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R9 > Chapter 191 - Erectile dysfunction > Flashcards

Chapter 191 - Erectile dysfunction Flashcards

1
Q

Prevalence of erectile dysfunction

A

50% of men > 40

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2
Q

Erectile dysfunction definition

A

recurrent or consistent inability to maintain penile erection for satisfactory sexual performance

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3
Q

Anatomy of the penis

A

1) paired dorsal corpora cavernosa - supported by tunica albuginea
2) ventral corpus spongiosum (urethra)

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4
Q

Blood flow to penis

A

internal pudendal artery –> common penile artery –>

1) dorsal
2) cavernosal
3) bulbourethral

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5
Q

Accessory pudendal artery origin

A

1) EIA
2) obturator
3) vesicle
4) femoral

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6
Q

Cavernosal arteries terminate at what

A

helicine arteries

provide tumescence of penis

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7
Q

Venous drainage of the penis

A

DEEP VEIN
Lacunar space –> subtunical venules –> emissary veins –>

1) cavernosal veins
2) deep dorsal vein
3) spongiosal veins

–> prostatic venous plexus or internal pudendal veins

SUPERFICIAL VEIN
Superficial dorsal vein –> saphenous vein

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8
Q

Innervation of the penis

A

1) somatic nerve
2) parasympathetic nerve
3) sympathetic nerve

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9
Q

Somatic nerve function for the penis

A

1) sensory

2) contraction of bulbocavernosus and ischiocavernosus muscle

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10
Q

Parasympathetic nerve for penis origin

A

S2-S4 - hypogastric plexus

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11
Q

Sympathetic nerve for penis origin

A

T12-L2 - pelvic plexus

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12
Q

Autonomic nerves coalesce into this nerve before entering penis

A

Cavernous nerve

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13
Q

Pathway of the cavernous nerve into penis

A

Posterolateral aspect of prostate –> urogenital diaphragm along with urethra

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14
Q

Innervation of the cavernous nerve

A

Helicine arteries

Trabecular smooth muscle

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15
Q

Physiology of erection

A

1) sexual stimulation
2) increase parasympathetic activity
3) cavenous nerve stimulation
4) penile smooth muscle relaxation (NO pathway)
5) increase bloodflow through penile arteries
6) sinusoid expansion
7) compressiong of subtunical venules (veno-occlusive mechanism)
8) increase intracavernous pressure

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16
Q

Cellular mechanism of nitric oxide in erection

A

NO –> cAMP and cGMP –> decrease Ca2+ intracellular –> smooth muscle relaxation

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17
Q

Causes of erectile dysfunction

A

1) psychogenic (10-15%)
2) neurogenic (uncomon)
3) endocrinologic
4) vasculogenic
5) drug-induced

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18
Q

Psychogenic ED feature

A

1) good nocturnal erection

2) sudden-onset ED with intermittency

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19
Q

Neurogenic ED subclassification

A

1) supraspinal
2) spinal
3) peripheral

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20
Q

Supraspinal ED causes

A

1) tumor
2) stroke
3) Parkinson
4) dementia
5) temporal lobe epilepsy

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21
Q

Spinal ED causes

A

1) MS
2) spinal cord injury
3) transverse myelitis
4) myelodysplasia
5) lumbar disc disease/surgery

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22
Q

Peripheral neurogenic ED causes

A

1) lower motor neuron lesion
2) trauma
3) pelvic pathology
4) pelvic surgery (radical prostatectomy)

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23
Q

Endocrine ED causes

A

1) androgen ? no clear link
2) hyperprolactinemia –> inhibit LH –> low libido
3) hypothyroidism –> low LH
4) hyperthyroidism –> high estradiol

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24
Q

Vasculogenic ED risk factors

A

1) CAD
2) DM
3) HTN

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25
Q

Vasculogenic ED theoretical mechanisms

A

1) flow-limiting stenosis
2) lower oxygen tension (low PGE1, high E2, high TGF beta1 (collagenization of cavenous smooth muscle)
3) endothelial dysfunction lack of NO
4) Corporal veno-occlusive dysfunction

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26
Q

Rate of abnormal ECHO in patients with vasculogenic ED

A

20%

27
Q

5 year risk of cardiovascular events in patients with ED

A

45%

28
Q

Peyronie disease in ED

A

scar tissue resulting in deranged drainage of the cavernous tissue

29
Q

Drugs associated with ED

A

1) thiazide
2) non-selective beta blocker
3) ARB
4) SSRI
5) antiandrogen (prostate cancer use)
6) 5-alpha reductase inhibitor (finasterid, dutasteride)
7) digoxin

30
Q

Penile brachial index

A

Cuff at base of flaccid penis

no evidence
not used

31
Q

Intracavernosal injection testing

A 
Vasodilatory meds (PGE1, papaverine, phentolamine) injected
test for erection and detumesce

if no relaxation after 1 hour then phenylephrine given

no evidence largely unused

32
Q

Duplex ultrasound of the penis how its done

A

vasodilator use
erection obtained then measure velocities

transducer frequency 7.5 - 12 MHz

33
Q

Duplex of penis cutoffs

A

PSV < 25 cm/s = arteriogenic ED
sen 100
spe 86

> 10 cm/s difference between sides = atherosclerotic lesion

EDV > 5cm/s = CVOD

RI < 0.75 = abnormal

34
Q

Dynamic infusion cavernosometry and cavernosography indications

A

1) young men with trauma for revascularization
2) young men failed pharmacotherapy to rule out CVOD
3) primary ED to rule out CVOD
4) medicolegal case
5) Peyronie disease with ED to rule out CVOD

