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Clin Med Exam 4 > Male GU-Paulson > Flashcards

Male GU-Paulson Flashcards

1
Q

Erectile Dysfunction=

A

Consistent inability to maintain an erect penis with sufficient rigidity to allow for intercourse

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2
Q

T/F: erectile dysfunction is the MC sexual problem in men

A

true

  • More than 50% ages 40-70
  • Incidence increases with increasing age
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3
Q

Things required for an erection:

A
  • Intact parasympathetic + somatic nerve supply
  • Unobstructed arterial inflow
  • Adequate venous constriction
  • Hormonal simulation
  • Psychological desire
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4
Q

Risk factors for ED

A

-Sedentary lifestyle
-Obesity
-Smoking
-Medical comorbidities:
Diabetes, HTN, obesity, OSA, dyslipidemia, CV disease, smoking, RLS
-Watching TV
-Lower frequency of sexual activity

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5
Q

ED causes:

A

-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
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6
Q

Erectile dysfunction: H&P

A
  • 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
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7
Q

ED: diagnostics

A

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

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8
Q

ED: treatment

A
  • 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

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9
Q

What is the mainstay of tx for ED?

A

**Phosphodiesterase-5 inhibitors (PDE-5)

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10
Q

How does the medication–Phosphodiesterase-5 inhibitors (PDE-5) work?
-ex’s?

A

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

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11
Q

When should a Pt take Avanafil (stendra)?

A

15-30 minutes prior to anticipated sexual activity

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12
Q

When are Phosphodiesterase-5 inhibitors (PDE-5) contraindicated?

A
  • *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
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13
Q

Penile injections

A

-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
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14
Q

What is the intraurethral version (med) for ED?

A

*Intraurethral alprostadil

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15
Q

Intraurethral alprostadil:

  • method of use?
  • S/E
A

Prostaglandin E1
Insert tablet into urethra –> massage penis for 1 minute to equally distribute the medication
-Side effects: penile pain and bleeding

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16
Q

DO NOT USE Intraurethral alprostadil in which Pts?

A

Do not use in: sickle cell anemia or sickle cell trait, leukemia, multiple myeloma, or any conditions that increase risk for a priapism

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17
Q

Vacuum erection device=

A

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

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18
Q

Vacuum erection device:

  • S/E?
  • may be used along w/ _____
A
  • May cause difficulty ejaculating

- May be used along with PDE-5 inhibitors

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19
Q

Vacuum erection device:

  • max application time?
  • Erection lasts?
  • S/E
A
  • Maximum application time of 30 minutes
  • Erection lasts until elastic ring is removed
  • Can cause penile bruising
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20
Q

ED: Surgical Options

A
  • Penile prosthesis
  • -Rigid
  • -Inflatable
  • Surgeries for disorders of the arterial system
  • -Vascular reconstruction
  • -Arterial bypass
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21
Q

Scrotal Abnormalities (list 5)

A 
Generally asymptomatic
Varicocele
Hydrocele
Spermatocele
Testicular cancer
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22
Q

Varicocele is caused by dilation of the ______

A

pampiniform plexus of spermatic veins

=a mass of varicose veins in the spermatic cord

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23
Q

Varicocele is usually ____ sided

A

left

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24
Q

Varicocele first appears at _____, and enlarges over time

A

puberty

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25
Q

Varicocele:

-S/Sx?

A
  • 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
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26
Q

Varicocele:

-intervention?

A

Most don’t need intervention

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27
Q

Varicocele: in younger men (≤21 years)–>
abnormal semen analysis- tx?

normal semen analysis- tx?

A

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

28
Q

Varicocele:

Older men- intervention?

A
  • If fertility desired–>semen analysis every 1-2 years
  • Scrotal support
  • NSAIDS
29
Q

Hydrocele=

A

Collection of peritoneal fluid between the parietal & visceral layers of the tunica vaginalis

30
Q

Hydrocele:

-list 2 types

A
  • idiopathic

- Acute reactive

31
Q

hydrocele:

-how common are idiopathic hydroceles?

A

**most common–> arises over a long period of time

32
Q

hydrocele:

-how do acute reactive hydroceles arise?

A

**from inflammatory conditions of scrotal contents–> Epididymitis, torsion, appendiceal torsion

33
Q

Hydrocele:

-clinical S/sx?

A
  • Soft, small to massive collections of several liters

- Pain/disability usually depend on the size

34
Q

T/F: hydroceles transilluminate well

A

TRUE

35
Q

Hydrocele:

-if dx is uncertain, get ____

A

U/S

36
Q

Hydrocele:

tx?

A
  • Usually don’t need intervention
  • Surgery: Excision of hydrocele sac–> Indicated in those who are symptomatic with pain/pressure sensation, or have scrotal irritation
37
Q

Spermatocele= an epidermal cyst in the head of the _______

A

**epididymis–> that is >2 cm

38
Q

Increased frequency of spermatoceles in Pts whose mom used _______ during pregnancy

A

**diethylstilbestrol

39
Q

Spermatocele:

  • Sx?
  • what does it feel like?
A
  • Generally asymptomatic

- Feels like a soft, round mass in the head of the epididymis

40
Q

Spermatocele:

-tx?

