affect ED
lifestyle modifications, including changes in diet, increased physical activity, will improve overall health and improve erectile function
What is an FDA approved initial treatment option for ED? What should be discussed?
GUIDELINE STATEMENT 8
PDE5i (phosphodiesterase type 5 inhibitor)
inhibit breakdown of cGMP → increase smooth muscle relaxation in corpus cavernosum → increased erection hardness
discuss benefits, risks, efficacy
contraindications: nitrates (hypotension), amyl nitrate (poppers) other interactions: antidepressants, anti-fungal, anti-hypertensives, HIV/AIDS drugs
*patients should be stable on alpha blocker prior to initiating PDE5i (some interaction for hypotension)
- PDE5i, particularly sildenafil, tadalafil, and vardenafil, appear to have similar efficacy for general population
- Dose-response effects across PDE5i meds are small and non-linear (i.e. doubling dose not double effect)
- On- demand dosing vs. daily for tadalafil appears to have same level of efficacy
Most common a/e of PDE5i
dyspepsia
headache
flushing
back pain
nasal congestion
myalgia
visual disturbance
dizziness
Detail instruction to maximize efficacy for PDE5i
GUIDELINE STATEMENT 9
Dosing of PDE5i should be:
GUIDELINE STATEMENT 10
titrated to provide optimal efficacy
Patients who try PDE5i without efficacy, what should be considered?
Incorrect usage
black market products
require sexual stimulation
waiting and adequate amount of time
fatty meals (sildenafil and vardenafil, tadalafil is unaffected by food)
How are PDE5i metabolized:
cytochrome CYP4A system
*dose reduction may be necessary with CYP450 i (ketoconazole, erythromycin, ritonavir, indinivir, grapefruit juice)
Others may enhance: rifampin, phenobarbital, phenytoin, carbamazepine
**Men with severe hepatic or renal dysfunction (GVR < 30) should be stared on lowest dose
How do you follow men on PDE5i
Recheck at 3 mo for BPH and efficacy/adverse effects
If satisfactory, q 6-12 mo for same
ask for changes in meds (nitrates, addition of alpha blocker, etc)
What should patients be informed about penile rehab after RP or RT?
GUIDELINE STATEMENT 11
men who desire preservation o f erectile function after treatment for prostate cancer by radical prostatectomy or radiotherapy should be informed that early use of PDE5i post-treatment may not improve spontaneous, unassisted erectile function
Men with ED and testosterone deficiency should be informed:
GUIDELINE STATEMENT 12
that PDE5i may be more effective if combined with testosterone therapy
In addition to medication therapy, what manual device should patients be informed of?
GUIDELINE STATEMENT 13
Vacuum erection device (VED)
*with vacuum limiter
including r/b and burdens
low cost, high degree of satisfaction
a/e: transient penile petechiae or bruising, discomfort or pain, difficulty with ejaculation, difficulty with device, loss of sensitivity
*caution with AC or bleeding disorders or hx of priapism
What intraurethral medication can be utilized?
GUIDELINE STATEMENT 14
Alprostadil (MUSE→PGE1)
GUIDELINE STATEMENT 15
an in-office test must be performed
100, 250, 500, 100 ug, 10-30 mins before intercourse
a/e: genital pain, minor urethra trauma, urethral pain/burning, dizziness, hypotension/syncope (rare), painful/prolonged erection (1%)
Contraindications to MUSE?
structural abnormalities such as urethral stricture, penile angulation/fibrosis, infections (balanitis/urethritis)
*condom must be used during sexual activity with pregnant women
Men should be informed of what injection therapy?
GUIDELINE STATEMENT 16
intracavernosal injections (ICI)
(alprostadil [FDA approved] urethral burning→ increases cGMP; phentolamine → alpha inhibitor inhibit detumescence; papaverine PDEi → together called Trimix [compounded])
GUIDELINE STATEMENT 17
in-office injection test should be performed
wipe with alcohol, inject dorsal 10:00 and 2:00, hold pressure 2-3 mins
pt to assess and self stimulate in office
can only leave when detumesced
a/e: priapism, pain with injection, penile pain, genital pain, penile fibrosis or plaque, and penile deformities
What surgical options should men be informed of?
