Erectile Dysfunction

Question 1

Normal Male Sex Function Components

Answer 1

• Libido
• Penile Erection
• Orgasm/ejaculation
• Fertilization

Question 2

Types of Sexual Dysfunction

Answer 2

• Decreased libido
• Erectile dysfunction (impotence)
• Abnormal ejaculation (premature, delayed, retrograde)
• Infertility

Question 3

Erectile Dysfunction

Answer 3

Failure to achieve penile erection suitable for sexual intercourse

Question 4

Penile Anatomy

Answer 4

• 2 dorsolateral cylindrical bodies
• Corpora cavernosa
• 1 midventral corpus spongiosum - encloses urethra and expands distally to form glans penis
• Tunica albuinea - thick, fibrous sheath enclosing cavernosa
• All bodies surrounded by deep, fibrous tissue called Buck’s fascia

Question 5

Penile Circulation

Answer 5

• Cavernosal tissue - spongelike with mesh interconnected cave like spaces
• Lined by vascular endothelium and separated by trabeculae
• Blood supplied by cavernosal arteries (branches of penile artery)
• Three sets of veins - deep, intermediate, and superficial veins
• Deep veins drain the cavernosa and spongiosum

Question 6

Physiology of Erection

Answer 6

• Sexual stimuli elicits response from CNS to penile nerves and endothelial cells
• ACh = important neurotransmitter
• Cavernous nerves and endothelial cells release NO
• NO stimulates formation of cGMP which causes relaxation of smooth muscle and allows for increased blood flow
• Trabecular spaces expand and erection is achieved
• Expansion compresses the venules to prevent blood from leaving penis

Question 7

Types of Erections

Answer 7

1. Psychogenic - initiated primarily by CNS stimuli received/generated by brain
2. Reflexogenic - result of direct stimulation of penis/surrounding tissues
3. Noctural - occurs during REM sleep, increases oxygen to penis

Question 8

ED Factors

Answer 8

• Vascular insufficiency
• Neurogenic - impair cholinergic innervation
• Endocrine - low testosterone or increased prolactin
• Psychological - disease states like depression

Question 9

ED Etiologies

Answer 9

1. Psychogenic - origin from mental and emotional processes
2. Organic - medical conditions, structural abnormalities, medications, surgery, trauma, endocrine malfunctions

ALMOST ALL ARE BELIEVED TO BE A COMBO OF THE TWO

Question 10

Diseases + ED

Answer 10

• Heart disease (CAD)
• Hypertension
• Diabetes
• Depression
• Chronic renal disease
• Prostate cancer
• Neurologic diseases

Question 11

ED Risk Factors

Answer 11

• Stress
• Lifestyle - smoking, drinking
• Surgery - radical prostatectomy, TURP
• Trauma
• Local disorders of penis
• Medications

Question 12

Medications + ED

Answer 12

• CV drugs - digoxin
• Diabetic drugs
• Anti-angrogenic agents - spironolactone, cimetidine, ketoconazole
• Anticholinergic agents
• Alpha adrenergic agonists
• Dopamine blockers
• Hypertensive meds - diuretics, B-blockers
• Antidepressants - SSRI, TCA
• NSAIDs

Question 13

ED Evaluation

Answer 13

• History and physical
• Consider SHIM in patients with risk factors
• Medication history
• Labs

Question 14

ED + Labs

Answer 14

• Testosterone, prolactin
• Fasting lipid panel
• Fasting blood sugar
• Complete blood count
• Creatinine and urinalysis
• TSH

Question 15

SHIM

Answer 15

• Five specific questions about sexual health
• Over past 6 months
• Scores =< 21 require further evaluation

Question 16

ED Affects

Answer 16

• Creates mental stress
• Affects family interactions
• May cause depression, loss of self-esteem, poor self image

Question 17

ED Treatment Options

Answer 17

• Counseling: primarily psychogenic
• Non-pharm: vacuum erection devices
• Pharm: oral, injectable, intraurethral
• Surgical: implants, vascular surgery
• Treatment should be reserved for patients with documented ED

Question 18

Primary/Secondary Hypogonadism Symptoms

Answer 18

• Decreased libido
• Malaise
• Loss of muscle strength
• Depressed mood
• Low serum testosterone (300-1100)

Question 19

PDE5 Inhibitors

Answer 19

• Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra)
• Inhibits PDE5, enzyme that breaks down cGMP
• PDE5-I enhances NO effect and allows for cGMP to remain in the body for longer time periods

