Male GU and Testicular Disorders UPDATED ACTUAL
Questions and CORRECT Answers
Erectile Dysfunction "Consistent or recurrent inability to acquire or maintain an erection or sufficient
rigidity or duration for sexual intercourse"
Early warning sign of CVD (endothelial damage)
Increased with aging
Affects 50% of those ≥40
Neurogenic, arterial, venous, hormonal, or psychological causes
Review of Anatomy: Penis A lot of blood flow into corpus cavernosum and small amount into corpus
spongiosum. Dorsal arteries fed off of iliac.
Need good blood flow into structures in order to have tumescence or rigidity.
Physiology of Erection Neurological stimulation due to a male arousal --> leads to release of nitric
oxide (main NT and chemical mediator of erection) from nerve endings and
endothelial cells --> NO stimulates enzyme (guanylate cyclase) in smooth
muscle cells, leading to production of cyclic GMP which causes SM cells of
penile arteries to relax --> leading to blood flow into the corpora cavernosa
As corpora cavernosa fill with blood, venous outflow is compressed, trapping
blood and maintaining the erection.
Process is regulated by enzymes phosphodiesterase type 5 (PDE5) which
breaks down cGMP. PDE5 inhibitors (Viagra) helps prolong erection by
keeping cGMP levels elevated.
Etiologies of ED Vascular: CVD, HTN, DM, HLD, smoking, major surgery (radical prostatectomy),
or radiotherapy (pelvis/retroperitoneum)
Neurologic: Spinal cord and brain injuries, Parkinsons, Alzheimer's, MS, stroke,
major surgery (radical prostatectomy) or radiotherapy of the prostate
Local penile (cavernous) factors: Peyronie's disease, cavernous fibrosis, penile
fracture
Hormonal: Hypogonadism, hyperprolactinemia, hyper-and hypo-thyroidism,
hyper/hypo-cortisolism
Drug induced: Antihypertensives, antidepressants, antipsychotics,
antiandrogens, recreational drugs, alcohol
Psychogenic: Performance-related anxiety, traumatic past experiences,
relationship problems, anxiety, depression, stress
,RFs for ED -Advancing age
-Smoking
-T2DM
-Obesity
-Low testosterone
-HTN
-Dyslipidemia
-CVD
-Many medications and recreational drugs
Drugs of concern (that can lead to ED) Prescription:
-SSRIs, TCAs
-Spironolactone
-Sympathetic blockers (e.g. clonidine)
-5-alpha-reductase inhibitors (e.g. finasteride)
-Thiazide diuretics
-Ketoconazole
-Cimetidine
Recreational:
-Nicotine
-EtOH
-Marijuana
-Cocaine
-Heroin
-Anabolic steroids
Clinical clues to causes of ED Rapid onset: Psychogenic/genitourinary trauma: radical prostatectomy
Nonsustained erection: Anxiety/Venous leak
Depression or use of certain drugs: Depression/ Drug induced
Complete loss of nocturnal erections: Vascular disease/ Neurologic disease
Get a good history: ED • slow progression vs rapid onset
• libido
• relationship status
• erectile function
• ejaculatory function
• nocturnal tumescence: spontaneous erections during sleep. (typically, during
REM sleep) Normal, healthy physiologic occurrences
• meds
• risk factors
• IIEF-5 questionnaire
The IIEF-5 questionnaire Sexual desire or libido can be evaluated with the International Index of Erectile
Function (IIEF)
, ED: Physical Exam Check femoral and peripheral pulses
Inspection of genitalia
--> Deformities/penile plaques
Gynecomastia/ small testes/ lack of normal male hair patterns
Cremasteric reflex: stroke inside of thigh, should see movement of scrotum (if
not intact... think neurologic)
Visual fields (think... pituitary tumor)
ED Dx Labs to consider
-Testosterone
-Lipids
-TSH (hypothyroidism)
-Fasting glucose vs A1C: high blood sugar levels damage the blood
vessels/nerves affect ability to obtain erection
Nocturnal penile tumescence testing (NPT):
-Home testing
-NPT testing is generally performed when the clinician is trying to assess
between psychogenic and organic ED
Duplex doppler studies (if don't respond to meds)
-Duplex doppler US can help assess penile vascular function and characterize
normal and abnormal penile structural anatomy, as well as assessment of
abnormal blood vessels
Neurological testing
ASCVD risk... ED = increased risk for adverse cardiac events
ED Tx -Lifestyle modification (e.g., diet, exercise, smoking cessation, decreased EtOH
consumption)
-Reduction of CVD risk factors
-Identification and tx of underlying comorbidites (e.g., HTN, T2DM,
dyslipidemia, hypogonadism).
-Psychogenic component: counseling, sexual therapy
-Assess CV risk... may need a stress test
ED Pharmacotherapy: 1st line Phosphodiesterase type-5 (PDE-5) inhibitors (1st line)
• e.g., sildenafil (Viagra), vardenafil (Levitra; ODT), tadalafil (Cialis), avanafil
(Stendra)
• Stendra has quickest onset…~15 minutes at higher doses
• Cialis can be taken as a daily dose (2.5 mg) for spontaneity
• No impact on libido
• Priapism rare
• Contraindicated with nitrates
• Caution with concomitant use of alpha- adrenergic receptor blockers (e.g.
tamsulosin (Flomax))…↓BP
ED Pharmacotherapy: 2nd line Prostaglandins E1 injection (Aloprastadil): 2nd line
• Has vasodilatory properties
• Self Injection into corpora cavernosa
• Risks include priapism, plaque formation
Prostaglandins E1, intraurethral:
• Not as effective as injection
• Pain, bleeding, priapism
• Avoid use in those with Peyronie’s disease.
