Erectile Dysfunction (ED) Definition  Inability to achieve or maintain an erection firm enough for intercourse Very common; prevalence increases with age May be vascular, neurologic, hormonal, medication-induced, or psychogenic  Risk Factors  

Erectile Dysfunction (ED) 
Definition 
<ul> 
<li>Inability to achieve or maintain an erection firm enough for intercourse</li> 
<li>Very common; prevalence increases with age</li> 
<li>May be vascular, neurologic, hormonal, medication-induced, or psychogenic</li> 
</ul> 
Risk Factors 
<ul> 
<li>Diabetes</li> 
<li>Hypertension</li> 
<li>Cardiovascular disease</li> 
<li>Smoking</li> 
<li>Obesity</li> 
<li>Low testosterone</li> 
<li>SSRIs, beta-blockers, thiazides, spironolactone</li> 
<li>Pelvic surgery (prostatectomy)</li> 
</ul> 
Clinical Presentation 
<ul> 
<li>Difficulty achieving or maintaining an erection</li> 
<li>Morning erections may be preserved in psychogenic ED</li> 
<li>Gradual onset suggests organic disease; sudden onset suggests psychogenic</li> 
<li>The question stem would likely describe a man with diabetes or vascular disease reporting difficulty maintaining erections</li> 
</ul> 
Diagnostics 
<ul> 
<li>Clinical diagnosis</li> 
<li>Basic labs: fasting glucose/A1c, lipid panel</li> 
<li>Serum testosterone (morning level) if hypogonadism suspected</li> 
<li>If unclear: nocturnal penile tumescence testing distinguishes psychogenic vs organic</li> 
<li>Consider cardiovascular evaluation because ED may precede coronary disease</li> 
</ul> 
Treatment 
<ul> 
<li>Lifestyle: weight loss, exercise, smoking cessation, reduce alcohol</li> 
<li>First-line medication: phosphodiesterase-5 inhibitors (sildenafil, tadalafil)</li> 
<li>Contraindication: nitrates (causes severe hypotension)</li> 
<li>Low testosterone → testosterone replacement when indicated</li> 
<li>Vacuum erection devices, penile injections (alprostadil), or penile prosthesis if refractory</li> 
</ul> 
Exam Keys 
<ul> 
<li>Gradual onset + vascular risk factors → organic ED</li> 
<li>Preserved morning erections → psychogenic ED</li> 
<li>First-line therapy → PDE-5 inhibitors</li> 
<li>Never combine PDE-5 inhibitors with nitrates</li> 
<li>Evaluate for underlying cardiovascular disease</li> 
</ul> 
Hypospadias and Epispadias 
Definition 
<ul> 
<li>Hypospadias: urethral meatus opens on ventral (underside) surface of penis</li> 
<li>Epispadias: urethral meatus opens on dorsal surface (less common)</li> 
<li>Congenital conditions due to abnormal urethral development</li> 
</ul> 
Risk Factors 
<ul> 
<li>Family history</li> 
<li>Maternal estrogen exposure</li> 
<li>Low birth weight or prematurity</li> 
<li>Associated with cryptorchidism</li> 
</ul> 
Clinical Presentation 
<ul> 
<li>Abnormal location of urethral meatus</li> 
<li>Ventral penile curvature (chordee) may accompany hypospadias</li> 
<li>Abnormal urinary stream</li> 
<li>The question stem would likely describe a newborn boy with a ventral urethral opening or abnormal urine stream</li> 
</ul> 
Diagnostics 
<ul> 
<li>Clinical diagnosis on newborn exam</li> 
<li>Do NOT circumcise — foreskin may be needed for repair</li> 
<li>Evaluate for undescended testes if present</li> 
</ul> 
Treatment 
<ul> 
<li>Surgical repair at 6–12 months</li> 
<li>Goals: normal urine stream, straight penis, normal appearance</li> 
<li>Epispadias often requires more complex reconstruction</li> 
</ul> 
Exam Keys 
<ul> 
<li>Ventral opening = hypospadias</li> 
<li>Do NOT circumcise before evaluation</li> 
<li>Repair at 6–12 months</li> 
<li>Associated with chordee and cryptorchidism</li> 
</ul> 
Phimosis 
Definition 
<ul> 
<li>Inability to retract foreskin over the glans</li> 
<li>Physiologic in young boys; pathologic from scarring or infection</li> 
</ul>

Physician Assistant Exam Review

146 Penile disorders, BPH and a key to focus

146 Penile disorders, BPH and a key to focus

Description