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PHYSICALEXAM

Signs and symptoms of hypogonadism: gynecomastia, small testicles, decreased body hair

Penile plaques (Peyronie disease)

Detailed examination of the cardiovascular, neurologic, and genitourinary systems

–Blood pressure, waist circumference, BMI

–Check femoral and lower extremity pulses to assess vascular supply to genitals.

–Check anal sphincter tone and genital reflexes, including cremasterics and bulbocavernosus.

DIFFERENTIALDIAGNOSIS

Premature ejaculation

Decreased libido

Anorgasmia

Sudden versus chronic ED

DIAGNOSTIC TESTS & INTERPRETATION

Vascular and/or neurologic assessment and monitoring of nocturnal erections may be indicated in selected patients but not for routine workup (2)[C].

Initial Tests (lab, imaging)

Depending on history, Hgb A1c, lipid panel, TSH, and morning total testosterone level (1)[C]

Doppler, angiogram, and cavernosogram are available radiologic modalities but not recommended in routine practice for the diagnosis of ED (2)[C].

Follow-Up Tests & Special Considerations

Other hormonal tests, such as prolactin, should only be ordered when there is suspicion for a specific endocrinopathy.

Diagnostic Procedures/Other

Questionnaires can be offered to assess the severity of ED, including the International Index of Erectile Function (IEFF) and its validated and more easily administered abridged version, the Sexual Health Inventory for Men (SHIM) (2) [C].

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TREATMENT

Lifestyle modifications and managing medications contributing to ED is firstline therapy for ED (3)[C]. Use least invasive therapy first; reserve more invasive therapies for nonresponders.

Cardiovascular risk stratification and risk-factor management is recommended in all men with vasculogenic ED (4).

Current smoking is significantly associated with ED, and smoking cessation has a beneficial effect on the restoration of erectile function (1)[A].

Phosphodiesterase type 5 (PDE-5) inhibitors are the first-line treatment for ED (1)[A].

GENERALMEASURES

Psychotherapy alone or in combination with psychoactive drugs may be helpful in men whose ED is related to depression or anxiety.

Weight loss and increased physical activity for obese men with ED. Men with metabolic syndrome should be counseled to make lifestyle modifications to reduce the risk of cardiovascular events and ED (1)[B].

MEDICATION

First Line

PDE-5 inhibitors are effective in the treatment of ED in many men, including those with diabetes mellitus and spinal cord injury and sexual dysfunction associated with antidepressants (5). Choice should be based on patient’s preference (cost, ease of use, and adverse effects). There is insufficient evidence to support the superiority of one agent over the others (3)[A]:

Sildenafil (Viagra): usual daily dose: 50 to 100 mg within at least 60 minutes of sexual intercourse

Vardenafil (Levitra): usual daily dose 5 to 20 mg within at least 60 minutes of sexual intercourse

Vardenafil (Staxyn): ODT: usual dose 10 mg within 60 minutes of sexual intercourse

Tadalafil (Cialis): usual daily dose 5 to 20 mg within at least 30 minutes of sexual intercourse or 2.5 mg once daily without regard to sexual activity Avanafil (Stendra): usual daily dose: 50 to 200 mg within at least 15 to 30

minutes of sexual intercourse

– Adverse effects of PDE-5 inhibitors: headache, facial flushing, dyspepsia,

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nasal congestion, dizziness, hypotension, increased sensitivity to light

(sildenafil and vardenafil), vision changes, lower back pain (tadalafil), and priapism (with excessive doses)

–Sildenafil and vardenafil should be taken on an empty stomach for maximum effectiveness.

Geriatric Considerations

Use doses at the lower end of the dosing range for elderly patients and evaluate exercise tolerance before prescribing.

