SM_232b: Male Sexual Dysfunction Flashcards
Erectile dysfunction is ____
Erectile dysfunction is inability to achieve or maintain an erection firm enough to have sexual intercourse
- Accompanied by performance anxiety
- Peaks at 70-79
Tunica albuginea is a ____
Tunica albuginea is a bilayered structure with outer longitudinal layer and inner circular fibers
- High tensile strength
Arterial inflow to penis is ____
Arterial inflow to penis is pudendal artery
- Common penile artery branches into superficial dorsal artery and deep cavernosal artery
Venous outflow to penis has 4 sources of drainage: ____, ____, ____, and ____
Venous outflow to penis has 4 sources of drainage: dorsal vein, spongiosal veins, crural veins, and cavernosal veins
Neural innervation of penis is ____ from ____
Neural innervation of penis is parasympathetic (NANC) from S2-4
Erection involves ____ and ____
Erection involves expansion of the corpora cavernosa and corpus spongiosum and thinning of the tunica albuginea
Describe the normal pathway to erection
Normal pathway to erection
- Sexual impulse (nerve signal)
- Neurotransmitter (nitric oxide release)
- Penile smooth muscle relaxation / arteries
- Start of rigidity (increase in sinusoidal blood flow)
- Compression of helical veins
- Erection
Describe male sexual response cycle
Male sexual response cycle
- Appetitive phase
- Excitement
- Plateau
- Orgasm
- Resolution
____ is main CNS center for erection
Hypothalamus is main CNS center for erection
Spinal cord erection generating center is ____
Spinal cord erection generating center is T10-L3
Describe cellular mechanisms of erection
Cellular mechanisms of erection
Describe erectogenic neurotransmitters
Erectogenic neurotransmitters
- PGE1
- cAMP
- cGMP
- ACh
- VIP
- Dopamine
____ and ____ are erectolytic neurotransmitters
Epinephrine and GABA are erectolytic neurotransmitters
Describe vascular risk factors for erectile dysfunction
Vascular risk factors for erectile dysfunction
- Diabetes
- HTN
- HLD
- Cigarette smoking
- CAD (MI, CABG, PTCA)
- PVD
- Cerebrovascular disease
- Pelvic / perineal disease
- Pelvic surgery
- Pelvic radiation therapy
Erectile dysfunction and vascular diseases are states of ___
Erectile dysfunction and vascular diseases are states of endothelial dysfunction
- Pelvic vascular surgery and angioplasty improve erectile dysfunction
- CVD is a predictor of erectile dysfunction
Erectile dysfunction is categorized as ___, ___, or ___
Erectile dysfunction is categorized as psychogenic / loss of confidence, organic, or mixed
Describe physical exam for erectile dysfunction
Physical exam for erectile dysfunction
- BMI and waist circumference are independent predictors of ED
- Examine chest for gynecomastia
- Assess secondary sex characteristics for hypogonadism: beard, pubic heart
- Penis: flaccid stretch, skin lesions, hypospadias - evaluate for Peyronie’s
- Scrotum: testis location, testis size, consistency
- Digital rectal exam: prostate pathology, bulbocavernous reflex (Osinski’s reflex)
Describe sexual health inventory for men (SHIM)
Sexual health inventory for men (SHIM)
- 1-7: severe ED
- 8-11: moderate ED
- 12-16: mild / moderate ED
- 17-21: mild ED
- 22-25: no ED
Laboratory study for erectile dysfunction includes ____
Laboratory study for erectile dysfunction includes early morning total testosterone level
Describe role of penile duplex doppler ultrasound
Penile duplex doppler ultrasound
- Define erectile hemodynamics
- Assess arterial inflow: occult / future CAD
- Assess venocclusive function: venous leak as a prognostic factor
Describe diagnosis of erectile dysfunction
Diagnosis of erectile dysfunction
- Penile duplex doppler ultrasound
- Nocturnal penile tumescence and rigidity
- Biothesiometry
Describe treatment of erectile dysfunction
Erectile dysfunction treatment
- Phase I: oral medication (PDE-5 inhibitors)
- Phase II: intraurethral suppository, intracavernosal injection, vacuum erection device
- Phase III: penile prosthesis, penile revascularization
- Optimize / current comorbidities: control DM / HTN / HLD, treat thyroid deficiency, lifestyle modification, consider psychosexual therapy
