There have been a couple of questions about this topic on the newer exams. I’ve been answering by equating libido to testosterone levels and nocturnal erections to health of vasculature (atherosclerosis or not). Is this correct?
Pretty much if they can masturbate or get it up alone in any way their nocturnal tumescence should be normal meaning that their innervation and reflex pathways are all intact. Libido aka sex drive from what I’ve seen so far is altered by depression. So like in the question on NBME 21 the stem stated that screening for depression was negative which is why libido would also be normal in this case. If there’s ever a Q with a depressed guy and normal lab values and physical exam, most likely gonna be decreased libido with normal night erections - courtesy of /u/diffuseaxonalinjury
How is this different from the question on NBME 21 in which a 68-year old man also had psychogenic ED? But the answer was normal libido and nocturnal erections.
Organic ED: normal libido, decreased nocturnal erections
Psychogenic ED: decreased libido, normal nocturnal erections
Got it.
So, I thought this question was super vague and not great... that being said, having gotten it wrong and not really having a good explanation for the answer, I did a little research and found this article: https://www.ahajournals.org/doi/pdf/10.1161/01.STR.30.4.715
This was the main conclusion: "The results of the present study, aimed at assessing the effects of stroke on sexual functioning, reveal a significant decline in libido, coital frequency, sexual arousal, and satisfaction with sexual life in both stroke patients and their spouses. The present results also demonstrate that disorders of sexual functions are most significantly associated with various psychosocial factors, such as patients’ general attitude toward sexuality, fear of impotence, and ability to discuss sexuality, as well as with the degree of poststroke functional disability. Moreover, sexual dysfunction was related to the presence and degree of depression, diabetes mellitus, and cardiovascular medication. The etiology or location of the stroke and the gender or marital status of the patients were not associated with changes in poststroke sexuality in patients in the present study."
Looking at the question again, I'm guessing the "fatigue and difficulting sleeping and concentrating" statement was supposed to be a clue for depression, especially since it started after his stroke. Also, no physical abnormalities suggest functioning is intact and thus nocturnal erections would be preserved normally. This is just stupid.
Is decreased nocturnal erections not possible due to the incongruity between onset of symptoms and stroke (2 mos versus 3)? Agree that these questions are very vague and frustrating. Not sure where to get a good grasp on this material.
Nocturnal penile tumescence measurement (phallography) is a test that measures spontaneous nightly erections in erectile dysfunction (primarily performed in a sleep laboratory). It's useful for differentiating between organic from psychogenic erectile dysfunction.
Vignette describes a possibly depressed patient => psychogenic erectile dysfunction. Since it is not an organic cause of ED, nocturnal erections would be normal. Organic etiologies of ED include neurogenic or vascular.
Libido part confuses me here. Libido means sexual desire or appetite. I was thinking since he's coming in to get ED checked, it indicates he's appetite for sex is enough that it made him get it check. So libido should be normal. Any help?
Answer = Decreased libido; normal nocturnal erections
I believe what they were trying to indicate in this question was Psychological Sexual Dysfunction (aka - Performance Anxiety).
In this case, it wasn't so much the performance that worried the man, but he may be so focused on his health issues (post stroke), that he is unable to perform adequately. Therefore, his natural libido would be decreased. However, because it's psychogenic & not physiologic, he should still have normal nighttime erections.
submitted by ∗paperbackwriter(161)
SPOILERS FOR NBME 21 -- DON'T READ AHEAD IF YOU HAVEN'T TAKEN 21
After getting it wrong (because of the NBME 21 Q), I understood it like this:
– Libido is a long term state, meaning your libido could be fine, but anxiety in that MOMENT might cause psychogenic ED
– This guy has some classic SIG E CAPS criteria going on: fatigue (energy loss), sleep disturbances, concentration problems
– It says he hasn't been able to maintain any erection (vs NBME 21 guy that was able to masturbate (his long term sex drive was OK) but had performance anxiety in the moment)
Therefore, lack of sex drive fueled by depression --> low libido, but physiologically nothing wrong with him --> nighttime erections