Erectile Dysfunction

Question 1

What is Phimosis?

Answer 1

This is where the foreskin is too tight to be pulled back on the head to the penis.

Question 2

What is Pyronine’s disease?

Answer 2

This is where there is built up scar tissue causing a bent penis.

Question 3

In a men with erectile dysfunction, when should a DR be performed?

Answer 3

This should be carried out in older men (>50 years). If there is history of prostate cancer or prostate symptoms.

Question 4

When should testosterone be tested?

Answer 4

Sample between 8am and 11am

Question 5

How many weeks should a PSA test be carried out after a UTI or DR exam?

Answer 5

A PSA test should be carried out at least 1-2 weeks as these two factors can increase the level.

Question 6

What is primary erectile dysfunction?

Answer 6

Primary erectile dysfunction is the absence of full, sustained erections since early childhood or puberty

Question 7

What is secondary erectile dysfunction?

Answer 7

Secondary erectile dysfunction is where there a problem maintaining erections in an older man.

Question 8

What is the definition of erectile dysfunction?

Answer 8

It is defined as the inability to achieve and maintain a penile erection adequate for satisfactory sexual intercourse. There is a significant impact on quality of life of patients but also their partners.

Question 9

What is the link with cardiovascular disease and erectile dysfunction?

Answer 9

The mechanism linking cardiovascular disease and erectile dysfunction probably involves endothelial dysfunction, which leads to impaired smooth muscle relaxation within the penis. There would be a lack of blood supply due to atherosclerosis and blood vessel damage from hypertension.

Question 10

What is the link with diabetes and erectile dysfunction?

Answer 10

Diabetes will affect erections due to neuropathy and lack of blood flow.

Question 11

What part of the nervous system is responsible for erection?

Answer 11

Parasympathetic

Question 12

What part of the nervous system is responsible for ejacualtion?

Answer 12

Sympathetic

Question 13

Describe Psychogenic causes of erectile dysfunction

Answer 13

Psychogenic is where there is no physiological or neurovascular condition identified. About 10% of ED cases are attributable to this case:

• Stress in relationship
• Performance anxiety
• Psychological problem

Question 14

Describe organic causes of erectile dysfunction

Answer 14

Organic accounts of 90% of cases. It is attributed to the central mechanism of endothelial dysfunction. The main abnormalities found include:

• Cardiovascular disease (40%)
• Diabetes (33%)
• Hormonal or Drugs (11%)
• Neurological disorders (10%): MS, Parkinson’s, Spinal cord trauma
• Pelvis surgery or trauma in 3.5%
• Anatomical abnormalities in 1-3% for example phimosis, Peyronie’s disease, short frenulum

Question 15

Will organic causes of erectile dysfunction cause men to lose all or some erections?

Answer 15

Organic causes will cause men to lose all of their erection.

Question 16

Will psychogenic causes of erectile dysfunction cause men to lose all or some erections?

Answer 16

Whereas in psychogenic, men will still get morning and night erections and the ability to masturbate is still possible.

Question 17

Name some common drugs that cause erectile dysfunction

Answer 17

• antidepressants
• antihypertensives
• antiarrhythmias
• diuretics
• hormonal
• H2 receptor antagonists
• recreational drugs

Question 18

Describe the symptoms suggestive of psychogenic causes of erectile dysfunction

Answer 18

• younger age
• lack of medial history
• sudden onset
• decreased libido
• spontaneous erections
• symptoms present a specific times e.g. with partner
• relationship changes
• previous psychological history

Question 19

Describe the symptoms suggestive of organic causes of erectile dysfunction

Answer 19

• older age
• gradual onset
• normal libido
• loss of nocturnal and early morning erections
• present in all situations
• risk factors for CVD and DM

Question 20

What is the first step in the treatment plan for erectile dysfunction?

Answer 20

The first plan is to identify and treat any reversible causes of erectile dysfunction. Advice lifestyle changes.

Question 21

What drugs are used for erectile dysfunction?

Answer 21

It would be appropriate to start drug therapy. PDE-5 inhibitors are first-line treatment for ED except if there are contradictions.

Question 22

What is the main example of a PDE-5 inhibitor?

Answer 22

Sildenafil (Viagra)

Question 23

Describe the mechanism action of Sildenafil

Answer 23

Drugs such as sildenafil are potent and selective inhibitors of phosphodiesterase type 5. These drugs act by inhibiting cGMP-specific PDE5. cGMP promotes smooth-muscle relaxation, increased blood flow to the penis, leading to compression of the subtunical venous plexus resulting in penile erection. Inhibiting PDE5 maintains concentrations of cGMP necessary for achieving and maintain erections.
Normal Mechanism: the nerve fibres release acetylcholine and this binds to muscarinic receptors. This activates the enzyme nitric oxide synthase. This enzyme converts arginine to citrulline and nitric oxide. Nitric oxide diffuses into the smooth muscle cells, activates guanylate cyclase. This converts GTP into cGMP. This leads to a fall in intracellular calcium levels causing smooth muscle relaxation. This allows the cavernosal spaces to expand and fill with blood.
The cavernosa grown size and compress the veins, making it difficult for the blood to leave.

Question 24

What are some contradictions for PDE-5 inhibitors?

Answer 24

• Nitrates and guanylate cyclase stimulators (i.e. riociguat)
• Severe/unstable heart disease
• Non-arteritic anterior ischaemic optic neuropathy
• Hypotension (systemic blood pressure below 90/50mmHg)
• Unstable angina or angina occurring during sexual intercourse
• Recent stroke of MI

Question 25

What is the dosing regime for viagra?

Answer 25

Take 50mg as needed around one hour before sexual activity. The max dose is 100mg daily.
The duration is 4-5 hours.

Question 26

Give other examples of PDE-5 inhibitors

Answer 26

Tadalafil
Vardenafil
Avanafil

Question 27

What are some common side effects of PED-5 inhibitors?

Answer 27

• backpain
• dyspepsia
• flushing
• myalgia
• nasal congestion
• dizziness
• nausea
• vomiting

Question 28

Patients normally have to pay for viagra. However, some patient say exempt. Who are some examples of patients who are exempt?

Answer 28

• diabetes
• neuro: Parkinson’s, MS, Polio
• Huntington’s
• spinal cord injury/bifida
• renal dialysis
• radical pelvis surgery
• prostate cancer
• treatment inited bore 1988
• severe stress secondar to ED

Question 29

Describe the second line of treatment for erectile dysfunction

Answer 29

Second line therapy for ED is the synthetic prostaglandin E1 analogue- alprostadil. It acts by increasing cGMP levels thus increasing smooth muscle relaxation and penile blood flow. This drug therapy can be given directly into the penis by two methods:

 MUSE -a small pellet is inserted directly into the urethral opening of the penis.
 Caverject- direct intracavernosal injection into the penis

Question 30

Describe the vacum erection device

Answer 30

VED -vacuum erection device is another alternative treatment for ED. Whereby a cylinder is placed over then of the penis and air is removed with a pump. This results in a vacuum, causing penile blood flow which results in an erection. However, caution is needed as a constriction ring is placed at the base of the penis to maintain an erection, but must not remain on for more than 30 minutes. The side effects include pain, bruising, and penile numbness, and more seriously events such skin necrosis.

Question 31

What is the third line of treatment for erectal dysfunction?

Answer 31

Third line therapy is penile prosthesis surgery and is only suitable for patients with severe organic erectile dysfunction which has not responded to drug treatments.