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
Peyronies
Dx
Diagnosis is often made clinically with the palpation of scar tissue in the penis
Peyronies
Tx
Acute and Chronic phase
Tx Depends on how long the disease has been present
Acute phase
6-12 months
Penile traction
Prevents length loss and minimizes the extent of curvature with a self-applied mechanical device
Chronic phase
Longer than 12 months
Scar formation has ended
Injection treatments: collagenase (only FDA-approved medication)
Surgery
Peyronies
Plication
During plication of the penis, an artificial erection is created from either injection of a saltwater solution or selected medications. The outer skin of the penis is pulled back. The penis is straightened, and the excess tissue on what had been the outer side of the curve is cinched together by placing a series of stitches. The final penile length will depend on the length of the shorter side…the side with the scarring from Peyronie’s disease.
Peyronies
Graft repair
Graft repair of the penis
During a graft repair procedure, your surgeon makes one or more cuts (incisions) in the scar tissue (plaque) of the penis, allowing the sheath to stretch out and the penis to straighten. A patch made of human or animal tissue or a synthetic material is placed to cover the defect.
Peyronies
Penile implants
Surgically placed penile implants are inserted into the spongy tissue that fills with blood during an erection. Implants might be semirigid. Another type of implant is inflated with a pump implanted in the scrotum.
Penile Cancer
general
Malignant lesions that arise from the squamous epithelium of the glans, prepuce, and penile shaft
Rare cancer in the United States: ~2,000/year
Highest incidence: Males 50-70 years
Penile cancer
RF
Uncircumcised males
Greatest risk contributing to malignant penile lesion (↑ by 22-fold)
History of HPV or HIV infection (↑ by 8-fold)
Up to 50% of penile cancers are associated withHPV serotypes 16 (most common), 6, and 18
Smoking
Chronic inflammatory conditions
Phimosis
Balanitis
Penile cancer
Patho
Most cancers of thepenis arise from the squamousepithelium of theepidermis anddermis
Cancer growth
Small lesions initially, often noted on the glans orprepuce
HPV-mediated penile carcinomas:
Oncoproteins E6 and E7 produced byHPV infections can interfere withtumor suppressor genefunction
Penile cancer
Cancer types
Carcinoma in situ (CIS)
Squamous cell carcinoma (SCC):
Common variant: ~60% of cases
Typically invades thecorpus spongiosum
Inguinal node metastases are present in 25%–40% of cases
Papillary carcinoma: 2%–15% of cases
Usually low grade, but superficially invasive
Not linked toHPV infection
Warty (condylomatous): 7%–10% of cases
Cauliflower-like lesions
Linked toHPV infection
Inguinal node metastasis in 17%–25% of cases
Penile cancer
Clin man
Initially presents as askin abnormality or palpable lesion on thepenis
Majority arise from the glanspenis, at thecoronal sulcus or on theprepuce
May be painful, but usually painless
Lesions can vary in size, color, and characteristics
Inguinal adenopathy presents in about 30%–60% of cases
Distantmetastasis
Affects adjacent genitourinary organs or distant organs
Present in about 1%–10% of cases
Penile Cancer
PE
Focused genitourinary exam
Focused genitourinary exam
Penile exam
Circumcision status
Characterize size, depth, location, and features of lesion(s)
Assess for discharge,erythema, and swelling
Inguinal exam
Assess foringuinal lymphadenopathy
Number of palpable inguinal nodes
Fixed or mobile nodes
Penile cancer
Dx and imaging
Tissuebiopsy to confirm
Punch, incisional, or excisional biopsy
Imaging:
Ultrasonography
MRI/CT:
Assesses primary tumor stage and surgical approach
Identifies invasion into the corpora cavernosa or spongiosa
Determines regional lymph node involvement
Imaging of other sites in case ofmetastasis
Penile cancer
Staging and Tx
Staging System: Tumor, Node, Metastasis (TNM)
Management
Depends on the TNM staging
Carcinoma in situ
Topical therapy
Fluorouracil cream or Imiquimod cream
Laser ablation
CO2laser commonly used
Total glans resurfacing followed byskin graft placement
Mohs micrographic surgery
Penile cancer
Penis-preserving interventions
Local excision with reconstruction
Glansectomy
Laser therapy
Radiotherapy
Brachytherapy
Internal radiation therapy in which seeds, ribbons, or capsules that contain a radiation source are placed in the body, in or near the tumor
Partial/total amputation of the penis
Lymph nodes
Palpablelymph nodes: inguinal lymphadenectomy