A
  • Generally don’t require treatment

- Surgical excision if causing chronic pain

41
Q

Benign Prostatic Hyperplasia (BPH) is present in ___% of men 40-50, >___% of men over 80

A
  • 50%

- 80%

42
Q

Benign Prostatic Hyperplasia (BPH):

-risk factors (list 4)

A
  • Obesity
  • Heart disease
  • Black men need treatment more often
43
Q

T/F: Excessive alcohol consumption reduces risk of developing Benign Prostatic Hyperplasia (BPH)

A

true! Alcohol consumption (especially excessive, >3 drinks/day) ↓risk–> Reduces androgen levels

44
Q

BPH develops in the _______ or ______ zone of the prostate

A

periurethral or transitional zone of the prostate

45
Q

BPH: there is an increase in _____ tissue and glandular components

A

stromal

46
Q

BPH: pathophysiology

-what 2 things are needed?

A

**Older age & functioning Leydig cells are needed

47
Q

BPH:

-describe the pathophysiology

A
  • Pathogenesis incompletely understood

- May occur because prostatic tissue reverts to an embryonic state in which it’s unusually sensitive to growth factors

48
Q

BPH:

clinical manifestations

A
  • Asymptomatic

- **Lower Urinary Tract Symptoms (LUTS)–> “storage symptoms” and “voiding Symptoms”

49
Q

BPH Lower urinary Tract symptoms:

list ex’s of “storage symptoms”

A
  • Increased daytime frequency
  • Nocturia
  • Urinary incontinence
50
Q

BPH Lower urinary Tract symptoms:

list ex’s of “voiding symptoms”

A
  • Slow urinary stream
  • Splitting/spraying of the stream
  • Intermittent stream
  • **Hesitancy
  • **Straining to void
  • Terminal dribbling
51
Q

BPH:

PE findings via DRE

A
  • 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
52
Q

BPH: diagnostic labs

A
  • UA–> Look for hematuria, UTI
  • PSA–> Pitfalls, as previously discussed
  • BMP for creatinine–> If renal failure/ obstruction suspected
53
Q

BPH: Behavioral modification

-3 things Pts can do

A
  • Avoid fluids prior to bedtime
  • Reduce consumption of caffeine, alcohol
  • Double voiding for more complete bladder emptying
54
Q

BPH: tx

-Best initial therapy for symptomatic BPH?

A

-**Alpha-1 Adrenergic antagonists

55
Q

Describe the fx of Alpha-1 Adrenergic antagonists

-list ex’s

A

Relax smooth muscle in the bladder neck, prostate capsule, & prostatic urethra

  • Terazosin, doxazosin(Cardura), Tamsulosin (Flomax), silodosin (Rapaflo)
  • Often given at bedtime
56
Q

Alpha-1 Adrenergic antagonists: S/E

A

hypotension, dizziness, interaction with PDE-5 inhibitors, ejaculatory dysfunction

57
Q

BPH: other tx options
5-alpha reductase inhibitors–> fx?
-how long does the Pt need to be on this med before Sx relief?

A
  • Reduce the size of the prostate

- ->Generally need to treat for 6-12 months before prostate size is reduced enough to provide symptomatic relief

58
Q

5-alpha reductase inhibitors:

  • list ex’s
  • Pros?
  • S/E?
A
  • Finasteride (Proscar), dutasteride (Avodart)
  • Decrease the incidence of prostate cancer
  • S/E= decreased libido, ED, ejaculatory dysfunction, pregnant females shouldn’t touch tablets
59
Q

5-alpha reductase inhibitors:

  • PSA levels?
  • In Pts with SEVERE Sx, combine with _____
A
  • **PSA concentrations will decrease

- In those with severe Sx, combine with Alpha-1 adrenergic antagonists

60
Q

BPH:

-herbal therapies? (list 4 ex’s)

A
  • *not recommended
  • Saw palmetto
  • Beta-sitosterol
  • Cermilton
  • Pygeum africanum
61
Q

BPH: surgical management

-Indicated for ?

A

Persistent or progressive symptoms despite combination therapy for 12-24 months

62
Q

BPH: Surgical management

-list ex procedures

A
  • Transurethral resection of prostate (TURP)
  • Transurethral ablation
  • Simple prostatectomy–> Open, laparoscopic, robotic assisted
  • Prostatic arterial embolization
63
Q

Describe Prostatic arterial embolization

A

Feeding arteries are selectively embolized to induce ischemic necrosis & volume reduction of prostate

64
Q

List possible complications associated with Surgical procedures for BPH

A

**Sexual dysfunction, postprostatectomy syndrome, bleeding, urethral strictures, urinary incontinence

(TURP comes along w several complications (sexual dysfunction is MC!!)

65
Q

Other complications of BPH (list 4)

A
  • Acute urinary retention
  • Recurrent UTIs
  • Hydronephrosis
  • Renal failure

Clin Med Exam 4 (14 decks)

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