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Clin med A 2 > Male Sexual Dysfunction > Flashcards

Male Sexual Dysfunction Flashcards

1
Q

What are the multiple components that are needed for normal male sexual function

A
  • intact libido
  • ability to achieve and maintain penile erection
  • ejaculation
  • detumescence
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2
Q

what is libido and what increases/decreases it?

A

Libido = sexual desire

Increased by sex steroids (testosterone)
decreased by hormonal/psychiatric disorders and medication

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3
Q

what is needed to achieve and maintain a penile erection

A
  • Intact autonomic and somatic nerve supply
  • Functional musculature of corpora cavernosa and pelvic floor
  • Intact arterial blood flow to penis
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4
Q

what CNS levels are common in central (psychogenic) erectile stimulus and reaction

A

T11-L2
more common in maturity

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5
Q

what CNS levels are common in peripheral (reflexogenic) erectile stimulus and reaction

A

S2-S4
more common in early sexual activity

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6
Q

what starts and maintains erections

A

neurotransmitters! such as:

  • Nitric oxide (NO) - promotes vascular relaxation
  • also vasoactive prostaglandins, Ach, others
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7
Q

what occurs during the normal erection pathway

A
  • Relaxed smooth muscle in the corpora cavernosa and increased
    blood flow to the penis → engorgement
  • Trabecular smooth muscle compresses venous
    return, promoting retention of blood and
    maintaining erection
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8
Q

what triggers ejaculation? what is occuring during this time

A

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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9
Q

what mediates detumescence and what occurs during this time

A
  • Mediated by norepinephrine, endothelin, smooth muscle contraction
  • Increases venous outflow and restores flaccid state
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10
Q

what is erectile dysfunction

A

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

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11
Q

is erectile dysfunction part of the normal aging process

A

NOOO
but over 50% of men 40-70 years old have it!

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12
Q

what are some associated risk factors for erectile dysfunction

A
  • DM, obesity, BPH, HTN, CV disease, low HDL (also the meds that treat them)
  • smoking
  • local radiation/surgery
  • depression, anxiety, stress, anger.
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13
Q

what are the 3 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 - veno occlusive dysfunction
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14
Q

what causes >80% of ED

A

DM
Atherosclerosis
medication

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15
Q

what is vasculogenic etiology for ED? what types of causes does it include?

A

disturbance of blood flow to or from penis!

MC organic cause of ED!
includes things such as:
atherosclerosis, traumatic arterial disease, and structural alterations to veins!

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16
Q

what is neurogenic etiology for ED? what types of causes does it include?

A

Trauma! - spinal cord injury, pelvic surgery, radiation

includes things such as multiple sclerosis and peripheral neuropathy (esp with DM and alcoholism)

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17
Q

what is endocrinologic etiology for ED? what types of causes does it include?

A

androgens increase libido

low testosterone - less libido
increased prolactin - suppresses GnRH and testosterone -> less libido

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18
Q

how common is ED in DM patients?

A

35-75%!

d/t vascular disease, neuropathy and decreased NO synthesis secondary to DM

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19
Q

what is psychogenic etiology for ED? what types of causes does it include?

A

psychological causes that inhibit reflexogenic responses and/or increases smooth muscle tone

MC causes:

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20
Q

How common is Medication etiology for ED? what types of meds typically cause this?

A

25% of men in general practice

  • anti-hypertensives (thiazides, BB, spironolactone)
  • hormonal (estrogen, GnHR agonists/antagonists)
  • antidepressants/antipsychotics (TCA, SSRI)
  • H2 antagonists
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21
Q

what are ED related questions you need to ask when obtaining a hx from a patient with cc of ED

A
  • attaining vs. maintaining?
  • chronic, situational?
  • any nocturnal erections?
  • Substances (tobacco, ETOH, drugs)
  • Medication history
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22
Q

what PE would need to be completed in a pt with a CC of ED

A

cardio
genital
Neuro

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23
Q

what labs would need to be done in a patients whos CC is ED

A
  • lipid profile
  • glucose
  • testosterone
  • prolactin
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24
Q