35
Q

DICC steps

A

CAVERNOSOMETRY

1) butterfly needle in each corporal body - one to pressure transducer, one to heparin
2) inject vasoactive drugs
3) record 4 things:

1) equilibrium pressure in corpus cavernosum
- assessment of intracavernosal pressure 10-15 min after vasoactive agent

2) cavernosal artery inflow gradient for both sides
- difference between brachial artery SBP and cavernosal artery occlusion pressure

3) flow to maintain a given intracavernosal pressure
4) pressure decay in mmHg/30s = pressure drop after raising intracavernosal pressure to 150 mmHg

CAVERNOSOGRAPHY

1) radioopaque non-ionic dye into intracavernosally
2) rule out CVOD

36
Q

DICC normal values

A

1) cavernosal artery occlusion pressure < 30 mmHg
2) flow to maintain ICP < 5 ml/min
3) pressure decay < 45 mmHg/30 seconds

37
Q

DICC result interpretation

A

Plot flow to maintain against ICP

1) curvilinear pattern = CVOD
2) parabolic pattern = excessive sympathetic tone

38
Q

Selective internal pudendal angiography indication

A

1) arterial insufficiency without CVOD
2) focal occlusion in one or both common penile or cavernosal arteries
3) perforating branches traveling from dorsal to cavernosal artery
4) at least one patent inferior epigastric artery as donor artery
5) at least one patent dorsal artery as recipient artery
6) patient with high flow priapism

39
Q

Treatment of ED algorithm

A

1) lifestyle
2) PDE5 inhibitor + psychosocial
3) intracavernosal injection, intraurethral suppository, vacuum constriction device
4) penile implant surgery, vascular surgery

40
Q

PDE5 inhibitor types, Tmax and half life

A

Sildenafil (1998) Viagra
- Tmax 60 min; half life 4 hours

vardenafil (Levitra)
- Tmax 42 min; half life 4.5 hours

tadalafil (Cialis)
- Tmax 120 min; half life 17.5 hours

Avanafil (Standra)
- Tmax 45 min; half life 5.1 hours

41
Q

PDE5 inhibitor mechanism of action

A

PDE5 normally degrades cGMP

Prolonged cGMP –> decrease intracellular calcium –> smooth muscle relaxation

42
Q

Side effects of PDE5 inhibitors

A

1) headache
2) flushing
3) nasal congestion
4) heartburn
5) altered color vision
6) n/v
7) cardiovascular
8) diarrhea
9) dizziness
10) myalgia

43
Q

Contraindication of PDE5 inhibitors

A

1) nitrate use

2) antiarrhythmic (Type 1A or 3) for vardenafil only = long QT

44
Q

Intracavernosal injection therapy types

A

1) PGE1 (alprostadil/Caverject)
2) phentolamine
3) papaverine

Trimix has all 3
Bimix doesn’t have PGE1

45
Q

Mechanism of PGE1

A

Activate prostaglandin receptor –> increase cAMP

46
Q

Mechanism of phentolamine

A

non-selective alpha antagonist –> relax SMC

47
Q

Mechanism of papaverine

A

nonspecific PDE inhibitor –> increase cAMP and cGMP –> erection

48
Q

Response time of ICI

A

5-10 minutes

49
Q

Success rate of PDE5

A

69%

50
Q

Success rate of ICI

A

89%

51
Q

Complication of ICI

A

Priapism 0.25 - 7.3%

52
Q

Reversal of prolonged erection

A

Alpha-adrenergic agonist Phenylephrine - intracavernosal administration

53
Q

Intraurethral PGE1 suppository steps, success and complication

A

1) small plastic device into urethral meatus
2) pellet deposited into urethra

variable efficacy
33% get pain
5% get bleeding

54
Q

Maximum time of vacuum constriction device with compression ring

A

30 min

55
Q

Implantable penile devices

A

1) malleable

2) hydrualic (two piece or three piece)

56
Q

Satisfaction after penile implant

A

75-97%

57
Q

Infection after penile implant

A

0.7-3%

58
Q

Surgical revascularization in ED

A

Inferior epigastric artery to dorsal artery bypass

59
Q

Success after surgical revascularization in ED

A

55%

60
Q

Key selection for surgical revascularization in ED

A 
young < 40
focal lesion
otherwise healthy
no other underlying disease
no CVOD
61
Q

Complication after surgical revascularization in ED

A

1) failure to improve
2) inguinal hernia
3) penile shortening
4) loss of penile sensation
5) glans hyperemia if dorsal vein used

62
Q

Venous ligation in crural enous leaks success rate

A

82-93%

63
Q

Rate of ED preop in AAA and AIOD

A

22-39% historically

higher in contemporary data with better definition

64
Q

Aneurysm detection and management ADAM study on ED

A

1136 patients with 4-5.4 cm AAA
surveillance vs immediate open repair

Impotence higher in immediate repair 18months to 4 years
higher ED over time also noted = progression of disease

R9 (200 decks)

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