Male sexual dysfunction Flashcards
Normal Male Sexual Function Requires multiple components to function:
- Intact libido
- Sexual desire - influenced by multiple stimuli
- Increased by sex steroids (e.g., testosterone)
- Decreased by hormonal or psychiatric disorders, medication - 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 - Ejaculation
- Detumescence
what is the Normal Erection Pathway
- Initial stimulus → neural reaction
- Central (psychogenic) - CNS to T11-L2
— MC in maturity - Peripheral (reflexogenic) - S2-S4
- MC in early sexual activity
what starts and maintains erection?
Neurotransmitters
what agent promotes vascular relaxation
Nitric oxide (NO) - promotes vascular relaxation
Vasoactive prostaglandins, Ach, other substances
what causes engorgement
Relaxed smooth muscle in the corpora cavernosa and increased
blood flow to the penis
what promotes retention of blood and
maintaining erection
Trabecular smooth muscle compresses venous
return
how does ejaculation happen?
- 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
what is/how does Detumesence happen
- Mediated by norepinephrine, endothelin, smooth muscle contraction
- Increases venous outflow and restores flaccid state
Consistent inability to attain or maintain a sufficiently rigid penile erection for sexual performance
ED
is ED part of the aging process
no
Increasing incidence with age
Over 50% of men 40-70 years old
associated factors to ED
- DM, obesity, BPH, HTN, CV disease, low HDL
- meds to treat DM, HTN, psychiatric disorders - Smoking
- Local radiation or surgery
- Depression, anxiety, stress, anger
Three basic mechanisms of ED
- Failure to initiate erection
- Psychogenic, endocrinologic, neurogenic - Failure to fill penile tissue
- Arteriogenic - Failure to store adequate blood volume in lacunar network
- Venoocclusive dysfunction
many ED cases are caused by multiple factors, but MC by what (3)?
> 80% of cases - DM, atherosclerosis, medication
causes of ED, which is MC?
- Vasculogenic (MC)
- neurogenic
- Endocrinologic
- DM
- Psychogenic
- Medication-Related
Vasculogenic Causes for ED?
disturbance of blood flow to or from penis
- Atherosclerosis, traumatic arterial disease
- Structural alterations to veins
- Aging, hypoxemia, hypercholesterolemia
Neurogenic causes of ED
- Trauma - Spinal cord injury, pelvic surgery, radiation
- Multiple sclerosis
- Peripheral neuropathy (especially with DM, alcoholism)
Endocrinologic causes of ED
- Androgens increase libido
- Low testosterone - less libido
- Increased prolactin - suppresses GnRH and testosterone - less libido
how does diabetes cause ED?
- 35-75% of men with DM have ED
- Multiple contributing factors!
- Vascular disease
- Neuropathy
- Decreased NO synthesis
psychogenic causes of ED
- May inhibit reflexogenic responses and/or increase smooth muscle tone
- MC causes
- performance anxiety
- depression
- relationship conflict
- loss of attraction
- sexual inhibition
- conflicts over sexual preference
- hx of abuse
- fear of pregnancy or STD - Most patients develop a psychogenic component eventually
Medication-Related causes of ED
- ~25% of men in general practice
- Anti-hypertensives - Thiazides, BBs
- Spironolactone also associated - Hormonal - Estrogens, GnRH agonists/antagonists
- Antidepressants and antipsychotics - TCAs, SSRIs
- H2 antagonists
how do you evaluate a pt with possible ED? (hx, PE, labs)
- Medical Hx: Associated diseases, risk factors
- ED-related questions
— attaining vs. maintaining?
— chronic, situational?
— any nocturnal erections?
