Male sexual dysfunction

Question 1

Normal Sexual Function includes

Answer 1

● Libido (sexual desire)
○ Influenced by a variety of stimuli and testosterone
● The ability to achieve and maintain penile erection
Parasympathetic response

Question 2

Detumescence

Answer 2

Norepinephrine, endothelin, and smooth-muscle contraction, related to α-adrenergic receptors and Rho kinase → increase venous outflow and restore the flaccid state. Followed by a refractory period

Question 3

Decreased Libido etiology

Answer 3

● Testosterone deficiency
● Stress or relationship issues
● Depression and other mental illnesses
● Chronic illnesses, fatigue, sleep disorder,
and/or thyroid disorders
● Secondary to other sexual dysfunction
● Medications
○ SSRIs, anti-androgens, 5-alpha reductase
inhibitors (finasteride), and opioids
● Alcoholism or recreational drugs

Question 4

Decreased Libido Diagnosis

Answer 4

● History – including the chronology of the symptoms
● Validated screening tools
○ International Index of Erectile dysFunction (IIEF)
● Partner history
● Social/relationship history
● Medical history
○ Testosterone, FSH/LH, prolactin,
estradiol, TSH, sleep apnea, depression

Question 5

Decreased Libido Management

Answer 5

● Treat the underlying condition
● Stop/decrease other causative agents
● For psychologic, treat with formal or informal
psychotherapy and couples therapy
○ Decrease dose SSRI, adding on bupropion, or try an SNRI

Question 6

Erectile Dysfunction

Answer 6

Consistent or recurrent inability to achieve, or maintain, an erection long enough to complete sexual intercourse

Question 7

Erectile Dysfunction epidemiology

Answer 7

● Most common type of male sexual dysfunction
● Incidence rate increases over lifespan
○ Ages 40–70
■ Some degree of ED= 52%
○ Ages 70-80
■ Some Degree = 67-75%

Question 8

Erectile Dysfunction etiology

Answer 8

Organic
● Vascular
● Neurologic
● Physical
● Hormonal
● Drug S/E

Psychogenic
● Mental health
○ Anxiety, depression, stress,
performance anxiety
● Conflict
○ Relationship
○ Past trauma

Question 9

Predictors for ED

Answer 9

● Increased age
● CVD
● Diabetes
● Obesity
● Smoking
● Depression
● Medications

Question 10

Spontaneous nocturnal erection

Answer 10

○ No → Organic
Yes → Psychogenic

Question 11

Erectile Dysfunction PE

Answer 11

● Cardiovascular
● Penile exam
● Hormonal changes
● Neurologic/sensation

Question 12

Lab Testing for ED

Answer 12

● A1C
○ Pts with ED have a 2x
increased risk of having
undiagnosed diabetes
● Serum testosterone
● CMP (kidney/liver function)
● Lipid (CVD)
● TSH

Question 13

Erectile Dysfunction Management

Answer 13

Determine underlying cause
● Psychogenic
○ Psychotherapy
■ Combine with organic treatments
● Organic
○ Treat underlying causes and/or lifestyle factors

Question 14

Phosphodiesterase-5 Inhibitors

Answer 14

Sildenafil (Viagra), Tadalafil (Cialis)

Question 15

Phosphodiesterase-5 Inhibitors MOA

Answer 15

○ Once GMP is used up,
detumescence occurs
○ PDE5 inhibits the breakdown of
guanosine monophosphate (GMP)
○ Onset – 15-60 minutes (still need
to have arousal/stimulation)

Question 16

ED Management

Answer 16

● Penile Self-injections
○ Intracavernosal injection
■ Trimix (Alprostadil, Papaverine, Phentolamine)
○ S/E – penile pain (50%), priapism (6%)
○ 85% satisfied
● Urethral Suppositories
● Vacuum Assisted Devices

Devices/Surgery
● For Those who don’t respond to other
treatments

Question 17

Devices/Surgery ED Types

Answer 17

○ Semi Rigid – malleable, penis can
be bent up or down
○ Inflatable – cylinders placed in
the corpora cavernosa, a saline
reservoir and pump are
implanted in the groin/scrotum
● Penile Revascularization – for focal arterial occlusion
● Low-intensity extracorporeal shock wave therapy (Li-ESWT)

Question 18

Premature Ejaculation Etiology

Answer 18

● Generally unknown
● Acute/acquired – more likely psychological
○ Anxiety, depression, stress
● Lifelong – more likely genetic/biological factors
○ May be related to low serotonin, vascular malformation
● Can be a learned behavior

Question 19

Premature Ejaculation Management

Answer 19

Behavioral Therapy
● Resolve underlying stressors
● Exercises – build tolerance and delay
ejaculation
Medical Therapy
● SSRI – 1st line (although off label)
● Topical anesthetics
○ Lidocaine-prilocaine topical
● PDE5 inhibitors – Helpful if co-existing ED

Question 20

Delayed Ejaculation,
Anejaculation, and Anorgasmia Etiology

Answer 20

Various organic and psychogenic factors
● Antidepressants
● Partner Conflict
● Alpha blockers (tamsulosin)
● Disease (DM, hypothyroid, parkinsons, MS, etc)
● Surgical (radical prostatectomy, pelvic, or low back)

Question 21

Delayed and Anejaculation
Dx and Management

Answer 21

● Evaluate possible organic or psychogenic factors
● Treat the underlying cause if possible
● Refer to urology in most cases if refractory

Question 22

Retrograde Ejaculation

Answer 22

Failure of the bladder neck to close during
ejaculation → ejaculate enters the bladder

Question 23

Causes of Retrograde Ejaculation

Answer 23

● Post BPH or bladder neck surgery
● Alpha blockers

Question 24

Delayed Ejaculation,
Anejaculation, and Anorgasmia management

Answer 24

● Treat lifestyle factors
● “Sex Therapy” and/or “Sensate Focus”
● Vitamins and supplements – DHEA, Zinc, Vitamin D

Question 25

Anorgasmia

Answer 25

Lack of orgasm

Question 26

Dysorgasmia

Answer 26

Painful orgasm

Question 27

Climacturia

Answer 27

Orgasm-associated urinary incontinence