week 14- erectile dysfunction and hypogonadism Flashcards
erectile dysfunction causes
organic and psychological causes
- ED may result from neurological, vascular, hormonal, or psychological changes
- Common conditions related to ED include: diabetes mellitus, hypertension, hyperlipidemia,
obesity, testosterone deficiency, and prostate cancer treatment.
ED and metabolic syndrome
↑ fasting serum glucose levels,
diabetes, hypertension, and abdominal obesity
most common cause of ED
decreased arterial flow resultant from progressive vascular
disease
loss of libido possible causes
androgen deficiency and depression
anejactulation causes
loss of seminal emission from pelvic or retroperitoneal surgery or radiation, androgen deficiency, sympathetic
denervation as a result of spinal cord injury, and/or diabetes mellitus
premature ejaculation types
primary/lifelong and secondarhy/acquired
retrograde ejaculation causes
Occurs when semen enters the bladder instead of emerging through the penis during orgasm.
* Although sexual climax reached, little or no semen emerges (“dry orgasm”)
- May result from: age-related prostate enlargement or mechanical disruption of the bladder neck due
to congenital abnormalities, transurethral prostate surgery, pelvic radiation, sympathetic
denervation, or treatment with alpha-blocker
peyronie disease
- A fibrotic disorder of the tunica albuginea
- Results in varying degrees of penile pain, curvature, or deformity
priapism
Prolonged penile erection in the absence of sexual stimulation
from improper dosing of PDE5 inhibitors
result in ischemic injury of the corpora cavernosa from venous congestion, blood coagulation
within the cavernous sinuses, and complete cessation of arterial inflow
ischemic priapism
medical emergency
CVD causing ED
coronary artery disease, PAD
endothelial dysfunction (non obstructive CAD) causes large blood vessels to contract instead of dilate –> decrease NO
ED can predict
CAD and PAD (heart disease)
ED can come first
men with ED and DV ents
44% more cardiovascular events, 62% more myocardial infarctions,
39% more strokes and a 25% increased risk of death
diabetes and ED
5-24% of cases
metbaolic syndrome and ED
increased fasting
serum glucose levels, diabetes, hypertension, and abdominal obesity, as well as to an increased risk of CVD
low serum testosterone
hypogonadism and ED
not enough sex hormones (testosterone) and LH to make T
sx: Reduced sexual desire/decreased libido, decreased spontaneous erections, loss of hair,
declining testicular volume, hot flashes
primary vs secondary hypogonadism
primary: in testes, testicular streoidogeneis insufficient
–> Klinefelter’s syndrome, undescended testicles, mumps orchitis, cancer
treatment, normal aging
secondary: in hypothalamus or pituitary
-signaling to testes from LH or GnRH is not enough from leydig cell testosterone prodcution
–>Kallman syndrome, pituitary disorders, HIV, obesity, trauma
lab findings in primary vs secondary hypogonadism
primary: low testosterone, high LH and FSH
secondary: low testosterone, low or normal LH and FSH
congenital vs acquired hypogonadism
congenital:
Manifestations in pre-pubertal males: ambiguous genitalia, micropenis, cryptorchidism
* Karyotype testing can help rule out conditions like Turner syndrome and Klinefelter
syndrome
acquired
–> Causes include aging, mumps orchitis, cancer treatment, and secondary factors like
obesity or trauma
Androgen Deficiency in Aging Male (ADAM) test for hypogonadism
screening tool for testosterone deficiency
Questions cover reduced sexual desire, decreased spontaneous erections, loss of axillary
and pubic hair, declining testicular volume, hot flashes, and low or zero sperm count
labs for hypogonadism
Laboratory tests include morning testosterone, FSH, LH, prolactin, TSH, free T4, vitamin D, CBC, metabolic panel
Ddx for hypogonadism
Consider hyperprolactinemia, congenital adrenal hyperplasia, anorexia nervosa, androgen
insensitivity syndrome, etc
LUTS and BPH and ED
5% of ED
prostate cancer and ED
Radical prostatectomy surgery → 85% of patients can expect ED as a post-operative SE
bike riding and ED
possible
most common medications and substances to cause ED
SSRIs and tobacco
medications and ED
antihypertensive, antidepressant, antipsychotic, and opioid agents
Chronic opioid use is associated with an increased risk of hypogonadism (opioid may disrupt hypothalamic pituitary gonadal axis)
smoking cessation and ED
good
psychogenic causes of ED
anxiety, relationship conflicts impairing arousal
situational, not consistent
depressed
Problems such as premature ejaculation, genital pain, or dyspareunia can lead to psychogenic ED,
as can cultural or religious taboos or a history of sexual abuse
sudden onset of ED
drugs or psychogenic
meds for men with depression and EDs
PDE-5 inhibitors to help
one question approach for erections
“Are you always, usually, sometimes, or never able to achieve and maintain a good
erection?”
