Sexual problems Flashcards
(43 cards)
Questions to ask in sexual problem history?
- When did it start?
- Does it happen at all times/with all partners?
Physical factors - Any significant past medical history/medication/ any CPPS symptoms?
Psychosocial factors
- How do you feel when it happens
- How does your partner respond?
- Any problems with ….arousal, libido, pain or orgasm?
What are the causes of primary/lifelong premature ejaculation?
Psychogenic
lack of sensory awareness
lack of learned control
What are the causes of secondary premature ejaculation?
- psychogenic- anxiety/stress
- Relationship- performance pressure, anger
- Social- pressure of perceived norms
- Organic- associated erectile problems, hyperthyroidism, neurological- MS, DM, pelvic surgery
What is 1st line treatment for Premature ejaculation?
Information- reassure, common Sex therapy- psychology, stop/start PFE Self help Ix/Rx if required (eg for CPPS) Medicines eg EMLA, SSRI antidepressants, PDE5I
Which antidepressants are used in PE?
Off license SSRI’s Eg Paroxetine 20mg daily 4-6 weeks then PRN Dapoxetine - 1st Licensed Medication •Short acting SSRI •30mg (or 60mg) 1-3 hours before sex
What are the side effects of SSRIs?
S/E’s include nausea, dizziness & headache;
Risk of orthostatic hypotension & syncope
Which nerve roots regulate male erection
Parasympathetic nervous system S2-4
Which nerve roots regulate male ejaculation?
Ejaculation Sympathetic nervous system L1-L2
What was most common sexual problem identified in NATSAL3?
Low libido
Premature ejaculation? (both 14.9%)
Then ED (12.9%) Physical pain least common 1.9%
Which examinations may need to be considered in people presenting with sexual problems?
General inspection Cardiovascular system Neurological system Abdominal system Musculoskeletal system
What might you consider in a 42 yo man with recent ED
BMI 37
Smokes 20 cod
Consider fasting glucose and lipids- ?silent underlying coronary artery disease
All men with ED should have a morning serum testosterone measured
(Hypogonadism is also a possibility)
Consider endocrine tests-
SHBG, FSH, LH and prolactin
(decline in sexual desire due to the possibility of prolactinoma.)
Do men with primary PE need any investigations?
No
Common prescription medication that can cause ED?
Carbamazepine TCAs SSRIs Lithium Methydopa beta blockers verapamil Digoxin Methotrexate Cyclophosphamide Thiazides Spironolactone Oestrogen/progestogen Steroids Cimetidine/ranitidine
It is recommended in ED that all patients have the following investigations
Cardiovascular risk assessment- smoking history, lipid profile, diabetes screening, blood pressure, BMI, and family history
FSH (if low testosterone)
LH (if low testosterone)
Prolactin
Early morning testosterone
PSA (only if clinically indicated or replacing testosterone)
TSH (some circumstances eg PE)
Treatment options for ED?
Specific treatments:
Corrective surgery (penile deformity, trauma)
Drug induced (treatment switch)
Androgen replacement therapy (hypogonadism)
Generic treatments: Psychosexual therapy Oral pharmacotherapy Vacuum constrictive devices Intraurethral and intracavernosal therapies Penile prosthesis
PDE5 I- list types and onset of action
Sildenafil (viagra) PRN
Onset of action 30-90 minutes
Half-life 3-5 hours
Vardenafil (levitra) PRN
Onset of action 25-50 minutes
Half-life 4–5 hours
Tadalafil (cialis)- once daily dosing
Onset of action 30 minutes to 2 hours (not affected by food)
Half-life 17.5 hours
5mg once a day is also licensed for lower urinary tract symptoms related to benign prostatic hyperplasia (BPH). This may be the treatment of choice for erectile dysfunction in men with BPH.
Avanafil (spedra)
Doses available 50mg, 100mg, 200mg
Onset of action 30-60 minutes
Half-life 1.5 hours
Can you use PDE-5 inhibitors if patient is on ARV or enzyme inducers?
Caution, - ? use a reduced dose in those taking concurrent medications affecting CYP450 isoenzymes (e.g. ritonavir)
These isoenzymes are responsible for the metabolic clearance of PDE-5 inhibitors and can lead to dangerous boosting of PDE5i levels.
When can you consider switching PDE5 I?
Before being considered non-effective, each drug should be administered at least four times (preferably eight) at the highest dose tolerated.
After this, patients should be switched to an alternate PDE-5 inhibitor, commencing at the highest dose.
When might PDE-5 inhibitors be contraindicated?
Contraindicated with nitrates
Nitrates (e.g. nitroglycerine, isosorbide mononitrate, amyl nitrate ‘poppers’) are absolute contraindications to the use of PDE-5 inhibitors. This also includes nicorandil.
Use of these results in cGMP accumulation and unpredictable drops in blood pressure, sometimes profound.
If a patient develops angina and PDE5i has been taken, glyceryl trinitrate (GTN) must be avoided for at least 24 hours (sildenafil, vardenafil) and for at least 48 hours with tadalafil.
What are the common side effects of PDE-5 inhibitors?
Common side effects include
Headache
Flushing
Heartburn
What needs to be excluded before starting testosterone?
Check PSA.
Androgens can enhance the growth of any existing prostatic carcinoma.
Therefore, carcinoma of the prostate has to be excluded before starting therapy with testosterone preparations.
When might testosterone be considered as treatment for ED?
In men with serum testosterone <12 nmol/l and symptoms consistent with hypogonadism
When should testosterone levels be taken?
There is a significant diurnal variation in serum testosterone levels.
It is recommended that testosterone levels are measured between 8 am- 11am.
Testosterone levels in men have also been shown to decrease after a meal.
The levels of free and bioavailable testosterone can be calculated and may further guide therapy
When should testosterone levels be measured in ED?
Testosterone should be measured in all patients presenting with erectile dysfunction