GUIDELINE STATEMENT 18
penile prosthesis implantation
malleable or inflatable
risks: risks of procedure, changes in penile appearance, potential for malfunction/failure, irreversible
a/e: penile edema/hematoma, corpus injury, urethral injury, acute urinary retention, crura injury, infection, erosion, mechanical failure
GUIDELINE STATEMENT 19
patients should be counseled on post-op expectations
(not full rigidity, no effect on libido, pain, penile length, girth, sensation
Penile prosthetic surgery should not be performed in presence of:
GUIDELINE STATEMENT 20
systemic, cutaneous, or UTI
(for sx vanco or first/second gen cephalosporin + aminoglycoside 1 h prior to sx–only in absence of infection)
Name 3 (2 popular) approaches to implanting penile prosthesis and advantages/disadvantages:
Key: shave at sx, thorough skin prep, Abx
Aminoglycoside + 1st/2nd Gen Cephalosporin or Vanc
- Penoscrotal
- Proximal corporotomies, cylinder tubing less palpable
- along ventrum of corpora
- direct visualization of pump placement
- disadvantage: reservoir placed blind through perforation of inguinal canal to place retropubic
- Infrapubic
- allow direct visualization of reservoir placement
- pump can be more challenging, dorsal nerves are more at risk, cylinder tubing is more likely to be palpable
- Sub-coronal for malleable
Intraoperative complications of penile implant?
- Urethral perforation: blood at meatus, stop, leave cath 7-10 d
- Corporal crossover: when dilating corpora if septum perforated, leave dilator in side cross over into, re-dilate the side cross over originated from
- Crus perforation: during proximal dilation, create mesh wind sock to buttress rear tip and secure to tunica, secure rear tip itself to tunica albuginea, close corpora around tunica
Post op ST and LT complications of penile implant?
- Infection (1-3%): early with fever, pain swelling, purulence (usually G+); late with chronic pain or skin fixation, elevated WBC or ESR; MUST REMOVE
- Malfunction (15-20% @ 10y): replacement of device or part
- Erosion: mc in DMII or lack sensation (paraplegia) or malleable → remove eroded cylinder and replace or leave and utilize one cylinder
- SST (poor glans support): insufficient distal dilation, small cylinders; remove and re-dilate, but can do glans plication to penile shaft also
- Buckling or S-shaped deformities: oversized cylinder; replace cylinders
- Auto-inflation: activity inflates device: replace device with lockout mechanism
For infected IPP, what are options for mgmt?
Remove and salvage (washout, abx) replace: success 80%
Remove and delay replacement, can be challenging due to corporal fibrosis, shortened length (6-12 weeks)
For young men with ED and focal pelvic/penile arterial occlusion what are parameters considered and what type of intervention can be considered?
GUIDELINE STATEMENT 21
without documented generalized vascular dz or veno-occlusive dysfunction → penile arterial reconstruction
GUIDELINE STATEMENT 22
for ED, penile venous surgery is not recommended
What treatments are considered investigational for ED?
GUIDELINE STATEMENT 23
low-intensity extracorporeal shock wave therapy (ESWT)
GUIDELINE STATEMENT 24
intracavernosal stem cell therapy
GUIDELINE STATEMENT 25
platelet-rich plasma (PRP)
Describe the relevant nerves of the penis:
Sensory: dorsal nerves via the pudendal nerve
Sympathetic nerves (T10-L2): superior and inferior hypogastric pelvic plexus, cavernous nerves (NE → maintain flaccidity and detumescence)
Parasympathetic nerves (S2-3): pelvic plexus cavernous nerves (release NO → erections)
Describe physiology of an erection:
Cavernosal artery smooth muscle relaxation
During stimulation → parasympathetic nerves release NO → increase cGMP → relaxes cavernosal smooth muscle
Arterial dilation → increased arterial inflow → expansion of lacunar spaces
Dilation compresses penile venous outflow (sub-tunical venules and emissary veins that transverse tunica albuginea)
Detumescence → release of NE from sympathetics → vasoconstriction → decreased arterial inflow and increased venous outflow
Key components of sexual history:
Personal: gender identity, sexual orientation, age of partner(s), relationship status, relationship duration, frequency of sexual activity
Sexual dysfunction: severity, onset, rate of decline, nocturnal erections, ability to sustain erection, exacerbating or alleviating factor, previous tx, degree of distress, goal of tx
Social: job, stress level, life changes, health changes associated with timing
Evaluations and Lab tests can be considered if concerned about comorbidities affecting ED?
BP
Exercise tolerance
CV risk assessment (High risk (uncontrolled HTN, untreated, uncontrolled conditions, severe CHF) → cardio clearance
Lipid profile
fasting glucose or HbA1c
testosterone (guideline recommended)
CBC (anemia)
BMP (renal failure)
Optional: tailored to patients complaints/risks
TSH
Prl
PSA
3 classifications of ED?
Organic: vasculogenic (arterial or veno-occlusive), neurogenic, endocrinologic, meds
Psychogenic
Mixed
Good questions to ask when initially evaluated patient with ED complaints:
Does he ejaculate, if so, pain or blood?
How man sexual partners, STDs?
Morning erections, nocturnal erections, masturbation, spontaneous?
Libido?
How long has ED been a problem?
Is he active, job, exercise? How far/fast can he walk, leg cramp?
