Flashcards in Erectile Dysfunction and Infertility Deck (60)
**** 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
- and rectal exam
**** What is the patient preference for ED treatment? (TEST QUESTION)
- ORAL therapies
**** Why is screening for ED is important? (TEST QUESTION)
- because pts can have other reciprocal/underlying conditions.
What is male infertility?
- a couple's inability to achieve a pregnancy following one year of unprotected intercourse.
What does LH stimulate in the male?
- Leydig cells to produce testosterone
What does FSH stimulate in the male?
- Sertoli cells to initiate Spermatogenesis
- Inhibin (postulated as negative feedback substance on the anterior pituiatry).
What does prolactin do in the male?
- inhibits GnRH release
When is the highest circadian production of testosterone?
- in the morning
*it is pulsatile and most is bound by albumin in peripheral circulation
To what is testosterone aromatized?
- estradiol and 5 alpha, which is reduced to DHT.
What does testosterone do to the hypothalamus?
- acts as negative feedback to decrease LH.
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).
How long does maturation of sperm (spermatogenesis) take?
- 74 days
*very sensitive to environmental factors.
What happens in the epididymis?
- maturation and storage of spermatozoa in the cauda
What happens in the vas deferens?
What is the role of the seminal vesicles?
- formation of coagulum
What is the role of the prostate?
- proteases for liquefaction
What is the neurologic innervation for ejaculation?
- point (parasympathetic) and shoot (sympathetic).
What are some anatomic problems that could lead to male infertility?
- congenital absence of the vas (seen in CF).
- ejaculatory duct obstruction
What else can adversely affect spermatogenesis?
- substance abuse (opioids, exogenous testosterone)
- vitamin deficiencies
- infections/inflammation (Mumps orchitis)
- history of herniorrhaphy
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
What makes up most of the testes volume?
- seminiferous tubules (85%)
What do we look for on physical exam for male infertility?
- testicular size
- prostate, penis, epididymus, vas (CF)
- spermatic cords (varicocele)
- ejaculatory duct obstruction via Trans-Rectal Ultrasound (TRUS)
What lab tests do we do for male infertility?
- semen analysis (2 separate specimens 2-3 days of abstinence).
- hormonal eval (FSH, LH, prolactin, testosterone)
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
What is oligospermia?
- sperm density less than 50 million
What is asthenospermia?
- defects in sperm motility
What is azoospermia?
- no sperm visualized
What is necrospermia?
- dead or immotile sperm
What is teratospermia?
- defects in morphology
What is cryptospermia?
- live sperm seen in a centrifuged pellet
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
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
*** 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.
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
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
- testosterone rebound
What are some assisted reproductive techniques for male infertility?
- semen processing (sperm washing...)
- intrauterine insemination (IUI)
- gamete intra-fallopian transfer (GIFT)
- MESA (microsurgical epididymal sperm aspiration)
- TESE (testicular sperm extraction)
- ICSI (Intracytoplasmic Sperm Injection)= BEST, but $10k
Is most erectile dysfunction (ED) psychologic or organic?
- ORGANIC (80%)
*can be successfully treated in all patients :)
May ED signal underlying disease?
*** Is ED under-diagnosed and under-treated?
What is erectile dysfunction (ED)?
- the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.
Should we incorporate sexual history into the normal medical work-up for every patient?
What is the best screening question for ED?
- "Many men with your medical condition experience sexual problems. Has this happened to you?"
What underlying diseases may be associated with ED?
- Neurologic disorders
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.
What is erection?
- neurovascular phenomenon that transforms the penis from a venous organ into an arterial organ
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.
*** What are the 4 relevant factors related to ED?
What is Peyronie's disease?
- calcification or fibrosis of corpora cavernosa
*Bill Clinton had this.
What are some drugs associated with ED?
- H2 blockers
What neurologic exams do we use to help diagnose ED?
- perianal sensation
- sphincter tone
- bulbocavernosus reflex
- penile brachial index (PBI)
What are some special tests for ED?
- vasoactive agent injection
- nocturnal penile tumescence
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
What are some problems with exogenous testosterone treatment?
- liver dysfunciton
- prostate hypertrophy
- metabolized to estradiol with potentially detrimental effects on sexual function.
Can testosterone lead to prostate cancer?
NO! It has never been proven.
What are the 2 types of penile implants?
*go into the corpora cavernosa (the 2 top cylinders) and the pump goes into the scrotum.
What are some disadvantages to vasoactive intracavernosal pharmacotherapy?
- priapism (prolonged erection)
What are the existing oral pharmacologic treatments for ED?
- PDE-5 inhibitors (SILDENAFIL; viagra, VARDENAFIL; levitra, TADALIFIL; cialis, AVANAFIL)
What drugs must you be mindful about when using PDE5 inhibitors?
- nitrates, and alpha-blockers, because they all cause vasodilation and decrease BP.
How do PDE-5 inhibitors work?
- decrease breakdown of cGMP allowing for prolonged vasodilation.