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Clin med A 2 > Male Sexual Dysfunction > Flashcards

Male Sexual Dysfunction Flashcards

1
Q

What are the multiple components that are needed for normal male sexual function

A
  • intact libido
  • ability to achieve and maintain penile erection
  • ejaculation
  • detumescence
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2
Q

what is libido and what increases/decreases it?

A

Libido = sexual desire

Increased by sex steroids (testosterone)
decreased by hormonal/psychiatric disorders and medication

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3
Q

what is needed to achieve and maintain a penile erection

A
  • Intact autonomic and somatic nerve supply
  • Functional musculature of corpora cavernosa and pelvic floor
  • Intact arterial blood flow to penis
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4
Q

what CNS levels are common in central (psychogenic) erectile stimulus and reaction

A

T11-L2
more common in maturity

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5
Q

what CNS levels are common in peripheral (reflexogenic) erectile stimulus and reaction

A

S2-S4
more common in early sexual activity

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6
Q

what starts and maintains erections

A

neurotransmitters! such as:

  • Nitric oxide (NO) - promotes vascular relaxation
  • also vasoactive prostaglandins, Ach, others
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7
Q

what occurs during the normal erection pathway

A
  • Relaxed smooth muscle in the corpora cavernosa and increased
    blood flow to the penis → engorgement
  • Trabecular smooth muscle compresses venous
    return, promoting retention of blood and
    maintaining erection
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8
Q

what triggers ejaculation? what is occuring during this time

A

sympathetic nervous system
- Contraction of epididymis, vas deferens, seminal vesicles, prostate
- Causes seminal fluid to enter the urethra → rhythmic contractions of bulbocavernosus and ischiocavernosus muscles → semen expulsion

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9
Q

what mediates detumescence and what occurs during this time

A
  • Mediated by norepinephrine, endothelin, smooth muscle contraction
  • Increases venous outflow and restores flaccid state
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10
Q

what is erectile dysfunction

A

“Consistent inability to attain or maintain a sufficiently rigid penile erection for sexual performance”

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11
Q

is erectile dysfunction part of the normal aging process

A

NOOO
but over 50% of men 40-70 years old have it!

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12
Q

what are some associated risk factors for erectile dysfunction

A
  • DM, obesity, BPH, HTN, CV disease, low HDL (also the meds that treat them)
  • smoking
  • local radiation/surgery
  • depression, anxiety, stress, anger.
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13
Q

what are the 3 basic mechanisms of ED

A
  1. failure to initiate erection - psychogenic, endocrinologic, neurogenic
  2. failure to fill penile tissue - arteriogenic
  3. failure to store adequate blood volume in lacunar network - veno occlusive dysfunction
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14
Q

what causes >80% of ED

A

DM
Atherosclerosis
medication

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15
Q

what is vasculogenic etiology for ED? what types of causes does it include?

A

disturbance of blood flow to or from penis!

MC organic cause of ED!
includes things such as:
atherosclerosis, traumatic arterial disease, and structural alterations to veins!

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16
Q

what is neurogenic etiology for ED? what types of causes does it include?

A

Trauma! - spinal cord injury, pelvic surgery, radiation

includes things such as multiple sclerosis and peripheral neuropathy (esp with DM and alcoholism)

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17
Q

what is endocrinologic etiology for ED? what types of causes does it include?

A

androgens increase libido

low testosterone - less libido
increased prolactin - suppresses GnRH and testosterone -> less libido

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18
Q

how common is ED in DM patients?

A

35-75%!

d/t vascular disease, neuropathy and decreased NO synthesis secondary to DM

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19
Q

what is psychogenic etiology for ED? what types of causes does it include?

A

psychological causes that inhibit reflexogenic responses and/or increases smooth muscle tone

MC causes:

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20
Q

How common is Medication etiology for ED? what types of meds typically cause this?

