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Urology/Renal > erectile dysfunction > Flashcards

erectile dysfunction Flashcards

1
Q

what is erectile dysfunction?

A

The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

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2
Q

what happens physiologically for erection to occur?

A
  • brain sends a signal via the spinal cord through the parasympathetic nervous system
  • causes release of nitric oxide, NO, a neurotransmitter which chemically relaxes the smooth muscles in thecorpora cavernosa, the two expansion chambers in the penis
  • This enables enhanced blood flow into the lacunar spaces of the corpora, a mechanical process, causing expansion of the erectile tissue
  • there is concomitant constriction of venous outflow resulting in blood containment, penile enlargement and rigidity = corporeal veno occlusive mechanism
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3
Q

what is the arterial supply of the penis?

A

the internal pudendal artery branch of the internal ileac artery
the internal pudendal artery branches into the dorsal penile artery, cavernosal artery and bulbar artery

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4
Q

which part of the penis does the dorsal penile artery supply?

A

the glans penis

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5
Q

which part of the penis does the bulbar artery supply?

A

bulb
spongiosum
glans penis

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6
Q

which part of the penis does the cavernosal artery supply?

A

corpora cavernosa

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7
Q

describe how the blood supply of the penis changes between the flaccid and erect state

A

flaccid: the penile smooth muscle is contracted, the helicine arteries are constricted, the cavernosal sinusoids are empty and the emissary veins are open
erect: the penile smooth muscle is relaxed, helicine arteries are dilated and so fill the cavernosal sinusoids which in turn compress the emissary veins against the tunica albuginea, resulting in reduced venous outflow

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8
Q

what are the different routes of venous drainage of the penis?

A

subtunical plexus which drains into the circumflex veins and deep dorsal vein
the coropora cavernosa is drained by the cavernous veins to the crural veins and internal pudendal veins

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9
Q

what type nerve supply causes the erection and what spinal levels is this?

A

parasympathetic

S2-4

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10
Q

what type of nerve supply causes ejaculation and what spinal levels is this?

A

sympathetic

T11-L2

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11
Q

what nerve carries both the parasympathetic and sympathetic nerve supply to the penis?

A

cavernous nerve

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12
Q

In the flaccid state, the penile smooth muscle is contracted, what is the biochemistry behind this?

A

noradrenaline release from sympathetic nerve terminals causes smooth muscle contraction
(also neuroppeptide Y released form sympathetic nerve terminals and endothelin and prostanoids released from the vascular endothelium cause contraction of smooth muscle)

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13
Q

in the erect state, the trabecular smooth muscle relaxes, what is the biochemistry behind this?

A

NO is released from the parasympathetic nerve terminals
NO is also released by the vascular endothelium after the endothelium has been stimulated by Ach from parasympathetic nerve fibres

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14
Q

which hormone is required for normal erectile function?

A

testosterone

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15
Q

what are the causes of low testosterone?

A
  • primary - hypopituitarism, hypothalamic dsiease
  • secondary - tumour of the testis, testicular injury, drugs
  • congenital - Klinefelters, Noonans
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16
Q

How does NO cause smooth muscle relaxation?

A
  • NO stimulates guanylate cyclase
  • guanylate cyclase converts GTP to cyclic guanosine monophosphate (cGMP)
  • cGMP causes protein kinase G to close calcium channels and open potassium channels
  • the reduction in cytoplasmic calcium concentration results in smooth muscle relaxation
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17
Q

How is the action of cGMP terminated?

A

phosphodiesterase converts cGMP to the inactive guanosine monophosphate GMP

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18
Q

How does viagra (ie sildenafil) work?

A

it is a phosphodiesterase inhibitor, so inhibits the conversion of cGMP to GMP which normally terminates the erection

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19
Q

what are the different causes of erectile dysfunction?

A 
vasculogenic 
neurogenic 
hormonal
anatomical
drug induced 
psychogenic
20
Q

what are the risk factors of ED?

