Erectile Dysfunction Flashcards
what are the two broad classes of RD etiology
organic
psychogenic
- must evaluate for underlying pathology of organic ED
- psychogenic is present in majority of cases–> consider patient and partner
list the classes of organic etiology for ED
vascular anatomical/structural neurogenic metabolic/endocrine medication
what are the vascular causes of ED
**DM
**CVD/PVD
HTN
pelvic or retroperitoneal irradiation
what are the anatomical/structural causes of ED
cavernous fibrosis
peyronie’s disease
hypospadias/epispadias
pelvic trauma or surgery
what are the neurogenic causes of ED
MS stroke alzheimers parkinsons spinal cord injury
what are the metabolic/endocrine causes of ED
hypogonadism
hyperprolactinemia
hypothyroid
hyperthyroid
what are the medication causes of ED
antihypertensives (CCB, beta blockers, thiazide)
antidepressants (SSRIs, TCAs, MAOIs)
diuretics (thiazides, spironolactone)
hormones (progesterone, estrogens, corticosteroids, 5 alpha reductase inhibitors)
what recreational drugs can cause ED
smoking
EtOH
marijuana
what are the psychogenic etiologies of ED
performance anxiety depression/anxiety stress traumatic past experiences marital or relationship discord history of sexual abuse
define ED
inability to achieve or maintain penile erection adequate for satisfactory sexual activity
what should you ask on HPI for ED
onset–sudden, gradual
non sustained erection?
presence of nocturnal or morning penile erections?
difficulty with arousal, ejaculation, orgasms (alone or with partner)
loss of libido
prior tx or diagnostic testing for ED
sexual history
what to ask on sexual history for ED
stable or new relationship duration of relationship age disparity health of partner alternative sexual activities condoms previous STIs past or present sexual abuse anxiety about sexual performance
consider interviewing patients partner
red flag for ED
lack of rigid nocturnal erections suggests vascular or neurogenic etiology
what should you think in sudden onset ED
reversible causes like meds, psych, trauma
what should you think in gradual onset ED
organic causes
what should you think in non sustained erection
anxiety
vascular leak
what should you think in present nocturnal/morning erections but struggle with partner or alone with stim
psych
what meds to ask specifically for ED
anti androgens
anti HTN
anti arrhythmics
antidepressants
what risk screening should u do if someone presents with ED
CV risk assessment
ED is a strong predictor of CAD, stroke, mortality
what to look for on exam for ED
secondary sex characteristics/?hypogonadism gynecomastia nipple discharge (hyperprolactinemia) decreased male hair distribution testicular atrophy signs of hyper or hypothyroid
visual field deficits (pituitary tumour)
pinprick and touch sensation to penile shaft and perineum
screening neuro exam
evaluate penis for size, scars, fibrosis/plaques, urethral meatus, elasticity (foreskin phimosis), curvature
evaluate scrotum for testicular size and consistency
DRE–size, consistency and tenderness of prostate
what are the special tests on evaluating ED
bulbocavernosus reflex–anal sphincter contraction in response to squeezing glans of penis (neurogenic ED)
cremasteric reflex–elevation of ipsilateral testicle in response to stroke of medial thigh (thoracolumbar erection center integrity)
labs for ED
CBC urea Cr fasting glucose lipid profile morning total testosterone prolactin TSH US
special:
nocturnal penile tumescence testing
neurophysiologic testing
psych eval
conservative management of ED
psychosocial–> patient or couple counselling
lifestyle modification–> weight reduction, smoking cessation, reduce etoh, increase exercise, reduce cholesterol and fat
drugs–> remove causative agents and replace, improve compliance with DM and CVD meds
first line medications for ED
PDE5 inhibitors (phosphodiesterase 5 inhibitors)
what medication is a contraindication with PDE5 inhibitors
nitrate drugs
list the PDE5 inhibitors
sildenafil/viagra (1 hour before, lasts 4 hrs)
tadalafil/cialis (1-12 hours before, lasts up to 36 hrs)
vardenafil (1 hr before, lasts up to 4 hours…faster onset than viagra)
second line ED tx
intracavernosal injection and transurethral therapy –> PGE1, alpha agonist
vacuum constriction pump
contraindications to vacuum constriction pump
sickle cell anemia
blood dyscrasias
patients on anticoagulants
