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Toronto Notes 2019 Trauma
Etiology (“IMPOTENCE”)
• Iatrogenic:pelvicsurgery,pelvicradiation
• Mechanical:Peyronie’s,post-priapism
• Psychological:depression,stress,anxiety,PTSD,widowersyndrome
• Occlusive:arterialHTN,DM,smoking,hyperlipidemia,PVD,impairedveno-occlusion
• Trauma:penile/pelvic,bicycling
• Extrafactors:renalfailure,cirrhosis,COPD,sleepapnea,malnutrition
• Neurogenic:CNS(e.g.Parkinson’s,MS,spinalcordinjury,Guillain-Barré,spinabifida,stroke),PNS
(e.g. DM, peripheral neuropathy)
• Chemical:antihypertensives,sedatives,antidepressants,antipsychotics,anxiolytics,anticholingerics,
antihistamines, anti-androgens (including 5-α reductase inhibitors), statins, GnRH agonists, illicit drugs • Endocrine:DM,hypogonadism,hyperprolactinemia,hypo/hyperthyroid
Diagnosis
• completeHx(includesexual,medical,andpsychosocialaspects)
• self-administeredquestionnaires(e.g.InternationalIndexofErectileFunction,SexualHealthInventory
for Men Questionnaire, ED Intensity Scale, ED Impact Scale)
• focusedP/E,includingvascularandneurologicexaminations,secondarysexualcharacteristics
• labinvestigations,dependentonclinicalpicture
■ risk factor evaluation: fasting blood glucose or HbA1c, cholesterol profile
■ optional: TSH, CBC, U/A, testosterone (free and total), prolactin, LH
• specializedtestingincludingnocturnalpeniletumescencemonitoringusuallyunnecessary
• evaluationofpenilevasculatureonlyrelevantwithpasthistoryoftrauma(i.e.pelvicfracture)
Treatment
• canoftenbemanagedbyfamilydoctor,seesidebarforwhentorefer
• mustfullyinformpatient/partnerofoptions,benefitsandcomplications • non-invasive
■ lifestyle changes (alcohol, smoking), psychological (sexual counselling and education) ■ change precipitating medications
■ treat underlying causes (DM, CVD, HTN, endocrinopathies)
• minimallyinvasive
■ oral medication (see Common Medications, U44)
◆ sildenafil, tadalafil, vardenafil, avanafil (not available in Canada): inhibits PDE-5 to increase intracavernosal cyclic GMP levels
– all four have similar effectiveness, difference in onset of action is not clinically significant
– tadalafil has longer half-life, no cyanopsia, and can be taken on empty or full stomach
◆ vacuum devices: draw blood into penis via negative pressure, then put ring at base of penis
◆ MUSE: male urethral suppository for erection – vasoactive substance (PGE1) capsule inserted
into urethra • invasive
■ intracavernous vasodilator injection/self-injection
◆ triple therapy (papaverine, phentolamine, PGE1) or PGE1 alone
◆ complications: priapism (overdose), fibrosis of tunica albuginea at site of repeated injections
(Peyronie’s plaque) and injection site injuries (pain, hematoma, etc.) • surgical
■ penile implant (last resort): malleable or inflatable
■ penile artery reconstruction (in young men with isolated vascular lesion – investigational)
Trauma
• seeEmergencyMedicine,ER7 Renal Trauma
Classification According to Severity
• minor
■ contusions and superficial lacerations/hematomas: 90% of all blunt traumas, surgical exploration
seldom necessary • major
■ laceration that extends into medulla and collecting system, major renal vascular injury, shattered kidney
Etiology
• 80%blunt(MVC,assaults,falls)vs.20%penetrating(stabwoundsandgunshots)
Clinical Features
• mechanismofinjuryraisessuspicion
• canbehemodynamicallyunstablesecondarytorenalvascularinjuryand/orothersustainedinjuries:ABCs • upperabdominaltenderness,flanktenderness,flankcontusions,lowerrib/vertebraltransverseprocess
Urology U33
1. Fibrous plaque
2. Tunica albuginea
3. Corpus cavernosum 4. Buck’s fascia
5. Corpus spongiosum 6. Urethra
Figure 20. Peyronie’s disease
1
2 3
4
5 6
© June Li
Penile vascular abnormalities may be a marker of risk for CV disease. Young men with vascular ED have 50x higher risk of having a CV event
fracture