Womens Health - Sexual Health Flashcards
What is bacterial vaginosis?
overgrowth of predominately anaerobic organisms eg Gardnerella Vaginalis.
leads to consequent fall in lactic acid = produces aerobic lactobacilli = raised vaginal ph
is Bacterial vaginosis (BV) STI?
NO but almost only seen in sexually active women.
features of bacterial vaginosis
vaginal discharge : “fishy” offensive
asymptomatic in 50%
What is amsels criteria?
used for?
used for bacterial vaginosis
diagnosis of BV - you need 3 of the following 4 :
- thin white homogenous discharge
- clue cells on microscopy- stippled vaignal epithelial cells
- vaginal ph > 4.5
- positive whiff test - addition of potassium hydroxide = fishy odour
how would you manage a BV patient?
asx: no tx. do swab. exception is if woman undergoing pregnancy termination
if symptomatic :
ORAL METRONIDAZOLE FOR 5-7 DAYS.
70-70% initial cure rate. relapse rate> 50% within 3 months.
if adherence issue: single oral dose metronidazole 2g.
topical metronidazole/clindamycin alternative
what pregnancy complications can BV have ?
results in increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
How to treat BV in pregnant pt?
previously they said no oral metronidazole in 1st trimester. NOW YOU CAN :)
TOPICAL CLINDAMYCIN TOO?
if asx: discuss with woman obstretrician
if sx: oral metronidazole 5-7 days or topical tx.
difference between BV and Trichomonasis?
BV: thin white discharge
TRI: frothy, yellow-green discharge
BV: microscopy :clue cells
TRI: wet mount: motile trophozoites
TRI: vulvovaginitis, strawberry cervix
similarities of BV and Trichomonasis?
offensive vaginal discharge
vaginal ph over 4.5
treat with metronidazole
what is trichomonas vaginalis?
highly motile flagellated protozoan parasite.
STI
features of trichomonas vaginalis
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
ph> 4.5
in men: usually asx - could cause urethritis
investigations for trichomonas vaginalis
microscopy of wet mount: motile trophozoites
how would you manage trichomonas vaginalis?
oral metronidazole for 5-7 days.
could do one-off dose of 2g metronidazole
What is Vaginal Candidiasis ? (THRUSH)
common women condition.
80% cases of candida albicans - rest other candida species
predisposing factors for vaginal candidiasis ?
DM
drugs: abx , steroids
pregnancy
immunosuppresion: HIV
can just happen with no predisposing factors though.
features of vaginal candidiasis?
(white curdy vaginal discharge) cottage cheese - non offensive discharge - ph < 4.5
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions possible?
investigations of vaginal candidiais?
high vaginal swab not normally needed if clinical features are consistent.
how would you manage vaginal candidasis?
local/oral tx
oral flulconazole 150 mg - single dose - 1ST LINE
clotrimazole 500 mg intravaginal pessary - single dose - if oral therapy contraindicated
if vulval sx: consider adding topical imidazole in addition to an oral or intravaginal antifungal
if pregnant: only local tx : cream/pessaries - oral tx contraindicated
how would you define recurrent vaginal candidiasis?
BASHHH define - 4 or more episodes per yr
check compliance with previous tx
rule out differentials: lichen schlerosis
do bloods check DM
do high vaginal swab for microscopy and culture - confirm candidiasis
how would you treat recurrent vaginal candidiasis?
induction : oral fluconazole every 3 days for 3 doses
maintenance: oral fluconazole weekly for 6 months
What is Balanitis?
inflammation of glans penis
sometimes extending to underside of foreskin = balanoposthitis.
many causes: most common are infective ( bacterial and candidal). some autoimmune.
presentation can be acute or chronic. adults or children
what can make balanitis worse?
improper washing under the foreskin
tight foreskin
if balanitis is caused by candidiasis tell me about it?
frequency
acute/chronic?
features?
children/adults
very common
acute
usually after intercourse and associated with itching and white non-urethral discharge
children and adults
if balanitis is caused by dermatitis ( contact or allergic) , tell me abit about it?
frequency
acute/chronic
features
children/adults
very common
acute
itchy
somtimes painful
occasionally non-urethral discharge.
no other body area affected
children and adults
if balanitis caused by dermatitis (eczema or psoriasis ) , tell me about it?
