Gynaecomastia + Impotence Flashcards
What is gynaecomastia?
abnormal amount of breast tissue in men, may occur in normal puberty
Oestrogen/androgen ratio is increased (vs galactorrhoea in which prolactin is increased)
Causes of gynaecomastia?
Hypogonadism, liver cirrhosis, hyperthryoidism, tumours (oestrogen producing, eg testicular, adrenal, HCG-producing)
drugs :oestrogens, spironolactone, digoxin, testosterone, marijuana
Treatment for gynaecomastia?
if stopping drugs is impossible
consider testosterone if hypogonadism, with or without oestrogen (tamoxifen)
Pathophysiology of erections
Impotence = erectile dysfunction
Erections result from neuronal release of nitric oxide (NO) which, via cGMO and Ca2+, hyperpolarizes and thus relaxes vascular and trabecular smooth muscle cells, allowing engorgement
Causes of impotence?
Common after 50yrs, and often multifactorial
A psychological facet is common
Organic:
The big three include smoking, diabetes, alcohol (reduce NO + autonomic neuropathy)
endocrine: hypogonadism, hyperthryoidism, increased prolactin
neurological: cord lesions, MS, autonomic neuropathy, pelvic surgery
drugs: digoxin, beta blockers, diuretics, antipsychotics, antidepressants, oestrogens, finasteride, narcotics
Factors favouring an organic cause of erectile dysfunction?
Gradual onset of symptoms
Lack of tumescence
Normal libido
Factors favouring a psychogenic cause of erectile dysfunction
Sudden onset of symptoms
Decreased libido
Good quality spontaneous or self-stimulated erections
Major life events
Problems or changes in a relationship
Previous psychological problems
History of premature ejaculation
Investigations for erectile dysfunction
As part of the assessment for erectile dysfunction Clinical Knowledge Summaries (CKS) recommend that all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels.
Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.
Investigations for erectile dysfunction
As part of the assessment for erectile dysfunction Clinical Knowledge Summaries (CKS) recommend that all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels.
Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.
Management of erectile dysfunction
PDE-5 inhibitors (such as sildenafil, ‘Viagra’) have revolutionised the management of ED
they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
sildenafil can be purchased over-the-counter without a prescription.
Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
Other points
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
Management of erectile dysfunction
PDE-5 inhibitors (such as sildenafil, ‘Viagra’) have revolutionised the management of ED
they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
sildenafil can be purchased over-the-counter without a prescription.
Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
Other points
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
