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
  • 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
  • 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)
  • Self-Reported Questionnaires
    • International Index of Erectile Function (IIEF)
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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
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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
  • 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
  • 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
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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%)
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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
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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)
  • 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
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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
  • 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
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