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40 Cards in this Set

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How do you define erectile dysfunction?
Inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.
Whats the prevalence of ED?
-in 5% of men @ age 40, w/ prevalence increasing to 15-25% by age 65.
What are the #1 & #2 causes of erectile dysfunction?
1) Diabetes
2) Hypertension
Normal erectile dysfunction is a complex interaction b/w what factors?
1) Psychological fxn: STRESS is major factory b/c sympathetics kick in and men won't be able to erect.
2) Hormonal fxn: dec testosterone, hypogonadal
3) vascular fxn: surgery, dz
4) neurologic fxn.
Describe the movement of blood in a flaccid & in an erect penis.
1) Flaccid: blood going in = blood going out.
2) amt of blood going in is more than amt of blood going out. You stretch the lacunar bodies that closed off & hold blood in at all full erection there & no blood is going in & out.
What are the 3 neuroeffector systems that control smooth muscle relaxation & penile blood flow?
1) Adrenergic fibers, 2) Cholinergic fibers, 3) Nonadrenergic-noncholinergic fibers.
Vasodilation of the arteries in the penis is mediated by what?
Nitric oxide & cGMP following activation of cholingeric & nonadrenergic noncholinergic fibers.
What causes relaxation of the corpus cavernosum?
Prostaglandin E1 (smooth muscle dilator)
What are the causes of ED?
Vascular Dz, Neuropathy (ex. DM-pudendal N-->erection), iatrogenic factors (radical prostatectomy), congenital abnormalities, peyronie's dz, psychological processes, drugs
When doing a Hx & PE, what are some risk factors for ED?
HTN, Hyperlipidemia, Hypogonadism, Endocrine d/o's, endocrine disorders, smoking, alcohol abuse, drug abuse (alcohol, estrogens, antiandrogens, H2 receptor blockers, anticholinergics, ketoconazole (tx for prostate cancer b/c blocks testosterone production), antidepressants, marijuaa, anti-HTN, narcotics, beta blockers, psychotropics, cigarettes, cocaine, spironolactone, lipid-lowering agents, NSAIDs, cytotoxic drugs, diuretics)
In diagnosis of ED, what should be done in PE?
1. Assessment of secondary male sexual characteristics
2. Femoral & lower extremity pulses
3. Focused neuro exam (perianal sensation, sphincter tone, bulbocavernosus reflex, PBI-biothesiometry when neuropathy is suspected)
4. Eval of prostate size by DRE
5. Detection of Peyronie's plaques.
What are the lab tests done for a patient who comes in with erectile dysfxn?
1. morning testosterone specimen
2. serum prolactin
3. Tests for other systemic dz
-CBC, urinalysis, serum creatinine, glucose, lipid profile (pts w/ hyperlipidemia have good chance of having vascular insufficiency)
-thyroid fxn tests.
What are the special tests indicated for pts coming in for ED diagnosis?
1. Vasoactive agent injection - prostaglandin E used b/c its a potent smooth muscle dilator (diagnostic tool & tx),
2. Nocturnal penile tumescence (screens for psychogenic vs organic ED)
3. Duplex ultrasonography.
4. DICC
5. Pharmacoarteriography.
What are the tx options for ED?
-psychosexual counseling
-hormone replacement
-vacuum pumps & constriction devices
-penile implants
-vascular surgery --not done anymore
-injectable meds (for those who can't take oral)
-oral meds.
When is psychotherapy and/or behavioral therapy alone effect for ED?
when no organic cause of ED is evident
When is individual or couples therapy for ED helpful?
Individual therapy--primary ED.
Couples therapy--secondary ED
In which ED patients will androgenic steroids be helpful?
-in ED pts w/ hypogonadism;
Does exogenous testosterone cause prostate CA?
NO, but it will make it more aggressive. It may just increase the risk of prostate hypertrophy & CA.
How does it exogenous testosterone effect sexual fxn?
-It can suppress remaining endogenous androgen production; may be metabolized to estradiol w/ potentially detrimental effects on sexual fxn (dec)
What's the most commonly used device for ED?
Vacuum constriction devices; It creates a negative P that sucks blood into cavernous tissues. High success rate, pt satisfaction. No tests req'd beyong initial eval.
What are the adverse effects of the vacuum constriction devices?
-Hematoma, eccymosis, petechiae;
-Pain, numbness of penis; blocked &/or painful ejaculation; pulling of scrotal tissue into vacuum cylinder.
What ED device ALWAYS works? What are the 2 types?
Penile implants; Types: semirigid & multicomponent inflatable;
-Avg life of prostheses: 7-10 yrs.
-Good in pts who fail or refuse tx's
-Needs pt/partner screening & education.
What are the complications of penile implants?
Perioperative infection (2%), device malfunction (4%), repeat surgery (9%)
What is the only erectile tissue in the penis?
Corpus cavernosum
What is the biggest problem w/ using a vasoactive intracavernosal injection like alprostadil oor phentolamine (basically injection of prostaglandin E)?
Priapism (injection > 4 hrs)D

(self-injection-->always midshaft, never 6 or 12 o'clock;
What are the disadvantages of using vasoactive intracavernosal drugs?
-Poor long term tolerability: many stop during 1st yr;
-Adverse effects: bruising, prolonged erection, pain, induration, plaque, nodule, curvature of penis, superficial infection, dizziness
Do viagra or levitra cause priapism?
No b/c they're just vasodilators.
In the transurethral version of aprostadil, 35.7% of men reported what adverse sx even though this did not cause them to discontinue drug usage?
Penile pain --the had no priapism or penile fibrosis)
What are the 3 types of existing oral therapies for ED?
1. Yohimbine-very old drug, not very effective.
2. Trazodone -psych drug w/ SE of priapism;
3. L-arginine;
What are the 2 drugs now under investigation for ED (oral)? What is the 1st FDA approved agent?
Apomorphine & Phentolamine;
FDA approved: Sildenafil
Whats the MOA for Sildenafil?
-Selective & potent PDE V inhibitor; Phosphodiesterase breaks down cGMP; Inhibition gives more cGMP thus more vasodilation. NO acts thru 2nd messenge, cGMP, in nl development of erections;
Whats the predominant PDE enzyme in the corpus cavernosum?
PDE type V
Whats the important side effect of Sildenafil?
Blue haze b/c of vasodilation due to PDE in eye.
Does Sildenafil show effectiveness in all groups of patients including those w/ DM, spinal cord injury, radical prostatectomy, pts w/ ED of psychogenic origin (confidence builder)?
YES!
If patient goes to the hospital w/ chest pain, why is it important that they tell their doctor that they're on viagra?
B/c they'll be put on a nitrous drop for the chest pain and get severe vasodilation and thus hypotension leading to shock & death!
Whereas 79% of patients w/ ED use an oral med like trazodone or yohimbine, their satisfaction rate is only 16%. However, 2% of ED pts use surgery & whats their satisfaction rate?
100%
What is the usual basis of erectile dysfunction?
Organic basis
Best treatments of ED involve who?
your sexual partner
What is the first step in treating ED?
Recongition--PCPs need to discuss sexual health & fxn w/ their patients.
Are there effective treatments available for all types of ED?
Yes!