medical history for ED
- Inquire about dyslipidemia, hypertension, depression, neurologic disease, diabetes, kidney disease,
endocrine disorders, and cardiac or peripheral vascular disease - Inquire about past surgeries or injuries to the low back and groin
- Specifically elicit histories of prostate cancer treatment and Peyronie disease
- Evaluate for the presence of associated urinary symptoms (LUTS and BPH)
ED and sex partner
- Having the sexual partner involved in the treatment process significantly improves outcomes
The International Index of Erectile Function (IIEF-5)
5 questions
physical exam for ED
anxiety, depress
vitals (BP)
BMI, waist
genitals
-Stretched length of the penis; Fibrosis of the penile shaft; Any abnormalities in size or consistency of either testicle.
male secondary sex characterisitcs
Cardiovascular exam
neurological
* Assessment of anal sphincter tone
* Investigation of the bulbocavernosus reflex
* Testing for peripheral neuropathy
red flag symptoms in ED
Concurrent hip and buttock
cramps with walking –> abdominal aortic aneurism
Leg weakness or numbness;
perineal numbness –> spinal cord compress, pelvic mass
bowel and bladder incontiennce –> spinal cord compress, pelvic mass
galactorrhea –> pituitary tumor
abnormal secondary sex characteristics (loss of body hair, female) –> pituitary tumor
visual field loss –> pituitary tumor
lab testing for ED
CBC (anemia)
lipids (hyperlipidemia)
glucose and hba1c (diabetes)
total testosterone (if abnormal do LH and free testosterone)
TSH (hypothyroid)
serum prolactin (hypogonad)
pt that dont response to oral medications for ED can do injection of vasoactive meds into penis
- Drugs used: prostaglandin E1, papaverine, phentolamine
- These drugs induce erections in men with an intact penile vascular system
- Patients who respond with a rigid erection require no further vascular evaluation
- Such testing also allows for visualization and measurement of penile curvature or deformity
if cant get erection from penile injection then need complex reconstructive surgery
how to test
Duplex Ultrasound
- Gold Standard for assessing penile hemodynamics, vascular function, and anatomy
assess penile vascular function and characterize normal and abnormal penile
structural anatomy, including fibrosis or calcification from Peyronie disease
Penile cavernosography and pudendal arteriography
Can distinguish arterial from venous erectile dysfunction
- Can help predict which patients may benefit from vascular surgery. Magnetic resonance
angiography may provide advanced detail of penile anatom
biothesiometry for ED
sensory testing
-vibrating device on penis
-compare sensitivity to fingertips
-assess hot and cold sensitivity
ED treatemtn
oral PDE5 inhibitors
or other options external vacuum devices, intraurethral prostaglandin pellets, intracavernosal injections, and
combined therapy
counselling if psychogenic
penile prostethisis implantation surgery
referral in ED
- Patients with unsatisfactory response to oral medications
- Patients with Peyronie disease or other penile deformity
- Patients with a history of pelvic surgery, radiation, or perineal trauma
- Patients with priapism for emergent intervention to allow restoration of penile perfusion
ED as senintel sx
ED represents a “sentinel symptom” in patients with occult cardiovascular and
peripheral vascular disease
- “sentinel symptoms” are symptoms that act as indicators and markers in a certain
symptom cluster
risk factors for ED
old
CVD
smoking
DM
pelvic irradiation or surgery
hormones (hypogonad, hypothyroid)
hypertension
illicit drugs
medication
nerulogic (AZ, MS, pakrinsons)
obesity
psychological (depress, anxiety)
peyronie disesae
venous leakage
sedentary lifesytle