Sildenafil 25 mg daily

Vardenafil 5 mg daily

Second Line

Intraurethral and intracavernosal injectables are second-line therapies shown to be effective and should be administered based on patient preference (1)[B]. Intraurethral suppositories are a less invasive treatment option than intracavernosal injections; however, they are not as effective (3)[C]. Alprostadil, also known as prostaglandin E1, causes smooth muscle relaxation of the arterial blood vessels and sinusoidal tissues in the corpora:

Intraurethral alprostadil (Muse):

–Urethral suppository: 125-, 250-, 500-, and 1,000-µg pellets. Administer 5 to 50 minutes before intercourse. No >2 doses in 24 hours are

recommended.

Intracavernosal alprostadil (available in 2 formulations):

–Alprostadil (Caverject): usual dose: 10 to 20 µg, with max dose of 60 µg. Injection should be made at right angles into one of the lateral surfaces of the proximal 3rd of the penis using a 0.5-inch, 27or 30-gauge needle. Do not use >3 times a week or more than once in 24 hours.

–Alprostadil may also be combined with papaverine (Bimix) plus phentolamine (Tri-Mix).

ALERT

Initial trial dose of second-line agents should be administered under supervision of a specialist or primary care physician with expertise in these therapies.

Patient should notify physician if erection lasts >4 hours for immediate attention.

Vacuum pump devices are a noninvasive second-line option and are

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available over the counter. Do not use vacuum devices in men with sickle cell anemia or blood dyscrasias.

Testosterone supplementation in men with hypogonadism improves ED and libido (5)[B]. Available formulations include injectable depots, transdermal patches and gels, SC pellets, and oral therapy.

Best practices in urology recommendation: Do not prescribe testosterone to men with ED who have normal testosterone levels (1). Contraindications:

–Nitroglycerin (or other nitrates) and phosphodiesterase inhibitors: potential for severe, fatal hypotension

–Precautions/side effects:

Testosterone: precautions: Exogenous testosterone reduces sperm count and thus do not use in patients wishing to keep fertility; side effects: acne, sodium retention

Intraurethral suppository: local penile pain, urethral bleeding, dizziness, and dysuria

Intracavernosal injection: penile pain, edema and hematoma, palpable nodules or plaques, and priapism

Sildenafil: hypotension (caution for patients on nitrates)

PDE-5 inhibitors: Use caution with congenital prolonged QT syndrome, class Ia or II antiarrhythmics, nitroglycerin, α-blockers (e.g., terazosin, tamsulosin), retinal disease, unstable cardiac disease, liver and renal failure.

Significant possible interactions

PDE-5 inhibitor concentration is affected by CYP3A4 inhibitors (e.g., erythromycin, indinavir, ketoconazole, ritonavir, amiodarone, cimetidine, clarithromycin, delavirdine, diltiazem, fluoxetine, fluvoxamine, grapefruit juice, itraconazole, nefazodone, nevirapine, saquinavir, and verapamil). Serum concentrations and/or toxicity may be increased. Lower starting doses should be used in these patients. PDE-5 inhibitor concentration may be reduced by rifampin and phenytoin.

ADDITIONALTHERAPIES

Men with relationship difficulties who received therapy plus sildenafil had more successful intercourse than those who received only sildenafil (6)[A].

SURGERY/OTHER PROCEDURES

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Penile prosthesis should be reserved for patients who have failed or are ineligible firstor second-line therapies.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Trazodone, yohimbine, and herbal therapies are not recommended for the treatment of ED, as they have not proven to be efficacious.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Treatment should be assessed at baseline and after the patient has completed at least 1 to 3 weeks of a specific treatment: Monitor the quality and quantity of penile erections and monitor the level of satisfaction patient achieves.

DIET

Diet and exercise recommended to achieve a normal body mass index; limit alcohol.

PROGNOSIS

All commercially available PDE-5 inhibitors are equally effective. In the presence of sexual stimulation, they are 55–80% effective.

–Lower success rates with diabetes mellitus and radical prostatectomy patients who suffer from ED

Overall effectiveness is 70–90% for intracavernosal alprostadil and 43–60% for intraurethral alprostadil (2)[B].

