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GUM/HIV > Sexual problems > Flashcards

Sexual problems Flashcards

1
Q

Questions to ask in sexual problem history?

A
  1. When did it start?
  2. Does it happen at all times/with all partners?
    Physical factors
  3. Any significant past medical history/medication/ any CPPS symptoms?

Psychosocial factors

  1. How do you feel when it happens
  2. How does your partner respond?
  3. Any problems with ….arousal, libido, pain or orgasm?
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2
Q

What are the causes of primary/lifelong premature ejaculation?

A

Psychogenic
lack of sensory awareness
lack of learned control

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3
Q

What are the causes of secondary premature ejaculation?

A
  1. psychogenic- anxiety/stress
  2. Relationship- performance pressure, anger
  3. Social- pressure of perceived norms
  4. Organic- associated erectile problems, hyperthyroidism, neurological- MS, DM, pelvic surgery
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4
Q

What is 1st line treatment for Premature ejaculation?

A 
Information- reassure, common
Sex therapy- psychology, stop/start
PFE
Self help
Ix/Rx if required (eg for CPPS)
Medicines eg EMLA, SSRI antidepressants, PDE5I
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5
Q

Which antidepressants are used in PE?

A 
Off license SSRI’s
Eg Paroxetine 20mg daily 4-6 weeks then PRN 
Dapoxetine - 1st Licensed Medication 
•Short acting SSRI
•30mg (or 60mg) 1-3 hours before sex
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6
Q

What are the side effects of SSRIs?

A

S/E’s include nausea, dizziness & headache;

Risk of orthostatic hypotension & syncope

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7
Q

Which nerve roots regulate male erection

A

Parasympathetic nervous system S2-4

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8
Q

Which nerve roots regulate male ejaculation?

A

Ejaculation Sympathetic nervous system L1-L2

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9
Q

What was most common sexual problem identified in NATSAL3?

A

Low libido
Premature ejaculation? (both 14.9%)

Then ED (12.9%)
Physical pain least common 1.9%
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10
Q

Which examinations may need to be considered in people presenting with sexual problems?

A 
General inspection
Cardiovascular system
Neurological system
Abdominal system
Musculoskeletal system
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11
Q

What might you consider in a 42 yo man with recent ED
BMI 37
Smokes 20 cod

A

Consider fasting glucose and lipids- ?silent underlying coronary artery disease

All men with ED should have a morning serum testosterone measured
(Hypogonadism is also a possibility)

Consider endocrine tests-
SHBG, FSH, LH and prolactin
(decline in sexual desire due to the possibility of prolactinoma.)

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12
Q

Do men with primary PE need any investigations?

A

No

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13
Q

Common prescription medication that can cause ED?

A 
Carbamazepine
TCAs
SSRIs
Lithium
Methydopa
beta blockers
verapamil
Digoxin
Methotrexate
Cyclophosphamide
Thiazides
Spironolactone
Oestrogen/progestogen
Steroids
Cimetidine/ranitidine
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14
Q

It is recommended in ED that all patients have the following investigations

A

Cardiovascular risk assessment- smoking history, lipid profile, diabetes screening, blood pressure, BMI, and family history
FSH (if low testosterone)
LH (if low testosterone)
Prolactin
Early morning testosterone
PSA (only if clinically indicated or replacing testosterone)
TSH (some circumstances eg PE)

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15
Q

Treatment options for ED?

A

Specific treatments:
Corrective surgery (penile deformity, trauma)
Drug induced (treatment switch)
Androgen replacement therapy (hypogonadism)

Generic treatments:
Psychosexual therapy
Oral pharmacotherapy
Vacuum constrictive devices
Intraurethral and intracavernosal therapies
Penile prosthesis
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16
Q

PDE5 I- list types and onset of action

A

Sildenafil (viagra) PRN
Onset of action 30-90 minutes
Half-life 3-5 hours

Vardenafil (levitra) PRN
Onset of action 25-50 minutes
Half-life 4–5 hours

Tadalafil (cialis)- once daily dosing
Onset of action 30 minutes to 2 hours (not affected by food)
Half-life 17.5 hours

5mg once a day is also licensed for lower urinary tract symptoms related to benign prostatic hyperplasia (BPH). This may be the treatment of choice for erectile dysfunction in men with BPH.