frequency
acute/chronic
features
children/adults
very common
both acute and chronic
very itchy
no discharge
medical hx of inflammatory skin condition with active areas elsewhere
children and adults
if balanitis is caused by bacterial , tell me about it
frequency
acute/chronic
features
children/adults
common
acute
painful
itchy with yellow non-urethral discharge
due to STAPHYLOCOCCUS SPP.
children and adults
if balanitis caused by anaerobic , tell me about it?
frequency
acute/chronic
features
children/adults
common
acute
chidlren and adults
itchy possibly
most associated with : very offensive yellow non-urethral discharge
if balanitis caused by lichen planus, tell me abit about it
frequency
acute/chronic
children/adult
features
uncommon
acute and chronic
more commonly adults
may be itchy
diagnostic feature: WICKHAM’S STRIAE AND VIOLACEOUS PAPULES
if balanitis caused by lichen sclerosus (balanitis xerotica obliterans) , tell me about it
frequency
children/adults
acute/chronic
features
rare
chronic
itchy, white plaques, can cause scarring
children and adults
if balanitis caused by plasma cell balanitis of zoon , tell me about it
features
frequency
acute/chronic
children/adults
rare
chronic
children and adults
not itchy
clearly circumscribed areas of inflammation
if balanitis is caused by circinate balanitis, tell me about it
features
frequency
acute/chronic
children/adults
uncommon
acute/chronic
adults
not itchy no discharge
painless erosions
can be associated with reactive arthritis
how would you investigate balanitis
clinically diagnosed - use hx and physical appearance of glans penis
if infective cause suspected: swab for microscopy and culture - might show bacteria or Candida Albicans
if doubt about cause and extensive skin change: do biopsy
general treatment of balanitis
gentle saline washes
ensure wash foreskin properly
severe irritation and discomfort: 1% hydrocortisone for short period
if cause isnt clear these usually resolve condition
specific treatment of balanitis
candida: topical clotrimazole - 2 weeks to tx infection
bacterial : staphylococcus spp. or group b streptococcus spp. - oral flucloxacillin or clarithromysin if penicillin allergic
anaerobic balanitis: saline wash. topical/oral metronidazole if not settling
dermaitits/circinate: mild potency topic corticosteroid - hydrocortisone
lichen sclerosis/plasma cell balantis of zoon: high potency steroids - clobetasol
circumcision - helps lichen sclerosus
what is chancroid?
tropical disease
caused by haemophilus ducreyi.
painful genital ulcers : unilateral, painful inguinal lymph node enlargement.
ulcers:
sharply defined
ragged undermined border
What is chalmydia?
MC STI in UK
caused by chlamydia trachomatis. - obligate intracellular pathogen.
1/10 young women in uk.
what is the incubation period of chlamydia?
7-21 days
large percentage are asx
features of chlamydia?
asx for 70% women and 50% of men
women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria
potential complications of chlamydia
epididymitis
endometritis
pelvic inflammatory disease
infertility
reactive arthritis
perihepatitis (fitz-hugh-curtis syndrome)
increase incidence of ectopic pregnancy
how would you investigate chlamydia?
nuclear acid amplification tests (NAATs)
urine( 1st void sample), vulvovaginal swab or cervical swab - tested using NAAT technique
women: vulvovaginal swab - 1st line
men : urine test - 1st line
chlamydia testing: should be done 2 weeks after possible exposure
screening for chlamydia?
open to all men and women : 15-24
relies heavily on opportunistic testing
how would you manage chlamydia?
1st line : doxycycline 7 days .
if contrainidicated:
azithromycin (1g od for one day, then 500mg od for 2 days)
why is first line doxycycline rather than azithromycin?
concerns about mycoplasma genitalium.
this infection coexists with chlamydia - rising levels of macrolide resistance.
how would you treat chlamydia in pregnant women?
azithromycin, erythromycin or amoxicillin.
azithro 1g stat - drug of choice.
who would you let know if the pt has chlamydia
they should be offered choice of provider for initial partner notification: trained practise nurse or referral to GUM
men with urethral sx: all contacts since, and in the 4 weeks prior to sx onset
women and asx men : all partners from last 6 months or most recent sexual partner
what should you do for contacts of confirmed chlaymydia cases ?
offer tx prior to results of ix being known.
treat then test
What is lymphogranuloma venereum?