Question 20

PDE-I CI

Answer 20

• Organic nitrates use regularly or intermittently in any form (separate S/V by 24 hours, T by 48)
• Resting hypotension (<90/50)
• Retinitis pigmentosa
• Allergic

Question 21

ED + CV - Low Risk

Answer 21

• Well-controlled HTN
• Mild, stable angina
• Mild CHF (NYHA class I and II)
• Mild valvular disease

Question 22

ED + CV - Intermediate Risk

Answer 22

• Moderate, stable angina
• MI within 2-8 weeks
• Moderate CHF (NYHA class III)

Question 23

ED + CV - High Risk

Answer 23

• Unstable angina
• Uncontrolled HTN
• Severe CHF (NYHA Class IV)
• Recent MI/stroke within 2 weeks
• Moderate/severe valvular disease
• High-risk cardiac arrhythmias
• Obstructive cardiac myopathy

Question 24

Risk Factors + Treatment

Answer 24

• Low: Start PDE5
• Intermediate: CV workup
• High: PDE5 contraindicated

Question 25

Specific Cautions/CIs for PDE-I

Answer 25

- Vardenafil/Tadalafil: caution when using with alpha-blockers - Sildenafil: with doses greater than 25 mg, delay alpha-blockers by 4 hours - Avanafil: should be on stable doses and hemodynamically stable

Question 26

PDE5-I AE

Answer 26

- Headache - Dyspepsia - Flushing - Rhinitisto light/nasal congestion - Myalgia and back pressure - Decreased blood pressure - Increased sensitivity to light, loss of blue-green color discrimination - Vision loss - Hearing loss

Question 27

PDE5-I Counseling Considerations

Answer 27

- Physician should discuss with patients the potential cardiac risk of sexual activity and symptoms - Use of organic nitrates in any form - Painful/long lasting erection (greater than 4 hours) - Doesn't protect against STDs - Engage in sexual stimulation for best response - Best response on empty stomach - Avoid alcohol - Try 5-8 times before declaring failure - Do NOT combine with any other therapy (including nonpharm)

Question 28

Additional ED Counseling

Answer 28

- Seek medical attention if sudden vision or hearing loss | - Those with testosterone deficiency may have better results combining PDE5-I and testosterone therapy

Question 29

Alprostadil

Answer 29

- Synthetic version of prostaglandin E1 (PGE1) - MoA: augments ACh activity, smooth muscle relaxes, blood flow increases, corpora cavernosa enlargesand preventing blood outflow - Results in erection without sexual stimulation - Available as both injection and intraurethral pellet - Limit to once a day or three times per week

Question 30

Alprostadil SE

Answer 30

- Nausea - Flushing - Hypotension - Penile pain - Penile/urethral injury - MUSE could cause vaginal burning or itching - Permanent fibrosis and dysfunction (1-15%)

Question 31

Alprostadil CI

Answer 31

- Increased risk for priapism, sick cell disease, leukemia, multiple myeloma - Risk from bleeding at injection site - anticoagulation

Question 32

Vacuum Erection Devices

Answer 32

- Therapeutic option - All consist of cylinder, vacuum pump, constriction ring - Ring prevents venous drainage and maintains ridigity

Question 33

Reasons to D/C Penis Pump

Answer 33

- Lack of spontaneity - Difficult to use - Discomfort - Delayed onset of erection

Question 34

Penis Pump Safety

Answer 34

- Most complications are minor: petechiae, numbness, ejaculatory discomfort - Ischemia - if ring is used for long periods - Avoid in those using anticoagulants

Question 35

Penile Implants

Answer 35

- Surgical prosthetic devices - Semirigid (always erect) and inflatable options - Used when other therapies fail - Destroys corporal tissue - Inflatable devices are prone to mechanical failure

Question 36

Implant Complications

Answer 36

- Infection - Erosion - Mechanical failure - Repeated surgery to remove or replace implant

Question 37

Vascular Surgery

Answer 37

- Vascular problems are key causes in many ED patients - Damage can be arterial or venous system - Venous surgery NOT recommended

Question 38

Patient Education/Counseling

Answer 38

- Treat underlying cause - Non-drug approaches: stop smoking/drinking, diet, exercise - Identify/replace offending drugs if possible - Be private, empathetic, and respect preferences