ED/Peyronies/penile cancer Flashcards

1
Q

ED

Erection

A

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

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2
Q

Erectile Dysfunction (ED)

general
primary vs secondary

A

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

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3
Q

ED

Causes

A

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

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4
Q

ED

Medical and sexual history for Dx

A

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

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5
Q

ED

Lifestyle and mecial history

A

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

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6
Q

ED

PE

A

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

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7
Q

ED

Labs

A

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

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8
Q

ED

Diagnostics

A

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

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9
Q

ED

Tx
Lifestyle and pharm

A

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)

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10
Q

ED

Phosphodiesterase-5 inhibitors
Contraindications

A

Contraindicated in patients taking medications containing nitrates (nitroglycerine) due to the potential of causing low blood pressure

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11
Q

ED

Alternative Tx

A

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

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12
Q

Peyronie’s disease

General

A

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

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13
Q

peyronies

patho

A

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

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14
Q

Peyronies

RF

A

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

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15
Q

Peyronies

S/Sx

A

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

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16
Q

Peyronies

Dx

A

Diagnosis is often made clinically with the palpation of scar tissue in the penis

17
Q

Peyronies

Tx
Acute and Chronic phase

Penile traction therapy involves stretching the penis with a self-applied mechanical device or a period of time to improve penile length, curvature, and deformity. Traction therapy may need to be worn for 30 minutes – 8 hours daily.
A

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

18
Q

Peyronies

Plication

A

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.

19
Q

Peyronies

Graft repair

A

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.

20
Q

Peyronies

Penile implants

A

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.

21
Q

Penile Cancer

general

A

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

22
Q

Penile cancer

RF

A

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

23
Q

Penile cancer

Patho

A

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

24
Q

Penile cancer

Cancer types

A

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

25
Q

Penile cancer

Clin man

A

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

26
Q

Penile Cancer

PE

Focused genitourinary exam

A

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

27
Q

Penile cancer

Dx and imaging

A

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

28
Q

Penile cancer

Staging and Tx

A

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

29
Q

Penile cancer

Penis-preserving interventions

A

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