ED/Peyronies/penile cancer Flashcards
ED
Erection
Occurs as a result of a complex neuropsychologic process
Parasympathetic innervation (S2-S4) is responsible for the vascular changes which cause erection
Increased blood flow to the penis via the arterioles
Compression of the venules causing veno-occlusion
Vasculature
Arterial blood is supplied to the penis by:
Dorsal arteries of the penis
Deep arteries of the penis
Bulbourethral artery
Venous blood is drained from the penis by:
Deep dorsal and superficial dorsal veins
Erectionis a balance between arterial blood inflow and venous drainage
Erectile Dysfunction (ED)
general
primary vs secondary
Previously referred to as impotence
Consistent inability to achieve or maintain an erection satisfactory for sexual intercourse
Affects ~30 million men > 18 years of age
Increased prevalence with age
~50% of men 40-70 years of age
Types:
Primary ED
Rare
Male that has never been able to achieve or maintain an erection
Due to psychological factors or clinically observable anatomic abnormalities
Secondary ED
> 80% of cases
Male that could previously attain and sustain an erection
ED
Causes
Vascular disease
Blood supply to the penis is blocked or narrowed
Atherosclerosis, CAD, HTN, HLD and diabetes
Neurological disorders
Multiple sclerosis, stroke, peripheral neuropathy, spinal cord injury
Endocrine disorders
Hypogonadism, hypothyroidism
Psychological states
Stress, depression, performance anxiety
Medications
Beta-blockers, antidepressants
Smoking, alcohol and illicit drugs
Trauma
Structural disorders
Peyronie’s disease
Surgeries
Prostate, bladder, and colon
ED
Medical and sexual history for Dx
Comprehensive medical and sexual history:
Marital orrelationship issues
Performanceanxiety
Validated International Index of Erectile Function (IIEF)
15-questionscale, assessing the following 5 domains of male sexual activity:
Sexual desire
Erectile function
Intercourse satisfaction
Orgasmic function
Overall sexual satisfaction
Depression
A psychological cause should be suspected in young healthy men with abrupt onset
ED
Lifestyle and mecial history
Assess for lifestyle factors:
Smoking, alcohol use, illicit drug use
Relevant medical and surgical history
Any prior genitourinary surgeries (prostate, bladder, colon)
Atherosclerosis, CAD, DM, PAD, HLD
ED
PE
Focus on the genitals and extragenital signs of hormonal, neurologic, and vascular disorders
Obtain resting vital signs and palpate peripheral pulse (diminished peripheral pulses → vascular dysfunction)
Measurewaist circumferenceandBMI
Observe the chest forgynecomastia
General genitourinary exam:
Scrotal exam with assessment of testicle size, consistency, and location
Penile exam to assess for lesions, plaques, or any anomalies
Poor rectal tone, decreased perineal sensation, abnormal anal wink → neurological dysfunction
ED
Labs
Total testosterone level; if low, reflex testing - FSH and LH
Fasting blood glucose or hemoglobin A1C
Lipid profile - ↑ may indicate atherosclerosis
Thyroid function tests - TSH, T4
Urinalysis
ED
Diagnostics
Duplex ultrasound on flaccid and erect penis
Nocturnal penile tumescence (NPT)
Measurement of a man’s erectile function while sleeping
Men with psychogenic ED usually have normal nocturnal erections
Men with an organic ED often have abnormal nocturnal erections
ED
Tx
Lifestyle and pharm
Stop medications that may be related to ED
Smoking cessation
Weight loss
Optimize diabetes care
Start medications for the treatment of depression if identified
Testosterone replacement
Phosphodiesterase-5 inhibitors
Increase blood flow to the penis
Sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis)
ED
Phosphodiesterase-5 inhibitors
Contraindications
Contraindicated in patients taking medications containing nitrates (nitroglycerine) due to the potential of causing low blood pressure
ED
Alternative Tx
Penile injections:
Men can be taught to inject the medication directly into the erection chambers of the penis to create an erection
Prostaglandin E1, papaverine, phentolamine
Vacuum devices and constriction rings
Penile implant
Peyronie’s disease
General
Inflammatory condition characterized by the formation of fibrous tissue within the tunica albuginea of the penis resulting in an abnormal curvature of the shaft of the penis and pain
Often has devastating physical and psychological consequences on affected individuals
Difficulty achieving or maintaining an erection
Inability to have sexual intercourse
Anxiety or stress about sexual abilities or the appearance of the penis
Develops in 5-10% of men
Sudden or gradual presentation
Incurable, but typically stabilizes after 3-12 months
peyronies
patho
Repeated injury to the penis (sex, athletic activity, or an accident)
Scar tissue forms in a disorganized fashion during the healing process
Not elastic and therefore the penis bends or becomes disfigured and painful
Normally forms on the dorsal aspect of the penis causing an upward curvature
Peyronies
RF
Heredity
↑ risk if a family member has the disease
Connective tissue disorders
Dupuytren’s contracture
Scleroderma
Tympanosclerosis
Age-↑ prevalence with age (50-60s)
Diabetes-associated erectile dysfunction 4-5x more likely
Smoking
Peyronies
S/Sx
Scar tissue
Plaque formation (flat lumps or a band of hard tissue) can be felt under the skin
Abnormal curvature of the penis
Curve upward, downward, or to either side
Shortening of the penis
Pain- With or without an erection
Erection problems
Trouble getting or maintaining an erection (erectile dysfunction)
Curvature > 30 degrees can interfere with sex