LGV
caused by chlamydia trachomatis serovars L1,L2,L3
risk factors of lymphogranuloma venereum
gay men
majority of pts who present in developed countries have HIV already
historically seen more in tropics
hiv + proctitis =
lymphogranuloma venereum
3 stages of infection for lymphogranuloma venereum
stage 1 : small painless pustule - later forms an ulcer
stage 2 : painful inguinal lymphadenopathy - may form fistulating buboes
stage 3 : proctocolitis
how would you treat lymphogranuloma venereum?
doxycycline
what bacterium causes normal chlamydia which leads to pelvic inflammatory disease and urethritis?
chlamydia trachomatis serovars d - k
Tell me a little about syphilis
STI
spirochaete treponema pallidum.
infection characterised by :
primary
secondary
tertiary
incubation period : 9-90 days
tell me primary stages of syphilis - features
chancre - painless ulcer at site of sexual contact
local non-tender lymphadenopathy
often not seen in women - lesion may be on cervix
tell me secondary stags of syphilis - features
systemic symptoms: fever, lymphadenopathy
rash on trunk, palms and soles
buccal “snail track” ulcers (30%)
condylomata lata (painless, warty lesions on genitalia)
tell me tertiary features of syphilis
gummas - granulomatous lesions of skin and bones
ascending aortic aneurysms
general paralysis of the insane (confusion,memory loss, paralysis)
tabes dorsalis (spinal cord damage - unsteady walking,sharp pain, coordination loss)
argyll-robertson pupil
what isthe argyll-robertson pupil?
pupil dont respond to light
still constrict when focusing on nearby object.
late stage syphillis
tell me some features of congenital syphillis
saber shins
saddle nose
deafness
keratitis
rhagades - linear scars at angle of mouth
blunted upper incisor teeth - hutchinsons teeth, “mulberry molars”
How would you investigate syphilis?
treponema pallidum sensitive organism - cant be grown on artificial media.
clinical features
serology
microscopic examination of infected tissue.
tell me about the serological tests for syphilis investigation?
non-treponemal tests:
-not specific for syphilis , might result in false positive
- based on reactivity of serum from infected patients to a cardiolipin-cholesterol-lecithin antigen
- assess the quantity of antibodies being produced.
- becomes negative after treatment
eg: rapid plasma reagin (RPR) and Venereal Disease Research Laboratory (VDRL)
treponemal-specific tests:
- generally more complex and expensive but specific for syphillis
- qualititive only - reported as “reactive” or “non-reactive”
- eg include: TP-EIA (t. pallidum enzyme immunoassay), TPHA (t. pallidum Hemagglutination test)
the TP-EIA is more popular
tell me some causes of false positive non-treponemal (Cardiolipin) test)
pregnancy
SLE, anti-phospholipid syndrome
TB
leprosy
malaria
HIV
Interpreting syphilis results
positive non-treponemal test + positiv treponemal test : active syphilis infection
positive non-treponemal test + negative treponemal test : false-positive syphilis result eg: due to pregnancy or SLE
negaive non-treponemal test + positive treponemal test : successfully treated syphilis
how would you manage syphilis?
intramuscular benzathine penicillin - 1st line
alternative : doxycycline
monitor nontreponemal titres (RPR or VDRL) after tx to assess response: should be fourfold decline 1:16 - 1:4. - adequate response.
what is the jarisch-herxheimer reaction?
seen following syphilis treatment
fever , rash, tachycardia after 1st dose of abx
in contrast to anaphylaxis - no wheeze or hypotension
due to release of endotoxins following bacterial death and typically occurs within few hrs of tx.
no tx needed other than antipyretic if required
what is genital herpes?
2 strains of HSV in humans: HSV-1 AND 2.
first ppl used to think 1 is oral lesions (cold sores) and 2 is genital herpes - but now its known to have considerable overlap
features of genital herpes
painful genital ulceration - dysuria and pruritis
primary infection often more severe than recurrent episodes :systemic features like:
- headache
-fever
- malaise
tender inguinal lymphadenopathy
urinary retention possible
how would you investigate for genital herpes?
