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General Internal Medicine > Erectile dysfunction and Male Sexual dysfunction > Flashcards

Erectile dysfunction and Male Sexual dysfunction Flashcards

1
Q

Vascular reasons for ED

A

HTN, smoking, DM2

abnormal vascular examination will show bruits, decreased pulses

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2
Q

Neurological reasons for ED

A

diabetic neuropathy, MM, spinal injury, spinal surgery

Grandual onset loss of bulbocavernosus reflex

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3
Q

Psychogenic reasons for ED

A

situational (ED w/ partner, normal erection with masturbation, normal non sexual nocturnal erections ) sudden in onset

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4
Q

Endocrine causes for ED

A

TSH, prolactin, underlying symptoms will be present

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5
Q

Medications that cause ED

A

SSRI, antihypertensives (HCTZ), anti-androgen medications

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6
Q

Hypogonadism

A

gradual onset, decreased libido, gynecomastia, testicular atrophy, low serum testosterone.

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7
Q

ESRD reasons for ED

A

multifactorial with vascular/vasoactive impairment, peripheral or autonomic neuropathy, gonadal dysfunction, psychological stress, concurrent medications.

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8
Q

Pts with ESRD and ED can respond to:

A

phosphodiesterase inhibitors

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9
Q

Pts with ESRD and ED will have

A

elevated prolactin without clinical dx because they are not able to clear it.

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10
Q

Signs and symptoms of male hypogonadism

A

sexual dysfunction, infertility, loss of body hair, gynecomastia, hot flashes, low bone density, testicular atrophy

(fatigue, weakness, and weight changes do not warrant testing)

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11
Q

1st test to order for evaluation of male hypogonadism

A

low serum testosterone
confirm on repeat testing

consider free Testosterone/SHBG (sex hormone binding globulin)

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12
Q

Next test to order in evaluation of male hypogonadism after getting low testosterone levels

A

check LH and FSH

- helps clarify if this is primary or secondary

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13
Q

What is the cause behind primary hypogonadism?

A

consider karotype analysis

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14
Q

Secondary hypogonadism causes

A

needs to get testing prolactin, iron studies, other pituitary causes or MRI of pituitary

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15
Q

how can obesity and diabetes lead to hypogonadism

A

they have low sex hormone binding globulin which leads to spuriously low total testosterone levels. If initial total testosterone level is low get the free testosterone level and this should confirm true hypogonadism in pts with these conditions. not part of initial evaluation because its expensive

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16
Q

What is low tesosterone?

A

<150 ng/ml, and if concerned about secondary with low,normal FSH and LH, get MRI of pituitary and TSH and GH and hypoprolactinemia and mass effect

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17
Q

nocturnal penile tumescence

A

swelling of penis at night

if can happen at night but not during sex it may mean that there’s a psychogenic component to ED

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18
Q

decreased morning erections implies

A

organic cause but not used in clinical practicie.

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19
Q

complications and side effects of testosterone therapy?

A

can develop secondary polycythemia (hgb>16.5 g/dl)

seen in 25% of men on testosterone

Can also see testosterone induced elevations in EPO and reductions in hepcidin

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20
Q

When do we stop testosterone replacement due to side effects?

A

stop when there’s secondary polycythemia and hematocrit levels >54%.

Polycythemia develops in a dose dependent manner and can be associated with VTE and cardiovascular events

21
Q

Risk factors for hypogonadotropic (central) hypogonadism in DM2

A

obesity with visceral adiposity

metabolic syndrome

22
Q

clinical presentation of hypogonadotropic (central) hypogonadism in DM2

A

decreased libido, energy and muscle mass
increased insulin resistance
low serum testosterone
low or inappropriately normal FSH or LH

23
Q

indications for pituitary imaging in someone with suspected hypogonadotropic (central) hypogonadism?

A

serum testosterone <200 at <65 yrs old or <150 at age >65 AND low or inappropriately normal FSH and LH.

mass effect like symptoms
multiple pituitary deficiencies
signs of hyperprolactinemia

24
Q

adverse effects of phosphodiesterase 5 inhibitors?

A

cardiovascular: hypotension esp with nitrates or alpha blockers,

Ocular: blue discoloration of vision and non arteritic ischemic optic neuropathy

genitourinary: priapism

Other: flushing, headache, and hearing loss

25
Q

why are there visual changes when on a phosphodiesterase 5 inhibitors?

