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ED Flashcards

1
Q

Physiology of an erection

A

neurovascular event

  • autonomic/somatic nerve supply
  • Arterial blood flow via cavernosal arteries
  • smooth/striated musculature of corpora cevernosa/pelvic floor
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2
Q

Neurotransmitters sustaining/initiating erection

A

Primary - nitrous oxide

Others - Ach, PGs, Vasoactive intestinal peptide

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3
Q

Erection caused and maintained by?

A

Increased arterial flow and venous resistance

Smooth muscle relaxation w/in corpora cavernosa

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4
Q

Increased erection rigidity is due to

A

Bulbocavernosus/ischiocavernosus muscle contraction

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5
Q

ED dysfx def?

A

Consistent inability to attain/maintain a sufficient erection for sexual performance

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6
Q

ED dysfx MC pop?

A

40-70 - >50%

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7
Q

ED dysfx etiologies?

A

Organic or psychogenic (freq overlap)

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8
Q

ED dysfx psychogenic occurs in what pop?

A

Young men

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9
Q

ED dysfx psychogenic will have what versus organic issues?

A

Normal - Nocturnal/morning erections

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10
Q

Two types of psycogenic ED dysfx?

A

Generalized (unresponsive and inhibition)

Situational (Partner, performance, psych/adujstment)

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11
Q

ED dysfx psychogenic generalized unresponsive -

A

Lack sexual arousability

Age related decline in arousability

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12
Q

ED dysfx psychogenic - generalized inhibition -

A

Chronic D/O of sexual intimacy

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13
Q

ED dysfx psychogenic - situational partner related -

A

Lack in specific relationship
Lack due to to sexual object preference
High central inhibition due to partner conflict/threat

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14
Q

ED dysfx psychogenic - situational performance related -

A

Ass/w other sexual dysfx (premature ejack)

Situational performance anxiety (fear of failure)

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15
Q

ED dysfx psychogenic - situational psych/adjustment -

A

Ass/w negative mood - depression or major life stress

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16
Q

Organic ED dysfx types?

A

Arterial/venous
Hormonal
Neurogenic
Rx-induced

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17
Q

Which type of ED dysfx is characterized w/ nocturnal erections?

A

Psychogenic only (Not organic)

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18
Q

Organic - Vascular reasons

A

CV Dz - HTN, DM, Hyperlipidemia, Tob

Major surgery/radiotherapy - Radical prostatectomy

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19
Q

Organic - Neurogenic reasons

A

Injuries to brain/spinal cord
Parkinsons/Alzheimers Dz
Multiple Sclerosis
Stroke

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20
Q

Organic - Cavernous reasons

A

Peyronies Dz
Cavernous fibrosis
Penile Fx

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21
Q

Organic - Hormonal reasons

A

Hypogonadism
Hyperprolactinemia
Thyroidism’s
Cortisolism’s

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22
Q

Organic - Rx-induced reasons

A

Anti-Htn
Anti-depressants
Opiods
Recreation Rx

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23
Q

Organic - Pyschogenic reasons

A

Performance-related anxiety
Traumatic past experiences
Relationship issues
Anxiety/depression/stress

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24
Q

RFs of males

A 
>40yo, fat (ETOH, Tob, Illict)
DM, HTN, Dyslipidemia, CAD/PAD
Psych (depression, anxiety, stress)
Neurologic Dz
CKD
Hx prostate cancer TXT
Pelvic (trauma/surgery/irradation)
Endocrine D/O
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25
Q

ED dysfx Hx

A 
Other sexual Dysfx
-Loss libido (androgen deficits)
-Loss of seminal emission (anejaculation) > 
-Anorgasmia
-Premature ejaculation
Chronic vs Occasional vs Situational
Attaining vs maintaining
PMHx/PSHx
Illicits, ETOH, Tob
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26
Q

What may make Hx taking easier/more comfortable for the patient?

A

Self administered - International Index of Erectile Fx (IIEF)

27
Q

Rx induced ED dysfx meds

A

Anti-HTN (BB, Thiazides, Spironolactone, Clonidine)
Antidepressants
Opioids
Prostate agents (Doxazosin/terazosin)

28
Q

Rapid onset finding causes

A 
Pyschogenic
GU trauma (prostatectomy)
29
Q

Nonsustained erection finding causes

A

Anxiety

Venous leak

30
Q

Complete loss of nocturnal Erections

A

Vascular/neurologic Dz

31
Q

ED dysfx PE

A

Vascular/neurosensory exam
Genitalia exam (scarring/plaques) or (testicular size)
Prostate exam
Note secondary sex characteristics (gynecomastia)

32
Q

ED dysfx labs

A

Lipid panel
Glucose
Testosterone/PRL
TSH

33
Q

If testosterone or PRL ABNL reflex?