Penile prostheses are associated with an 85–90% patient satisfaction rate (2) [C].

REFERENCES

1.Rew KT, Heidelbaugh JJ. Erectile dysfunction. Am Fam Physician. 2016;94(10):820–827.

2.McVary KT. Clinical practice. Erectile dysfunction. N Engl J Med. 2007;357(24):2472–2481.

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3.American Urological Association. Guideline on the management of erectile dysfunction: diagnosis and treatment recommendations. http://www.auanet.org/education/guidelines/erectile-dysfunction.cfm. Accessed January 13, 2017.

4.Miner M, Nehra A, Jackson G, et al. All men with vasculogenic erectile dysfunction require a cardiovascular workup. Am J Med. 2014;127(3):174– 182.

5.Heidelbaugh JJ. Management of erectile dysfunction. Am Fam Physician. 2010;81(3):305–312.

6.Melnik T, Soares BG, Nasselo AG. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst Rev. 2007;(3):CD004825.

CODES

ICD10

N52.9 Male erectile dysfunction, unspecified

N52.1 Erectile dysfunction due to diseases classified elsewhere F52.21 Male erectile disorder

CLINICALPEARLS

Nitrates should be withheld for 24 hours after sildenafil or vardenafil administration and for 48 hours after use of tadalafil. PDE-5 inhibitors are contraindicated in patients taking concurrent nitrates of any form (regular or intermittent nitrate therapy), as it can lead to severe hypotension and syncope.

Reserve surgical treatment for patients who do not respond to drug treatment.

The use of PDE-5 inhibitors with α-adrenergic antagonists may increase the risk of hypotension. Tamsulosin is the least likely to cause orthostatic hypotension.

Avanafil should not be used with strong CYP3A4 inhibitors and max dose should be 50 mg with moderate CYP3A4 inhibitors.

ED may be a marker for subclinical cardiovascular disease. Thoroughly assess patients with nonpsychogenic ED for CV risks.

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ERYSIPELAS

Fozia Akhtar Ali, MD Barbara M. Kiersz, DO

BASICS

DESCRIPTION

Distinct form of cellulitis: notable for acute, well-demarcated, superficial bacterial skin infection with lymphatic involvement almost always caused by

Streptococcus pyogenes

Usually acute, but a chronic recurrent form can also exist (1)

Nonpurulent

System(s) affected: skin, exocrine

EPIDEMIOLOGY

Predominant age: infants, children, and adults >45 years

Greatest in elderly (>75 years)

No gender/racial predilection

Incidence

Erysipelas occurs in ~1/1,000 persons/year.

Incidence on the rise since the 1980s (2)

Prevalence

Unknown

ETIOLOGYAND PATHOPHYSIOLOGY

Group Astreptococci induce inflammation and activation of the contact system, a proinflammatory pathway with antithrombotic activity, releasing proteinases and proinflammatory cytokines.

The generation of antibacterial peptides and the release of bradykinin, a proinflammatory peptide, increase vascular permeability and induce fever and pain.

The M proteins from the group Astreptococcal cell wall interact with neutrophils, leading to the secretion of heparin-binding protein, an inflammatory mediator that also induces vascular leakage.

This cascade of reactions leads to the symptoms seen in erysipelas: fever,

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pain, erythema, and edema.

Group Aβ-hemolytic streptococci primarily; commonly S. pyogenes, occasionally, other Streptococcus groups C/G

Rarely, group B streptococci/Staphylococcus aureus may be involved.

