Erectile Dysfunction

Question 1

Define erectile dysfunction

Answer 1

The inability to achieve and maintain a penile erection for satisfactory sexual intercourse

Question 2

Erectile dysfunction is more common with increasing age. T/F?

Answer 2

True

Question 3

Give examples of psychological factors which can cause erectile dysfunction

Answer 3

stress
performance anxiety
depression

Question 4

Give examples of physiological factors which can cause erectile dysfunction

Answer 4

inadequate blood supply due to atherosclerosis or blood vessel damage from hypertension
type 2 diabetes mellitus

Question 5

Give examples of neurological factors which can cause erectile dysfunction

Answer 5

stroke, MS, back or pelvic trauma causing direct damage to parasympathetic nerve fibres

Question 6

Give examples of endocrine factors which can cause erectile dysfunction

Answer 6

hypogonadism

low testosterone

Question 7

Give examples of medications which can cause erectile dysfunction

Answer 7

Antidepressants e.g. SSRIs, MAOIs, TCAs
Antihypertensives e.g. beta blockers, verapamil, clonidine
Antiarrythmics - digoxin, amiodarone
Diuretics - spironolactone, thiazides
Hormonal - anti-androgens, 5-alpha reductase inhibitors
H2 receptor antagonists
Recreational drugs - alcohol, marijuana, cocaine

Question 8

Psychogenic erectile dysfunction accounts for approximately what percentage of erectile dysfunction?

Answer 8

10%

Question 9

Organic erectile dysfunction accounts for approximately what percentage of erectile dysfunction?

Answer 9

90%

Question 10

What questions should be asked when taking a psychosexual history from a man experiencing erectile dysfunction?

Answer 10

Onset and duration of erectile dysfunction, partial or full erection
Presence of nocturnal and morning erections
Situations in which ED occurs e.g. when with partner, self
Previous history of ED
Sexual orientation and gender identity
Past and current sexual relationships
Current emotional issues

Question 11

What factors or symptoms would suggest a psychogenic cause of erectile dysfunction?

Answer 11

Younger age
Lake of medical history / risk factors
Sudden onset
Decreased libido
Spontaneous erections
Symptoms present at specific time e.g. when with partner
Major life events
Relationship changes
Previous psychological history

Question 12

What factors or symptoms would suggest an organic cause of erectile dysfunction?

Answer 12

Older age
Gradual onset
Normal libido
Loss of nocturnal and early morning erections
Present in all situations e.g. when with partner / stimuli
Risk factors for CVD/DM

Question 13

Other than a psychosexual history, what other systems checks would you want to discuss in a man presenting with erectile dysfunction?

Answer 13

Cardiovascular history and symptoms
Symptoms of diabetes mellitus
Lower urinary tract symptoms
Social history - relationship with partner, current emotional state, stress, alcohol and drug use

Question 14

What general examinations would you want to perform in a man presenting with erectile dysfunction and explain the reason for doing these examinations?

Answer 14

Blood pressure
Pulse
BMI
To assess CV risk factors

Question 15

An examination of the external genitalia should be conducted in a man presenting with erectile dysfunction. What abnormalities should you look for?

Answer 15

Penile abnormalities - premalignant or malignant conditions
Phimosis
Peyronie’s disease
Signs of secondary sexual characteristics

Question 16

A digital rectal examination may be performed in a man presenting with erectile dysfunction. For which patients would this investigation be indicated?

Answer 16

Men >50 years of age
Hx of prostate cancer
Prostate symptoms
Ejaculatory dysfunction present

Question 17

What blood tests would you do for a man presenting with erectile dysfunction? Explain your reasoning

Answer 17

Fasting glucose or HbA1c to assess glycemic control
Fasting lipids to calculate 10 years CVD risk
LFTs including GGT (alcohol use)
Total testosterone ( to check for low testosterone)
PSA if >50 years or DRE indicates enlarged prostate

Question 18

Withdrawal of antipsychotic medication due to drug induced erectile dysfunction requires a review from psychiatry. T/F?

Answer 18

True

Question 19

What lifestyle modifications should be suggested for a man presenting with erectile dysfunction?

Answer 19

Dietary changes
Smoking cessation
Reduction in alcohol
Increased exercise
Suggest counselling or mindfulness to help with stress

Question 20

What class of drugs are used as first line treatment fo erectile dysfunction and give an example of this?

Answer 20

PDE-5 inhibitors such as sildenafil

Question 21

Explain the mechanism of action of PDE-5 inhibitors used as a first line treatment for erectile dysfunction.

Answer 21

Inhibit the PDE-5 enzyme in endothelial cells which normally breaks down cGMP, this results in higher levels of cGMP and more smooth muscle relaxation which facilitates an erection

Question 22

What are the contraindications for the use of PDE-5 inhibitors to treat erectile dysfunction?

Answer 22

Nitrates and granulate cyclase stimulators
Severe or unstable heart disease
Non-arteric anterior ischaemic optic neuropathy
Hypotension
Unstable angina or angina occurring during sexual intercourse
Recent stroke or mI

Question 23

What are the cautions for the use of PDE-5 inhibitors to treat erectile dysfunction?

Answer 23

Stratify CVD risk according to Princeton consensus 2
Left ventricular outflow obstruction
Anatomical penile abnormalities
Predisposition to priapism

Question 24

How long before sexual activity does sildenafil need to be taken and what is its duration of action?

Answer 24

One hour before

4-5 hours

Question 25

Priapism is the persistence of an erection for more than how many hours?

Answer 25

4 hours

Question 26

Why is priapism dangerous?

Answer 26

Can cause necrosis if blood is not drained

Question 27

What are the common side effects of PDE-5 inhibitors used to treat erectile dysfunction?

Answer 27

``` Back pain Dyspepsia Flushing Migraine Myalgia Nasal congestion Dizziness Nausea Vomiting ```

Question 28

What are the uncommon yet serious side effects of PDE-5 inhibitors used to treat erectile dysfunction?

Answer 28

Visual disturbances including non-arteric anterior ischaemic optic neuropathy sudden hearing loss priapism

Question 29

Although patients are given a prescription, they must pay for PDE-5 inhibitors to treat erectile dysfunction themselves. In what cases are patients prescribed these drugs for free?

Answer 29

``` DM PD MS Polio Single gene neurological disease Spinal cord injury Spina bifida Renal dialysis Radial pelvic surgery Prostate cancer Treatment initiated before 1998 Severe stress secondary to ED (assessed by psychiatrist) ```

Question 30

What is the second line medication for the treatment of erectile dysfunction?

Answer 30

Synthetic prostaglandin E1 such as alprostadil

Question 31

What is the mechanism of action of synthetic prostaglandin E1 analogues used as the second line treatment for erection dysfunction?

Answer 31

Increases cGMP levels to increase smooth muscle relaxation to facilitate an erection

Question 32

Via what routes can synthetic prostaglandin E1 analogues (the second line treatment for erectile dysfunction) be administered?

Answer 32

Directly into penis via a small pellet inserted into the urethral opening (MUSE) Direct intracavernosal injection

Question 33

Other than medication, what secondary care treatments can be offered for erectile dysfunction?

Answer 33

Vacuum erection device | Penile prosthesis surgery

Question 34

What are the side effects of vacuum erection devices (used to treat erectile dysfunction)?

Answer 34

Pain Bruising penile numbness skin necrosis