Male GU-Paulson Flashcards
Erectile Dysfunction=
Consistent inability to maintain an erect penis with sufficient rigidity to allow for intercourse
T/F: erectile dysfunction is the MC sexual problem in men
true
- More than 50% ages 40-70
- Incidence increases with increasing age
Things required for an erection:
- Intact parasympathetic + somatic nerve supply
- Unobstructed arterial inflow
- Adequate venous constriction
- Hormonal simulation
- Psychological desire
Risk factors for ED
-Sedentary lifestyle
-Obesity
-Smoking
-Medical comorbidities:
Diabetes, HTN, obesity, OSA, dyslipidemia, CV disease, smoking, RLS
-Watching TV
-Lower frequency of sexual activity
ED causes:
-Decrease in arterial flow from progressive vascular disease (** most common)
-Medications:
-Antidepressants:
*SSRIs most common
-Beta blockers**
Spironolactone
Thiazide diuretics
Clonidine
Ketoconazole
Cimetidine
- Psychosocial factors:
- -Depression
- -Stress
-Neurologic:
Stroke
SCI
MS
-Bicycling: Prolonged pressure on pudendal & cavernosal nerves/ compromises blood flow to cavernosal artery –> penile numbness & impotence
- Endocrine disorders:
- -Testosterone deficiency
- -Hypo/hyperthyroidism
Erectile dysfunction: H&P
- Chronic, occasional, or situational? Ability to masturbate?
- Timing of dysfunction
- Does pt ever have normal erections? (early morning, during sleep)
- Any chronic medical conditions?
- Trauma to pelvis?
- Pelvic or prostate radiation?
- Peripheral vascular surgery?
- Medications taking
- Use of drugs, alcohol, tobacco?
- Physical exam- look for scarring, plaque formation of Peyronie disease, testicular atrophy, peripheral neuropathy, HTN
ED: diagnostics
Depending on suspected cause:
- CBC
- UA
- TSH
- Lipid panel
- Serum testosterone
- Glucose
- Prolactin–>If serum testosterone or prolactin abnormal, may proceed to FSH & LH measurement
-Nocturnal penile tumescence testing
-Direct injection of vasoactive substances (ie: prostaglandin E1) into penis –> erection if vascular system intact
If no erection –> studies to evaluate arterial and venous vasculature–>Ultrasound of cavernous arteries, pelvic arteriography, cavernosonography
ED: treatment
- If truly psychogenic –>behaviorally oriented sex therapy
- -Those with organic causes will also benefit from counseling
- If low T, may benefit from testosterone replacement
- -Injection, gel, or patches
- -S/e: HTN (may ↑ CV events), worsen BPH, worsen CHF, increased breast cancer, hepatic toxicity, VTE, prostate cancer, application site pruritis, virilization in those exposed (ie: kids, nurse applying product)
-Weight loss if obese
What is the mainstay of tx for ED?
**Phosphodiesterase-5 inhibitors (PDE-5)
How does the medication–Phosphodiesterase-5 inhibitors (PDE-5) work?
-ex’s?
Work by sustaining levels of cyclic GMP within the penile corpora cavernosa to allow for erections in response to appropriate sexual stimuli
-Sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis) 45- 60 minutes prior to anticipated sexual activity
When should a Pt take Avanafil (stendra)?
15-30 minutes prior to anticipated sexual activity
When are Phosphodiesterase-5 inhibitors (PDE-5) contraindicated?
- *Contraindicated in patients on nitrates
- If a man on a PDE-5 inhibitor develops CP, delay giving nitrate by 24 hours
- Combo of PDE-5 inhibitors & α-blockers can result in ↓BP
- -Side effects: blue vision (sildenafil), sudden hearing loss
Penile injections
-Alprostadil (Caverject)
=Prostaglandin E1 injected into base of penis –>smooth muscle relaxation in corpus cavernosum
- Inject 10-20 minutes before sex
- Erection can last >60 minutes
What is the intraurethral version (med) for ED?
*Intraurethral alprostadil
Intraurethral alprostadil:
- method of use?