- Substances (tobacco, ETOH, drugs)
- Medication history - PE: cardiovascular, genital, neuro
- Labs: lipid profile, glucose, testosterone, prolactin
pt education for ED
Diet and exercise
Manage disease - HTN, DM, lipids
Avoiding smoking, ETOH, drugs
special testing for ED
- If no response to oral meds → direct injection of vasoactive meds
- + response = intact vasculature - If no response to injection → duplex US, cavernosography, arteriography
- Penile nocturnal tumescence study
general tx for ED
- Psychogenic component
- Behaviorally oriented sex therapy, counseling
- Stress reduction - Organic component
- Medications
— Oral PDE-5 inhibitors
— Injection therapies
— Testosterone replacement therapy
- Surgery
— Vacuum devices
— Penile implants
— Vascular surgery
what tx is Only beneficial in men with documented hypogonadism and low testosterone levels
testosterone replacement
Rule out contraindications and high-risk conditions which would preclude testosterone tx for ED:
Prostate cancer
Abnormal DRE
Severe LUTS with BPH
Unexplained PSA elevation
Unstable CHF
Untreated OSA
Breast cancer
Prolactinoma
Erythrocytosis
types of testosterone replacement therapy
-
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 -
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 - 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
SE of testosterone therapy
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
monitoring for testosterone replacement
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
DDI with testosterone therapy
warfarin, GnRH agonists/antagonists, steroids
MOA of PDE5 inhibitors
inhibit PDE-5 enzyme which degrades cGMP, allowing sustained inflow of blood to penis
First line treatment for many patients
what are the 4 hr duration PDE 5 inhibitors
- Sildenafil (Viagra) - PO 1 hr prior to sexual encounter
- Must take on empty stomach - Vardenafil (Levitra) - PO 1 hr prior to sexual encounter
- Must take on empty stomach
- Also available in ODT with more rapid onset - Avanafil (Stendra) - PO 30 min prior to sexual encounter
- May be taken with food
what is the extended duration PDE5 inhibitor
Tadalafil (Cialis) - longest duration (up to 36 hrs)
- May also be used daily for treatment of LUTS due to BPH
- May take with food
SE of PDE5 inhibitors
HA, flushing, dyspepsia
Dizziness and hypotension
Nasal congestion, rhinitis
Hearing loss, vision changes
Anterior optic neuropathy
Priapism (rare)
CI for PDE5 inhibitors
often cardiac-related
patients taking nitrates in any form (including PRN NTG)
severe CV disease with risk for CV event with intercourse
DDI with PDE5 inhibitors
nitrates, alpha-blockers, antifungals
what is a Intracavernosal injection? SE?
- 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
how does a vacuum device for ED work? SE?
- 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
Indicated for patients with vascular system disorders causing refractory ED
Vascular Surgery
Rarely used - low success rates, high cost, invasive, risk of complications
what is the 3 methods of vascular surgeries
Proximal arterial - endarterectomy, balloon dilation
Distal arterial - arterial bypass
Venous - ligation of specific affected veins
how does a penile prosthesis work? SE?
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
Key to treatment for decreased libido
identifying cause!
- Psychological - psychotherapy, sex therapy, stress mgmt
- Hypogonadism - testosterone replacement therapy
- Erectile dysfunction - correction of ED
- Medications - adjusting dose or changing medication
- SSRIs - MC associated drug
- Other common causes - 5-alpha-reductase inhibitors, ETOH - Partner/Relationship - couples therapy, managing relationship
increases with age
Often accompanies other sexual dysfunction
May be a sign of androgen deficiency
MC ejaculatory disorder - 20-30% prevalence
Premature Ejaculation
3 criteria for diagnosing Premature Ejaculation
- Brief ejaculatory latency
- Loss of control to delay or stop ejaculation
- Psychological distress in patient and/or partner
tx for premature ejac primary or secondary to ED?
- 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 - Secondary - correction of underlying ED
Inability to ejaculate, or ejaculation only with great effort after prolonged stimulation
Delayed Ejaculation
causes for Delayed Ejaculation
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
tx for Delayed Ejaculation
addressed to underlying cause
- Counseling, sex therapy
- Medication adjustments
how does retrograde ejac happen?
Semen enters the bladder instead of emerging through the external urethral meatus during orgasm
Also known as “dry orgasm”
Retrograde Ejaculation is MC seen after what?
surgery for BPH
Mechanical disruption of bladder neck, TURP
Pelvic radiation, sympathetic denervation
Alpha-blockers
tx for Retrograde Ejaculation
only if fertility desired
- Imipramine, chlorpheniramine, pseudoephedrine
- Help keep bladder neck closed during ejaculation - Assisted reproduction
