Flashcards in Sexual Dysfunction Deck (25):
Definition of impotence?
Failure to attain erection of sufficient strength to carry out sexual intercourse - at least 25% of the time. PREVALENCE is HIGH (50% of men over 50)
What's thought to drive increased rates of impotence with older age?
2 neural systems leading to erection?
1) Central, forebrain limbic system -> generates sexual drive
2) Maintained by circulating androgens
- Increased parasymp inflow, decreased symp outflow
- Local parasymp reflex arc in response to tactile stimuli (penis--> spinal cord--> penis)
3 specific physiological events in the penis that cause erection?
1) Relaxation of helicine arteries in corpora cavernosa.
2) Relaxation of smooth muscle of trabeculae in corpora cavernosa.
3) Impeded venous drainage due to engorged corpora cavernosa.
First 2 GENERATE erection, 3rd one MAINTAINS erection
What drives blood vessel relaxation in erectile tissue at the molecular/cellular level? (She emphasized this..)
NO -> guanylate cyclase -> increased cGMP -> maintains vasodilation (erection)
- NO induces local changes in blood flow
- NO comes from 2 different sources (endothelial cells and from post synaptic parasymp neurons)
What are a few prescribed drugs that cause impotence?
Beta-blockers, ACEIs, anticholinergics, antihistamines, Disulfiram SSRIs, estrogens
6+ common causes of impotance?
1) Prostatectomy etc. (local reflex arc interrupted by scar tissue)
2) Diabetes, hypothyroidism
3) Vascular disease
5) Neuro disease (MS) and trauma
6) Liver and/or renal failure
Various ways to Dx ED?
Bulbocavernosis reflex test (test nerves)
Nocturnal Penile Tumescence (test for erections while sleeping)
Inject vasodilators (test for vascular cause)
Ultrasound or MR angiography
...but this isn't commonly done.
4 ways to treat underlying causes of ED?
1) Counseling if psychogenic.
2) Surgery if local abnormality (rare).
3) Adjust meds, if iatrogenic.
4) Testosterone, if androgen deficient.
What is alprostadil? How is it given?
A PGE1 analogue.
Intracavernosal injection (ouch) or intrameatal suppository.
What is the class of the drugs of choice these days for ED?
Oral PDE 5 inhibitors (Viagra)
What is a PDE 5 inhibitor (Sildenafil aka Viagra) actually do?
Inhibits cGMP phosphodiesterase isozyme 5, which will maintain vasodilation (but will NOT initiate erection--> for that need parasympathetic activation)
4 Important notes about the pharmokinetics of PDE 5 inhibitors?
1) Rapidly absorbed- rapid onset of acton
2) Concentrations peak at 30-90 minutes
3) Metabolized by CYP 3A4.*** (more likely to get priapism!)
4) Active metabolite prolongs the effect (longer half life than you'd anticipate)
5) Excreted renally
What is complication of PDE 5 inhibitors, especially if taking drugs that compete for CYP 3A4?
Priapism -> ischemic pain.
Aside from ED, what is another indication for PDE 5 inhibitors?
Primary Pulmonary Hypertension (shows that they're not totally specific for erectile tissue- do work on all PDE enzymes in body)
3 Common, less severe side effects of PDE 5 inhibitors?
1) Reduced esophageal motility -> reflux.
2) Altered color vision (blue green tinge)
3) Headache, flushing, rhinitis.
3 Cardiovascular adverse effects of PDE 5 inhibitors?
1) Hypotension and 2) Subsequent tachycardia -> can cause stroke or MI.
3) Platelet inhibition.
What's one particularly fatal drug to combine with PDE 5 inhibitors?
Nitrates for angina. Big problem- lots of old guys with chest pain trying to get busy... Taking both can lead to severe hypotension and can be lethal.
3 theories as to the origin of female sexual dysfunction (FSD)?
5 categories of things that cause female sexual dysfunction?
1) Psychological (anxiety, depression, etc.)
2) Diabetes / atherosclerosis
3) Trauma (physical)
4) Drugs (SSRIs, etc.)
5) Urinary incontinence (with associated anxiety)
What physiological test, rarely done, can provide an objective measure of physiological arousal?
Measuring vaginal pH - should increase during arousal.
Medical assessment for sexual dysfunction (i.e. things to rule out)? (4-5 things)
Diabetes, pituitary, thyroid disease
Neuro stuff: MS, trauma
3 categories of treatment for female sexual dysfunction?
Hormone Replacement Therapy (E, sometimes T)
3 forms of vascular treatment of female sexual dysfunction?
PDE5 inhibitors. (esp for SSRI-induced FSD)
Clitoral vacuum pump (Eros therapy)