How much of problem for him and partner?
Important physical exam elements?
Gross neuro
General appearance, weight, vitals
Abdomen
External genitalia
DRE
Pulses, extremities
Antihypertensive that affect ED? Antihypertensive safe for ED?
Adverse: Thiazide, Beta blockers
Safe: Ca antagonists, ACE, ARBs
Arterial supply of penis
pudendal artery –> common penile artery -> superficial dorsal artery and deep cavernosal artery
Penile innervation
Parasympathetic (S2-4)
ED risk factors
Vascular Disease Diabetes Medications Neurogenic Pelvic surgery/radiation Endocrine
Medications associated with ED
Cardiac - ____
Psych - ____
Urologic - ____
CCBs, Beta blockers, Digoxin, Diuretics
SSRIs, Benzos
ADT, Finasteride
PDE5-is promote erections by inhibiting breakdown of ___ to ___
cGMP –> GMP
____ catalyzes guanyl cyclase to synthesis GMP –> cGMP to promote smooth muscle relaxation & erectile function
NO
Levitra & viagra must be taken ____ eating
before eating on an empty stomach
no food effect for Cialis
Onset of Viagra is ___ minutes
Onset of Cialis is ____ minutes
Viagra = 60 min
Cialis = 120 min
Contraindications to PDE5is
Poor cardiac function
Nitrates
PDE-5i side effects
Facial flushing GI effects (Heartburn) Nasal congestion Visual disturbances (diplopia, changing colors) Myalgia
What are the 3 drugs in trimix and their mechanisms of action?
PGE1: cAMP activator
Papaverine: non‐specific PDE inhibitor
Phentolamine: alpha blocker
Trimix side effects
Pain from PGE1
Bruising
Priapism
Mechanism of intraurethral MUSE
PGE-1
Side effects of MUSE
Priapism Urethral bleeding Penile pain (PGE1 hypersensitivity) Inconsistent response Vaginal irritation
Vacuum device contraindications
Poor penile sensation (SCI)
Poor cognitive function
Peyronie’s
Anti-coagulation
IPP has a ___% infection risk
3%
IPP has a ___% device failure rate at 10 years
20%
During IPP placement, procedure must be aborted if ___ perforation occurs
urethral
What are the common risk factors that should be asked about during the workup of ED
Common risk factors for ED include vascular disease, tobacco use, neurologic disease, endocrinopathies, medication-related side effects, and psychosocial issues.
What should the physical exam focus on during the workup of ED?
Blood pressure
BMI
Secondary sex characteristics
Genital exam.
What are the validated questionaires for ED?
Erection hardness score (EHS)
Sexual health inventory for Men (SHIM)
International index of erectile function (IIEF)
Male sexual health questionaire.
What should every physician counsel patients on when managing their ED?
Association with CVD. 25% increased risk of CVD when someone has ED.
What is the definition of testosterone deficiency?
Testosterone <300ng/dl
with signs and symptoms
What is the recommended lab testing for men with ED according to AUA guidelines?
Morning testosterone.
At least two morning testosterone values if abnormal for confirmation.
What are the indications for specialized evaluations for ED?
1 Young 2 Family history of CVD 3 Pelvic trauma 4 Failure of previous ED therapies 5 Liklihood of psychogenic etiology 6 Lifelong ED 7 Peyronies disease
How can psychogenic ED be differentiated?
Nocturnal penile tumescence and rigidity testing.
How can penile vascular function be evaluated?
In office ICI or penile duplex ultrasound (gold standard)
How is penile duplex ultrasound interpreted?
PSV < 30 indicates arterial insufficiency
EDV > 5cm/s indicates veno-occlusive dysfunction.
Resistive index (PSV-EDV/PSV) <0.80 is normal veno occlusive function
What 2nd/3rd line diagnostics for vascular function are available?
Cavernosometry
How is cavernosometry interpreted?
Intracorporeal pressure of >60mmHg
Pressure to maintain errection <35ml/min
<45mmHg/30sec pressure decay
brachial artery inflow gradient <30mmHg
What should be offered along with any treatment for ED?
Mental health referral
What should be the first management recommendation for ED per the AUA guidelines?
Behavioral modification such as diet or exercise for reversible comorbidities.
What is the first line treatment for ED per the AUA guidelines?
Phosphodiesterase inhibitors
What is the MOA for PDE5i?
PDE5i inhibit the phosphodiesterase type 5 enzyme from breaking down cyclic guanasine monophosphate (cGMP). This inhibition results in an increase in the concentration of penile cavernosal cGMP that then causes smooth muscle relaxation in the corpus cavernosum vasculature resulting in increased erection hardness and duration
What are the contraindications to PDE5i use?
- Nitrate containing medications.
- Hepatic impairment (use with caution)
- Renal impairment (use with caution)
