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825 > Erectile Dysfunction > Flashcards

Erectile Dysfunction Flashcards

1
Q

Normal Male Sex Function Components

A
  • Libido
  • Penile Erection
  • Orgasm/ejaculation
  • Fertilization
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2
Q

Types of Sexual Dysfunction

A
  • Decreased libido
  • Erectile dysfunction (impotence)
  • Abnormal ejaculation (premature, delayed, retrograde)
  • Infertility
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3
Q

Erectile Dysfunction

A

Failure to achieve penile erection suitable for sexual intercourse

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4
Q

Penile Anatomy

A
  • 2 dorsolateral cylindrical bodies
  • Corpora cavernosa
  • 1 midventral corpus spongiosum - encloses urethra and expands distally to form glans penis
  • Tunica albuinea - thick, fibrous sheath enclosing cavernosa
  • All bodies surrounded by deep, fibrous tissue called Buck’s fascia
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5
Q

Penile Circulation

A
  • Cavernosal tissue - spongelike with mesh interconnected cave like spaces
  • Lined by vascular endothelium and separated by trabeculae
  • Blood supplied by cavernosal arteries (branches of penile artery)
  • Three sets of veins - deep, intermediate, and superficial veins
  • Deep veins drain the cavernosa and spongiosum
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6
Q

Physiology of Erection

A
  • Sexual stimuli elicits response from CNS to penile nerves and endothelial cells
  • ACh = important neurotransmitter
  • Cavernous nerves and endothelial cells release NO
  • NO stimulates formation of cGMP which causes relaxation of smooth muscle and allows for increased blood flow
  • Trabecular spaces expand and erection is achieved
  • Expansion compresses the venules to prevent blood from leaving penis
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7
Q

Types of Erections

A
  1. Psychogenic - initiated primarily by CNS stimuli received/generated by brain
  2. Reflexogenic - result of direct stimulation of penis/surrounding tissues
  3. Noctural - occurs during REM sleep, increases oxygen to penis
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8
Q

ED Factors

A
  • Vascular insufficiency
  • Neurogenic - impair cholinergic innervation
  • Endocrine - low testosterone or increased prolactin
  • Psychological - disease states like depression
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9
Q

ED Etiologies

A
  1. Psychogenic - origin from mental and emotional processes
  2. Organic - medical conditions, structural abnormalities, medications, surgery, trauma, endocrine malfunctions

ALMOST ALL ARE BELIEVED TO BE A COMBO OF THE TWO

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10
Q

Diseases + ED

A
  • Heart disease (CAD)
  • Hypertension
  • Diabetes
  • Depression
  • Chronic renal disease
  • Prostate cancer
  • Neurologic diseases
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11
Q

ED Risk Factors

A
  • Stress
  • Lifestyle - smoking, drinking
  • Surgery - radical prostatectomy, TURP
  • Trauma
  • Local disorders of penis
  • Medications
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12
Q

Medications + ED

A
  • CV drugs - digoxin
  • Diabetic drugs
  • Anti-angrogenic agents - spironolactone, cimetidine, ketoconazole
  • Anticholinergic agents
  • Alpha adrenergic agonists
  • Dopamine blockers
  • Hypertensive meds - diuretics, B-blockers
  • Antidepressants - SSRI, TCA
  • NSAIDs
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13
Q

ED Evaluation

A
  • History and physical
  • Consider SHIM in patients with risk factors
  • Medication history
  • Labs
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14
Q

ED + Labs

A
  • Testosterone, prolactin
  • Fasting lipid panel
  • Fasting blood sugar
  • Complete blood count
  • Creatinine and urinalysis
  • TSH
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15
Q

SHIM

A
  • Five specific questions about sexual health
  • Over past 6 months
  • Scores =< 21 require further evaluation
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16
Q

ED Affects

A
  • Creates mental stress
  • Affects family interactions
  • May cause depression, loss of self-esteem, poor self image
17
Q

ED Treatment Options

A
  • Counseling: primarily psychogenic
  • Non-pharm: vacuum erection devices
  • Pharm: oral, injectable, intraurethral
  • Surgical: implants, vascular surgery
  • Treatment should be reserved for patients with documented ED
18
Q

Primary/Secondary Hypogonadism Symptoms

A
  • Decreased libido
  • Malaise
  • Loss of muscle strength
  • Depressed mood
  • Low serum testosterone (300-1100)
19
Q

PDE5 Inhibitors

A
  • Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra)
  • Inhibits PDE5, enzyme that breaks down cGMP
  • PDE5-I enhances NO effect and allows for cGMP to remain in the body for longer time periods
20
Q