Questions and CORRECT Answers
Erectile Dysfunction "Consistent or recurrent inability to acquire or maintain an erection or sufficient
rigidity or duration for sexual intercourse"
Early warning sign of CVD (endothelial damage)
Increased with aging
Affects 50% of those ≥40
Neurogenic, arterial, venous, hormonal, or psychological causes
Review of Anatomy: Penis A lot of blood flow into corpus cavernosum and small amount into corpus
spongiosum. Dorsal arteries fed off of iliac.
Need good blood flow into structures in order to have tumescence or rigidity.
Physiology of Erection Neurological stimulation due to a male arousal --> leads to release of nitric
oxide (main NT and chemical mediator of erection) from nerve endings and
endothelial cells --> NO stimulates enzyme (guanylate cyclase) in smooth
muscle cells, leading to production of cyclic GMP which causes SM cells of
penile arteries to relax --> leading to blood flow into the corpora cavernosa
As corpora cavernosa fill with blood, venous outflow is compressed, trapping
blood and maintaining the erection.
Process is regulated by enzymes phosphodiesterase type 5 (PDE5) which
breaks down cGMP. PDE5 inhibitors (Viagra) helps prolong erection by
keeping cGMP levels elevated.
Etiologies of ED Vascular: CVD, HTN, DM, HLD, smoking, major surgery (radical prostatectomy),
or radiotherapy (pelvis/retroperitoneum)
Neurologic: Spinal cord and brain injuries, Parkinsons, Alzheimer's, MS, stroke,
major surgery (radical prostatectomy) or radiotherapy of the prostate
Local penile (cavernous) factors: Peyronie's disease, cavernous fibrosis, penile
fracture
Hormonal: Hypogonadism, hyperprolactinemia, hyper-and hypo-thyroidism,
hyper/hypo-cortisolism
Drug induced: Antihypertensives, antidepressants, antipsychotics,
antiandrogens, recreational drugs, alcohol
Psychogenic: Performance-related anxiety, traumatic past experiences,
relationship problems, anxiety, depression, stress
,RFs for ED -Advancing age
-Smoking
-T2DM
-Obesity
-Low testosterone
-HTN
-Dyslipidemia
-CVD
-Many medications and recreational drugs
Drugs of concern (that can lead to ED) Prescription:
-SSRIs, TCAs
-Spironolactone
-Sympathetic blockers (e.g. clonidine)
-5-alpha-reductase inhibitors (e.g. finasteride)
-Thiazide diuretics
-Ketoconazole
-Cimetidine
Recreational:
-Nicotine
-EtOH
-Marijuana
-Cocaine
-Heroin
-Anabolic steroids
Clinical clues to causes of ED Rapid onset: Psychogenic/genitourinary trauma: radical prostatectomy
Nonsustained erection: Anxiety/Venous leak
Depression or use of certain drugs: Depression/ Drug induced
Complete loss of nocturnal erections: Vascular disease/ Neurologic disease
Get a good history: ED • slow progression vs rapid onset
• libido
• relationship status
• erectile function
• ejaculatory function
• nocturnal tumescence: spontaneous erections during sleep. (typically, during
REM sleep) Normal, healthy physiologic occurrences
• meds
• risk factors
• IIEF-5 questionnaire
The IIEF-5 questionnaire Sexual desire or libido can be evaluated with the International Index of Erectile
Function (IIEF)
, ED: Physical Exam Check femoral and peripheral pulses
Inspection of genitalia
--> Deformities/penile plaques
Gynecomastia/ small testes/ lack of normal male hair patterns
Cremasteric reflex: stroke inside of thigh, should see movement of scrotum (if
not intact... think neurologic)
Visual fields (think... pituitary tumor)
ED Dx Labs to consider
-Testosterone
-Lipids
-TSH (hypothyroidism)
-Fasting glucose vs A1C: high blood sugar levels damage the blood
vessels/nerves affect ability to obtain erection
Nocturnal penile tumescence testing (NPT):
-Home testing
-NPT testing is generally performed when the clinician is trying to assess
between psychogenic and organic ED
Duplex doppler studies (if don't respond to meds)
-Duplex doppler US can help assess penile vascular function and characterize
normal and abnormal penile structural anatomy, as well as assessment of
abnormal blood vessels
Neurological testing
ASCVD risk... ED = increased risk for adverse cardiac events
ED Tx -Lifestyle modification (e.g., diet, exercise, smoking cessation, decreased EtOH
consumption)
-Reduction of CVD risk factors
-Identification and tx of underlying comorbidites (e.g., HTN, T2DM,
dyslipidemia, hypogonadism).
-Psychogenic component: counseling, sexual therapy
-Assess CV risk... may need a stress test
ED Pharmacotherapy: 1st line Phosphodiesterase type-5 (PDE-5) inhibitors (1st line)
• e.g., sildenafil (Viagra), vardenafil (Levitra; ODT), tadalafil (Cialis), avanafil
(Stendra)
• Stendra has quickest onset…~15 minutes at higher doses
• Cialis can be taken as a daily dose (2.5 mg) for spontaneity
• No impact on libido
• Priapism rare
• Contraindicated with nitrates
• Caution with concomitant use of alpha- adrenergic receptor blockers (e.g.
tamsulosin (Flomax))…↓BP
ED Pharmacotherapy: 2nd line Prostaglandins E1 injection (Aloprastadil): 2nd line
• Has vasodilatory properties
• Self Injection into corpora cavernosa
• Risks include priapism, plaque formation
Prostaglandins E1, intraurethral:
• Not as effective as injection
• Pain, bleeding, priapism
• Avoid use in those with Peyronie’s disease.
