Erectile Dysfunction and Infertility Flashcards
1
Q
** A 64 y/o male with HTN and adult onset DM c/o poor erections with intercourse. The initial workup should include what? (TEST QUESTION)
A
- AM testosterone
- LH/FSH
- prolactin
- and rectal exam
2
Q
** What is the patient preference for ED treatment? (TEST QUESTION)
A
- ORAL therapies
3
Q
** Why is screening for ED is important? (TEST QUESTION)
A
- because pts can have other reciprocal/underlying conditions.
4
Q
What is male infertility?
A
- a couple’s inability to achieve a pregnancy following one year of unprotected intercourse.
5
Q
What does LH stimulate in the male?
A
- Leydig cells to produce testosterone
6
Q
What does FSH stimulate in the male?
A
- Sertoli cells to initiate Spermatogenesis
- Inhibin (postulated as negative feedback substance on the anterior pituiatry).
7
Q
What does prolactin do in the male?
A
- inhibits GnRH release
8
Q
When is the highest circadian production of testosterone?
A
- in the morning
* it is pulsatile and most is bound by albumin in peripheral circulation
9
Q
To what is testosterone aromatized?
A
- estradiol and 5 alpha, which is reduced to DHT.
10
Q
What does testosterone do to the hypothalamus?
A
- acts as negative feedback to decrease LH.
11
Q
What is the maturation of sperm (spermatogenesis) process?
A
- spermatogonia (stem cell)
- spermatocyte (meiosis)
- spermatids (develop acrosome, tail of 9 paired microtubules, and form blood-testes barrier).
12
Q
How long does maturation of sperm (spermatogenesis) take?
A
- 74 days
* very sensitive to environmental factors.
13
Q
What happens in the epididymis?
A
- maturation and storage of spermatozoa in the cauda
14
Q
What happens in the vas deferens?
A
- transport
15
Q
What is the role of the seminal vesicles?
A
- formation of coagulum
16
Q
What is the role of the prostate?
A
- proteases for liquefaction
17
Q
What is the neurologic innervation for ejaculation?
A
- point (parasympathetic) and shoot (sympathetic).
18
Q
What are some anatomic problems that could lead to male infertility?
A
- congenital absence of the vas (seen in CF).
- cryptorchidism
- ejaculatory duct obstruction
- varicocele
19
Q
What else can adversely affect spermatogenesis?
A
- obesity
- substance abuse (opioids, exogenous testosterone)
- vitamin deficiencies
- chemoradiation
- surgery
- medications
- infections/inflammation (Mumps orchitis)
- history of herniorrhaphy
20
Q
What are some syndromes that can cause male infertility?
A
- cystic fibrosis (absence of vas)
- Kartagener’s syndrome (primary ciliary dyskinesia)
- Kallman’s syndrome (absence of GnRH)
- Klinefelters syndrome
21
Q
What makes up most of the testes volume?
A
- seminiferous tubules (85%)
22
Q
What do we look for on physical exam for male infertility?
A
- hypogonadism/gynecomastia
- testicular size
- prostate, penis, epididymus, vas (CF)
- spermatic cords (varicocele)
- ejaculatory duct obstruction via Trans-Rectal Ultrasound (TRUS)
23
Q
What lab tests do we do for male infertility?
A
- urinalysis
- semen analysis (2 separate specimens 2-3 days of abstinence).
- hormonal eval (FSH, LH, prolactin, testosterone)
24
Q
What are the normal values of semen?
A
- volume= more than 2 mL
- pH= 7.2- 8.0
- concentration= more than 20 million per mL
- morphology= 30% normal
25
What is oligospermia?
- sperm density less than 50 million
26
What is asthenospermia?
- defects in sperm motility
27
What is azoospermia?
- no sperm visualized
28
What is necrospermia?
- dead or immotile sperm
29
What is teratospermia?
- defects in morphology
30
What is cryptospermia?
- live sperm seen in a centrifuged pellet
31
When should antisperm antibody (ASA) be suspected?
- in clumping or agglutination, dimished motility, and a poor post-coital test.
* may occur due to breach of blood-testis barrier
32
What is the sperm penetration assay (Humster Test)?
- sperm are mixed with zona free hamster ovum and observed for timed penetration of the ovum.
* has high predictive value for IVF outcome
33
*** What is the most common surgically correctable cause of male infertility?
- VARICOCELE= enlarged veins in scrotum (33% of infertile males)
* 90% LEFT sided bc the left spermatic vein drains into the renal vein at a sharp angle.
