Repro - 1-19 - Erectile Dysfunction

Front 1

3 cylinders in the penis

Back 1

2 - corpus cavernosum (erectile tissue)

1 - corpus spongiosum - ends in the glans of the penis. a chamber that allows for expulsion of semen from the urethra.

Front 2

Blood supply of the penis

Back 2

Originates in the pelvis.
Pudendal arteries are the most important (has surgical significance)
The cavernous artery is a branch of the pudendal.

Front 3

Parasymp innervation of the penis

Back 3

Allows for tumescence (AKA erection)

Via NO and cGMP

Front 4

Sympathetic innervation of the penis

Back 4

Detumescence

Responsible for shrinkage (e.g. in cold water) too

Front 5

Somatic innervation of the penis

Back 5

Sensation - via the dorsal nerve of the penis.

Front 6

Categories of erection

Back 6

psychogenic (looking at stimuli)
Cortical output activates spinal erection center (S2-4)

Reflexogenic (from touching)
Tactile stimulus via dorsal nerve activates spinal erection center (S2-4)

Nocturnal (during REM)
Unknown mech activates spinal erection center (S2-4)

Front 7

Flaccid state

Back 7

Smooth muscle is tonically contracted with low arterial inflow.

Front 8

Stimulated state

Back 8

Release of NTs leads to SM relaxation in sinusoids so they expand and eventually become filled.
Arterial dilation leads to increased blood flow into the sinusoidal space.
Expansion of sinusoids compresses emissary veins so blood is effectively trapped.
Then an increase in intracavernosal pressure leads to rigid erection with contraction of the ischiocav muscles.

Front 9

NO pathway

Back 9

release of NO from nerve terminal or endothelial cell diffuses into the cell and activates guanylate cyclase to make cGMP, which basically activates SM relaxation.

Front 10

PDE5

Back 10

degrades cGMP to 5'GMP

Front 11

To get an erection with Viagra or something like that...

Back 11

you need to be STIMULATED (it maintains the erection and makes it stronger - but you need to make cGMP on your own)

Front 12

Prostaglandin E1

Back 12

relaxes SM cells as well - injected directly into the penis.

Front 13

Risk factors for ED (lifestyle)

Back 13

same as CV disease/stroke/PAD...

sedentary
obesity
heavy drinking
recreational drugs
smoking

Front 14

Psychogenic subclassifications of ED

Back 14

I - anxiety, fear of failure
II - depression (incl drug and disease induced)
III - marital conflict or strained relationship
IV - ignorance, misinformation, religious scruples.

Front 15

Neurogenic ED

Back 15

Central (Parkinson's, stroke, etc)

Spinal Cord (spina bifida, MS, etc.)

Peripheral autonomics (post-surgical, EtOH, diabetes, vitamins deficiency)

Front 16

Arteriogenic ED

Back 16

Atherosclerotic or traumatic (e.g. bicycle seats)

THIS IS THE MOST COMMON CAUSE OF ED

Front 17

Drug-induced ED

Back 17

beta blockers (decreased libido)
spironolactone
ketoconazole
cimetidine
antipsychotics

Front 18

Endocrine ED

Back 18

diabetes (due to arteriogenic and neurogenic issues)

thyroid disease

testosterone deficiency (but note that this is overdiagnosed)

Front 19

Labs to order

Back 19

Testosterone, LH, TSH, lipid and chol, A1c, prolactin

Front 20

Does Viagra help health people?

Back 20

no

Front 21

Which PDE5 inhibitor lasts the longest?

Back 21

Tadalafil (Cialis)

Front 22

One serious issue with PDE5 inhibitors

Back 22

psychological addiction

Front 23

Contraind with Viagra

Back 23

Organc nitrates.

Because you build up cGMP with them.

Front 24

Common SEs of PDE5 inhibitors

Back 24

HA, facial flushing, dyspepsia, visual effects.

all these are transient and mild-moderate.

Front 25

High cardiac risk pt who should not be rx PDE5 inhibitor because they shouldn't be exercising...

Back 25

Unstable angina, uncontrolled HTN, CHF, less than 2 weeks post-MI, critical arrythmia, cardiomyopathy, mod-severe vascular disease.

Front 26

Low cardiac risk pt

Back 26

have them resume sexual activity or tx for ED

Front 27

intermed cardiac risk pt

Back 27

CV assessment and recategorization

Front 28

One very serious but rare SE of Viagra

Back 28

loss of vision (38 cases of it) - less often with tadalfil.

Local NO and vasodilation disrupted the microvasc of the eye and caused reduced perfusion pressure in the posterior ciliary arteries.

Front 29

Vacuum erection device

Back 29

put a band around the base of the penis and trap the blood.

Front 30

Intraurethral prostaglandin E1

Back 30

diffuses through the corpus cav

literally goes in the pee-hole

Front 31

intracavernosal injection

Back 31

Papverine, phentolamine, PG E1

Better for a pt with neurogenic issue or less than optimal blood flow in.

Front 32

Papvarine

Back 32

inhibits phosphodiesterase

Blocks Ca++ influx

Front 33

Phenoxybenzamine/phentolamine

Back 33

alpha-blockade

Front 34

PG E1

Back 34

Vasodilation

Front 35

When to use penile prosthesis?

Back 35

resistant to meds

Front 36

Priapism

Back 36

Painful erection without detumescence

Aterial or venous.

Common with trazadone.

The erection can last for days and results in ischemic tissue. Causes irrev damage.

Tx with oral meds, irrigation, sympathomimetic agents and shunts (don't have to know all those)