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CLIN MED PA 581: GU > Erectile Dysfunction > Flashcards

Erectile Dysfunction Flashcards

Objectives

1
Q

Erectile Dysfunction (ED) definition

A

the inability to attain and /or maintain penile etection sufficient for satisfactory sexual performance

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2
Q

ED Epidemiology

A
  • Usually first emerges for men in early 40s and increases with age
  • Prevalence increases with age
  • 52% of men >40 years old have some degree of ED
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3
Q

Basic physiology of erections

A
  • Two processes
    • Cavernosal artery smooth muscle relaxation
    • Increased venous outflow resistance
  • High arterial inflow and low venous outflow
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4
Q

Cavernosal artery smooth muscle relaxation

A
  • Active process – initial event of erection
  • Parasympathetic nerves release nitric oxide →increased cyclic GMP → decreased intracellular calcium → greater smooth muscle relaxation
  • Smooth muscle relaxation = arterial dilation, increased blood flow, increased intracavernosal pressure, cavernosal expansion
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5
Q

Increased venous outflow resistance

A
  • Passive process
  • Cavernosa expand and compress sub-tunic venous sinus
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6
Q

Erection phys image

A
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7
Q

ejaculation

A
  • Sympathetic nerve release norepinephrines → stimulates alpha–1 adrenergic receptors→smooth muscle contraction →reopening venous channels→ flaccid
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8
Q

Erection/ ejaculation main point

A
  • Parasympathetic = vasodilation = erections
  • Sympathetic = vasoconstriction = flaccid
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9
Q

Etiology of ED

A
  • Vasculogenic
  • neurogenic
  • psychogenic
  • endocrinologic
  • local penile fx
  • medication induced
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10
Q

Etiology of ED chart

A
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11
Q

Relevant Medical PMHx for ED

A
  • Renal failure
  • diabetes
  • liver failure
  • alcoholism
  • neurologic disease
  • thyroid disorders
  • atherosclerosis
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12
Q

Relevant Surgical PMHx for ED

A
  • Prostatectomy
  • cystectomy
  • proctocolectomy
  • aorto-iliac vascular surgery
  • pituitary surgery
  • penile surgery
  • etc
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13
Q

Relevant Trauma PMHx for ED

A
  • Pelvic fracture
  • penile fracture
  • perineal trauma
  • priapism
  • spinal cord injury
  • pelvic radiation
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14
Q

Antihypertensives causing ED

A
  • Beta blockers
  • Thiazide diuretics
  • Sympathetic blockers
    • clonidine
    • methyldopa
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15
Q

Antidepressants/Antipsychotics causing ED

A
  • SSRIs
  • SNRIs
  • TCAs
  • MAO inhibitors
  • lithium
  • phenothiazines
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16
Q

Meds that block or reduce testosterone and ED

A
  • Cimetidine
  • spironolactone
  • anti-androgens
17
Q

Other meds that cause ED

A
  • Sedatives
  • phenytoin
  • anticholinergics
  • alcohol
  • smoking
18
Q

ED Work-up

A
  • Review medical, surgical, psychological, social, medications
  • Onset and duration of ED
  • Sustaining capability
  • Penetration capability
  • Nocturnal/morning erections
  • Erections with masturbation
  • Libido
  • Ejaculatory dysfunction
  • Penile curvature
  • Relationship problems
  • Performance anxiety
  • Stress
19
Q

Types of ejeculatory dysfxn

A
  • premature
  • delayed
  • retrograde ejaculation
  • anorgasmia
20
Q

Clinical clues to cause ED Chart

A
21
Q

ED: Physical exam work-up

A
  • General
    • body habitus
    • lack or loss of normal male hair patterns
    • gynecomastia
  • Cardiovascular
    • Auscultate heart
    • femoral and peripheral pulses
    • bruits
  • External genitalia
    • Penile plaque
    • curvature
    • presence of testes and their size
  • Basic neuro exam
    • visual fields
22
Q

ED: lab work-ups

A
  • Fasting glucose, hemoglobin A1C
  • CBC/CMP – kidney and liver function
  • TSH – rule out thyroid disorders
  • Lipid profile – cardiac risk factors
  • Serum total AM testosterone – 7-11AM
    • if low, obtain FSH, LH, prolactin, repeat testosterone
  • PSA
23
Q

Other testing: Nocturnal penile tumescence testing

A
  • Detects erections during REM, psychogenic versus organic causes
  • Normal NPT = psychogenic…. Abnormal NPT = organic (vascular/neuro)
24
Q

Other testing: Duplex doppler imaging

A
  • Typically with injection to induce artificial injections
  • Examine venous and arterial flow/velocities
25
Q

Other testing: Cavernosometry/cavernosography

A
  • Detect veno-occlusive dysfunction
  • Needles places into corpora measuring pressure
  • Radiographic contrast infused into corpora – visualize for venous leak
26
Q

Other testing: Bilateral internal pudendal and inferior epigastric arteriography

A
  • Internal pudendal artery supplies common penile artery supplies cavernosal artery
27
Q

ED Tx

A
  • Treatment is individualized
  • Patient education
  • Psychogenic
    • Psychological support and counseling
  • Offer testosterone if low
28
Q

ED Tx general recommendations

A
  • Avoid smoking
  • Weight loss
  • Exercise
  • Stop alcohol abuse
  • Consider medication changes
  • Optimize management of diabetes, hypertension, and heart disease
29
Q

ED Tx meds: PDE-5 Inhibitors

A
  • Sildenafil
  • tadalafil
  • vardenafil
  • avanafil

*Do not initiate an erection.. once erection is present, make erection stronger

*First line therapy, unless contraindicated

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30
Q

PDE-5 Inhibitors Contraindications

A
  • CONTRAINDICATED in patient’s taking nitrates!!
    • (hypotension)
31
Q

PDE-5 Inhibitors Side Effects

A
  • headache
  • flushing
  • blurry vision
  • Most tend to lessen after several weeks of use
  • Retina contains PDE-6
    • inhibition of PDE-6 can cause visual side effects – tadalafil and avanafil have lowest rate of visual side effects
32
Q

PDE-5 Inhibitors Diagram

A
33
Q

Other ED Tx meds

A
  • Alpha -2 Adrenergic Receptor inhibitor
    • Yohimbine
  • Prostaglandin E1
    • MUSE (medicated urethral system for erections)
    • Increases intracellular cAMP
  • Intracavernosal Injections
    • Alprostadil (prostaglandin E1)
    • Phentolamine
    • Combination therapies
34
Q

Vacuum Erection Device Tx

A
  • Cylindrical vacuum pump placed over penis
  • Air drawn from cylinder causing blood to flow in
  • Occlusive ring placed around base
35
Q

Penile Prosthesis Tx

A
  • Surgical implanation

CLIN MED PA 581: GU (7 decks)

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