A

phosphodiesterase 5 inhibitors interact with phosphodiesterase 6 which is needed for normal function of rods and cones in retina. This then causes temporary bluishin tinting and blurry vision and photophobia in 3% of pts on sildenafil.

26
Q

sudden onset of ED while continuing to have intact early morning erections suggests

A

psychogenic (inorganic) etiology or a mood disorder causing ED.

Can see impaired sleep, poor appetite and low energy and guilt as being subtle trigger signs

27
Q

nocturnal erections

A

happen in REM sleep and continue in pts with psychogenic ED

28
Q

medications that can cause ED are?

A

SSRI, spironolactone, clonidine, thiazide diuretics.

29
Q

Causes of hypogonadism in men are divided into

A

testicular (primary)
pituitary/hypothalamic (secondary)

Combined (primary and secondary)

30
Q

primary causes of hypogonadism in men

A

primary/testicular:

congenital (Klienfelter, cryptoorchidsm)
drugs (alkylating agents and ketoconazole
CKD
orchitis - mumps, trauama, torsion

31
Q

secondary causes of hypogonadism in men

A

gonadotroph damage: tumor, cranial trauma, infiltrative diseases and hemochromatosis or apoplexy

gonadotropin suppression: exogenous androgens, hyperprolactinemia, DM2 and morbid obeisty

32
Q

combined causes of hypogonadism in men:

A

hypercortisol and cirrhosis

33
Q

extreme fatigue arthralgia, loss of libido and conduction abnormality from unclear reasons

A

consider secondary hypogonadism from hereditary hemochromatosis.

34
Q

Lyme disease doesn’t cause hypogonadism true or false

A

true. Lyme carditis only happens weeks to months after and can cause AV blocks

35
Q

ED 1st line therapy is

A

phosphodiesterase inhibitors PDE i (sildenafil, vardenafil, tadalafil) which increase cGMP to increase NO mediated vasodilation and erection.

Side effects: nitrates and PDE inhibitors can have hypotension and syncope

36
Q

what if someone has ED and CAD and stable angina and is using nitrates? how do you treat their ED?

A

They can get a penile self injectable drug (intraurethral alprostadil or vacuum devices)

Well tolerated with few side effects and no drug interactions with nitrates.

37
Q

pseudogynecomastia

A

seen with men who have obeisty and see increase in breast fat without proliferation of glandular tissue

See subareolar adipose tissue without glandular proliferation.

True gynecomastia will distort the normal flat contour of the male nipple causing it to protrude and owing the mass of the glanular tissue beneath it

38
Q

chronic opioid use can suppress

A

gonadtroph function and results in hypogonadotropic hypogonadism

it works by decreasing gonadotropin releasing hormone and subsequent LH and FSH and decreases testosterone production.

39
Q

if someone has low testosterone and low LH and FSH need to make sure they also are not on

A

a chronic longterm opioid

Especially if they have been able to have kids and no problems previously.

in women, can see depression, hot flashes, night sweats and osteoporosis and menstrual irregularities)

40
Q

Klinefelter syndrome

A

delayed puberty, tall stature, gynecomastia, small firm testes, testosterone deficiency and elevated gonadotrophins

karyotype shows XXY or extra X chromosome

41
Q

Treatment of Klinefelter’s syndrome

A

give testosterone replacement

42
Q

why are the testes small in Klinefelter’s syndrome?

A

see damaged seminiferous tubules

43
Q

longterm management of Klinefelter’s syndrome?

A

high risk for cancers- breast, extra gonadal germ cell tumors and non hodgkin lymphoma and COPD and bronchiectasis

need screening

44
Q

breast cancer screening for Klinefelter syndrome

A

after 45 yrs old and careful palpation of breast tissue

45
Q

what king of cancer are Klinefelter pts at highest risk for developing?

A

breast cancer

46
Q

most common genetic cause of primary hypogonadism

A

Klinefelter’s dx

47
Q

hyperprolactinoma in men

A

cause decreased libido, less sexual desire
see migraine headaches and visual disturbances

usually will have larger prolactinomas at time of diagnosis likely due to delayed diagnosis.

48
Q

high prolactin causes what effect?

A

it inhibits GnRH and this means less FSH and LH is released and less testosterone is made.

49
Q

small testes, azoospermia, oligospermia gyecomastia and learning disabilities or behavioral problems

less hair

has lower libido and doesn’t seem bothered by it

A

KS 47 XXY

can see infertility issues
long legs
cryptorchidism

General Internal Medicine (54 decks)

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