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GU: Clin Med IIA > Male sexual dysfunction > Flashcards

Male sexual dysfunction Flashcards

1
Q

Normal Male Sexual Function Requires multiple components to function:

A
  1. Intact libido
    - Sexual desire - influenced by multiple stimuli
    - Increased by sex steroids (e.g., testosterone)
    - Decreased by hormonal or psychiatric disorders, medication
  2. Ability to achieve and maintain penile erection
    - Intact autonomic and somatic nerve supply
    - Functional musculature of corpora cavernosa and pelvic floor
    - Intact arterial blood flow to penis
  3. Ejaculation
  4. Detumescence
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2
Q

what is the Normal Erection Pathway

A
  1. Initial stimulus → neural reaction
    - Central (psychogenic) - CNS to T11-L2
    — MC in maturity
  2. Peripheral (reflexogenic) - S2-S4
    - MC in early sexual activity
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3
Q

what starts and maintains erection?

A

Neurotransmitters

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4
Q

what agent promotes vascular relaxation

A

Nitric oxide (NO) - promotes vascular relaxation
Vasoactive prostaglandins, Ach, other substances

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5
Q

what causes engorgement

A

Relaxed smooth muscle in the corpora cavernosa and increased
blood flow to the penis

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6
Q

what promotes retention of blood and
maintaining erection

A

Trabecular smooth muscle compresses venous
return

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7
Q

how does ejaculation happen?

A
  • Stimulated by sympathetic nervous system
  • Contraction of epididymis, vas deferens, seminal vesicles, prostate
  • Causes seminal fluid to enter the urethra → rhythmic contractions of bulbocavernosus and ischiocavernosus muscles → semen expulsion
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8
Q

what is/how does Detumesence happen

A
  • Mediated by norepinephrine, endothelin, smooth muscle contraction
  • Increases venous outflow and restores flaccid state
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9
Q

Consistent inability to attain or maintain a sufficiently rigid penile erection for sexual performance

A

ED

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10
Q

is ED part of the aging process

A

no
Increasing incidence with age
Over 50% of men 40-70 years old

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11
Q

associated factors to ED

A
  1. DM, obesity, BPH, HTN, CV disease, low HDL
    - meds to treat DM, HTN, psychiatric disorders
  2. Smoking
  3. Local radiation or surgery
  4. Depression, anxiety, stress, anger
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12
Q

Three basic mechanisms of ED

A
  1. Failure to initiate erection
    - Psychogenic, endocrinologic, neurogenic
  2. Failure to fill penile tissue
    - Arteriogenic
  3. Failure to store adequate blood volume in lacunar network
    - Venoocclusive dysfunction
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13
Q

many ED cases are caused by multiple factors, but MC by what (3)?

A

> 80% of cases - DM, atherosclerosis, medication

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14
Q

causes of ED, which is MC?

A
  1. Vasculogenic (MC)
  2. neurogenic
  3. Endocrinologic
  4. DM
  5. Psychogenic
  6. Medication-Related
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15
Q

Vasculogenic Causes for ED?

A

disturbance of blood flow to or from penis

  1. Atherosclerosis, traumatic arterial disease
  2. Structural alterations to veins
    - Aging, hypoxemia, hypercholesterolemia
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16
Q

Neurogenic causes of ED

A
  1. Trauma - Spinal cord injury, pelvic surgery, radiation
  2. Multiple sclerosis
  3. Peripheral neuropathy (especially with DM, alcoholism)
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17
Q

Endocrinologic causes of ED

A
  • Androgens increase libido
  • Low testosterone - less libido
  • Increased prolactin - suppresses GnRH and testosterone - less libido
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18
Q

how does diabetes cause ED?