RISK FACTORS

Disruption in the skin barrier (surgical incisions, insect bites, eczematous lesions, local trauma, abrasions, dermatophytic infections, intravenous drug user [IVDU])

Chronic diseases (diabetes, malnutrition, nephrotic syndrome, heart failure)

Immunocompromised (HIV)/debilitated

Fissured skin (especially at the nose and ears)

Toe-web intertrigo and lymphedema

Leg ulcers/stasis dermatitis

Venous/lymphatic insufficiency (saphenectomy, varicose veins of leg, phlebitis, radiotherapy, mastectomy, lymphadenectomy)

Alcohol abuse

Morbid obesity

Recent streptococcal pharyngitis

Varicella

GENERALPREVENTION

Good skin hygiene

It is recommended that predisposing medical conditions, such as tinea pedis and stasis dermatitis, be appropriately managed first.

Men who shave within 5 days of facial erysipelas are more likely to have a recurrence.

With recurrences, search for other possible sources of streptococcal infection (e.g., tonsils, sinuses).

Compression stockings should be encouraged for patients with lower extremity edema.

Consider suppressive prophylactic antibiotic therapy, such as penicillin, in patients with >2 episodes in a 12-month period.

Pediatric Considerations

Group B Streptococcus may be a cause of erysipelas in neonates/infants.

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DIAGNOSIS

Prodromal symptoms before the skin eruption of erysipelas may include:

Moderateto high-grade fever

Chills

Headache

Malaise

Anorexia, usually in the first 48 hours

Vomiting

Arthralgias

ALERT

It is important to differentiate erysipelas from a methicillin-resistant S. aureus (MRSA) infection, which usually presents with an indurated center, significant pain, and later evidence of abscess formation.

PHYSICALEXAM

Vital signs: moderateto high-grade fever with resultant tachycardia. Hypotension may occur.

The presence of a fever in erysipelas can be considered a differentiating factor from other skin infections.

Headache and vomiting may be prominent.

Acute onset of intense erythema; well-demarcated painful plaque (3)

Peau d’orange appearance

Milian ear sign (erythema involves skin of ear as well as face implies erysipelas)

Vesicles and bullae may form but are not uniformly present.

Desquamation may occur later.

Lymphangitis

Location

–Lower extremity 70–80% of cases

–Face involvement is less common (5–20%), especially nose and ears.

–Chronic form usually recurs at site of the previous infection and may recur

years after initial episode.

Patients on systemic steroids may be more difficult to diagnose because signs and symptoms of the infection may be masked by anti-inflammatory action of the steroids.

Systemic toxicity resolves rapidly with treatment; skin lesions desquamate on

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days 5 to 10 but usually heal without scarring.

In geriatric patients, facial involvement presents in a butterfly pattern. Pustules characteristically absent and regional lymphadenopathy with lymphangitic streaking is seen.

Pediatric Considerations

Abdominal involvement is more common in infants, especially around umbilical stump.

Face, scalp, and leg involvement are common in older children due to the excoriations when scratching in atopic dermatitis, allowing an easy port of entry.

Geriatric Considerations

Fever may not be as prominent.

80% of cases affect the lower extremities. The rest are usually on the face.

High-output cardiac failure may occur in debilitated patients with underlying cardiac disease.

More susceptible to complications

DIFFERENTIALDIAGNOSIS

Cellulitis (margins are less clear and does not involve ear)

Necrotizing fasciitis (systemic illness and more pain)

Skin abscess (feel for area of fluctuance)

DVT (need to rule out if clinically suspected)

Acute gout (check patient history)

Insect bite (check patient history)

Dermatophytes

Impetigo (blistered/crusted appearance; superficial)

Ecthyma (ulcerative impetigo)

Herpes zoster (dermatomal distribution)

Erythema annulare centrifugum (raised pink-red ring/bull’s-eye marks)

Contact dermatitis (no fever, pruritic, not painful)

Giant cell urticaria (transient, wheal appearance, severe itching)

Angioneurotic edema (no fever)

Scarlet fever (widespread rash with indistinct borders and without edema; rash is most common early in skin folds; develops generalized “sandpaper” feeling as it progresses)

Toxic shock syndrome (diffuse erythema with evidence of multiorgan

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