Term
| what % of ED is thought to be psychologic? |
|
Definition
| 20% psychologic, 80% organic - may signal/accompany underlying disease |
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Term
| can ED be successfully treated in virtually all pts? |
|
Definition
|
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Term
| what is the definition of ED? |
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Definition
| the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance. |
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Term
| is ED an inevitable and untreatable consequence of aging? |
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Definition
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Term
| what % of physicians feel they are able to treat testosterone deficiency? what % ask male pts about sexual function? |
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Definition
| only 15% feel able to treat testosterone deficiency and only 28% asked male pts about sexual function. |
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Term
| who knows more about sex hormones and their relation to sexual function, men or women? |
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Definition
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Term
| do most pts believe that physicians should inquire about sexual function? |
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Definition
| yes, most think that their PCP should inquire about sexual function - therefore you should incorporate sexual history into the normal medical work-up for every patient |
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Term
| what risk factors need to be managed in terms of ED? |
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Definition
| smoking, alcohol, drug abuse, obesity |
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Term
| what comorbidities need to be managed in terms of ED? |
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Definition
| HTN, DM, (these 2 are the worst entities causing/worsening ED) depression, hyperlipidemia, CAD, peripheral vascular disease |
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Term
| what is a good way of opening the discussion for ED in DM/HTN pts? |
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Definition
| “many men with your medical condition experience sexual problems. has this happened to you?” |
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Term
| why is ED important to recognize systemically? |
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Definition
| ED may signal serious underlying disease: DM, HTN, cardiovascular disease, peripheral vascular disease, and neurologic disorders |
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Term
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Definition
| a neurovascular phenomenon - transforms the penis into an arterial organ |
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Term
| what are the 3 neuroeffector systems which control smooth muscle relaxation and penile blood flow? |
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Definition
| adrenergic fibers, cholinergic fibers, and nonadrenergic-noncholinergic (NANC) fibers |
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Term
| what is vasodilation in penile erection mediated by? |
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Definition
| *NO and *cGMP - following activation of *cholinergic and *NANC fibers |
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Term
| how does prostaglandin E1 affect the penis? |
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Definition
| prostaglandin E1 relaxes the corpus cavernosum |
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Term
| in the flaccid state, what is the vascular state of the penis? |
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Definition
| in the flaccid state, the penis is under venous O2 tension/pressure. (when flaccid-penis acts like a vein, when erect-penis acts like an artery) |
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Term
| what is normal erectile function dependent on? |
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Definition
| complex interaction between psychologic function, hormonal function, vascular function, and neurologic function |
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Term
| what are chronic diseases/conditions associated with low testosterone? |
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Definition
| DM (insulin resistance), chronic renal failure (hypogonadotropic hypogonadism), obesity, coronary atherosclerosis (link w/abdominal visceral fat), chronic liver disease (increase in serum estradiol, androstenedione, and SHBG), HIV/AIDS, and alzheimer's disease. |
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Term
| what are common causes of ED? |
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Definition
| vascular disease, neuropathy, iatrogenic factors, congenital abnormalities, peyronie's disease, psychological problems, and drugs |
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Term
| what is the link between ED and common comorbidities? |
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Definition
| screening for common disorders may reveal ED and vice versa - screening for ED may reveal common disorders |
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|
Term
| what are common comorbidities associated with ED? |
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Definition
| CAD, vasculopathy, HTN, DM, depression, drug/alcohol abuse, sleep disruption, and hormonal abnormalities |
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Term
| what other conditions does ED share endothelial injury with? |
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Definition
