Male Sexual Dysfunction 3 Flashcards
The learner will be able to compare and contrast the available behavioral, medical, and surgical therapies for ED.
1
Q
What are some important diagnostic tests for erectile dysfunction?
A
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Detailed medical, psychosocial, and sexual history
- differential organic from psychogenic causes
- determine severity, onset, and duration of ED
- presence of confounding medical or social issues
- elicit if issue is ED or other sexual dysfunction
- psychosocial assessment of relationships with past and current partners
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Thorough physical examination
- vital signs (BP, HR)
- full physical examination
- Peyronies disease
- signs of hypogonadism - testicular atrophy and decreased secondary sexual characteristics
-
Laboratory testing
- serum testosterone level (Draw between 8-10 AM)
- lipid profile
- hemoglobin A1c (If patient is diabetic)
- serum LH, FSH, prolactin (if testosterone level is low)
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Self-Reported Questionnaires
- International Index of Erectile Function (IIEF)
2
Q
What are some first line, nonpharmacological therapeutic methods for erectile dysfunction?
A
-
Behavioral/Lifestyle changes (First Line Therapy)
- exercise
- healthy diet (Mediterranean style (fruits, vegetables, nuts, whole grains, olive oil, low saturated fat diet)
- smoking cessation
- weight loss if overweight/obese
- ergonomic bicycle sit if a cyclist (avert perineal compression of penile arteries)
-
Adjustment in Medications (First Line Therapy)
- beta adrenergic antogonists-switch to another antihypertensive medication
- thiazide diuretics-switch to another diuretic medication
-
Psychosexual Therapy (First Line Therapy)
- psychologist or sex therapist
- cognitive-behavioral intervention
- couple therapy
- psychologist or sex therapist
3
Q
What are some first line hormonal and oral pharmacological therapies for erectile dysfunction?
A
-
Hormonal Therapy for Hypogonadism (First Line Therapy)
- testosterone replacement therapy
- topical transdermal (gel, cream, patch)
- intramuscular
- pellet
- testosterone replacement therapy
-
Oral Pharmacologic Therapy (First Line Therapy)
- Phosphodiesterase (PDE) Inhibitors
- Sildenafil (t ½ 5 hours)
- Tadalafil (t ½ 17 hours)
- Vardenafil (t ½ 5 hours)
- all highly effective at treating ED
- equal efficacies, similar contraindications/warnings
- Phosphodiesterase (PDE) Inhibitors
-
Mechanism of Action:
- increase in the release of nitric oxide (NO) from nerve terminals and vascular endothelial cells
- stimulates guanyl cyclase, which results in increased production of cGMP
- cGMP causes decreased penile smooth muscle cytoplasmic calcium, resulting in penile smooth muscle relaxation and penile erection
-
Adverse Effects:
- flushing
- headache
- rhinitis
- dyspepsia
- visual disturbances (sildenafil and vardenafil)
- back ache (tadalafil)
-
Contraindications:
- nitroglycerine use
- angina or anginal equivalent during sexual activity or with similar level of physical exertion
4
Q
What is the first line transurethral therapy for erectile dysfunction?
A
-
Alprostadil urethral pellet
- < 50% response rate in post marketing trials
- can be combined with elastic ring at base of penis
- penile pain common (33% of men using)
- partner vaginal discomfort post ejaculation (10%)
5
Q
How does the vacuum constriction device work?
A
- Plastic cylinder connected by tubing to a vacuum generating source
- Used in combination with a penile ring
- Portion of penis proximal to the ring is flaccid (different than typical erection)
- Penile bruising and numbness common
- More commonly used by men in long-term, stable relationships
6
Q
What is intracavernosal injection therapy?
A
- Second line therapy
- Vasoactive drugs injected directly into corpus cavernosum
- Most effective nonsurgical therapy for ED
-
Papaverine
- alkaloid derived from opium poppy
- nonspecific inhibition of phosphodiesterase, increase in cGMP, penile smooth muscle relaxation, erection
- t ½ 1-2 hours
-
Phentolamine Methylate
- alpha adrenergic antagonist
- monotherapy disappointing because increase in blood flow but no significant rise in corpus cavernosal pressure
- t½ 30 minutes
-
Alprostadil (Prostaglandin E1)
- increased cAMP levels, penile smooth muscle relaxation, erection
- T ½ < 1 hour
-
Combinations
- Bimix (Papaverine and Phentolamine)
- Trimix (Papaverine, Phentolamine, Alprostadil)
-
Papaverine
- Goal is erection lasting < 4 hours
- High long-term drop out rate (20-60%)
-
Adverse side effects
- penile fibrosis
- priapism (Can be a medical emergency)
- medical evaluation for erection lasting > 4 hours
- intracavernosal injection of phenylephrine until detumescence
- may require corporal irrigation with phenylephrine/saline mixture
- may require surgical shunting procedure
7
Q
What are the surgical options for erectile dysfunction?
A
-
Insertion of Penile Prosthesis (Third Line Therapy)
- malleable (semirigid)
- silicone rubber, central entwined metal core;
- flaccid when device bent
- inflatable
- penile cylinders (2), pump mechanism, reservoir, connecting tubing
-
risks:
- infection
- erostion
- mechanical failure
- pain
- satisfaction rate is 85-90% after 10 years with inflatable penile prosthesis
- malleable (semirigid)
-
Penile Vascular Surgery
- very rare condition
- isolated stenosis or occlusion of extrapenile arteries
- commonly history of pelvic trauma, injury
- anastomosis of inferior epigastric artery to dorsal artery of the penis or deep dorsal vein of the penis