Uro -ED and Infertility

What is erectile dysfunction?

inability to achieve or maintain an erection sufficient for satisfactory performance

Are most cases of ED organic or psychogenic in cause?

Organic

How is an erection maintained?

-relaxation of smooth muscle elements of the sinusoids with the corporal bodies of the penis

-contraction of the bulbocavernosus and ischiocavernosus muscles

What neurotransmitters initiate erection?

NO, acetylcholine, prostaglandins

What systemic & endocrine disease can cause ED?

DM

What anti-HTN meds that can cause ED?

BBs, thiazides, spironolactone, clonidine

What are RFs erectile dysfunction?

M > 40 yo, DM, dyslipidemia, HTN, CVD, drug use, smokers, alcoholics, obesity

What hormones should be checked when working up a patient with ED? What should be ordered if they are abnormal?

Serum testosterone and prolactin, if abnml then FSH and LH

What type of injection can be used as a special test for ED to stimulate an erection?

Papaverine

What is biothesiometry?

penile skin nerve test where a small electromagnetic test probe is placed on the right and left side of the penile shaft and on the glans

What is used to measure blood flow in the cavernosal arteries before and after the intracavernosal injection?

Penile US

What is considered an abnormal penile duplex doppler US?

peak systolic velocity < 25 cm/sec following intracavernosal injection is considered arterial insufficiency

What is nocturnal penile tumescence testing (RigiScan)?

used to differentiate between organic and psychogenic causes of ED by wearing a device 2-3 nights to monitor for erections during REM sleep

If the patient has an inadequate or absent erection during nocturnal penile tumescence testing, does this indicate a psychogenic or organic cause of ED?

Organic cause

When is angiography used to diagnose ED?

traumatic vascular injury

What patients should have neuro testing for ED?

Diabetic neuropathy, hx of CNS problems, penile sensory deficiency

What are the lifestyle changes for ED?

inc physical activity, healthy diet, smoking cessation, avoid drug/alcohol, tx underlying conditions (DM, hyperlipidemia)

What is the 1st line tx for ED?

PDE-5 inhibitors: sildenafil (Viagra) or tadalafil (Cialis)

What are CI for PDE-5 inhibitors?

use of nitrates or alpha-blockers (for BPH) → risk of profound hypotension

What PDE-5 inhibitor was found to be a safe and effective treatment for men with diabetes and ED as early as 15 min?

Avanafil (Stendra)

What are side effects of PDE-5 inhibitors?

Hypotension, color vision disturbances, HA, facial flushing, priapism

What alpha-blocker is an exception and CAN be used with tadalafil (Cialis)?

Tamsulosin (Flomax)

What are relative CI for PDE-5 inhibitors?

active coronary ischemia (not on nitrates), CHF, borderline hypotension, taking multiple HTN meds, taking 3A4 inhibitors

What are 3A4 inhibitors that may interact with PDE-5 inhibitors?

EES, cimetidine, ketoconazole, itraconazole

What prostaglandins can be injected into the penis for vasoactive therapy for ED? Where should they be injected?

Papaverine, Phentolamine, Alprostadil, at base and lateral aspect

What are SE of intracavernosal injections?

pain, priapism, bleeding, bruising, scarring

What is Alprostadil?

medication that stimulates adenyl cyclase to increase intracellular levels of cAMP → smooth muscle relaxation & vasodilation; pellets that are inserted w/ applicator into the urethra

What is an external erection-facilitating devices?

constriction device placed at the base of the penis to maintain their erection; for men w/ vascular (venous) leak phenomenon

How do external vacuum devices work?

draws blood into the penis via vacuum, after erection obtained a constricting band is placed at the base of the penis

What are indications for hormonal replacement for ED?

low libido, hypogonadism w/ ED

When is surgical revascularization indicated to tx ED?

ED secondary to trauma to pelvic arteries

When treating ED, what must be ruled out before using hormonal replacement?

Prostate cancer

What is the last option considered for treatment of ED?

Penile prostheses

What is the most important part of tx for patients with sexual problems?

Sexual counseling

T/F: Men who do not have organic dysfunction will benefit from sex therapy

True

What is infertility defined as?

failure to conceive after 1 yr of unprotected intercourse

What is Oligospermia?

Presence of <15 million sperm/mL in the ejaculate

What is Azoospermia?

Complete absence of sperm

What is Teratospermia?

abn shaped sperm

What is Asthenospermia?

reduced sperm motility

How long does spermatogenesis take?

~74 days (important to review pt hx and events for last 3 months!)

What is a genetic cause of male infertility?

Klinefelter’s syndrome

What is the MCC of male infertility?

Idiopathic

(#2 varicocele)

How do you check for a varicocele?

pt is standing & valsalva

How should a semen analysis be done?

2 separate samples, 1 week apart

pt should be abstinent 72 hrs and sample should be analyzed w/in 1 hr of collection

What is considered a normal semen analysis?

60% of sperm are motile, > 15 million, 1.5-5 mL

What grade of sperm motility in semen analysis:

No movement

Grade 0

What grade of sperm motility in semen analysis:

Sluggish movement

Grade 1

What grade of sperm motility in semen analysis:

Slow movement in a poorly defined direction

Grade 2

What grade of sperm motility in semen analysis:

Slow or curved forward movement

Grade 3

What grade of sperm motility in semen analysis:

Fast movement straight forward

Grade 4

What semen analysis result is the best predictor of success?

≥30% normal morphology

When is an endocrine evaluation warranted for male infertility? What should be ordered?

low or no sperm count → order FSH, LH, prolactin, testosterone

When is a Transrectal US (TRUS) used in infertility workups?

evaluates for complete or partial ejaculatory duct obstruction, particularly when the vasa are palpable and low ejaculate volume is noted

What is suggested by enlarged seminal vesicles on TRUS?

Obstruction

What is the "Gold standard" procedure for diagnosing pelvic, inguinal, scrotal, and vasal obstruction, but being replaced by TRUS?

Vasography

What is the purpose of post-masturbation urinalysis?

for azoospermic pts; sample is analyzed for sperm to confirm retrograde ejaculation

What may help with infertility?

identify/tx underlying cause, tx any GU infxn, pt education regarding timing of intercourse, avoid ALL lubricants, d/c toxic meds, no hot tubs