Erectile dysfunction – a growing problem   Erection Physics
 
 
 
 
Sequence of events <ul><li>Stimulus </li></ul><ul><li>Either cerebral cortex or tactile </li></ul>
<ul><li>Visual  </li></ul><ul><li>Auditory </li></ul><ul><li>Imagined </li></ul><ul><li>tactile </li></ul>
<ul><li>Penile artery relaxation due to </li></ul><ul><li>NO release in muscle cells </li></ul><ul><li>Passive engorgement...
<ul><li>Corpus cavernosa ( 2 main tubes in penis) </li></ul><ul><li>corpus spongiosum </li></ul><ul><li>These engorge </li...
Blood and nerve function  <ul><li>Blood and nerve supply in perineal area: </li></ul><ul><li>Affected by injury (spinal co...
Other causes  <ul><li>Age ( nerve function, diabetes, proper NO function, testosterone deficiency) </li></ul><ul><li>Hyper...
Erectile Dysfunction (ED) <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Aetiology </li></ul><ul><li>...
Definition <ul><li>The consistent inability to obtain and maintain penile erection sufficient to complete satisfactory sex...
definitions <ul><li>ED. </li></ul><ul><li>Impotence </li></ul><ul><li>Infertility </li></ul>
 
 
Basic Penis biology <ul><li>3 types of cells in penile corpora cavernosa: </li></ul><ul><li>Neuron cells release Nitric Ox...
<ul><li>Stimuli--  hypothalamus   autonomic nerves--   NO--  penile muscle relaxation  endothelial cells flatten on s...
<ul><li>Summary: </li></ul><ul><li>Messages via autonomic, cholinergic, norepinephrine and “T” control Nitric Oxide levels...
treatments <ul><li>Penile injections ( smooth muscle relaxants) </li></ul><ul><li>Converts cGTP to cGMP  </li></ul><ul><l...
Name a famous drug? <ul><li>A  phosphodiesterase type 5 inhibitor, often shortened to PDE5 inhibitor, is a drug used to bl...
Does Viagra need an intact apparatus? <ul><li>Needs penile blood flow </li></ul><ul><li>Intact nerves and sensory impulses...
 
 
 
Epidemiology <ul><li>Estimated to affect 152m men worldwide </li></ul><ul><li>Non-diabetic men 0.1-18.4% prevalence </li><...
Aetiology <ul><li>Vascular </li></ul><ul><li>Neurological </li></ul><ul><li>Endocrine </li></ul><ul><li>Psychological </li...
Vascular <ul><li>Arterial insufficiency </li></ul><ul><ul><li>Endothelial dysfunction (up to 95%) </li></ul></ul><ul><ul><...
Neurological <ul><li>Damage to autonomic nervous system </li></ul><ul><ul><li>Predominant parasympathetic damage </li></ul...
Endocrine <ul><li>Hypogonadism </li></ul><ul><ul><li>Most commonly primary testosterone deficiency </li></ul></ul><ul><ul>...
Other causes of ED <ul><li>Penile </li></ul><ul><ul><li>Balinitis </li></ul></ul><ul><ul><li>Phymosis </li></ul></ul><ul><...
<ul><li>PMH </li></ul><ul><ul><li>Glycaemic control </li></ul></ul><ul><ul><li>Vascular/neurological disease </li></ul></u...
Oral therapies <ul><li>Phosphodiesterase V inhibitors </li></ul><ul><ul><li>Sildenafl ( Viagra) 4hr </li></ul></ul><ul><ul...
 
