Erectile dysfunction and Male Sexual dysfunction Flashcards
Vascular reasons for ED
HTN, smoking, DM2
abnormal vascular examination will show bruits, decreased pulses
Neurological reasons for ED
diabetic neuropathy, MM, spinal injury, spinal surgery
Grandual onset loss of bulbocavernosus reflex
Psychogenic reasons for ED
situational (ED w/ partner, normal erection with masturbation, normal non sexual nocturnal erections ) sudden in onset
Endocrine causes for ED
TSH, prolactin, underlying symptoms will be present
Medications that cause ED
SSRI, antihypertensives (HCTZ), anti-androgen medications
Hypogonadism
gradual onset, decreased libido, gynecomastia, testicular atrophy, low serum testosterone.
ESRD reasons for ED
multifactorial with vascular/vasoactive impairment, peripheral or autonomic neuropathy, gonadal dysfunction, psychological stress, concurrent medications.
Pts with ESRD and ED can respond to:
phosphodiesterase inhibitors
Pts with ESRD and ED will have
elevated prolactin without clinical dx because they are not able to clear it.
Signs and symptoms of male hypogonadism
sexual dysfunction, infertility, loss of body hair, gynecomastia, hot flashes, low bone density, testicular atrophy
(fatigue, weakness, and weight changes do not warrant testing)
1st test to order for evaluation of male hypogonadism
low serum testosterone
confirm on repeat testing
consider free Testosterone/SHBG (sex hormone binding globulin)
Next test to order in evaluation of male hypogonadism after getting low testosterone levels
check LH and FSH
- helps clarify if this is primary or secondary
What is the cause behind primary hypogonadism?
consider karotype analysis
Secondary hypogonadism causes
needs to get testing prolactin, iron studies, other pituitary causes or MRI of pituitary
how can obesity and diabetes lead to hypogonadism
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
What is low tesosterone?
<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
nocturnal penile tumescence
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
decreased morning erections implies
organic cause but not used in clinical practicie.
complications and side effects of testosterone therapy?
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
When do we stop testosterone replacement due to side effects?
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
Risk factors for hypogonadotropic (central) hypogonadism in DM2
obesity with visceral adiposity
metabolic syndrome
clinical presentation of hypogonadotropic (central) hypogonadism in DM2
decreased libido, energy and muscle mass
increased insulin resistance
low serum testosterone
low or inappropriately normal FSH or LH
indications for pituitary imaging in someone with suspected hypogonadotropic (central) hypogonadism?
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
adverse effects of phosphodiesterase 5 inhibitors?
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
why are there visual changes when on a phosphodiesterase 5 inhibitors?
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.
sudden onset of ED while continuing to have intact early morning erections suggests
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
nocturnal erections
happen in REM sleep and continue in pts with psychogenic ED
medications that can cause ED are?
SSRI, spironolactone, clonidine, thiazide diuretics.
Causes of hypogonadism in men are divided into
testicular (primary)
pituitary/hypothalamic (secondary)
Combined (primary and secondary)
primary causes of hypogonadism in men
primary/testicular:
congenital (Klienfelter, cryptoorchidsm)
drugs (alkylating agents and ketoconazole
CKD
orchitis - mumps, trauama, torsion
secondary causes of hypogonadism in men
gonadotroph damage: tumor, cranial trauma, infiltrative diseases and hemochromatosis or apoplexy
gonadotropin suppression: exogenous androgens, hyperprolactinemia, DM2 and morbid obeisty
combined causes of hypogonadism in men:
hypercortisol and cirrhosis
extreme fatigue arthralgia, loss of libido and conduction abnormality from unclear reasons
consider secondary hypogonadism from hereditary hemochromatosis.
Lyme disease doesn’t cause hypogonadism true or false
true. Lyme carditis only happens weeks to months after and can cause AV blocks
ED 1st line therapy is
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
what if someone has ED and CAD and stable angina and is using nitrates? how do you treat their ED?
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.
pseudogynecomastia
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
chronic opioid use can suppress
gonadtroph function and results in hypogonadotropic hypogonadism
it works by decreasing gonadotropin releasing hormone and subsequent LH and FSH and decreases testosterone production.
if someone has low testosterone and low LH and FSH need to make sure they also are not on
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)
Klinefelter syndrome
delayed puberty, tall stature, gynecomastia, small firm testes, testosterone deficiency and elevated gonadotrophins
karyotype shows XXY or extra X chromosome
Treatment of Klinefelter’s syndrome
give testosterone replacement
why are the testes small in Klinefelter’s syndrome?
see damaged seminiferous tubules
longterm management of Klinefelter’s syndrome?
high risk for cancers- breast, extra gonadal germ cell tumors and non hodgkin lymphoma and COPD and bronchiectasis
need screening
breast cancer screening for Klinefelter syndrome
after 45 yrs old and careful palpation of breast tissue
what king of cancer are Klinefelter pts at highest risk for developing?
breast cancer
most common genetic cause of primary hypogonadism
Klinefelter’s dx
hyperprolactinoma in men
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.
high prolactin causes what effect?
it inhibits GnRH and this means less FSH and LH is released and less testosterone is made.
small testes, azoospermia, oligospermia gyecomastia and learning disabilities or behavioral problems
less hair
has lower libido and doesn’t seem bothered by it
KS 47 XXY
can see infertility issues
long legs
cryptorchidism
