Episode 40: Erectile Dysfunction Basics.
Erectile dysfunction fundamentals, allergy to penicillin label removal, jokes
Today is February 5, 2021.
Question of the month: Diabetes management
This is a reminder of our question for this month. Please answer before Feb 15, 2021. The best answer will receive a prize. Question: What is the first treatment approach for type 2 DM? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random BG of 210.
Send your answer to RBresidency@clinicasierravista.org. Don’t miss this chance to win.
Penicillin Allergy Study: How many times have you heard a patient say that they are allergic to penicillin? Exactly, a lot! Skin allergy testing continues to be the best test to diagnose penicillin allergy. All patients who have a negative penicillin allergy skin test should be challenged with penicillin in a medical setting for 1-2 hours to ensure that immediate reaction does not occur. Many patients labeled as “allergic to penicillin” may not be truly allergic. We recognize that true penicillin allergy exists, and allergic reactions range from mild rash to life-threatening anaphylaxis, but many patients needing penicillin may not get it because of a wrong diagnosis of penicillin allergy.
Up to 15% of the US population are labeled as “allergic to penicillin”. The American Journal of Respiratory and Critical Care Medicine published in February 2020 a way to remove low-risk penicillin allergy labels in an ICU. The investigators created a risk-stratification tool after evaluating 318 patients in an allergy clinic. Low risk indicators include urticaria to penicillin >5 years ago, a self-limited rash, GI symptoms only, a remote childhood history, a family history only, avoidance from fear of allergy only, a known tolerance to penicillin since the reported reaction, or non-allergic symptoms.
Using that tool, 216 patients admitted to the MICU labeled as “allergic to penicillin” were evaluated. 68 patients qualified as “low risk.” 54 patients agreed to be challenged with a single oral dose of 250 mg amoxicillin and observed for 1 hour. None of the challenged patients had any immediate or delayed reaction. Their penicillin allergy label was removed. Later, 41 of the 54 challenged patients received multiple doses of either penicillin’s (17 patients) or cephalosporins (24 patients) without any reaction. This tool has not been validated to be used in an outpatient setting yet, but it sets the foundation for further investigation in this matter.
This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home.
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Erectile Dysfunction.
Arreaza: Today our guest is Dr. John Ihejirika.
Ihejirika: My name is Dr. John Ihejirika. I am one of the third/Final-year residents at the Rio Bravo Family Medicine residency program, here in Bakersfield, California. I am glad to be back on the podcast and thanks for having me again.
Arreaza: What topic are you discussing today?
Today I will be talking about Erectile dysfunction.
Arreaza: What is Erectile dysfunction?
Ihejirika: Erectile dysfunction [ED] can be defined as the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance.
It is very common, affecting at least 12 million men in the United States. The condition can be caused by vascular, neurologic, psychological, medications and hormonal factors.
Arreaza: What are common conditions associated with ED?
Ihejirika: Common conditions related to ED include diabetes mellitus, hypertension, hyperlipidemia, obesity, testosterone deficiency, and prostate cancer treatment.
Performance anxiety and relationship issues are common psychological causes.
Medications and substance use can also cause or exacerbate ED
Medications: Antidepressants are a common cause especially the SSRI and SNRI drugs.
Substances: Tobacco, alcohol, and illicit drugs can cause ED. Marijuana use may cause ED, although further study is needed.
Arreaza: Is ED related to any other risks?
Ihejirika: Cardiovascular risk: ED is associated with an increased risk of cardiovascular disease, particularly in men with metabolic syndrome.
Initial treatment: Tobacco cessation, regular exercise, weight loss, and improved control of diabetes, hypertension, and hyperlipidemia are recommended initial lifestyle interventions.
Arreaza: Let’s talk about the “blue pill.”
Ihejirika: Oral phosphodiesterase-5 inhibitors are the first-line treatments for ED. Second-line treatments include alprostadil and vacuum devices.
Arreaza: Vaccum: No medication interaction.
Ihejirika: Surgically implanted penile prostheses are an option when other treatments have been ineffective. Counseling is recommended for men with psychogenic ED.
Arreaza: However, most cases have an organic cause. How is Erectile Dysfunction assessed?