NAAT - nucleic acid amplification test
HSV serology - if recurrent genital ulceration of unknown cause
how would you manage genital herpes?
saline bathing
analgesia
topic anaesthetic agent: lidocaine
oral aciclovir : if frequent exacerbations - longer term aciclovir
what would you do in pregnancy with genital herpes?
elective caesarean section at term - if primary attack occurs during pregnancy at greater than 28 weeks gestation.
if recurrent herpes pregnant : treat with supressive therapy. - be advised that risk of transmission to baby is low.
what are genital warts? (condylomata accuminata)
caused by many varieties of human papillomavirus HPV - especially types 6 and 11.
what does hpv predispose you to?
hpv 16,18,33 predisposes to cervical cancer.
features of genital warts
small (2-5mm) fleshy protuberances which are slightly pigmented.
may itch/bleed
how would you manage genital warts?
topical podophyllum or cryotherapy : 1st line
if multiple non-keratinised warts : topical agents
if solitary keratinised warts : cryotherapy
second line: imiquimod - topical cream
genetal warts usually resistant to tx. recurrent common.
in most anogenital infections with HPV clear without intervention in 1-2 yrs.
what is gonorrhoea caused by?
gram-negative diplococcus Neisseria gonorrhoeae.
where does acute infection of gonorrhoea occur?
genitourinary
rectum
pharynx
incubation period of gonorrhoea?
2-5 days
features of gonorrhoea
male: urethral discharge, dysuria
female: cervicitis eg : leading to vaginal discharge
rectal and pharyngeal infection: usually asx
Microbiology of gonorrhoea
cant immunise for gonorrhoea
reinfection common due to : - antigen variation of type 4 pili (proteins which adhere to surfaces)
- opa proteins (surface proteins which bind to receptors on immune cells)
local complications of gonorrhoea
urethral strictures - scarring narrowing the tube that releases urine
epididymitis - tube at back of testicles swollen and painful
salpingitis (might lead to infertility) - inflammation of fallopian tubes
disseminated infection
what is disseminated gonococcal infection?
what is gonococcal arthritis?
DGI: not fully understood.
due to haematogenous spread from mucosal infection (eg asx genital infection).
classic triad:
- tenosynovitis
- migratory polyarthritis
- dermatitis
later comps:
- septic arthritis
-endocarditis
-perihepatitis (fits-hugh-curtis syndrome)
how would you manage gonorrhoea?
ciprofloxacin used to be - NOW CEPHALOSPORINS bc 36% resistance in uk to ciprofloxacin
previous 1st line : im ceftriaxone + oral azithromycin.
new 1st line : single dose IM ceftriaxone 1g.
IF SENSATIVES ARE KNOWN: oral ciprofloxacin 500mg
if ceftriaxone refused (needle phobic) - oral cefixime 400mg single dose + oral azithromycin 2g single dose.
what is hiv?
RNA retrovirus.
HIV-1 MC.
HIV-2 in west africa.
virus enters and destroys the cd4 t-helper cells of immune system.
initial seroconversion flu-like illness occurs within a few weeks of infection.
the infection is then asx until it progresses to immunodeficiency. - could be years after initial infection.
tranmission of HIV
unprotected anal vaginal oral sex
mother to child at any stage of pregnancy , birth or breastfeeding (vertical transmission)
mucous membrane, blood or open wound exposure to infected blood or bodily fluids (sharing needles,needle-stick injuries or blood splashed in eye)
what is aids-defining illnesses?
happens with end-stage hiv infection.
when cd4 count dropped to level allowing for opportunitistic infections and malignancies to appear.
eg:
- kaposi sarcoma
- TB
-Lymphoma
- Candidiasis - oesophageal or bronchial)
- cytomegalovirus infection
- pneumocystic jirovecii pneumonia (PCP)
features of hiv seroconversion
occurs 3-12 weeks after infection
sore throat
lymphadenopathy
diarrhoea
mouth ulcers
rarely meningoencephalitis
maculopapular rash
malaise,myalgia, arthralgia
how would you diagnose HIV?
HIV antibodies -
might not present in early infection - 99% by 3 months.