A

25% of men in general practice

  • anti-hypertensives (thiazides, BB, spironolactone)
  • hormonal (estrogen, GnHR agonists/antagonists)
  • antidepressants/antipsychotics (TCA, SSRI)
  • H2 antagonists
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21
Q

what are ED related questions you need to ask when obtaining a hx from a patient with cc of ED

A
  • attaining vs. maintaining?
  • chronic, situational?
  • any nocturnal erections?
  • Substances (tobacco, ETOH, drugs)
  • Medication history
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22
Q

what PE would need to be completed in a pt with a CC of ED

A

cardio
genital
Neuro

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23
Q

what labs would need to be done in a patients whos CC is ED

A
  • lipid profile
  • glucose
  • testosterone
  • prolactin
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24
Q

what special testing could be done in a patient with ED

A
  • direct injection of vasoactive meds (+ response = intact vasculature)
  • if no response, duplex US, cavernosography, ateriography
  • penile nocturnal tumescence study
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25
Q

what is the psychogenic component of treatment for ED

A

Behaviorally oriented sex therapy, counseling
Stress reduction

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26
Q

what is the medication options for treatment in ED

A
  • Oral phosphodiesterase-5 (PDE-5) inhibitors
  • Injection therapies
  • Testosterone replacement therapy
27
Q

what is the surgical options for treatment

A
  • Vacuum devices
  • Penile implants
  • Vascular surgery
28
Q

who is testosterone replacement therapy beneficial in

A

Only beneficial in men with documented hypogonadism and low testosterone levels

29
Q

what must you tule out prior to doing testosterone replacement therapy

A
30
Q

what are options for testosterone replacement therapy

A
  • transdermal (gels/patches)
  • intramuscular injection
  • oral (avoid d/t hepatotoxicity, efficacy is questionable)
  • hCG injections (can stimulate production)
  • buccal tablet, SC pellet, nasal (not studied, may be costly)
31
Q

how is transdermal testosterone used? what are the pros and cons?

A

applied to the skin daily!

Pros
- easy to use
- stable levels of testosterone

Cons
- skin irritation
- expensive
- transfer of testosterone to others

32
Q

how is intramuscular testosterone given? what are the pros and cons?

A

usually given Q1-2 weeks

pros
- biologically effective
- no transfer of testosterone
- inexpensive

Cons
- regular injections
-fluctuations in serum levels

33
Q

What are the potential SE of testosterone replacement therapy?

A
  • Prostate growth factor - increased prostate CA risk, BPH exacerbation
  • OSA worsening
  • Erythrocytosis
  • Skin irritations
  • Spermatogenesis suppression,
  • Improved bone density
  • Virilization, increased libido, aggression
  • Controversial - VTE, cardiovascular events
34
Q

How does a person need to be monitored when on testosterone replacement therapy

A
  • measure levels 2-3 months after starting tx and after dose changes
  • once stable, measure levels every 6-12 months
35
Q

what are DDI for testosterone

A
  • warfarin (surprise)
  • GnRH agonists/antagonists
  • steroids
36
Q

what is the MOA of PDE 5 inhibitors

A

inhibit PDE-5 enzyme which degrades cGMP, allowing sustained inflow of blood to penis

this is FIRST LINE for many patients!

37
Q

what are the PDE5 inhibitors, which one is the extended duration ones?

A
  • sildenafil (viagra) (take 1 hr prior)
  • vardenafil (levitra) (take 1 hr prior)
  • avanafil (stendra) (take 30 min prior)
  • tadalafil (cialis) longest duration! up to 36 hrs.
38
Q

which PDE5 inhibitors can you take with food?