____ used to treat chronic conditions are associated with erectile dysfunction
Medications used to treat chronic conditions are associated with erectile dysfunction
Sildenafil, Tadalafil, Vardenafil, and Avanafil are ___
Sildenafil, Tadalafil, Vardenafil, and Avanafil are PDE-5 inhibitor
- Switch to another PDE-5 inhibitor to avoid bothersome side effects
- Generally well-tolerated and effective
- Contraindications: nitrates, amyl nitrate, people for whom intercourse is not advisable, and caution with alpha-blockers or HIV meds
Side effects of PDE-5 inhibitors are ____, ____, ____, ____, and ____
Side effects of PDE-5 inhibitors are flushed face, headache, nasal congestion, gastric reflux, and muscle / back pain
If PDE-5 inhibitors fail for erectile dysfunction, switch to more ___ treatment
If PDE-5 inhibitors fail for erectile dysfunction, switch to more invasive treatment
- VED
- Intraurethral agents
- Intracavernosal agents
- Penile prosthesis
Intraurethral alprostadil (PGE1) ____
Intraurethral alprostadil (PGE1) promotes NO synthesis, leading to smooth muscle relaxation and penile vasodilation
____ uniformly produces erection
Vacuum erection device uniformly produces erection
Intracavernosal injection for erectile dysfunction can be with ____ or ____
Intracavernosal injection for erectile dysfunction can be with alprostadil (PGE1) or some mix of phentolamine / papverine / PGE1 / atropine
Penile prosthesis is ___ or ___
Penile prosthesis is malleable (semirigid) or inflatable
- High satisfaction rate
Ejaculation is a ___
Ejaculation is a reflex involving interplay between somatic, sympathetic, and parasympathetic pathways modulated by dopamine and serotonin
Antegrade ejaculation consists of ____ and ____
Antegrade ejaculation consists of emission and expulsion
- Emission: sympathetic spinal cord reflex, semen introduced into posterior urethra
- Expulsion: combined action of sympathetic and somatic pathways
- Interplay between peri-urethral muscle contractions, bladder neck closer, and relaxation of external sphincter
- Orgasm is a pleasurable sensation resulting from cerebral processing of the increased pressure in the posterior urethra and contraction of the bulbar urethra bulb and accessory sexual organs
Describe parts of CNS involved in ejaculation
Parts of CNS involved in ejaculation
- Medial preoptic area, paraventricular nucleus, nucleius paragigantocellularis
- L3-L4: spinal ejaculatory generator
- T10-L2: secretory center (sequential contractions of epididymis, vas deferens, seminal vesicles, and prostate and closure of bladder neck)
- S2-4: mechanical center (contractions of bulbospongiosus, bulbocavernosus, and perineal muscles)
Describe neurotransmitters involved in ejaculation
Neurotransmitters involved in ejaculation
Describe role of hormones in erectile dysfunction
Hormones in erectile dysfunction
- Testosterone: high -> premature ejaculation, low -> delayed ejaculation
- Thyroid: high -> premature ejaculation, low -> delayed ejaculation
- Prolactin: high levels suppress testosterone and ejaculatory function
- Oxytocin: increases ejaculation, paternal nurturing, sexual desire and long-term bonds and attachments
Lifelong premature ejaculation is ____
Lifelong premature ejaculation is poor ejaculatory control, associated bother, and ejaculation within about 2 minutes of initiation of penetrative sex that has been present since sexual debut
Premature ejaculation can be ____, ____, ____, or ____
Premature ejaculation can be lifelong, acquired, natural variable, and subjective
Premature ejaculation is treated with ____, ____, and ____
Premature ejaculation is treated with behavioral therapy, transdermal therapy, and SSRIs
- Behavioral therapy: stop / start technique, squeeze technique, partner required, poor compliance, and poor sustainability
- Transdermal therapy: lidocaine and prilocaine, needs transdermal permeator
Delayed orgasm is ___
Delayed orgasm is persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation which causes personal distress
- Hormonal imbalances, medication, penile sensation loss, hyperstimulation, or psychiatric
____, ____, ____, and ____ may be used to treat delayed orgasm
Buproprion, cyproheptadine, amantadine, and yohimbine may be used to treat delayed orgasm
