ED

Question 1

What are the causes for ED

Answer 1

Organic ( VENAM )
Psychogenic

Question 2

How do you get an erection

Answer 2

Flaccid state ( most of the time )
NA, Endothelin , ATII,PGF2 activates receptors on the SM to initiate a cascade of reactions leading to —> Increased intracellular calcium , Activation of Rho- kinase —-> SM contraction

Erections ( Relaxation ) —-> parasympathetic nerve fibres—> Release ACh —-Binds to muscaranic receptors on endothelial cells —> Activates eNOs —-> NOs converts arginine into NO + citruline —> NO diffuse into the SM cell and activate Guanyl cyclase to convert GTP—> CGMP —-> Opens potassium channels —> sequestration of intracellular calcium —> less free calclium —> SM relaxation

Question 4

Phases of erection

Answer 4

• Flaccid
• Latent - subtunical plexus compression
• Tumesence = Emissary vein compression
• Full erection = complete emissary vein compression ( Pressure > 100mmHg)
• Rigid erection = Ischiocavernosus relflex contraction
• Initial detumesence - arteria vasoconstriction
• Slow detumesence - emissary veins open
• Fast detumesence

Question 5

History taking on pt with ED

Answer 5

History :
Presenting complaint
- ED onset , duration, severity , presence of morning erectons
- Sexual desire
- Ejaculation
- Orgasm
- IIEF5 score
- Sexual orientation
- Emotional status
- Curvuture
- LUTS ?

Trauma History - Penile fracture
Medical : Co - morbidities
Surgery
Medication
Screen for Hypogonadal function and OSA

Everyone must get a Cardiac risk score - QRISK3 = 10 year cardiovascular risk score

Question 6

QRISK

Answer 6

Include tha age, gender, ethnicity, BP, cholesterol, BMI, Smoking, Medical conditions ( DM, RA< CKD), FHx

QRISK < 10 % =0,1 Low
QRISK = 10-20 % Moderate
QRISK > 20 % high

10 yr ASCVD risk is similar to Qrisk

Question 7

CVS Risk assessment in patient with no cardiac symptoms

Answer 7

Question 8

Mx of ED in pt with CVS Sx

Answer 8

Question 9

Physical examination of pt with ED

Answer 9

Focused physical exam :
- Penile deformities
- Prostatic disease
- Signs of hypogonadism
- CVS status
- Neuro Satus

Question 10

Investigations for pt with ED

Answer 10

All pt
FBC, U&E
HBA1C
Lipogram
Testosterone

Urologist discretion = TSH , PSA

If TT is low :
- LH
- FSH
- Prolactin
- Free TT
- SHBG

Question 11

Specialised test for ED

Answer 11

Rigiscan - Nocturnal penile tumesence & rigidity scan

Penile Doppler Ultrasound
ICI injected
Measurement 10 mins after ICI with lineral array transducer
PSV > 35cm/sec and EDV< 5cm.sec = Normal

PSV <25cm/sec = Arterial insufficiency

EDV >5cm/sec =VOD

Dynamic infusion cavernosometry - Designed to asess Veno occlusive dysfunction
I : Primary ED, Hx of penile fracture/ Peyronies

Question 12

Treatment of ED

Answer 12

1. Identify the patients needs and expectations
2. Shared decision making
3. If any psychological component consider combined psycho sexual medical/physical treatment
4. Identify and treat curable causes for ED
5. Lifestyle changes
   - LOW
   - Control DM, HPT, METS
6. If pt is Hypogonadal —> Offer TRT
7. Offer all options
   - Oral PDE5i
   - Intra urethral / topical Alprostadil
   - Vacuum device
   - ICI

Assess outcome- if no adequate use , retrial
If no improvement = Penile Prosthesis

Question 13

How do you differentiate between psychogenic and organic ED

Answer 13

Question 14

How does Thyroid function relate to ED

Answer 14

Hyperthyroidism = ED
Hypothyroidism = Decreased libido

Question 15

What is the relation between MI and ED

Answer 15

ED can precede overt CVD by 2-5 years

Question 16

Pharmacological Treatment of ED

Answer 16

PDE5 i - MOA
BLocks the catalytic actionc of the enzyme that degrades cGMP to GMP

Contraindications :
Nitrate use
Severe CVS disease
Uncontrolled BP

Question 17

Mechanism of action of ICI

Answer 17

Question 18

Surgical options for ED

Answer 18

Question 19

Complications/ Side effects of PDE5i

Question 20

Complications/Side effects of ICI

Answer 20

Priapism
Alprostadil :Painfull erections
Phentolamine - Hypotension
Reflex tacchy
Nasal congestion
GIT upset

Papaverine - Liver enzyme elevation

Question 21

Complications/ Side effects of Surgery

Answer 21

Mechanical failure
Infection

Question 22

What is this ?

Answer 22

Inflatable hydraulic penile prosthesis

Question 23

What is this used for ?

Answer 23

Nocturnal penile tumesence and rigidity test
- Measures the nr of erections, tumesence, maximal rigidity and duration
Perform - 2 nights
Functional erection > 60 % rigidity > 10 min

To distinguish between organic and psychogenic ED