Sexual Dysfunction

Question 1

What history should be obtained from a man with sub fertility?

Answer 1

Sexual function
Previous testicular problems/ injury (eg orchitis, trauma, undescended testes)
Medical problems (diabetes, epilepsy, tuberculosis, kidney disorders)
Past history of STI
Past history of mumps
Past history of urethral problems
Genitourinary surgery eg hernia
Recent severe febrile illness
Occupational history (exposure to heat, pesticides, herbicides)
Drug intake (possible adverse effects from): alcohol, chemotherapy, anabolic steroids, aminoglycoside, ranitidine, colchicine, narcotics, phenytoin, nicotine, marijuana)

Question 2

What is required for male fertility?

Answer 2

Normal hypothalamic function producing GnRH
Normal pituitary function producing FSH and LH
Normal seminiferous tubule and leydig cell function
Normal sperm transport and delivery

Question 3

What examination findings should be looked for in a man with sub fertility?

Answer 3

Secondary sexual characteristics
Note any gynaecomastia
Genitalia: size and consistency of testes, palpate epidydmis and vas (present and non tender), PR to check prostate, note penis and location of urethra (always retract foreskin)

Question 4

What initial investigation should be done in a man with sub fertility?

Answer 4

Semen analysis.

Question 5

What further investigations could be done in a man with sub fertility?

Answer 5

If azoospermia or severe oligospermia: serum FSH (if 2.5 x normal then indicates irreversible testicular failure), LH and inhibin (low inhibin indicates irreversible testicular failure), antisperm antibodies, sperm function tests, chromosome analysis, testosterone, testicular ultrasound

Question 6

What is erectile dysfunction?

Answer 6

Inability to achieve or maintain an erection of sufficient quality for satisfactory intercourse

Question 7

What are some causes of erectile dysfunction?

Answer 7

Psychogenic
Neurogenic eg MS
Vascular
Diabetes
Hypertension
Chronic kidney disease
Urological problems eg peyronie disorder
Hormone disorder eg androgen deficiency, hypothyroidism, hyperprolactinaemia
Drug induced eg alcohol, cocaine, cannabis, nicotine, antihypertensives 
Aging

Question 8

What investigations should be done for erectile dysfunction?

Answer 8

Free testosterone
Thyroid function
Prolactin
LH
Glucose
LFT (esp GGT for alcohol)
EUC 
Further tests include nocturnal penile tumescence, dynamic tests of penile function

Question 9

What management should be offered for erectile dysfunction?

Answer 9

Address modifiable risk factors including medications, psychosocial issues and lifestyle
Give testosterone for androgen deficiency, thyroxine for hypothyroidism, bromocriptine for hyperprolactinaemia
PDE-5 inhibitors are first line treatment. They do not initiate and erection but enhance whatever erection the man is capable of having. They are contraindicated if a man has unstable angina, recent AMI or stroke. They should not be used with 24 hours of a nitrate.
Other options include intracavernosal injections, transurethral alprostadil, vacuum constriction, surgery