Sexual Medicine Flashcards
(79 cards)
1
Q
Major arterial supply to penis
A
pudendal artery
2
Q
Mechanism of erections
Release of _____
____ in cAMP & cGMP
____ in intracellular Ca++
smooth muscle ____
A
Release of NO
Increases cAMP & cGMP
Decreases Ca++
Smooth muscle relaxation
3
Q
Duplex penile doppler u/s
Normal values
Peak systolic > ___
End diastolic < ___
A
Peak systolic > 30
End diastolic < 5
4
Q
Venous leak ED leads to ____ end diastolic velocities
A
HIGH (>5)
5
Q
PDE-5 mechanism
Inhibits degradation of ____
A
inhibits cGMP degradation into GMP
6
Q
Take Viagra (sildenafil) ____ food
Take Cialis (tadalafil) ___ food
A
Viagra –> NO FOOD
Cialis–> okay for food
7
Q
Duration of action for Cialis (tadalafil)
A
36 hrs
8
Q
Duration of active for Viagra/Levitra (sildenafil/vardenafil)
A
4-6 hrs
9
Q
Protease inhibitors increase the _____ of PDE-5is
A
concentration (2-3x as potent)
10
Q
Separate alpha blocker & PDE-5i by ___ hrs to avoid cumulative hypotension
A
4 hrs
11
Q
PDE-5i side effects
A
Headache Facial flushing GERD Nasal congestion Diplopia, blurred vision, chromatopsia
12
Q
Trimix components & mechanisms
___ : cAMP activator
___ : PDE inhibitor
___ : alpha blocker
A
PGE-1 : cAMP activator
Papaverine : PDE inhibitor
Phentolamine : alpha blocker
13
Q
Psych med that is a contrindication to Trimix
A
MAOI
cannot give phenylephrine to reverse possible priapism*
14
Q
Pain with ICIs is due to ___ hypersensitivity
A
PGE-1
15
Q
Intra-urethral suppositories can cause ___ bleeding, priapism, and penile pain
A
urethral
16
Q
Vacuum contraindications
A
Anti-coagulation
Poor penile sensation
Poor cognition
17
Q
Infected IPP board answer for management
A
EXPLANT everything
18
Q
During IPP, you must abort if _____ perforation
A
urethral
19
Q
Ischemic priapism
___ flow
veno___
A
low flow
veno-occlusive (smooth muscle paralysis)
20
Q
Non-ischemic priapism
___ flow
___
A
high flow
arterial (cavernous artery to cavernosal fistula)
21
Q
Cause of Priapisms
A
ICI
Cocaine
Hematologic cancer
22
Q
Cause of Priapisms
A
ICI
Cocaine
Hematologic cancer
23
Q
1 diagnostic test for priapism
A
Corporal blood gas
24
Q
Purpose of distal penile shunt in priapism
A
return oxygenated blood to penis
rigidity may not improve
25
Last line treatment of non-ischemic priapism
Embolization
26
Xiaflex
Curvature between ___ & ___
Must have intact ____
30-90 degrees
erectile function
27
Biggest risk of intralesional collagenase for peyronie's
penile fracture
28
Treatment of patient with Peyronie's & severe ED OR peyronie's with hinging
IPP
29
___ nerve is responsible for ejaculate explusion
pudendal
30
Sensory stimulation of _____ nerve stimulates ejaculation
dorsal penile nerve
31
Majority of ejaculate is contributed by ___ & ____
epididymis & vas deferens
32
Process of ejaculation: Ejection
- Forcel contractions of the bulbospongiosus and ischiocavernosus in coordinatino with the external urethral sphinter lead to expulsion of semen.
Tight coaptation of the bladder neck is needed to prevent retrograde ejaculation
Process is mediated by the Somatic NS S2- S4 (not the bladder neck contraction)
33
Process of ejaculation: Emission
- Sperm from vas is deposited in the posterior urethra along with seminal fluid form the prostate and SV.
Bladder neck closes tightly to prevent retrograde ejaculation.
Under control of the sympathetic nervous system T10 - T12extending to the pelvic plexus then to the hypogastric nerves.
34
Part of brain that plays a central role in ejaculation in animal models
medial pre-optic area MPOA
stimulation induces ejaculation whereas ablation prevents it.
35
Medications approved by the FDA in the management of PE
None.
All meds are classified as off-label and include SSRIs: paroxetine, sertraline, Fluoxetine, TCA, Clomipramine, topical anesthetics
36
PDE5i MOA
PDE5i are competitive inhibitors of PDE5 by binding to the catalytic domain48 and hence promote high levels of cGMP in the penile vasculature
37
When should Sildenafil or Vardenafil be taken
1-2 hours prior to a meal.
Both are pyrazolopyrimidine compounds. Absorption is lowed by dietary lipids.
Peak absorption is 30-60 mins and T1/2 = 3-5 hours
38
PDE5i contraindications
The only strict contraindication to use of PDE5i is concurrent use of nitrate containing medications (e.g. sublingual nitroglycerin, isosorbide mononitrate or dinitrate)
PDE5i can also potentiate the hypotensive effect of alpha blockers
PDE5i are metabolized primarily by the cytochrome CYP3A4 system
39
PDE5i Adverse Events
The most common adverse events (AE) associated with this class of medications include headache, facial flushing, dyspepsia/heartburn, nasal congestion, visual changes, and myalgia
40
Phases of Male Sexual Response
* excitement/arousal: tachycardia, increase in blood pressure, penile erection, testicular retraction, sexual excitement
*Plateau: tachycarda, increase in blood pressure, muscle contraction, increasing sexual excitement.