A
  1. 35-75% of men with DM have ED
  2. Multiple contributing factors!
    - Vascular disease
    - Neuropathy
    - Decreased NO synthesis
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19
Q

psychogenic causes of ED

A
  1. May inhibit reflexogenic responses and/or increase smooth muscle tone
  2. MC causes
    - performance anxiety
    - depression
    - relationship conflict
    - loss of attraction
    - sexual inhibition
    - conflicts over sexual preference
    - hx of abuse
    - fear of pregnancy or STD
  3. Most patients develop a psychogenic component eventually
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20
Q

Medication-Related causes of ED

A
  1. ~25% of men in general practice
  2. Anti-hypertensives - Thiazides, BBs
    - Spironolactone also associated
  3. Hormonal - Estrogens, GnRH agonists/antagonists
  4. Antidepressants and antipsychotics - TCAs, SSRIs
  5. H2 antagonists
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21
Q

how do you evaluate a pt with possible ED? (hx, PE, labs)

A
  1. Medical Hx: Associated diseases, risk factors
    - ED-related questions
    — attaining vs. maintaining?
    — chronic, situational?
    — any nocturnal erections?
    - Substances (tobacco, ETOH, drugs)
    - Medication history
  2. PE: cardiovascular, genital, neuro
  3. Labs: lipid profile, glucose, testosterone, prolactin
22
Q

pt education for ED

A

Diet and exercise
Manage disease - HTN, DM, lipids
Avoiding smoking, ETOH, drugs

23
Q

special testing for ED

A
  1. If no response to oral meds → direct injection of vasoactive meds
    - + response = intact vasculature
  2. If no response to injection → duplex US, cavernosography, arteriography
  3. Penile nocturnal tumescence study
24
Q

general tx for ED

A
  1. Psychogenic component
    - Behaviorally oriented sex therapy, counseling
    - Stress reduction
  2. Organic component
    - Medications
    — Oral PDE-5 inhibitors
    — Injection therapies
    — Testosterone replacement therapy
    - Surgery
    — Vacuum devices
    — Penile implants
    — Vascular surgery
25
Q

what tx is Only beneficial in men with documented hypogonadism and low testosterone levels

A

testosterone replacement

26
Q

Rule out contraindications and high-risk conditions which would preclude testosterone tx for ED:

A

Prostate cancer
Abnormal DRE
Severe LUTS with BPH
Unexplained PSA elevation

Unstable CHF
Untreated OSA
Breast cancer
Prolactinoma
Erythrocytosis

27
Q

types of testosterone replacement therapy

A
  1. Transdermal - gels, patches
    - Androgel, Androderm, Fortesta, Testim, Axiron
    - Applied to skin daily
    - Pros - easy to use, stable levels of testosterone
    - Cons - skin irritation, expensive, transfer of testosterone to others
  2. Intramuscular Injection
    - q 1-2 weeks - 50-100 mg/wk (LA available)
    - Pros - biologically effective, no transfer of testosterone, inexpensive
    - Cons - regular injections, fluctuations in serum levels
  3. Other forms:
    - Oral - avoid - potential hepatotoxicity, questionable efficacy
    - hCG injections - can stimulate testosterone production
    - Buccal tablet, SC pellet, nasal - not as well studied, may be costly
28
Q

SE of testosterone therapy

A

Prostate growth factor - increased prostate CA risk, BPH exacerbation
OSA worsening
Erythrocytosis
Skin irritations
Spermatogenesis suppression,
Improved bone density
Virilization, increased libido, aggression
Controversial - VTE, cardiovascular events

29
Q

monitoring for testosterone replacement

A

measure level 2-3 months after starting tx and dose changes, then 6-12 months for maintenance
- Midway between injections, or anytime for daily forms
- Monitor CBC, PSA, DRE

30
Q

DDI with testosterone therapy

A

warfarin, GnRH agonists/antagonists, steroids

31
Q

MOA of PDE5 inhibitors

A

inhibit PDE-5 enzyme which degrades cGMP, allowing sustained inflow of blood to penis

First line treatment for many patients

32
Q

what are the 4 hr duration PDE 5 inhibitors

A
  1. Sildenafil (Viagra) - PO 1 hr prior to sexual encounter
    - Must take on empty stomach
  2. Vardenafil (Levitra) - PO 1 hr prior to sexual encounter
    - Must take on empty stomach
    - Also available in ODT with more rapid onset
  3. Avanafil (Stendra) - PO 30 min prior to sexual encounter
    - May be taken with food
33
Q

what is the extended duration PDE5 inhibitor

A

Tadalafil (Cialis) - longest duration (up to 36 hrs)
- May also be used daily for treatment of LUTS due to BPH
- May take with food

34
Q

SE of PDE5 inhibitors

A

HA, flushing, dyspepsia
Dizziness and hypotension
Nasal congestion, rhinitis
Hearing loss, vision changes
Anterior optic neuropathy
Priapism (rare)

35
Q

CI for PDE5 inhibitors

A

often cardiac-related
patients taking nitrates in any form (including PRN NTG)
severe CV disease with risk for CV event with intercourse

36
Q

DDI with PDE5 inhibitors

A

nitrates, alpha-blockers, antifungals

37
Q

what is a Intracavernosal injection? SE?

