Erectile Dysfunction and Infertility Flashcards Preview

RGU 3 > Erectile Dysfunction and Infertility > Flashcards

Flashcards in Erectile Dysfunction and Infertility Deck (60)
1

**** A 64 y/o male with HTN and adult onset DM c/o poor erections with intercourse. The initial workup should include what? (TEST QUESTION)

- AM testosterone
- LH/FSH
- prolactin
- and rectal exam

2

**** What is the patient preference for ED treatment? (TEST QUESTION)

- ORAL therapies

3

**** Why is screening for ED is important? (TEST QUESTION)

- because pts can have other reciprocal/underlying conditions.

4

What is male infertility?

- a couple's inability to achieve a pregnancy following one year of unprotected intercourse.

5

What does LH stimulate in the male?

- Leydig cells to produce testosterone

6

What does FSH stimulate in the male?

- Sertoli cells to initiate Spermatogenesis
- Inhibin (postulated as negative feedback substance on the anterior pituiatry).

7

What does prolactin do in the male?

- inhibits GnRH release

8

When is the highest circadian production of testosterone?

- in the morning
*it is pulsatile and most is bound by albumin in peripheral circulation

9

To what is testosterone aromatized?

- estradiol and 5 alpha, which is reduced to DHT.

10

What does testosterone do to the hypothalamus?

- acts as negative feedback to decrease LH.

11

What is the maturation of sperm (spermatogenesis) process?

- spermatogonia (stem cell)
- spermatocyte (meiosis)
- spermatids (develop acrosome, tail of 9 paired microtubules, and form blood-testes barrier).

12

How long does maturation of sperm (spermatogenesis) take?

- 74 days
*very sensitive to environmental factors.

13

What happens in the epididymis?

- maturation and storage of spermatozoa in the cauda

14

What happens in the vas deferens?

- transport

15

What is the role of the seminal vesicles?

- formation of coagulum

16

What is the role of the prostate?

- proteases for liquefaction

17

What is the neurologic innervation for ejaculation?

- point (parasympathetic) and shoot (sympathetic).

18

What are some anatomic problems that could lead to male infertility?

- congenital absence of the vas (seen in CF).
- cryptorchidism
- ejaculatory duct obstruction
- varicocele

19

What else can adversely affect spermatogenesis?

- obesity
- substance abuse (opioids, exogenous testosterone)
- vitamin deficiencies
- chemoradiation
- surgery
- medications
- infections/inflammation (Mumps orchitis)
- history of herniorrhaphy

20

What are some syndromes that can cause male infertility?

- cystic fibrosis (absence of vas)
- Kartagener's syndrome (primary ciliary dyskinesia)
- Kallman's syndrome (absence of GnRH)
- Klinefelters syndrome

21

What makes up most of the testes volume?

- seminiferous tubules (85%)

22

What do we look for on physical exam for male infertility?

- hypogonadism/gynecomastia
- testicular size
- prostate, penis, epididymus, vas (CF)
- spermatic cords (varicocele)
- ejaculatory duct obstruction via Trans-Rectal Ultrasound (TRUS)

23

What lab tests do we do for male infertility?

- urinalysis
- semen analysis (2 separate specimens 2-3 days of abstinence).
- hormonal eval (FSH, LH, prolactin, testosterone)

24

What are the normal values of semen?

- volume= more than 2 mL
- pH= 7.2- 8.0
- concentration= more than 20 million per mL
- morphology= 30% normal

25

What is oligospermia?

- sperm density less than 50 million

26

What is asthenospermia?

- defects in sperm motility

27

What is azoospermia?

- no sperm visualized

28

What is necrospermia?

- dead or immotile sperm

29

What is teratospermia?

- defects in morphology

30

What is cryptospermia?

- live sperm seen in a centrifuged pellet

31

When should antisperm antibody (ASA) be suspected?

- in clumping or agglutination, dimished motility, and a poor post-coital test.
*may occur due to breach of blood-testis barrier

32

What is the sperm penetration assay (Humster Test)?

- sperm are mixed with zona free hamster ovum and observed for timed penetration of the ovum.
*has high predictive value for IVF outcome

33

*** What is the most common surgically correctable cause of male infertility?

- VARICOCELE= enlarged veins in scrotum (33% of infertile males)
*90% LEFT sided bc the left spermatic vein drains into the renal vein at a sharp angle.