Ihejirika: The American Urological Association (AUA) recommends that the initial evaluation of ED include a complete medical, sexual, medication and psychosocial history.
The five-item version of the International Index of Erectile Function Questionnaire is a validated survey instrument that can be used to assess the severity of ED symptoms.
| QUESTIONS | SCORES |
| 1 | 2 | 3 | 4 | 5 |
| Over the past six months: |
| 1. How do you rate your confidence that you could get and keep an erection? | Very low | Low | Moderate | High | Very high |
| 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? | Almost never or never | A few times* | Sometimes† | Most times‡ | Almost always or always |
| 3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? | Almost never or never | A few times* | Sometimes† | Most times‡ | Almost always or always |
| 4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? | Extremely difficult | Very difficult | Difficult | Slightly difficult | Not difficult |
| 5. When you attempted sexual intercourse, how often was it satisfactory for you? | Almost never or never | A few times* | Sometimes† | Most times‡ | Almost always or always |
Five-Item Version of the International Index of Erectile Function Questionnaire
note: The score is the sum of the above five question responses. Erectile dysfunction is classified based on these scores: 17 to 21 = mild; 12 to 16 = mild to moderate; 8 to 11 = moderate; 5 to 7 = severe.
* —Much less than one half the time.
† —About one half the time.
‡ —Much more than one half the time.
Summary of diagnosis and Treatment of Erectile Dysfunction.
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Sources: I got this knowledge from the AAFP website, Up to Date, Review/Journal and from some my faculty. You can see our website for further details on theses references.
Conclusion: It is very important to be aware of this condition because as stated earlier It is very common, affecting at least 12 million men in the United States. Most male patients feel depressed or “incomplete” when experiencing ED and it is one of the most common reasons for male patients to visit the doctor, although most patients do not disclose the reason for the visit during the rooming process or with a female provider. Knowledge of the management of ED is also vital to have as a provider as it helps you restore your patients’ self-esteem and gives you reciprocal gratification in addition, so be ready to treat your patients.
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For your Sanity: Jokes
by Claudia Carranza, Gina Cha, an guest notary public
-What do you call a bear with no teeth? A gummy bear.
-How do you keep geese from speeding? Goose bumps.
-Why do fish choirs always sign off-key? Because you can’t tuna fish.
-Why did the toilet paper run down the hill? To get to the bottom.
-How do make a slug drink? Stick it in the blender.
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Now we conclude our episode number 39 “Erectile Dysfunction Basics.” Today, Dr Ihejirika gave us the tools to address this common issue among our male patients. Diabetes and hypertension are to blame for ED in most cases. He taught us how to assess and treat our patients with many methods, including the famous “blue pill.” We also hope you enjoyed our goofy jokes.
Don’t forget to participate in our contest by answering our question of the month and receive a prize. Our question is: What is the first treatment approach for type 2 Diabetes? For example, for a patient who had polydipsia, polyuria for a few weeks and at your office had a random blood sugar of 210. Send your answer to rbresidency@clinicasierravista.org before February 15, 2021.
And remember… Even without trying, every night you go to bed being wiser than when you woke up.
Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, John Ihejirika, Claudia Carranza, Gina Cha, and a notary public guest. Audio edition: Suraj Amrutia. See you next week!
References:
Stone CA Jr et al., Risk-stratified management to remove low-risk penicillin allergy labels in the intensive care unit. Am J Respir Crit Care Med 2020 Feb 21; [e-pub]. (https://doi.org/10.1164/rccm.202001-0089LE) https://www.jwatch.org/na51025/2020/03/25/approach-removing-penicillin-allergy-labels
Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res. 1999;11:322.
Rew, Karl T. and Joel Heidelbaugh, MD, Erectile dysfunction, University of Michigan Medical School, Ann Arbor, Michigan. Am Fam Physician. 2016 Nov 15;94(10):820-827. https://www.aafp.org/afp/2016/1115/p820.html.
Khera, Mojit, MD, MBA, MPH, Peter J Snyder, MD, Michael P O'Leary, MD, MPH and Kathryn A Martin, MD, Treatment of male sexual dysfunction, Up To Date, accessed on February 1, 2021. https://www.uptodate.com/contents/treatment-of-male-sexual-dysfunction?search=erectile%20dysfunction&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