A

Free testosterone and LH = differentiates hypothalamic-pituitary dysfx vs testicular failure

34
Q

To differentiate organic vs psychogenic test with?

A

Nocturnal penile tumescemce testing device

35
Q

Special test - trial of (PO) PDE-5 inhibitors

A

Inadequate response to (PO) > directly inject vasoactive substances > erection = intact vascular system (no further eval)

36
Q

Direct injection of vasoactive substances?

A

PG E1
Papaverine
Phentolamine

37
Q

Failure to achieve erections after (PO/INJ) reflex?

A

Penile duplex doppler U/S
Penile cavernosography
Pudendal arteriography

38
Q

Psychogenic ED dysf TXT

A

Sexual health therapy/counseling

39
Q

ED dysfx TXT

A 
Lifestyle mods and decrease CV risk
PDE-5 Inhibitors
Vasoactive Rx (Alprostadil (PG E2) (INJ/Suppository)
Hormonal replacement
Adjunct Devices
Surgical
40
Q

MOA of PDE-5 Inhibitors?

A

inhibits phosphodiesterase type 5 > allowing cGMP to fx unopposed = more blood flow into erect penis

41
Q

PDE-5 Inhibitors Rx

A

Vardenafil
Avandafil
Sildenafil
Tadalafil

42
Q

Adverse SEs PDE-5 Inhibitors

A

HOTN - (caution if patient is on Alpha Blks for lower urinary tract S/S - titrate carefully)
Priapism - rare

43
Q

PDE-5 Inhibitors Rx CI’s?

A 
Nitroglycerin/nitrates > excess preload reduction/HOTN
CYP450 - 3A4 inhibitors
-erythromycin
-cimetidine
-ketoconazole
-intraconazole
-Grapefruit juice
44
Q

PDE-5 Inhibitors relative CI’s?

A 
Active coronary ischemia in men not on nitrates
HF
Borderline HOTN or multiple HTN Rx's
CYP450 - 3A4 inhibitors
-erythromycin
-cimetidine
-ketoconazole
-intraconazole
-Grapefruit juice
45
Q

PDE-5 Inhibitors - Sildenafil attributes

A

Viagra
- 1hr prior to sex
- lasts 4hrs
50-100mg (empty stomach - high fat meal = delays)

46
Q

All PDE-5 Inhibitors requires what for effective use?

A

Stimulation

47
Q

PDE-5 Inhibitors - Vardenafil attributes

A

Levitra
- 1hr prior sex
- onset/duration similar to sildenafil
20mg PO (1/day max)

48
Q

PDE-5 Inhibitors - Tadalafil attributes

A

Cialis
- 1hr prior sex
- 30-60m onset lasting 3 days*
10-20mg PO (no more than 1 Q2 days)

49
Q

Which PDE-5 Inhibitors is FDA approved for BPH ED?

A

Tadalafil (cialis)

-2.5mg and 5mg daily dosing

50
Q

PDE-5 Inhibitors - Avanafil attributes

A

Stendra
- 15m prior sex*
- similar duration to sildenafil
100-200mg

51
Q

Vasoactive therapy Rx?

A

Alprostadil (PG E2)

52
Q

MOA of Alprostadil (PG E2)?

A

Stimulates adenyl cyclade to increase intracellular cAMP levels > smooth muscle relaxation and V-dil

53
Q

Alprostadil routes?

A

Injectable

Urethral Suppository

54
Q

Direct injection of alprostadil notes

A

Use tuberculin syringe

Inject at base/lateral aspect (avoid superficial BVs/nerves)

55
Q

Urethral Suppository of alprostadil notes

A 
Small pellet (MUSE) inserted w/ applicator
3x1 mm pellet is inserted 3cm into urethra
- Absorbs from urethra > corpus spongiosum > corpora cavernosa
56
Q

ED dysf - hormonal replacement TXT?

A

If - documented androgen deficits

Testosterone injections/topical patches (androderm)

57
Q

What must be performed prior to hormonal replacement?

A

R/O prostate cancer 1st

58
Q

Vacuum Erection Device

A

Best for patients w/ venous D/O of penis and fail to achieve erection w/ vasoactive substance injection

59
Q

Vasoactive substance injection failure + venous D/O reflex?

A

Vacuum erection device

60
Q

Vacuum erection device - methodology?

A 
creates negative pressure around penis >
blood drawn into corpora cavernosa >
tumescence/erection achieved >
place elastic constriction band around penile base >
PVTs loss of erection
61
Q

ED dysfx surgical options?

A

Inflatable penile implant
Flexible rod penile implant
Vascular reconstruction - last resort

62
Q

Vascular reconstruction of penis is indicated for?

A

Vascular D/O

  • Trauma-induced focal arterial occlusion
  • Congenital venous occlusion
63
Q

Vascular reconstruction success rate?

A

Many will still fail to achieve rigid erection

Urology (7 decks)

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