Avanafil (spedra)

Doses available 50mg, 100mg, 200mg
Onset of action 30-60 minutes
Half-life 1.5 hours

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17
Q

Can you use PDE-5 inhibitors if patient is on ARV or enzyme inducers?

A

Caution, - ? use a reduced dose in those taking concurrent medications affecting CYP450 isoenzymes (e.g. ritonavir)

These isoenzymes are responsible for the metabolic clearance of PDE-5 inhibitors and can lead to dangerous boosting of PDE5i levels.

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18
Q

When can you consider switching PDE5 I?

A

Before being considered non-effective, each drug should be administered at least four times (preferably eight) at the highest dose tolerated.

After this, patients should be switched to an alternate PDE-5 inhibitor, commencing at the highest dose.

19
Q

When might PDE-5 inhibitors be contraindicated?

A

Contraindicated with nitrates

Nitrates (e.g. nitroglycerine, isosorbide mononitrate, amyl nitrate ‘poppers’) are absolute contraindications to the use of PDE-5 inhibitors. This also includes nicorandil.

Use of these results in cGMP accumulation and unpredictable drops in blood pressure, sometimes profound.

If a patient develops angina and PDE5i has been taken, glyceryl trinitrate (GTN) must be avoided for at least 24 hours (sildenafil, vardenafil) and for at least 48 hours with tadalafil.

20
Q

What are the common side effects of PDE-5 inhibitors?

A

Common side effects include
Headache
Flushing
Heartburn

21
Q

What needs to be excluded before starting testosterone?

A

Check PSA.
Androgens can enhance the growth of any existing prostatic carcinoma.
Therefore, carcinoma of the prostate has to be excluded before starting therapy with testosterone preparations.

22
Q

When might testosterone be considered as treatment for ED?

A

In men with serum testosterone <12 nmol/l and symptoms consistent with hypogonadism

23
Q

When should testosterone levels be taken?

A

There is a significant diurnal variation in serum testosterone levels.
It is recommended that testosterone levels are measured between 8 am- 11am.

Testosterone levels in men have also been shown to decrease after a meal.

The levels of free and bioavailable testosterone can be calculated and may further guide therapy

24
Q

When should testosterone levels be measured in ED?

A

Testosterone should be measured in all patients presenting with erectile dysfunction

25
Q

When should constriction ring be removed in use with vacuum pump as management of ED?

A

A constriction ring is placed around the base of the penis to prevent collapse of erection due to venous drainage.
This ring should be removed within 30 minutes to avoid skin necrosis.

26
Q

Which patients with ED should not use vacuum pumps?

A

Vacuum devices are contraindicated in those with bleeding disorders or on anticoagulation therapy

27
Q

What are intraurethral treatments for ED?

A

Medicated urethral system for erection (MUSE) -delivers intraurethral alprostadil.
The drug is inserted directly into the urethra in pellet form using a plastic applicator.
It is available in three doses, 250 mg, 500 mg and 1000 mg. The dose should be titrated up to minimise local irritation.

28
Q

What is onset of action of intraurethral alprostadil?

A

The onset of effect is within 5 to 30 minutes after administration.
The duration of effect is approximately 1 to 2 hours.
The maximum frequency of use is no more than 2-3 times per week and only once per 24-hour period.

29
Q

Which intracavernosal injections for ED are available?

A

The prostaglandin- alprostadil
The combination of phentolamine with aviptadil.

Erection occurs 5-15 minutes after the injection and usually lasts 30-40 minutes.