A
  • avanafil
  • tadalafil
39
Q

what is the dosing idea for PDE 5 inhibitors

A

Start at the lowest dose and titrate to effect

40
Q

what are the SE for PDE 5 inhibitors

A
  • headache, flushing, dyspepsia
  • Dizziness and hypotension
  • Nasal congestion, rhinitis
  • Hearing loss, vision changes
  • Anterior optic neuropathy
  • Priapism (rare)
41
Q

what are CI for PDE 5 inhibitors

A
  • patients taking nitrates in any form (including PRN NTG)
  • severe CV disease with risk for CV event with intercourse
42
Q

what are the DDI for PDE5 inhibitors

A
  • nitrates
  • alpha blockers
  • antifungals
43
Q

what are the two modalites (this is not the right word) of prostagladin

A
  • intracavernosal injection - Vasoactive prostaglandin (alprostadil) injected directly into penile tissue at the base and lateral aspect
  • urethral suppository - less effective and costly
44
Q

what are the SE of injectable prostaglandins

A
  • local pain
  • bruising
  • dizziness
  • local pain
  • fibrosis
  • infection
  • priapism
45
Q

what are vacuum devices

A
  • Creates a vacuum chamber around the penis, thereby drawing blood into corpora cavernosa
  • after tumescence achieved -> elastic constriction band to proximal penis
46
Q

what are the SE and cons of vacuum devices

A
  • cons - cumbersome and can only use for max 20-30 min
  • Penile discomfort
  • irritation at band site
  • no forward ejaculation
47
Q

when is vascular surgery indicated in ED

A

Indicated for patients with vascular system disorders causing refractory ED

Surgery is rarely used due to low success rates, high cost, invasice and risk of complications

48
Q

what are the surgical methods that can be used with erectile dysfunction

A
  • Proximal arterial - endarterectomy, balloon dilation
  • Distal arterial - arterial bypass
  • Venous - ligation of specific affected veins
49
Q

what is penile prosthesis

A

a penile prosthetic implanted directly into corpora cavernosa
Semi-rigid (malleable) or inflatable
Custom-fit to individual patient

this is expensive and used for refractory cause

50
Q

what are complications to penile prosthesis

A
  • mechanical failure
  • infection
  • injury to surrounding structures during surgery
51
Q

how common is decreased libido in men, what may decreased libido be a sign of?

A
  • 5-15% of men; increases with age
  • Often accompanies other sexual dysfunction
  • May be a sign of androgen deficiency
52
Q

what is the MC ejaculatory disorder

A

premature ejaculation

53
Q

what are the 3 criteria for diagnosis of premature ejaculation

A
  • Brief ejaculatory latency
  • Loss of control to delay or stop ejaculation
  • Psychological distress in patient and/or partner
54
Q

what is the treatment options for primary premature ejaculation

A
  • SSRIs - paroxetine (1st line)
  • topical anesthetics - apply 5 min prior to sex
  • combo of pharm + counseling is most effective
55
Q

how do you treat secondary premature ejaculation?

A

correction of underlying ED

56
Q

what is delayed ejaculation

A

Inability to ejaculate, or ejaculation only with great effort after prolonged stimulation

57
Q

what are psychological causes of delayed ejaculation

A
  • religious background treating sex as “dirty”
  • lack of attraction to partner
  • anger toward partner
  • traumatic events
58
Q

what are physical causes of delayed ejaculation

A
  • blockage of spermatic ducts
  • injury to nervous system
  • ETOH
  • illicit drug use
  • psych medication
59
Q

what is the treatment for delayed ejaculation

A
  • Counseling, sex therapy
  • Medication adjustments
60
Q

what is retrograde ejaculation

A

Semen enters the bladder instead of emerging through the external urethral meatus during orgasm

aka “dry orgasm”

61
Q

when is retrograde ejaculation commonly seen?

A
  • commonly after BPH surgery!
  • also seen with other treatments for BPH such as:
  • Mechanical disruption of bladder neck, TURP
  • Pelvic radiation, sympathetic denervation
  • Alpha-blockers
62
Q

what is treatment for retrograde ejaculation

A

only treated if fertility is desired!

Imipramine, chlorpheniramine, pseudoephedrine used

63
Q

yay! donezo, flip for doggo

A

Clin med A 2 (30 decks)

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