A
  • Vasoactive prostaglandin (alprostadil) injected directly into penile tissue
  • Administered to base and lateral aspect
  • SE - local pain, bruising, dizziness, local pain, fibrosis, infection, priapism

Urethral suppository (alprostadil)
Slightly less effective < injectables; costly

38
Q

how does a vacuum device for ED work? SE?

A
  • Creates a vacuum chamber around the penis, thereby drawing blood into corpora cavernosa
  • Cumbersome; max 20-30 min use
  • SE - penile discomfort, irritation at band site, no forward ejaculation
39
Q

Indicated for patients with vascular system disorders causing refractory ED

A

Vascular Surgery

Rarely used - low success rates, high cost, invasive, risk of complications

40
Q

what is the 3 methods of vascular surgeries

A

Proximal arterial - endarterectomy, balloon dilation
Distal arterial - arterial bypass
Venous - ligation of specific affected veins

41
Q

how does a penile prosthesis work? SE?

A

Implanted directly into corpora cavernosa
- Semi-rigid (malleable) or inflatable
- Custom-fit to individual patient

  • Complications - mechanical failure,
    infection, injury to surrounding
    structures during surgery
  • Good spontaneity and reliability
  • Expensive; used for refractory cases
42
Q

Key to treatment for decreased libido

A

identifying cause!

  1. Psychological - psychotherapy, sex therapy, stress mgmt
  2. Hypogonadism - testosterone replacement therapy
  3. Erectile dysfunction - correction of ED
  4. Medications - adjusting dose or changing medication
    - SSRIs - MC associated drug
    - Other common causes - 5-alpha-reductase inhibitors, ETOH
  5. Partner/Relationship - couples therapy, managing relationship

increases with age
Often accompanies other sexual dysfunction
May be a sign of androgen deficiency

43
Q

MC ejaculatory disorder - 20-30% prevalence

A

Premature Ejaculation

44
Q

3 criteria for diagnosing Premature Ejaculation

A
  1. Brief ejaculatory latency
  2. Loss of control to delay or stop ejaculation
  3. Psychological distress in patient and/or partner
45
Q

tx for premature ejac primary or secondary to ED?

A
  1. Primary - behavioral modification, counseling, medications
    - SSRIs - first line treatment (paroxetine may be most effective)
    - Topical anesthetics - apply 5 min. before sex; well tolerated
    - Combo pharm + counseling may be most effective
  2. Secondary - correction of underlying ED
46
Q

Inability to ejaculate, or ejaculation only with great effort after prolonged stimulation

A

Delayed Ejaculation

47
Q

causes for Delayed Ejaculation

A

Psychological causes - religious background treating sex as “dirty”, lack of attraction to partner, anger toward partner, traumatic events
Physical causes - blockage of spermatic ducts, injury to nervous system, ETOH, illicit drug use, psych medication

48
Q

tx for Delayed Ejaculation

A

addressed to underlying cause
- Counseling, sex therapy
- Medication adjustments

49
Q

how does retrograde ejac happen?

A

Semen enters the bladder instead of emerging through the external urethral meatus during orgasm
Also known as “dry orgasm”

50
Q

Retrograde Ejaculation is MC seen after what?

A

surgery for BPH

Mechanical disruption of bladder neck, TURP
Pelvic radiation, sympathetic denervation
Alpha-blockers

51
Q

tx for Retrograde Ejaculation

A

only if fertility desired

  1. Imipramine, chlorpheniramine, pseudoephedrine
    - Help keep bladder neck closed during ejaculation
  2. Assisted reproduction

GU: Clin Med IIA (13 decks)

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