PDE-I CI

A
  • Organic nitrates use regularly or intermittently in any form (separate S/V by 24 hours, T by 48)
  • Resting hypotension (<90/50)
  • Retinitis pigmentosa
  • Allergic
21
Q

ED + CV - Low Risk

A
  • Well-controlled HTN
  • Mild, stable angina
  • Mild CHF (NYHA class I and II)
  • Mild valvular disease
22
Q

ED + CV - Intermediate Risk

A
  • Moderate, stable angina
  • MI within 2-8 weeks
  • Moderate CHF (NYHA class III)
23
Q

ED + CV - High Risk

A
  • Unstable angina
  • Uncontrolled HTN
  • Severe CHF (NYHA Class IV)
  • Recent MI/stroke within 2 weeks
  • Moderate/severe valvular disease
  • High-risk cardiac arrhythmias
  • Obstructive cardiac myopathy
24
Q

Risk Factors + Treatment

A
  • Low: Start PDE5
  • Intermediate: CV workup
  • High: PDE5 contraindicated
25
Q

Specific Cautions/CIs for PDE-I

A
  • Vardenafil/Tadalafil: caution when using with alpha-blockers
  • Sildenafil: with doses greater than 25 mg, delay alpha-blockers by 4 hours
  • Avanafil: should be on stable doses and hemodynamically stable
26
Q

PDE5-I AE

A
  • Headache
  • Dyspepsia
  • Flushing
  • Rhinitisto light/nasal congestion
  • Myalgia and back pressure
  • Decreased blood pressure
  • Increased sensitivity to light, loss of blue-green color discrimination
  • Vision loss
  • Hearing loss
27
Q

PDE5-I Counseling Considerations

A
  • Physician should discuss with patients the potential cardiac risk of sexual activity and symptoms
  • Use of organic nitrates in any form
  • Painful/long lasting erection (greater than 4 hours)
  • Doesn’t protect against STDs
  • Engage in sexual stimulation for best response
  • Best response on empty stomach
  • Avoid alcohol
  • Try 5-8 times before declaring failure
  • Do NOT combine with any other therapy (including nonpharm)
28
Q

Additional ED Counseling

A
  • Seek medical attention if sudden vision or hearing loss

- Those with testosterone deficiency may have better results combining PDE5-I and testosterone therapy

29
Q

Alprostadil

A
  • Synthetic version of prostaglandin E1 (PGE1)
  • MoA: augments ACh activity, smooth muscle relaxes, blood flow increases, corpora cavernosa enlargesand preventing blood outflow
  • Results in erection without sexual stimulation
  • Available as both injection and intraurethral pellet
  • Limit to once a day or three times per week
30
Q

Alprostadil SE

A
  • Nausea
  • Flushing
  • Hypotension
  • Penile pain
  • Penile/urethral injury
  • MUSE could cause vaginal burning or itching
  • Permanent fibrosis and dysfunction (1-15%)
31
Q

Alprostadil CI

A
  • Increased risk for priapism, sick cell disease, leukemia, multiple myeloma
  • Risk from bleeding at injection site - anticoagulation
32
Q

Vacuum Erection Devices

A
  • Therapeutic option
  • All consist of cylinder, vacuum pump, constriction ring
  • Ring prevents venous drainage and maintains ridigity
33
Q

Reasons to D/C Penis Pump

A
  • Lack of spontaneity
  • Difficult to use
  • Discomfort
  • Delayed onset of erection
34
Q

Penis Pump Safety

A
  • Most complications are minor: petechiae, numbness, ejaculatory discomfort
  • Ischemia - if ring is used for long periods
  • Avoid in those using anticoagulants
35
Q

Penile Implants

A
  • Surgical prosthetic devices
  • Semirigid (always erect) and inflatable options
  • Used when other therapies fail
  • Destroys corporal tissue
  • Inflatable devices are prone to mechanical failure
36
Q

Implant Complications

A
  • Infection
  • Erosion
  • Mechanical failure
  • Repeated surgery to remove or replace implant
37
Q

Vascular Surgery

A
  • Vascular problems are key causes in many ED patients
  • Damage can be arterial or venous system
  • Venous surgery NOT recommended
38
Q

Patient Education/Counseling

A
  • Treat underlying cause
  • Non-drug approaches: stop smoking/drinking, diet, exercise
  • Identify/replace offending drugs if possible
  • Be private, empathetic, and respect preferences

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