*Orgasm: Pelvic muscular contractions, ejaculation, intense pleasure or satisfaction
*Resolution: Loss of penile erection, decline in heart rate, blood pressure, decreasing sexual excitement, refractory period
41
When is penile duplex doppler ultrasound indicated
i) patients with a high likelihood of psychogenic ED, to establish the absence of an organic etiology and provide reassurance to the patient,
(ii) men with the possibility of arteriogenic ED, where cardiology evaluation may be indicated,
(iii) young men with a history of pelvic trauma who might be candidates for surgical revascularization,
(iv) men with Peyronie's disease who are considering invasive intervention, and
(v) identification of men with severe veno-occlusive dysfunction who are unlikely to respond to medical therapy and should consider surgical intervention
42
What values are considered as evidence of arterial insufficiency vs venous leak
PSV < 25-30 cm/sec is considered evidence of arterial insufficiency (arteriogenic ED) and EDV > 5 cm/sec is consistent with venous leak
43
How can the dx of veno-occlusive dysfunction as cause of ED be confirmed?
cavernosography
44
Describe the phases of an erection
1. Flaccid: Arterial flow is low and corporal resistance is high d/t contraction of smooth msucle in the corporal arteries. pO2 is low at 35mmhg
2. Filing: Increasing firmness of the penis from increased blood flow
3. Full erection phase: erection of the penis to a non-dependent position. Partial pressure of O2 increase to 90 mmHg
4. Rigid Erection: Engorgement of the coprus spongiosum occurs as blood is forced into the penis by contraction of the pelvic floor musculature, intra-penile pressure may exceed systolic blood pressure.
45
Phases of penile detumescence
1. Slight rise in intracoporal pressure related to construction of the cavernousus arteries against the engorged spongy tissues of the corpora cavernosa
2. slow process of detumescence as partial venous drainage resumes
3. Third and final phase of detumescence is rapid and associated with complete restoration of venous drainage.
46
How does hyprolactinemia contribute to ED
Suppresses LH secretion
may be a/w prolactin secreting adenoma or medications that results in prolactin level increases
47
How does hyperthyroidism contribute to ED
Hyper-estrogenism
48
Medications a/w ED
-5-Alpha Reductase Inhibitors
Anti-androgens
LH-RH agonists/antagonists
Anti-hypertensives
H2 Blockers
Psychiatric Drugs
Digoxin
49
Major arterial supply to penis
pudendal artery
50
Mechanism of erections
Release of _____
____ in cAMP & cGMP
____ in intracellular Ca++
smooth muscle ____
Release of NO
Increases cAMP & cGMP
Decreases Ca++
Smooth muscle relaxation
51
Duplex penile doppler u/s
Normal values
Peak systolic > ___
End diastolic < ___
Peak systolic > 30
| End diastolic < 5
52
Venous leak ED leads to ____ end diastolic velocities
HIGH (>5)
53
PDE-5 mechanism
Inhibits degradation of ____
inhibits cGMP degradation into GMP
54
Take Viagra (sildenafil) ____ food
Take Cialis (tadalafil) ___ food
Viagra --> NO FOOD
Cialis--> okay for food
55
Duration of action for Cialis (tadalafil)
36 hrs
56
Duration of active for Viagra/Levitra (sildenafil/vardenafil)
4-6 hrs
57
Protease inhibitors increase the _____ of PDE-5is
concentration (2-3x as potent)
58
Separate alpha blocker & PDE-5i by ___ hrs to avoid cumulative hypotension
4 hrs
59
PDE-5i side effects
```
Headache
Facial flushing
GERD
Nasal congestion
Diplopia, blurred vision, chromatopsia
```
60
Trimix components & mechanisms
___ : cAMP activator
___ : PDE inhibitor
___ : alpha blocker
PGE-1 : cAMP activator
Papaverine : PDE inhibitor
Phentolamine : alpha blocker
61
Psych med that is a contrindication to Trimix
MAOI
**cannot give phenylephrine to reverse possible priapism***
62
Pain with ICIs is due to ___ hypersensitivity
PGE-1
63
Intra-urethral suppositories can cause ___ bleeding, priapism, and penile pain
urethral
64
Vacuum contraindications
Anti-coagulation
Poor penile sensation
Poor cognition
65
Infected IPP board answer for management
EXPLANT everything
66
During IPP, you must abort if _____ perforation
urethral
67
Ischemic priapism
___ flow
veno___
low flow
| veno-occlusive (smooth muscle paralysis)
68
Non-ischemic priapism
___ flow
___
high flow
| arterial (cavernous artery to cavernosal fistula)
69
Cause of Priapisms
ICI
Cocaine
Hematologic cancer
70
Cause of Priapisms
ICI
Cocaine
Hematologic cancer
71
#1 diagnostic test for priapism
Corporal blood gas
72
Purpose of distal penile shunt in priapism
return oxygenated blood to penis
**rigidity may not improve**
73
Last line treatment of non-ischemic priapism
Embolization
74
Xiaflex
Curvature between ___ & ___
Must have intact ____
30-90 degrees
erectile function
75
Biggest risk of intralesional collagenase for peyronie's
penile fracture
76
Treatment of patient with Peyronie's & severe ED OR peyronie's with hinging
IPP
77
___ nerve is responsible for ejaculate explusion
pudendal
78
Sensory stimulation of _____ nerve stimulates ejaculation
dorsal penile nerve
79
Majority of ejaculate is contributed by ___ & ____
epididymis & vas deferens