A 
(same as those of CVS disease)
obesity
lack of exercise 
smoking 
hypercholesterolaemia 
metabolic syndrome 
diabetes
21
Q

list some specific conditions that can cause ED?

A 
DM
cardiovascular dsiease - MI and hypertension
liver disease 
alcohol
renal failure 
trauma - eg pelvic fracture 
iatrogenic - prostatectomy
22
Q

can ED be improved by lifestyle modification?

A

yes

23
Q

can ED be an early sign of cardiovascular disease

A

yes

24
Q

What are the indicators of psychological aetiology?

A

sudden onset ED
good nocturnal and early morning erections
situational ED
younger pt

25
Q

What are the components of the physical examination for ED?

A 
BP and HR 
hepatosplenomegaly 
genitalia - for Peyronie's disease
prostatic enlargement or cancer 
hypogonadism - small testis, lack of secondary sexual characteristics
26
Q

What questionnaire is used for assessment of sexual history?

A

IIEF (International index for Erectile Function)

27
Q

what are the components of the international index for erectile function?

A

Erectile function, orgasmic function, sexual desire, ejaculation, intercourse and overall satisfaction

28
Q

What lab investigations are commonly done for ED?

A

fasting glucose (diabetes)
lipid profile
morning testosterone (as this is when testosterone is highest)
if testosterone is low, perform prolactin, FSH and LH

29
Q

what are the specialised tests that can be done for ED (rarely)

A

Nocturnal penile tumescence (how swollen it is) and rigidity
Intracavernosal injection test
Duplex USS of penile arteries
Arteriography

30
Q

In most pts a cause for their ED is found T or F?

A

False - in most causes no cause is found and results of tests are normal

31
Q

How is ED treated?

A

identify the causes and treat if reversible
lifestyle and risk modification
pt and partner involvement in education and counselling to help psychologically

32
Q

How are hormonal causes of ED treated?

A

testosterone deficiency is treated with gels and injections containing testosterone

33
Q

When is testosterone therapy contraindicated?

A

if history of prostate cancer

34
Q

What is monitored in pts who are on testosterone therapy?

A
  • check DRE and PSA beforehand and monitor through therapy as it does increase your risk of prostate cancer
  • monitor for hepatic or prostatic disease
35
Q

What is the first line therapy for ED?

A

phosphodiesterase PDE5 inhibitors

36
Q

what are the second line treatments for ED?

A

intracavernous injections
intraurethral alprostadil
vacuum devices

37
Q

How are the treatments assessed?

A

Therapeutic response
Side effects
Satisfaction with treatment
if there is an inadequate outcome, then make sure the pt is doing the treatment correctly

38
Q

What is the last resort for ED?

A

penile implant (two types, one is malleable and one is a pump device)

39
Q

Do phosphodiesterase type 5 inhibitors stimulate erection?

A

no - needs sexual stimulation

40
Q

How do you

test whether the medication is working or not?

A

6 attempts at maximum dosage after advising pt on how to take the drug properly with adequate sexual stimulation, waiting long enough for the drug to work

41
Q

how does the second line agent sublingual apomorphine work?

A

centrally acting dopamine agonist

42
Q

what are the side effects of the vacuum pump?

A 
pain 
inability to ejaculate 
petechiae 
bruises 
numbness
43
Q

what are the contraindications for the vacuum device?

A

bleeding disorders

anticoagulants

44
Q

what are the complications of intracavernosal injections?

A

penile pain
priapism
fibrosis
bruising

45
Q

what is a priapism?

A

an erection that lasts more than 4 hours

risk of permanent ischaemic damage to the corpora and permenant erectile dysfunction

46
Q

what are the side effects of intraurethral alprostadil?

A

pain
dizziness
urethral bleeding

47
Q

what are the complications of prosthesis?

A

infection

mechanical failure

Urology/Renal (14 decks)

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