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RGU 3 > Erectile Dysfunction and Infertility > Flashcards

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
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2
Q

** What is the patient preference for ED treatment? (TEST QUESTION)

A
  • ORAL therapies
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3
Q

** Why is screening for ED is important? (TEST QUESTION)

A
  • because pts can have other reciprocal/underlying conditions.
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4
Q

What is male infertility?

A
  • a couple’s inability to achieve a pregnancy following one year of unprotected intercourse.
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5
Q

What does LH stimulate in the male?

A
  • Leydig cells to produce testosterone
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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).

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7
Q

What does prolactin do in the male?

A
  • inhibits GnRH release
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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

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9
Q

To what is testosterone aromatized?

A
  • estradiol and 5 alpha, which is reduced to DHT.
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10
Q

What does testosterone do to the hypothalamus?

A
  • acts as negative feedback to decrease LH.
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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).
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12
Q

How long does maturation of sperm (spermatogenesis) take?

A
  • 74 days

* very sensitive to environmental factors.

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13
Q

What happens in the epididymis?

A
  • maturation and storage of spermatozoa in the cauda
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14
Q

What happens in the vas deferens?

A
  • transport
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15
Q

What is the role of the seminal vesicles?

A
  • formation of coagulum
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16
Q

What is the role of the prostate?

A
  • proteases for liquefaction
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17
Q

What is the neurologic innervation for ejaculation?

A
  • point (parasympathetic) and shoot (sympathetic).
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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
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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
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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
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21
Q

What makes up most of the testes volume?

A
  • seminiferous tubules (85%)
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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)
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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)
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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
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25
Q

What is oligospermia?

A
  • sperm density less than 50 million
26
Q

What is asthenospermia?

A
  • defects in sperm motility
27
Q

What is azoospermia?

A
  • no sperm visualized
28
Q

What is necrospermia?

A
  • dead or immotile sperm
29
Q

What is teratospermia?

A
  • defects in morphology
30
Q

What is cryptospermia?

A
  • live sperm seen in a centrifuged pellet
31
Q

When should antisperm antibody (ASA) be suspected?

A
  • in clumping or agglutination, dimished motility, and a poor post-coital test.
  • may occur due to breach of blood-testis barrier
32
Q

What is the sperm penetration assay (Humster Test)?

A
  • sperm are mixed with zona free hamster ovum and observed for timed penetration of the ovum.
  • has high predictive value for IVF outcome
33
Q

*** What is the most common surgically correctable cause of male infertility?

A
  • 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
Q

What specific therapies do we use for male infertility?

A
  • hyperprolactinemia= bromocriptine
  • Kallmann’s syndrome= hCG followed by hMG
  • antisperm antibodies= steroids
  • retrograde ejaculation= antihistamine and alpha stimulation
  • congenital adrenal hyperplasia= glucocorticoids
35
Q

What are the empiric therapies for male infertility? (aka therapy for those in which we can’t find a discernible cause)

A
  • anti-estrogens (clomiphene, tamoxifen)
  • hCG, hMG
  • GnRH, LHRH
  • kallikrein
  • testosterone rebound
36
Q

What are some assisted reproductive techniques for male infertility?

A
  • 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
Q

Is most erectile dysfunction (ED) psychologic or organic?

A
  • ORGANIC (80%)

* can be successfully treated in all patients :)

38
Q

May ED signal underlying disease?

A

YES

39
Q

*** Is ED under-diagnosed and under-treated?

A
  • YES
40
Q

What is erectile dysfunction (ED)?

A
  • the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.
41
Q

Should we incorporate sexual history into the normal medical work-up for every patient?

A
  • YES
42
Q

What is the best screening question for ED?

A
  • “Many men with your medical condition experience sexual problems. Has this happened to you?”
43
Q

What underlying diseases may be associated with ED?

A
  • DM
  • HTN
  • CVD
  • PVD
  • Neurologic disorders
44
Q

How is ED related to underlying diseases?

A
  • from oxidative stress on the cells causing endothelial injury to the vessels that supply blood to the penis.
45
Q

What is erection?

A
  • neurovascular phenomenon that transforms the penis from a venous organ into an arterial organ
46
Q

What mediates vasodilation?

A
  • nitric oxide and cGMP following activation of cholinergic and NANC (nonadrenergic-noncholinergic) fibers.
  • prostaglandin E1 relaxes corpus cavernosum to increase the blood flow.
47
Q

*** What are the 4 relevant factors related to ED?

A
  1. psychologic
  2. hormonal
  3. vascular
  4. neurologic
48
Q

What is Peyronie’s disease?

A
  • calcification or fibrosis of corpora cavernosa

* Bill Clinton had this.

49
Q

What are some drugs associated with ED?

A
  • alcohol
  • estrogens
  • H2 blockers
  • anticholinergics
  • marijuana
  • cigarettes
  • B-blockers
  • antihypertensives
  • diuretics
  • spironlactone
  • cocaine
  • antidepressants
50
Q

What neurologic exams do we use to help diagnose ED?

A
  • perianal sensation
  • sphincter tone
  • bulbocavernosus reflex
  • penile brachial index (PBI)
51
Q

What are some special tests for ED?

A
  • vasoactive agent injection

- nocturnal penile tumescence

52
Q

How do we manage ED?

A
  • First-line= PDE5 inhibitors, psychosexual therapy, vacuum constriction devices.
  • Second-line= intraurethral therapy (alprostadil), injection therapy, and combination therapy.
  • Third-line= surgery
53
Q

What are some problems with exogenous testosterone treatment?

A
  • liver dysfunciton
  • prostate hypertrophy
  • metabolized to estradiol with potentially detrimental effects on sexual function.
54
Q

Can testosterone lead to prostate cancer?

A

NO! It has never been proven.

55
Q

What are the 2 types of penile implants?

A
  1. maleable
  2. inflatable
    * go into the corpora cavernosa (the 2 top cylinders) and the pump goes into the scrotum.
56
Q

What are some disadvantages to vasoactive intracavernosal pharmacotherapy?

A
  • priapism (prolonged erection)
  • bruising
  • pain
57
Q

What are the existing oral pharmacologic treatments for ED?

A
  • Yohimbine
  • Trazodone
  • L-arginine
  • PDE-5 inhibitors (SILDENAFIL; viagra, VARDENAFIL; levitra, TADALIFIL; cialis, AVANAFIL)
58
Q

What drugs must you be mindful about when using PDE5 inhibitors?

A
  • nitrates, and alpha-blockers, because they all cause vasodilation and decrease BP.
59
Q

How do PDE-5 inhibitors work?

A
  • decrease breakdown of cGMP allowing for prolonged vasodilation.
60
Q

How are PDE-5 inhibitors metabolized?

A
  • by cytochrome P450 in the liver (mostly CYP3A4).

* so drugs that inhibit CYP3A4 will cause decreased clearance of PDE-5 inhibitors.

RGU 3 (19 decks)

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