| DM, HTN, tobacco use, dyslipidemia, etc cause oxidative stress on the cells leading to endothelial injury (leading to vasoconstriction, atherosclerosis, thrombosis and ED). the penis may be the first organ "screaming for help". |
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Term
| what diseases are most prevalent among men, including those w/ED? |
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Definition
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Term
| what is the first step in tx for all male pts? |
|
Definition
| medical/sexual hx then physical/lab tests - *do not jump to tx w/o these first steps.* |
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|
Term
| what is the preferred therapy for ED by pts? |
|
Definition
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Term
| what are the first-line tx options for ED? |
|
Definition
| oral therapy (PDE5 inhibitors), psychosexual therapy, and vacuum constriction devices |
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Term
| what are the second-line tx options for ED? |
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Definition
| intraurethral tx, injection tx, combination tx |
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Term
| what is the third-line tx option for ED? |
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Definition
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|
Term
| what is particularly important when taking the hx for ED pts? |
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Definition
| note the nature, frequency of ED, and risk factors: concurrent diseases/drug use/psychiatric illness |
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|
Term
| what are some particularly common risk factors for ED? |
|
Definition
| prostate CA tx (sx, irradiation, antiandrogen tx), back sx (lower motor neuron problems, laminectomy) |
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Term
| what are some drugs commonly associated with ED? |
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Definition
| antihypertensives, diuretics (hydrochlorothiazide), lipid lowering agents, NSAIDs, alcohol, estrogens, antiandrogens, H2 receptor blockers, ketoconazole, antidepressants, marijuana, antihypertensives, narcotics, beta-blockers, psychotropics, cigarettes, cocaine, spironolactone, and cytotoxic drugs |
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Term
|
Definition
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Term
| what are important parts of the physical exam for ED pts? |
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Definition
| assessment of 2ndary male sexual characteristics, femoral/lower extremity pulses, focused neurologic exam: perianal sensation, sphincter tone, bulbocavernosus reflex, PBI/biothesiometry (when neuropathy suspected), exam of penile vasculature (doppler), evaluation of prostate size (DRE), and detection of peyronie's disease |
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|
Term
| what are important lab tests to order for ED pts? |
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Definition
| morning serum testosterone (highest in AM), serum prolactin (if testosterone is low), CBC, urinalysis, serum creatinine, glucose, lipid profile, and thyroid function tests. |
|
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Term
| what are special lab tests to order for ED pts? |
|
Definition
| *doppler flow US of the penis: measure diameter of corporal arteries w/ and w/o vasoactive substances. *nocturnal penile tumescence: screen for psychogenic vs organic ED (regiscan: pressure monitor, snap-gauge erection bands/stamp test: will break if erection occurs overnight). |
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Term
| what does post-workup ED pt management consist of? |
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Definition
| assessment of etiology/discussion of tx options along with immediate lifestyle modification implementation: diet, exercise, stress reduction, alcohol, smoking, and illicit drug use (if an issue). |
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Term
| what does education and counseling in ED pts consist of? |
|
Definition
| consideration of psychosocial factors (psycho/behavioral therapy may be enough tx), early intervention, education concerning normal sexual response, and individual therapy for primary ED/couples therapy for secondary ED |
|
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Term
| what are the limitations of counseling in ED pts? |
|
Definition
| outcome data for psychological/behavioral therapy not quantified, success rates for specific tx not documented/compared, and the success of psychological/behavioral therapy is unlikely in men w/organically-related ED |
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|
Term
| if testosterone levels are not normal in an ED pt, why will only oral tx not help them? |
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Definition
| their androgen receptors are not being stimulated |
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|
Term
| what characterizes androgenic steroid tx in ED pts? |
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Definition
| androgenic steroid tx may be effective in a small fraction of ED pts w/documented hypogonadism. there are no good oral testosterone replacements available at this point, so patches are used. *however: exogenous testosterone can suppress remaining endogenous androgen production, it may be metabolized to estradiol w/potentially detrimental effects on sexual function, and it may increase risk of prostate hypertrophy and CA. androderm, testoderm, and *androgel are all currently available testosterone replacement therapies. |
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Term
| what is the most common device used to tx ED? what characterizes its use? ADRs? |
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Definition
