Erectile Dysfunction Flashcards
Objectives (35 cards)
1
Q
Erectile Dysfunction (ED) definition
A
the inability to attain and /or maintain penile etection sufficient for satisfactory sexual performance
2
Q
ED Epidemiology
A
- Usually first emerges for men in early 40s and increases with age
- Prevalence increases with age
- 52% of men >40 years old have some degree of ED
3
Q
Basic physiology of erections
A
- Two processes
- Cavernosal artery smooth muscle relaxation
- Increased venous outflow resistance
- High arterial inflow and low venous outflow
4
Q
Cavernosal artery smooth muscle relaxation
A
- Active process – initial event of erection
- Parasympathetic nerves release nitric oxide →increased cyclic GMP → decreased intracellular calcium → greater smooth muscle relaxation
- Smooth muscle relaxation = arterial dilation, increased blood flow, increased intracavernosal pressure, cavernosal expansion
5
Q
Increased venous outflow resistance
A
- Passive process
- Cavernosa expand and compress sub-tunic venous sinus
6
Q
Erection phys image
A
7
Q
ejaculation
A
- Sympathetic nerve release norepinephrines → stimulates alpha–1 adrenergic receptors→smooth muscle contraction →reopening venous channels→ flaccid
8
Q
Erection/ ejaculation main point
A
- Parasympathetic = vasodilation = erections
- Sympathetic = vasoconstriction = flaccid
9
Q
Etiology of ED
A
- Vasculogenic
- neurogenic
- psychogenic
- endocrinologic
- local penile fx
- medication induced
10
Q
Etiology of ED chart
A
11
Q
Relevant Medical PMHx for ED
A
- Renal failure
- diabetes
- liver failure
- alcoholism
- neurologic disease
- thyroid disorders
- atherosclerosis
12
Q
Relevant Surgical PMHx for ED
A
- Prostatectomy
- cystectomy
- proctocolectomy
- aorto-iliac vascular surgery
- pituitary surgery
- penile surgery
- etc
13
Q
Relevant Trauma PMHx for ED
A
- Pelvic fracture
- penile fracture
- perineal trauma
- priapism
- spinal cord injury
- pelvic radiation
14
Q
Antihypertensives causing ED
A
- Beta blockers
- Thiazide diuretics
- Sympathetic blockers
- clonidine
- methyldopa
15
Q
Antidepressants/Antipsychotics causing ED
A
- SSRIs
- SNRIs
- TCAs
- MAO inhibitors
- lithium
- phenothiazines
16
Q
Meds that block or reduce testosterone and ED
A
- Cimetidine
- spironolactone
- anti-androgens
17
Q
Other meds that cause ED
A
- Sedatives
- phenytoin
- anticholinergics
- alcohol
- smoking
18
Q
ED Work-up
A
- Review medical, surgical, psychological, social, medications
- Onset and duration of ED
- Sustaining capability
- Penetration capability
- Nocturnal/morning erections
- Erections with masturbation
- Libido
- Ejaculatory dysfunction
- Penile curvature
- Relationship problems
- Performance anxiety
- Stress
19
Q
Types of ejeculatory dysfxn
A
- premature
- delayed
- retrograde ejaculation
- anorgasmia
20
Q
Clinical clues to cause ED Chart
A
21
Q
ED: Physical exam work-up
A
- General
- body habitus
- lack or loss of normal male hair patterns
- gynecomastia
- Cardiovascular
- Auscultate heart
- femoral and peripheral pulses
- bruits
- External genitalia
- Penile plaque
- curvature
- presence of testes and their size
- Basic neuro exam
- visual fields
22
Q
ED: lab work-ups
A
- Fasting glucose, hemoglobin A1C
- CBC/CMP – kidney and liver function
- TSH – rule out thyroid disorders
- Lipid profile – cardiac risk factors
- Serum total AM testosterone – 7-11AM
- if low, obtain FSH, LH, prolactin, repeat testosterone
- PSA
23
Q
Other testing: Nocturnal penile tumescence testing
A
- Detects erections during REM, psychogenic versus organic causes
- Normal NPT = psychogenic…. Abnormal NPT = organic (vascular/neuro)
24
Q
Other testing: Duplex doppler imaging
A
- Typically with injection to induce artificial injections
- Examine venous and arterial flow/velocities
25
Other testing: Cavernosometry/cavernosography
* Detect veno-occlusive dysfunction
* Needles places into corpora measuring pressure
* Radiographic contrast infused into corpora – visualize for venous leak
26
Other testing: Bilateral internal pudendal and inferior epigastric arteriography
* Internal pudendal artery supplies common penile artery supplies cavernosal artery
27
ED Tx
* Treatment is individualized
* Patient education
* Psychogenic
* Psychological support and counseling
* Offer testosterone if low
28
ED Tx general recommendations
* Avoid smoking
* Weight loss
* Exercise
* Stop alcohol abuse
* Consider medication changes
* Optimize management of diabetes, hypertension, and heart disease
29
ED Tx meds: PDE-5 Inhibitors
* Sildenafil
* tadalafil
* vardenafil
* avanafil
\*Do not initiate an erection.. once erection is present, make erection stronger
\*First line therapy, unless contraindicated
30
PDE-5 Inhibitors Contraindications
* CONTRAINDICATED in patient’s taking nitrates!!
* (hypotension)
31
PDE-5 Inhibitors Side Effects
* headache
* flushing
* blurry vision
* Most tend to lessen after several weeks of use
* Retina contains PDE-6
* inhibition of PDE-6 can cause visual side effects – **tadalafil** and **avanafil** have lowest rate of visual side effects
32
PDE-5 Inhibitors Diagram
33
Other ED Tx meds
* Alpha -2 Adrenergic Receptor inhibitor
* Yohimbine
* Prostaglandin E1
* MUSE (medicated urethral system for erections)
* Increases intracellular cAMP
* Intracavernosal Injections
* Alprostadil (prostaglandin E1)
* Phentolamine
* Combination therapies
34
Vacuum Erection Device Tx
* Cylindrical vacuum pump placed over penis
* Air drawn from cylinder causing blood to flow in
* Occlusive ring placed around base
35
Penile Prosthesis Tx
* Surgical implanation