- screening : ELISA (enzyme linked immunosorbent Assay) and confirmatory west blot assay
most ppl develop antibodies to hiv at4-6 weeks but all do by 3 months.
p24 antigen - viral core protein appears earluy in blood as viral rna levels rise.
positive from 1 week to 3-4 weeks after infection with hiv.
combition tests : hiv p24 antigen and hiv antibody - standard for diagnosis for screening of hiv
- if combined positive - repeat to confirm diagnosis
when should you test for hiv in asx patients
4 weeks after possible exposure
if a suspected hiv patient is asx and inital negative result, what to do?
repeat in 12 weeks
where might a hiv rna test be useful? (qualititive or quantitive)
non used much in screening/testing
use for diagnosis of neonatal hiv infection and screening blood donors.
what are the possible causes for diarrhoea in HIV?
could be due to the virus itself (HIV enteritis) or opportunistic infections
possible causes:
- cryptosporidium + other protozoa (MC)
- cytomehgalovirus
- mycobacterium avium intracellulare
- giardia
what is the most common infective cause of diarrhoea in hiv patients?
cryptospoidium
intracellular protozoa.
incubation period: 7 days.
variable presentation.
modified ziehl-neelsen stain (acid-fast) - red cysts of cryptosporidium.
tx: difficult
Tell me about mycobacterium avium intracellulare?
atypical mycobacteria
cd4 - below 50.
typical features:
- fever
- sweats
- abdo pain
- diarrhoea
- hepatomegaly
- deranged lfts.
diagnosis: blood cultures. bone marrow exam.
management:
- rifabutin
-ethambuton
-clarithromycin
what is the renal involvement in hiv patients?
due to tx or virus.
protease inhibitor eg indinavir prepitate intratubular crystal obstruction.
tell me the 5 key features of hiv associated nephropathy?
massive proteinuria = nephrotic syndrome because it causes collapsing focal segmental grolerulosclerosis
normal or large kidneys
elevated urea and creatinine
normotension
focal segmental glomerulosclerosis with focal or global capillary collapse on renal biopsy.
what is the treatment for hiv associated nephropathy?
antiretroviral therapy.
what opportunistic infections can occur due to hiv if the cd4 count is 200-500?
oral thrush - secondary to candida albicans
shingles- secondary to herpes zoster
hairy leukoplakia - secondary to EBV
kaposi sarcoma - secondary to HHV-8
what opportunistic infections can happen if cd4 count is 100-200? HIV
cryptosporidiosis - its self limiting
cerebral toxoplasmosis
progressive multifocal leukoencephalopathy - secondary to JC virus
pneumocystis jirovecii pneumonia
HIV dementia
tell me what opportunistic infections you can get if the cd4 count is 50-100 : hiv?
aspergillosis - secondary to aspergillus fumigatus
oesophageal candidiasis - secondary to candidia albicans
cyrptococcal meningitis
primary CNS lymphoma - secondary to EBV
tell me about cd4 count under 50 ? - hiv
cytomegalovirus retinitis - affects 30-40% of pts with cd4 under 50
mycobacterium avium - intracellulare infection
tell me a little about kaposi sarcoma - hiv complications
caused by HHV-8 - human herpes
presentation:
- purple papules or plaques on skin or mucosa - eg gi and resp tract.
skin lesions may later ulcerate
respiratory involvement might cause massive haemoptysis and pleural effusion
radiotherapy + resection.
tell me about pneumocystis jiroveci pneumonia - HIV
use pneumocystis carinii pneumonia (PCP)
unicellular eukaryote , classified as fungus
PCP - MC opportunistic infection in aids
which patients should recieve pneumocystis jiroveci pneumonia prophylaxis?
all pts with cd4 count under 200
features of pneumocystic jiroveci pneumonia: hiv
dyspnoea
dry cough
fever
very few chest signs
common complication of pcp
pneumothorax
what are the extrapulmonary manifestations for pcp: hiv?
rare
hepatosplenomegaly
lymphadenopathy
choroid lesions
how would you investigate for pcp? hiv?