34

What specific therapies do we use for male infertility?

- hyperprolactinemia= bromocriptine
- Kallmann's syndrome= hCG followed by hMG
- antisperm antibodies= steroids
- retrograde ejaculation= antihistamine and alpha stimulation
- congenital adrenal hyperplasia= glucocorticoids

35

What are the empiric therapies for male infertility? (aka therapy for those in which we can't find a discernible cause)

- anti-estrogens (clomiphene, tamoxifen)
- hCG, hMG
- GnRH, LHRH
- kallikrein
- testosterone rebound

36

What are some assisted reproductive techniques for male infertility?

- semen processing (sperm washing...)
- intrauterine insemination (IUI)
- gamete intra-fallopian transfer (GIFT)
- IVF
- MESA (microsurgical epididymal sperm aspiration)
- TESE (testicular sperm extraction)
- ICSI (Intracytoplasmic Sperm Injection)= BEST, but $10k

37

Is most erectile dysfunction (ED) psychologic or organic?

- ORGANIC (80%)
*can be successfully treated in all patients :)

38

May ED signal underlying disease?

YES

39

*** Is ED under-diagnosed and under-treated?

- YES

40

What is erectile dysfunction (ED)?

- the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.

41

Should we incorporate sexual history into the normal medical work-up for every patient?

- YES

42

What is the best screening question for ED?

- "Many men with your medical condition experience sexual problems. Has this happened to you?"

43

What underlying diseases may be associated with ED?

- DM
- HTN
- CVD
- PVD
- Neurologic disorders

44

How is ED related to underlying diseases?

- from oxidative stress on the cells causing endothelial injury to the vessels that supply blood to the penis.

45

What is erection?

- neurovascular phenomenon that transforms the penis from a venous organ into an arterial organ

46

What mediates vasodilation?

- nitric oxide and cGMP following activation of cholinergic and NANC (nonadrenergic-noncholinergic) fibers.
- prostaglandin E1 relaxes corpus cavernosum to increase the blood flow.

47

*** What are the 4 relevant factors related to ED?

1. psychologic
2. hormonal
3. vascular
4. neurologic

48

What is Peyronie's disease?

- calcification or fibrosis of corpora cavernosa
*Bill Clinton had this.

49

What are some drugs associated with ED?

- alcohol
- estrogens
- H2 blockers
- anticholinergics
- marijuana
- cigarettes
- B-blockers
- antihypertensives
- diuretics
- spironlactone
- cocaine
- antidepressants

50

What neurologic exams do we use to help diagnose ED?

- perianal sensation
- sphincter tone
- bulbocavernosus reflex
- penile brachial index (PBI)

51

What are some special tests for ED?

- vasoactive agent injection
- nocturnal penile tumescence

52

How do we manage ED?

- First-line= PDE5 inhibitors, psychosexual therapy, vacuum constriction devices.
- Second-line= intraurethral therapy (alprostadil), injection therapy, and combination therapy.
- Third-line= surgery

53

What are some problems with exogenous testosterone treatment?

- liver dysfunciton
- prostate hypertrophy
- metabolized to estradiol with potentially detrimental effects on sexual function.

54

Can testosterone lead to prostate cancer?

NO! It has never been proven.

55

What are the 2 types of penile implants?

1. maleable
2. inflatable
*go into the corpora cavernosa (the 2 top cylinders) and the pump goes into the scrotum.

56

What are some disadvantages to vasoactive intracavernosal pharmacotherapy?

- priapism (prolonged erection)
- bruising
- pain

57

What are the existing oral pharmacologic treatments for ED?

- Yohimbine
- Trazodone
- L-arginine
- PDE-5 inhibitors (SILDENAFIL; viagra, VARDENAFIL; levitra, TADALIFIL; cialis, AVANAFIL)

58

What drugs must you be mindful about when using PDE5 inhibitors?

- nitrates, and alpha-blockers, because they all cause vasodilation and decrease BP.

59

How do PDE-5 inhibitors work?

- decrease breakdown of cGMP allowing for prolonged vasodilation.

60

How are PDE-5 inhibitors metabolized?

- by cytochrome P450 in the liver (mostly CYP3A4).
*so drugs that inhibit CYP3A4 will cause decreased clearance of PDE-5 inhibitors.