- S/E
Prostaglandin E1
Insert tablet into urethra –> massage penis for 1 minute to equally distribute the medication
-Side effects: penile pain and bleeding
DO NOT USE Intraurethral alprostadil in which Pts?
Do not use in: sickle cell anemia or sickle cell trait, leukemia, multiple myeloma, or any conditions that increase risk for a priapism
Vacuum erection device=
Used in conjunction with occlusive penile rings, uses vacuum pressure to encourage increased arterial inflow (draws blood into penis) and limit venous blood loss from the corpora cavernosa by holding blood in penis
Vacuum erection device:
- S/E?
- may be used along w/ _____
- May cause difficulty ejaculating
- May be used along with PDE-5 inhibitors
Vacuum erection device:
- max application time?
- Erection lasts?
- S/E
- Maximum application time of 30 minutes
- Erection lasts until elastic ring is removed
- Can cause penile bruising
ED: Surgical Options
- Penile prosthesis
- -Rigid
- -Inflatable
- Surgeries for disorders of the arterial system
- -Vascular reconstruction
- -Arterial bypass
Scrotal Abnormalities (list 5)
Generally asymptomatic Varicocele Hydrocele Spermatocele Testicular cancer
Varicocele is caused by dilation of the ______
pampiniform plexus of spermatic veins
=a mass of varicose veins in the spermatic cord
Varicocele is usually ____ sided
left
Varicocele first appears at _____, and enlarges over time
puberty
Varicocele:
-S/Sx?
- Asymptomatic
- Dull, aching scrotal discomfort worse with standing, relieved with sitting/laying down
- Atrophy of left testicle
- Decreased fertility
- Left-sided scrotal fullness on Valsalva
- Large left-sided scrotal mass “bag of worms” that decompresses/disappears In the recumbent position
Varicocele:
-intervention?
Most don’t need intervention
Varicocele: in younger men (≤21 years)–>
abnormal semen analysis- tx?
normal semen analysis- tx?
If evidence of testicular atrophy and/or abnormal semen analysis–> **surgical ligation or percutaneous venous embolization
-If semen analysis normal–> monitor with semen analysis every 1-2 years
Varicocele:
Older men- intervention?
- If fertility desired–>semen analysis every 1-2 years
- Scrotal support
- NSAIDS
Hydrocele=
Collection of peritoneal fluid between the parietal & visceral layers of the tunica vaginalis
Hydrocele:
-list 2 types
- idiopathic
- Acute reactive
hydrocele:
-how common are idiopathic hydroceles?
**most common–> arises over a long period of time
hydrocele:
-how do acute reactive hydroceles arise?
**from inflammatory conditions of scrotal contents–> Epididymitis, torsion, appendiceal torsion
Hydrocele:
-clinical S/sx?
- Soft, small to massive collections of several liters
- Pain/disability usually depend on the size
T/F: hydroceles transilluminate well
TRUE
Hydrocele:
-if dx is uncertain, get ____
U/S
Hydrocele:
tx?
- Usually don’t need intervention
- Surgery: Excision of hydrocele sac–> Indicated in those who are symptomatic with pain/pressure sensation, or have scrotal irritation
Spermatocele= an epidermal cyst in the head of the _______
**epididymis–> that is >2 cm
Increased frequency of spermatoceles in Pts whose mom used _______ during pregnancy
**diethylstilbestrol
Spermatocele:
- Sx?
- what does it feel like?
- Generally asymptomatic
- Feels like a soft, round mass in the head of the epididymis
Spermatocele:
-tx?
- Generally don’t require treatment
- Surgical excision if causing chronic pain
Benign Prostatic Hyperplasia (BPH) is present in ___% of men 40-50, >___% of men over 80
- 50%
- 80%
Benign Prostatic Hyperplasia (BPH):
-risk factors (list 4)
- Obesity
- Heart disease
- Black men need treatment more often
T/F: Excessive alcohol consumption reduces risk of developing Benign Prostatic Hyperplasia (BPH)
true! Alcohol consumption (especially excessive, >3 drinks/day) ↓risk–> Reduces androgen levels
BPH develops in the _______ or ______ zone of the prostate
periurethral or transitional zone of the prostate
BPH: there is an increase in _____ tissue and glandular components
stromal
BPH: pathophysiology
-what 2 things are needed?