34
What specific therapies do we use for male infertility?
- hyperprolactinemia= bromocriptine
- Kallmann's syndrome= hCG followed by hMG
- antisperm antibodies= steroids
- retrograde ejaculation= antihistamine and alpha stimulation
- congenital adrenal hyperplasia= glucocorticoids
35
What are the empiric therapies for male infertility? (aka therapy for those in which we can't find a discernible cause)
- anti-estrogens (clomiphene, tamoxifen)
- hCG, hMG
- GnRH, LHRH
- kallikrein
- testosterone rebound
36
What are some assisted reproductive techniques for male infertility?
- semen processing (sperm washing...)
- intrauterine insemination (IUI)
- gamete intra-fallopian transfer (GIFT)
- IVF
- MESA (microsurgical epididymal sperm aspiration)
- TESE (testicular sperm extraction)
- ICSI (Intracytoplasmic Sperm Injection)= BEST, but $10k
37
Is most erectile dysfunction (ED) psychologic or organic?
- ORGANIC (80%)
| * can be successfully treated in all patients :)
38
May ED signal underlying disease?
YES
39
*** Is ED under-diagnosed and under-treated?
- YES
40
What is erectile dysfunction (ED)?
- the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.
41
Should we incorporate sexual history into the normal medical work-up for every patient?
- YES
42
What is the best screening question for ED?
- "Many men with your medical condition experience sexual problems. Has this happened to you?"
43
What underlying diseases may be associated with ED?
- DM
- HTN
- CVD
- PVD
- Neurologic disorders
44
How is ED related to underlying diseases?
- from oxidative stress on the cells causing endothelial injury to the vessels that supply blood to the penis.
45
What is erection?
- neurovascular phenomenon that transforms the penis from a venous organ into an arterial organ
46
What mediates vasodilation?
- nitric oxide and cGMP following activation of cholinergic and NANC (nonadrenergic-noncholinergic) fibers.
- prostaglandin E1 relaxes corpus cavernosum to increase the blood flow.
47
*** What are the 4 relevant factors related to ED?
1. psychologic
2. hormonal
3. vascular
4. neurologic
48
What is Peyronie's disease?
- calcification or fibrosis of corpora cavernosa
| * Bill Clinton had this.
49
What are some drugs associated with ED?
- alcohol
- estrogens
- H2 blockers
- anticholinergics
- marijuana
- cigarettes
- B-blockers
- antihypertensives
- diuretics
- spironlactone
- cocaine
- antidepressants
50
What neurologic exams do we use to help diagnose ED?
- perianal sensation
- sphincter tone
- bulbocavernosus reflex
- penile brachial index (PBI)
51
What are some special tests for ED?
- vasoactive agent injection
| - nocturnal penile tumescence
52
How do we manage ED?
- First-line= PDE5 inhibitors, psychosexual therapy, vacuum constriction devices.
- Second-line= intraurethral therapy (alprostadil), injection therapy, and combination therapy.
- Third-line= surgery
53
What are some problems with exogenous testosterone treatment?
- liver dysfunciton
- prostate hypertrophy
- metabolized to estradiol with potentially detrimental effects on sexual function.
54
Can testosterone lead to prostate cancer?
NO! It has never been proven.
55
What are the 2 types of penile implants?
1. maleable
2. inflatable
* go into the corpora cavernosa (the 2 top cylinders) and the pump goes into the scrotum.
56
What are some disadvantages to vasoactive intracavernosal pharmacotherapy?
- priapism (prolonged erection)
- bruising
- pain
57
What are the existing oral pharmacologic treatments for ED?
- Yohimbine
- Trazodone
- L-arginine
- PDE-5 inhibitors (SILDENAFIL; viagra, VARDENAFIL; levitra, TADALIFIL; cialis, AVANAFIL)
58
What drugs must you be mindful about when using PDE5 inhibitors?
- nitrates, and alpha-blockers, because they all cause vasodilation and decrease BP.
59
How do PDE-5 inhibitors work?
- decrease breakdown of cGMP allowing for prolonged vasodilation.
60
How are PDE-5 inhibitors metabolized?
- by cytochrome P450 in the liver (mostly CYP3A4).
| * so drugs that inhibit CYP3A4 will cause decreased clearance of PDE-5 inhibitors.