| vacuum constriction devices. no tests are required beyond initial evaluation, they have a high success rate (90%). ADRs: hematoma, ecchymosis, petechiae, pain, numbness, blocked/painful ejaculation, and pulling of scrotal tissue into the vacuum cylinder. |
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|
Term
| what are the 2 types of penile implants? what is their avg functional life? |
|
Definition
| semirigid and multicomponent inflatable - avg functional life: 7-10 yrs |
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|
Term
| what are complications associated with penile implants? |
|
Definition
| perioperative infection, device malfunction, repeat sx (5%/yr), and lack of normal physiologic erection after device removal |
|
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Term
| what parts of the penis are involved in penile implantation? |
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Definition
| there are 3 corporal bodies - 2 cavernosa and 1 spongiosa. the cavernosa are involved w/implantation and the spongiosa, which contains the urethra is not involved. |
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Term
| what characterizes vascular sx for ED pts? |
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Definition
| vascular sx (reanastomosis of inf epigastric artery w/dorsal penile vein/corpus cavernosal artery) for ED pts is generally considered experimental but it may be used to correct demonstrated venous leakage or have a limited role in correcting congenital vascular abnormalities/traumatic injury. however, a rubber band may work just as well. |
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Term
| what is vasoactive intracavernosal pharmacotherapy? |
|
Definition
| intracavernosal injection of a vasoactive agent (*alprostadil: prostaglandin E1, phentolamine, papaverine) *relaxes the cavernous and arterial smooth muscle - allowing filling of the penile sinusoids w/blood and *restriction of venous outflow. these agents may be used along or in combination to increase efficacy to reduce ADRs. vasoactive intracavernosal pharmacotherapy is effective in pts w/neurogenic, vascular, hormonal and psychogenic dysfunction. it is self-injected. |
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|
Term
| what are ADRs associated vasoactive intracavernosal pharmacotherapy? |
|
Definition
| bruising, prolonged erection, pain, induration/plaque/nodule, curvature of the penis, superficial infection, and dizziness. *also, many pts stop therapy during the first year b/c of self injection dislike (poor long-term tolerability). |
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Term
| what is transurethral alprostadil (MUSE)? ADRs? |
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Definition
| another method of administering alprostadil, where a pellet is inserted into the urethra. ADR: possible dysuria |
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Term
| what were existing oral therapies for ED before PDE-5 inhibitors? |
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Definition
| yohimbine (alpha adrenergic substance - causes higher blood pressure), trazodone (antidepressant w/priapism side effect), and L-arginine (herb) |
|
|
Term
| what are the newer, first-line oral therapies for ED? |
|
Definition
| PDE-5 inhibitors: sildenafil, vardenafil, and tadalifil |
|
|
Term
| what is the MOA for PDE-5 inhibitors? |
|
Definition
| NO is an NT which goes down the pudendal nerves and increases guanylate cyclase activity - creating more cGMP. however, PDE5 breaks down cGMP to GMP. cGMP is a very potent vasodilator, so blocking its breakdown by PDE5 results in *vasodilatation, smooth muscle relaxation and erection |
|
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Term
| why would PDE-5 inhibitors like sildenafil not work for some patients at all? |
|
Definition
| pts must have endogenous NO to start the process - so PDE-5 inhibitors will not work on pts who have had *lamenectomies or *radical prostatectomies with disruption in nerves to penis. |
|
|
Term
| how does time from first thought of intercourse to beginning of intercourse differ between men w/ and w/o ED? |
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Definition
| men with ED: 59 minutes, men without ED: 55 minutes. frequency of intercourse is also about the same between both groups. |
|
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Term
| what is the reason for some ADRs associated with PDE-5 inhibitors such as colorblindness and back pain? |
|
Definition
| there are other PDEs in the body, ie PDE-6 in the retina (colorblindness due to sildenafil) and PDE-11 in the testis/prostate/skeletal muscle/kidney (back pain due to tadalafil) |
|
|
Term
| how do the PDE-5 inhibitors differ in terms of half life? |
|
Definition
| sildenafil and vardenafil have similar, shorter half-lives and tadalafil (cialis) has a longer half-life (weekend drug) |
|
|
Term
| what is the general rule of thumb for when to take PDE-5 inhibitors? |
|
Definition
| take 2-4 hrs before intercourse on an empty stomach |
|
|
Term
| who are PDE-5 inhibitors absolutely contraindicated in due to drug interaction? other interactions? |
|
Definition
| any pt taking *nitroglycerine - due to hypotension risk. *alpha blockers should be used w/caution (not supposed to use w/in 4 hrs of PDE-5 inhibitor). any drug (erythromycin, ketoconazole, ritonavir, indinavir, etc) that inhibits CYP3A4 will cause decreased clearance of PDE-5 inhibitors (erection for days). |
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Term
| what do you do it a pt fails on PDE-5 inhibitor therapy? |
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Definition
| re-educate and re-challenge w/the same agent, then switch to another PDE-5 inhibitor, then try a different therapeutic approach (vacuum device, PGE1 injections, implants). *also make sure serum testosterone is correct, if not, prescribe androgel. |
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