**Older age & functioning Leydig cells are needed
BPH:
-describe the pathophysiology
- Pathogenesis incompletely understood
- May occur because prostatic tissue reverts to an embryonic state in which it’s unusually sensitive to growth factors
BPH:
clinical manifestations
- Asymptomatic
- **Lower Urinary Tract Symptoms (LUTS)–> “storage symptoms” and “voiding Symptoms”
BPH Lower urinary Tract symptoms:
list ex’s of “storage symptoms”
- Increased daytime frequency
- Nocturia
- Urinary incontinence
BPH Lower urinary Tract symptoms:
list ex’s of “voiding symptoms”
- Slow urinary stream
- Splitting/spraying of the stream
- Intermittent stream
- **Hesitancy
- **Straining to void
- Terminal dribbling
BPH:
PE findings via DRE
- DRE to assess prostate size & consistency
- Normal prostate approximately the size of a walnut, firm, nontender
- Should NOT be tender (prostatitis) or have nodules (possible malignancy)
- Assess rectal sphincter tone
BPH: diagnostic labs
- UA–> Look for hematuria, UTI
- PSA–> Pitfalls, as previously discussed
- BMP for creatinine–> If renal failure/ obstruction suspected
BPH: Behavioral modification
-3 things Pts can do
- Avoid fluids prior to bedtime
- Reduce consumption of caffeine, alcohol
- Double voiding for more complete bladder emptying
BPH: tx
-Best initial therapy for symptomatic BPH?
-**Alpha-1 Adrenergic antagonists
Describe the fx of Alpha-1 Adrenergic antagonists
-list ex’s
Relax smooth muscle in the bladder neck, prostate capsule, & prostatic urethra
- Terazosin, doxazosin(Cardura), Tamsulosin (Flomax), silodosin (Rapaflo)
- Often given at bedtime
Alpha-1 Adrenergic antagonists: S/E
hypotension, dizziness, interaction with PDE-5 inhibitors, ejaculatory dysfunction
BPH: other tx options
5-alpha reductase inhibitors–> fx?
-how long does the Pt need to be on this med before Sx relief?
- Reduce the size of the prostate
- ->Generally need to treat for 6-12 months before prostate size is reduced enough to provide symptomatic relief
5-alpha reductase inhibitors:
- list ex’s
- Pros?
- S/E?
- Finasteride (Proscar), dutasteride (Avodart)
- Decrease the incidence of prostate cancer
- S/E= decreased libido, ED, ejaculatory dysfunction, pregnant females shouldn’t touch tablets
5-alpha reductase inhibitors:
- PSA levels?
- In Pts with SEVERE Sx, combine with _____
- **PSA concentrations will decrease
- In those with severe Sx, combine with Alpha-1 adrenergic antagonists
BPH:
-herbal therapies? (list 4 ex’s)
- *not recommended
- Saw palmetto
- Beta-sitosterol
- Cermilton
- Pygeum africanum
BPH: surgical management
-Indicated for ?
Persistent or progressive symptoms despite combination therapy for 12-24 months
BPH: Surgical management
-list ex procedures
- Transurethral resection of prostate (TURP)
- Transurethral ablation
- Simple prostatectomy–> Open, laparoscopic, robotic assisted
- Prostatic arterial embolization
Describe Prostatic arterial embolization
Feeding arteries are selectively embolized to induce ischemic necrosis & volume reduction of prostate
List possible complications associated with Surgical procedures for BPH
**Sexual dysfunction, postprostatectomy syndrome, bleeding, urethral strictures, urinary incontinence
(TURP comes along w several complications (sexual dysfunction is MC!!)
Other complications of BPH (list 4)
- Acute urinary retention
- Recurrent UTIs
- Hydronephrosis
- Renal failure
