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Summer FDTN Exam 1 > ED > Flashcards

ED Flashcards

1
Q

What is ED

A

Inability to attain or maintain an erection sufficient for sexual performance
Affects 52% of men 40+

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2
Q

How does a normal erection occur

A

Relaxation of smooth muscle in cavernosal artery= increased inflow of blood into corpus carvernosa
Increased venous outflow resistance= decreased outflow

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3
Q

What is the physiology behind attaining a normal erection

A 
PNS releases nitric oxide 
Increased cGMP/cAMP 
Decreased intracellular calcium 
smooth muscle relaxation/ vasodilation 
greater inflow of blood into cavernosa

(very similar to what B3 agonists do in UUI!)

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4
Q

What is the physiology behind maintaining a normal erection

A

High inflow into cavernosa causes expansion= compression of venous sinuses
Decreased outflow of blood via venous system

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5
Q

What are vasculogenic causes of ED (MCC)

A

Arterial inflow problem

Venous outflow problem

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6
Q

What are neurogenic causes of ED

A

Prostatectomy (2 nerves run very close to the prostate and can be damaged in surgery)

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7
Q

What are psychogenic causes of ED

A

Depression, stress, anxiety, psych d/o

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8
Q

What are endocrine causes of ED

A

Hyperprolactinemia (PRL suppresses testosterone)
Thyroid d/o
Hypogonadism (sex hormone binding globulin)

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9
Q

What medications can cause ED

A

Anti-HTN (BB, thiazide, clonidine, methyldopa)
Antidepressants/psychotics (TCA, MAOI, lithium, phenothiazine)
Sedatives, anticholinergics, Phenytoin, alcohol, tobacco

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10
Q

What medications can reduce testosterone and secondarily cause ED

A

Cimetidine, spironalactone, ketoconazole, LHRH agonists (leuprolide), non steroidal anti androgens (flutamide, biclumatide), Estrogens

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11
Q

What disease states can cause ED

A

chronic renal insufficiency
DM
chronic hepatic disease
Neurologic, atherosclerotic, endocrine dz

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12
Q

What trauma can cause ED

A 
Pelvic Fx 
Penile Fx (tunica vaginalis can snap 2/2 stiffness when erect)
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13
Q

What sexual history is important to ask with a CC of ED

A 
onset, rigidity, duration
Morning erections (reflex- when the bladder gets full, erection) 
Libido
Relationship
PReformance anxiety/stress 
Curvature (Peyronie's) 
IIEF scale
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14
Q

On PE for ED complaint it is important to assess

A

Circulaiton
Gynecomastia, galactorrhea, visual field deficit
External genitalia exam (penis and testes)

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15
Q

What labs could you check with a CC of ED

A

Testosterone (if decreased libido, check total and bioavailable testosterone between 7-11 AM)
PRL if indicated
Nocturnal penile tumescence (BP cuff around penis that measurea how many times per night the penis gets erect; normal is a few)

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16
Q

What is Penile duplex doppler sonography

A

test for ARTERY insufficiency

inject vasoactive med into cavernosa to measure arterial flow and diameter

17
Q

What is Cavernosometry

A

test for VENOUS leak
inject vasoactive med into cavernosa- then use needle for inflow of saline and measure rate of inflow of saline required to maintain erection

18
Q

General Tx of ED can include (before meds, etc.)

A 
Is CV status appropriate for sex? 
Smoking cessation 
weight control 
alcohol 
change meds if needed
treat medical conditions
19
Q

Other Tx for ED include

A 
Yohimbine 
PDE5 inhibitors 
VED
MUSE (medicated urethral system for erection) 
Penile injection 
constriction ring 
penile splint 
penile prosthesis
penile revascularization
20
Q

PDE5-I are contraindicated with

A

Nitrate use!
can cause severe orthostatic hypotension
*Use caution with alpha blockers (tamulosin, alfuzosin); use lowest dose of each and separate doses

21
Q

What is the normal role of PDE5

A

PDE5 decreases amount of cGMP= decreased blood flow to penis= Detumescence

22
Q

What is the MOA of PDE5-Inhibitors

A

Block PDE5= cGMP can continue to have vasodilatory effect

Erection is prolonged

23
Q

ADE of PDE5-I include

A 
Nasal congestion 
facial flushing 
HA
dyspepsia
back pain/myalgias 
visual changes (blue halo) 
Non-arteritic ischeimc optic neuropathy 
priapism
24
Q

What are the PDE5 inhibitors

A

Sildenafil (viagra)
Tadalafil (cialis)
Vardenafil
Avanafil

25
Q

How do you take PDE5 inhibitors

A

30-60 min prior to sex
Avoid with food (except tadalafil)
Physical stimulation is still needed! PDE-I allow erection to be sustained, they do NOT initiate erection

26
Q

What is significant about Tadalafil

A

Approved for low dose daily dosing for BPH and ED!
Has a longer half life, stays in system 36 hrs when used prn
Back pain is associated with tadalafil (isoenzyme 11 inhibitor)

27
Q

What is Yohimbine

A

a natural ED Tx, not significantly better than placebo

28
Q

What is a VED

A

Cylinder placed over penis to create vacuum
Causes increased arterial blood flow
When removed, place constriction ring at base of penis to maintain erection
**REMOVE ring before falling asleep!

29
Q

What is MUSE

A

Alprostadil (PGE1) in form of Urethral suppository (pellet)
Increases cAMP= decreased IC calcium= cavernosal artery vasodilation
Take 5-20 min before sex
**first dose should be taken under medical supervision to monitor for hypotension

30
Q

What is an intracavernosal injection

A

Alprostadil (PGE), brand name Caverject or Edex, is injected into ONE side of the cavernosa causing vasodilation
Do not exceed 3 doses x week. Take first dose under supervision, titrate at home
After injection, apply pressure to prevent fibrosis
Erection should occur in 10-15 min, and last no longer than ONE HOUR

31
Q

What are risks of penile injection

A 
Pain 
infection 
bleeding
fibrosis and curvature 
priapism
32
Q

What is a priapism

A

erection maintained beyond 4 hours
causes pain, stasis, hypoxia (CHECK ABGs), acidosis, fibrosis, and ED
this is a urologic EMERGENCY

33
Q

How do you treat a priapism

A

18-19 gauge needle in cavernosum, aspirate blood
Infuse saline
Inject phenylephrine (vasoconstrictor)
May need surgery for shunt!
We want to prevent fibrosis, loss of cavernosal tissue, and recurrent priapisms

34
Q

What is a constriction ring

A

Tx for venous leakage! adjustable and should be easily removed

35
Q

What is a penile splint

A

ring placed at base of glans (corona), rigid bar runs along spongiosum, and another ring at base of penis
Sized to patient, tumescence is NOT required

36
Q

What is penile prosthesis

A

surgical implant of rods into penile shaft
Non-inflatable are goose neck rods that are malleable and bent into and out of position
Inflatable is two rods placed in peniv, with reservoir posterior to abdominal wall, and pump in scrotum

37
Q

What are complications of inflatable penile prosthesis

A

erosion
infection
autoinflation
mechanical failure

38
Q

What is penile revascularization

A

Tx for focal arterial occlusion of cavernosal artery

Anastomose inferior epigastric artery to dorsal penile artery

39
Q

What does ED allow the opportunity for as a provider

A

discussion of CVD and motivation for lifestyle changes

Summer FDTN Exam 1 (12 decks)

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