what special testing could be done in a patient with ED

A
  • direct injection of vasoactive meds (+ response = intact vasculature)
  • if no response, duplex US, cavernosography, ateriography
  • penile nocturnal tumescence study
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25
what is the psychogenic component of treatment for ED
Behaviorally oriented sex therapy, counseling Stress reduction
26
what is the medication options for treatment in ED
* Oral phosphodiesterase-5 (PDE-5) inhibitors * Injection therapies * Testosterone replacement therapy
27
what is the surgical options for treatment
* Vacuum devices * Penile implants * Vascular surgery
28
who is testosterone replacement therapy beneficial in
Only beneficial in men with documented hypogonadism and low testosterone levels
29
what must you tule out prior to doing testosterone replacement therapy
30
what are options for testosterone replacement therapy
* transdermal (gels/patches) * intramuscular injection * oral (avoid d/t hepatotoxicity, efficacy is questionable) * hCG injections (can stimulate production) * buccal tablet, SC pellet, nasal (not studied, may be costly)
31
how is transdermal testosterone used? what are the pros and cons?
applied to the skin daily! Pros - easy to use - stable levels of testosterone Cons - skin irritation - expensive - transfer of testosterone to others
32
how is intramuscular testosterone given? what are the pros and cons?
usually given Q1-2 weeks pros - biologically effective - no transfer of testosterone - inexpensive Cons - regular injections -fluctuations in serum levels
33
What are the potential SE of testosterone replacement 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
34
How does a person need to be monitored when on testosterone replacement therapy
* measure levels 2-3 months after starting tx and after dose changes * once stable, measure levels every 6-12 months
35
what are DDI for testosterone
* warfarin (surprise) * GnRH agonists/antagonists * steroids
36
what is the MOA of PDE 5 inhibitors
inhibit PDE-5 enzyme which degrades cGMP, allowing sustained inflow of blood to penis this is FIRST LINE for many patients!
37
what are the PDE5 inhibitors, which one is the extended duration ones?
* sildenafil (viagra) (take 1 hr prior) * vardenafil (levitra) (take 1 hr prior) * avanafil (stendra) (take 30 min prior) * tadalafil (cialis) longest duration! up to 36 hrs.
38
which PDE5 inhibitors can you take with food?
* avanafil * tadalafil
39
what is the dosing idea for PDE 5 inhibitors
Start at the lowest dose and titrate to effect
40
what are the SE for PDE 5 inhibitors
* headache, flushing, dyspepsia * Dizziness and hypotension * Nasal congestion, rhinitis * Hearing loss, vision changes * Anterior optic neuropathy * Priapism (rare)
41
what are CI for PDE 5 inhibitors
* patients taking nitrates in any form (including PRN NTG) * severe CV disease with risk for CV event with intercourse
42
what are the DDI for PDE5 inhibitors
* nitrates * alpha blockers * antifungals
43
what are the two modalites (this is not the right word) of prostagladin
* intracavernosal injection - Vasoactive prostaglandin (alprostadil) injected directly into penile tissue at the base and lateral aspect * urethral suppository - less effective and costly
44
what are the SE of injectable prostaglandins
* local pain * bruising * dizziness * local pain * fibrosis * infection * priapism
45
what are vacuum devices
* Creates a vacuum chamber around the penis, thereby drawing blood into corpora cavernosa * after tumescence achieved -> elastic constriction band to proximal penis
46
what are the SE and cons of vacuum devices
* cons - cumbersome and can only use for max 20-30 min * Penile discomfort * irritation at band site * no forward ejaculation
47
when is vascular surgery indicated in ED
Indicated for patients with vascular system disorders causing refractory ED Surgery is rarely used due to low success rates, high cost, invasice and risk of complications
48
what are the surgical methods that can be used with erectile dysfunction
* Proximal arterial - endarterectomy, balloon dilation * Distal arterial - arterial bypass * Venous - ligation of specific affected veins
49
what is penile prosthesis
a penile prosthetic implanted directly into corpora cavernosa Semi-rigid (malleable) or inflatable Custom-fit to individual patient this is expensive and used for refractory cause
50
what are complications to penile prosthesis
* mechanical failure * infection * injury to surrounding structures during surgery
51
how common is decreased libido in men, what may decreased libido be a sign of?
* 5-15% of men; increases with age * Often accompanies other sexual dysfunction * May be a sign of androgen deficiency
52
what is the MC ejaculatory disorder
premature ejaculation
53
what are the 3 criteria for diagnosis of premature ejaculation
* Brief ejaculatory latency * Loss of control to delay or stop ejaculation * Psychological distress in patient and/or partner
54
what is the treatment options for primary premature ejaculation
* SSRIs - paroxetine (1st line) * topical anesthetics - apply 5 min prior to sex * combo of pharm + counseling is most effective
55
how do you treat secondary premature ejaculation?
correction of underlying ED
56
what is delayed ejaculation
Inability to ejaculate, or ejaculation only with great effort after prolonged stimulation
57
what are psychological causes of delayed ejaculation
* religious background treating sex as “dirty” * lack of attraction to partner * anger toward partner * traumatic events
58
what are physical causes of delayed ejaculation
* blockage of spermatic ducts * injury to nervous system * ETOH * illicit drug use * psych medication
59
what is the treatment for delayed ejaculation
* Counseling, sex therapy * Medication adjustments
60
what is retrograde ejaculation
Semen enters the bladder instead of emerging through the external urethral meatus during orgasm aka "dry orgasm"
61
when is retrograde ejaculation commonly seen?
* commonly after BPH surgery! * also seen with other treatments for BPH such as: * Mechanical disruption of bladder neck, TURP * Pelvic radiation, sympathetic denervation * Alpha-blockers
62
what is treatment for retrograde ejaculation
only treated if fertility is desired! Imipramine, chlorpheniramine, pseudoephedrine used
63
yay! donezo, flip for doggo

Clin med A 2 (30 decks)

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