30
Q

What are the benefits of intracavernosal injection for ED?

A 
Efficacious	
Few side effects due to low doses required	
Suitable for most patients	
Rapid onset of action (<10 minutes)	
High patient satisfaction reported
31
Q

Which conditions may predispose someone to priapism?

A 
Sickle cell anaemia or trait
Thrombocythemia
Polycythemia
Multiple myeloma
Leukaemia
Hyperviscosity syndrome
Venous thrombosis
32
Q

Who is eligible for NHS treatment of ED?

A 
Diabetes mellitus
Multiple sclerosis
Parkinson's disease
Poliomyelitis
Prostate cancer
Prostatectomy
Radical pelvic surgery
Renal failure
Severe pelvic injury
Single gene neurological disease
Spina bifida
Spinal cord injury
PDE-5 inhibitors are prescribed on occasion to HIV positive patients
People whose treatment commenced on or before 14 September 1998.
Others who are caused severe distress by impotence, treatment is available in exceptional circumstances following assessment at a specialist clinic.
All others outside of these criteria should be issued medication on private prescription
33
Q

What is the definition of Premature ejaculation as defined by the International Society for Sexual Medicine (ISSM) in 2007?

A

Ejaculation which occurs, or nearly always occurs, prior to or within about a minute of vaginal penetration

The inability to delay ejaculation on all or nearly all vaginal penetrations

Negative personal consequences, such as distress, bother, frustration and/or the avoidance of sexual intimacy

34
Q

For acquired PE is examination required?

A

YES- For acquired PE, a targeted physical examination is mandatory to seek out associated problems, such as ED, thyroid dysfunction, and prostatitis; choice of any investigation should be guided the clinical picture

35
Q

What are main treatment options for PE?

A

Topical anaesthetic agents, e.g. EMLA™ cream
Dapoxetine - SSRI licensed for on demand use in PE.
Other SSRIs have been used off license for the treatment of PE as on demand or once daily dosing
PDE-5 inhibitors, where there is a significant contribution from comorbid erectile dysfunction
Alpha-1 adrenoceptor antagonists

36
Q

What conditions should be excluded in retarded ejaculation?

A 
Diabetic autonomic neuropathy
MS
Spinal cord injury
Hypogonadism
Hypothyroidism.
37
Q

What are possible causes of painful ejaculation?

A

Associated with BPH
Acute/chronic prostatitis
Chronic pelvic pain syndrome.

38
Q

What are causes of retrograde ejaculation?

A

The patient will report feeling the sensation of orgasm but ejaculate is absent.

This may occur post-operatively following transurethral resection of the prostate (TURP) or prostatectomy.

Other causes include multiple sclerosis, diabetic neuropathy and medications, e.g. alpha-blockers.

39
Q

What is peyronie’s disease

A

Peyronie’s disease is characterised by a lump within the shaft of the penis
Penile pain
and/or abnormal angulation of the penis.

40
Q

What ages does peyronie’s disease affect?

A

It can occur from any age, but most commonly in men aged 40-60 years.

Surgical intervention (Nesbit’s procedure) can be undertaken to straighten the penis. Patients with significant deformity and erectile dysfunction may require a penile prosthesis to be inserted.

41
Q

What is the aetiology of peyronie’s disease?

A

The aetiology of Peyronie’s is unknown and treatments often have limited success.
High dose Vitamin E and Potaba (potassium aminobenzoate) are frequently tried with minimal response.

42
Q

For the management of erectile dysfunction, which treatments would be considered first, second and third line?

A

First line:

PDE-5 inhibitors
Vacuum device
Second line:

Intracavernosal injections
Intraurethral alprostadil
Third line:

Penile prosthesis

43
Q

Name some conditions associated with priapism?

A

Sickle cell disease
Leukaemia
Erectile dysfunction drugs
Rarely infection e.g. GC

GUM/HIV (25 decks)

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