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Genitourinary > Erectile Dysfunction > Flashcards

Erectile Dysfunction Flashcards

1
Q

What is erectile dysfunction?

A

Failure to initiate an erection
OR
Failure to maintain an erection until ejaculation

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2
Q

What is an erection?

A

A physiological phenomenon in which the penis becomes firmer, engorged with blood and enlarged.

Under hormonal control, usually triggered by sexual arousal

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3
Q

What are the ‘corpora’ of the penis? What do they do?

A

2x corpora cavernosa
1x corpus spongiosum

Sponge-like erectile tissue that fills with blood during erection, making the penis firm

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4
Q

Describe the layout of the corpora within the penis?

A

Looking at a cross section, the corpora cavernosa are superior and lie side by side

The corpus spongiosum lies below and surrounds the urethra

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5
Q

There are 2 corpora spongiosa.

True or false?

A

False!

There’s one corpus spongiosum and two corpora cavernosa

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6
Q

Which ‘corpus’ does the urethra run through?

A

Corpus spongiosum

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7
Q

What is the nerve supply to the penis?

A

Pudendal nerve:

  • parasympathetic
  • sympathetic

Cavernous nerve

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8
Q

Which parasympathetic nerves supply the penis?

i.e. T1

A

S2-4

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9
Q

Which sympathetic nerves supply the penis?

i.e. T1

A

T11 - S2

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10
Q

What does parasympathetic stimulation do to the penis? How?

A

Causes an erection

Causes a release of NO into the penis arteries and smooth muscles

This stimulates arteriolar dilatation and trabecular smooth muscle relaxation

Blood flows into the corpora and causes rigidity, erection

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11
Q

What does sympathetic stimulation do to the penis?

A

Causes flaccidity

It causes arteriolar constriction, so blood can’t fill up the erectile tissue, no erection occurs

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12
Q

What is the trabecular smooth muscle in the penis?

A

The muscle that makes up the erectile tissue in the corpora

When it relaxes, the corpora fill with blood = erection

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13
Q

What is the blood supply to the penis?

A

Aorta branches into internal iliac artery

Internal iliac branches into internal pudendal

Internal pudendal has 3 branches:

  1. Bulbar artery
  2. Dorsal penile artery
  3. Cavernous artery
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14
Q

Which artery in the penis supplies the arterioles that dilate and cause erection?

A

Cavernous artery

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15
Q

What is the tunica albuginea?

A

Tough fibrous membrane covering the corpora cavernosa

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16
Q

Describe the physiology of an erection?

A

Central areas in the brain initiate desire for erection

Descending pathways carry stimulus to the parasympathetic nerves at S2, 3 + 4

Parasympathetic nerves cause release of NO

NO causes vasodilation of arterioles and smooth muscle

Muscles compress the veins of the corpora preventing blood flow out, maintaining the erection

Blood flows into corpora and causes an erection

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17
Q

What causes an erection to stop?

A

When parasympathetic activity reduces back to baseline

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18
Q

What are two types of causes of ED?

A

Organic: a physical problem preventing the erection

Psychogenic: a psychological cause prevents erection

19
Q

How can you distinguish between organic ED and psychogenic ED?

A

Organic:

  • gradual onset
  • occurs in all contexts
  • lack of morning erections

Psychogenic:

  • sudden onset
  • only in some contexts
  • morning erections unaffected
20
Q

A man presents with inability to attain an erection. His morning erections are unaffected.
Do you suspect organic or psychogenic?

A

Psychogenic, because his morning erections are unaffected

21
Q

What are some organic causes of ED?

A

The big 3:

  • Smoking
  • Alcohol
  • Diabetes
Endocrine disorders
Neurological disorders
Vascular disorders
Anatomical problems
Iatrogenic
22
Q

What are some endocrine disorders that cause ED?

A

Hypogonadism: low testosterone

Hyperprolactinaemia: high levels of prolactin

Thyroid disease: hyper and hypo

23
Q

What is prolactin?

A

A hormone involved in breast and milk development during pregnancy

24
Q

What are some neurological disorders that cause ED?

A

Spinal cord lesions

MS

Autonomic neuropathy: affecting para and sympathetic nerves

25
Q

What are some vascular disorders that cause ED?

A

Cardiovascular disease

Atherosclerosis

Hypertension

Hyperlipidaemia

26
Q

Alarm bells should ring when you encounter a patient with ED caused by vascular disease (hypertension, atherosclerosis etc.). Why?

A

ED usually precedes a vascular event by 3 to 5 years

27
Q

What anatomical problems cause ED?

A

Peyronie’s disease: fibrous plaque in the soft tissue of the penis, causes abnormal curvature of penis, pain and ED

Micropenis

28
Q

What are some iatrogenic cause of ED?

A

Drugs:

  • anti-hypertensives: B blockers
  • antidepressants
  • hormonal drugs

Surgery and radiotherapy

29
Q

What causes psychogenic ED?

A

Disorders of sexual intimacy, lack of arousability

Situational: partner, stress, environment

30
Q

Investigations of ED?

A

Full sexual and general history: is it psychogenic or organic?

Check general health: BP, HR, BMI

Examine genitalia: Peyronie’s disease, hypogonadism

Do a peripheral neuro and vascular exam

Blood tests

31
Q

What blood tests would you do?

A 
FBC
U+E
LFT
Thyroid function test
Testosterone levels
Prolactin levels
32
Q

What should you do initially to manage ED?

A

Treat the causes, if you can.

Provide counselling for psychogenic causes

Lifestyle advice: lose weight, control BP, diabetes, cholesterol

33
Q

What is the first line therapy for treating ED?

A

Drugs!

Phosphodiesterase type 5 inhibitors

34
Q

How do phosphodiesterase type 5 (PDE5) inhibitors work?

A

cGMP causes relaxation of smooth muscle in the penis

cGMP is degraded by PDE5 in smooth muscle cells

PDE5 inhibitors mean the cGMP is not degraded, so cGMP can cause smooth muscle to relax more

35
Q

What are some examples of PDE5 inhibitors?

A

Sildenafil: Viagra
Tadalafil: Cialis

36
Q

Do PDE5 inhibitors stimulate erections?

A

No, they simply make obtaining an erection easier. Sexual stimulation is still required

37
Q

What are the 2nd line therapies for treating ED?

A

Vacuum constriction device: passive engorgement by vacuum

Intra-cavernosal injection: drug that relaxes smooth muscles allowing blood flow into corpora cavernosa

Intra-urethral therapy: a pellet that is inserted into the urethra

38
Q

What is the 3rd line therapy for treating ED?

A

Implant!

Penile prostheses:

  • Malleable implant: manually point up and down
  • Mechanical implant: cylinders in corpora cavernosa that can be filled and emptied using a pump
39
Q

What can you do to treat hypogonadism?

A

Testosterone supplements

40
Q

How can you give testosterone supplements?

A

Not orally!

  • transdermal patch
  • buccal (cheek)
  • nasal
  • injections
  • subcutaneous implants
41
Q

Why can’t you give testosterone orally?

A

Because it is metabolised by he liver and won’t be effective

need to use a method that bypasses liver

42
Q

What is priapism?

A

An erection that lasts over 4 hours

Becomes painful and there can be permanent ischaemic damage as a result

43
Q

How do you treat priapism?

A

Aspirate corpora with needle

Genitourinary (13 decks)

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