CXR - bilateral interstitial pulmonary infiltrates - present with other xray findings: lobar consolidation. - could be normal
exercise induced desaturation
sputum fails to show PCP - bronchoalveolar lavage ( BAL) needed to demonstrate PCP - silver stain shows characteristic cysts
how would you manage pcp? hiv?
co-trimoxazole
iv pentamidine in severe
aerosolized pentamidine - alternative - less effective with pneumothorax
steroids if hypoxic - po2<9.3 kpa - reduced risk of rep failure by 50% and death by 1/3.
what is the most common cause of oesophagitis in patients with hiv?
oesophageal candidiasis
cd4 count less than 100.
sx:
dysphagia
odynophagia
tx:
fluconazole +
itraconazole = 1st lne
how would you manage hiv?
antiretroviral therapy - (ART)
combo of at least 3 drugs
2 nucleoside reverse transcriptase inhibitors (NRTI)
and
either:
- protease inhibitor (PI)
- non-nucleoside reverse transcriptase inhibitor (NNRTI).
this combo decreases viral replication and reduces risk of viral resistance emerging.
when to start ART?
as soon as diagnosed with HIV
entry inhibitors
maraviroc( binds to CCR5, prevents interaction with gp41) , enfuvirtide (binds to gp41, fusion inhibitor)
prevent HIV-1 from entering and infecting immune cells
give examples of nucleoside analgoue reverse transcriptase inhibitors (NRTI)
zidovudine
abacavir
emtricitabine
didanosine
lamivudine
stavudine
zalcitabine
tenofovir
give me some ntri side effects:
peripheral neuropathy
tenofovir: renal impairement , osteoporosis
zidovudine: anaemia, myopathy, black nails
didanosine : pancreatitis
give me some exmaples and side effects of non-nucleoside reverse transcriptase inhibitors (NNRTI)
nevirapine
efavirenz
side effects: p450 enzyme interaction (nevirapine induces) , rashes
give me some examples of protease inhibitors
indinavir
nelfinavir
ritonavir
saquinavir
side effects of protease inhibitors
DM
hyperlipidaemia
buffalo hump
central obesity
p450 enzyme inhibition
indinavir: renal stones, asx hyperbilirubinaemia
ritonavir: potent inhibitor of p450 system
examples of integrase inhibitors and pathophy
raltegravir
elvitegravir
dolutegravir
block action of integrase - viral enzyme inserts viral genome into dna of host cell
untreated gonorrhoea in pregnancy can lead to what comps?
tx?
premature rupture of membranes
preterm labor
neonatal infections - conjunctivity.
tx: ceftriazone
trichomonas vaginalis in pregnancy?
preterm birth
low birth weight
premature rupture of membrane.
tx: metronidazole - after 1st trimester.
tell me about hiv in pregnancy?
increasing number of hiv positive women giving birth in uk.
factors which reduce vertical tranmission (from25-30% to 2%)
maternal antiretroviral therpay
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)
screening for hiv in pregnancy
offered to all pregnant women
what mode of delivery is recommended in hiv pregnant women?
vaginal delivery if viral load less than 50 copies/ml at 36 weeks. otherwise caesarean
zidovudine infusion - 4hrs before beginning the caesarean section
how infant feed if women has hiv
not breast fed
tell me about neonatal antiretroviral therapy
zidovudine - orally to neonate if maternal viral load is under 50 copies/ml.
otherwise triple ART.
therapy continued for 4-6 weeks.
what is erectile dysfunction?
persistent inability to attain and maintain erection to permit satisfactory sex performance.
symptom.
causes:
organic
psychogenic
mixed
factors causing organic cause of ED
gradual onset of symptoms
lack of tumescense
normal libido
factors favouring a psychogenic cause of ED
sudden onset of sx
decreased libido
major life events
problems or changes in relationship
previous psychological problems
hx of premature ejaculation
good quality spontaneous or self-stimulated erections
risk factors of ed
increasing age
cv disease rf: obesity, dm, dysplipidaemia, metabolic syndrome, htn, smoking
alcohol use
drugs: SSRIs, beta blockers
how to investigate ed?
all men have 10yr cv risk calculated: measure lipid and fasting glucose serum levels.
measure free testosterone : between 9 and 11am.
if low/borderline: repeat with follicle stimulating hormone - luteinizing hormone and prolactin levels.
how would you manage ed?
PDE-5 inhibitor: sildenafil, viagria
- prescribed to all pts
- can be otc.
vaccum erection devices - 1st line - if not take pde-5 inhibitor.
what would you do for a young man that has always had difficulty achieving erection
refer to urology.
what to do if ed pt cycles more than 3 hours per week?
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