Male Sexual Dysfunction 3

Question 1

What are some important diagnostic tests for erectile dysfunction?

Answer 1

• 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)

Question 2

What are some first line, nonpharmacological therapeutic methods for erectile dysfunction?

Answer 2

• 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

Question 3

What are some first line hormonal and oral pharmacological therapies for erectile dysfunction?

Answer 3

• 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

Question 4

What is the first line transurethral therapy for erectile dysfunction?

Answer 4

• 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%)

Question 5

How does the vacuum constriction device work?

Answer 5

• 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

Question 6

What is intracavernosal injection therapy?

Answer 6

• 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

Question 7

What are the surgical options for erectile dysfunction?

Answer 7

• 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