 
 
Efficacy of PDE-V inhibitors <ul><li>Hundreds of studies internauinally </li></ul><ul><li>Improved erections and increased...
PDE V inhibitor prescribing <ul><li>Following conditions </li></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>PD, MS, polyi...
Vacuum devices <ul><li>Can improve erection </li></ul><ul><li>Messy and user dependent </li></ul><ul><li>Satisfaction vari...
Intracavernosal injections <ul><li>Intracavernosal injections with prostaglandins </li></ul><ul><ul><li>Alprostadil (prost...
Testosterone replacement <ul><li>Improves erectile function and libido </li></ul><ul><li>Preparations </li></ul><ul><ul><l...
Penile implant <ul><li>Inflatable </li></ul><ul><li>Malleable </li></ul>
Psychosexual counselling <ul><li>Talking therapies for men and couples </li></ul>
Summary <ul><li>ED </li></ul><ul><ul><li>Common </li></ul></ul><ul><ul><li>Marker for other forms of neurovascular complic...
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Erection physics witkov modification

  1. 1. Erectile dysfunction – a growing problem Erection Physics
  2. 6. Sequence of events <ul><li>Stimulus </li></ul><ul><li>Either cerebral cortex or tactile </li></ul>
  3. 7. <ul><li>Visual </li></ul><ul><li>Auditory </li></ul><ul><li>Imagined </li></ul><ul><li>tactile </li></ul>
  4. 8. <ul><li>Penile artery relaxation due to </li></ul><ul><li>NO release in muscle cells </li></ul><ul><li>Passive engorgement of pudendal arteries </li></ul>
  5. 9. <ul><li>Corpus cavernosa ( 2 main tubes in penis) </li></ul><ul><li>corpus spongiosum </li></ul><ul><li>These engorge </li></ul><ul><li>Blood pressure strains on sheath </li></ul><ul><li>Closes vein escape of blood </li></ul>
  6. 10. Blood and nerve function <ul><li>Blood and nerve supply in perineal area: </li></ul><ul><li>Affected by injury (spinal cord) </li></ul><ul><li>pressure </li></ul><ul><li>plaque ( diabetes and CVD) </li></ul><ul><li>medication ( also marijuana) </li></ul><ul><li>smoking </li></ul><ul><li>drugs (alcohol) </li></ul>
  7. 11. Other causes <ul><li>Age ( nerve function, diabetes, proper NO function, testosterone deficiency) </li></ul><ul><li>Hypertension </li></ul><ul><li>High estrogens </li></ul><ul><li>Prostate cancer treatment ( surgery or hormonal) </li></ul><ul><li>Transmitter problems </li></ul>
  8. 12. Erectile Dysfunction (ED) <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Aetiology </li></ul><ul><li>Clinical features </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Examination </li></ul></ul><ul><li>Investigation </li></ul><ul><li>Treatment </li></ul>
  9. 13. Definition <ul><li>The consistent inability to obtain and maintain penile erection sufficient to complete satisfactory sexual performance </li></ul>
  10. 14. definitions <ul><li>ED. </li></ul><ul><li>Impotence </li></ul><ul><li>Infertility </li></ul>
  11. 17. Basic Penis biology <ul><li>3 types of cells in penile corpora cavernosa: </li></ul><ul><li>Neuron cells release Nitric Oxide which causes calcium ions to enter storage areas and decrease calcium levels in tissue </li></ul><ul><li>Then smooth muscles relax and endothelial cells flatten and block exodus of blood </li></ul>
  12. 18. <ul><li>Stimuli--  hypothalamus  autonomic nerves--  NO--  penile muscle relaxation  endothelial cells flatten on sides of sinusoids, block veins. </li></ul><ul><li>Other neurotransmitters, like norepinephrine </li></ul><ul><li>Increase calcium which contracts muscle cells </li></ul><ul><li>Testosterone and acetylcholine also influence erection. </li></ul>
  13. 19. <ul><li>Summary: </li></ul><ul><li>Messages via autonomic, cholinergic, norepinephrine and “T” control Nitric Oxide levels-  Calcium levels </li></ul><ul><li>Autonomic nerve fibers  NO  enzyme (Guanylyl cyclase) -  converts cGTP into cGMP  calcium storage  sliding filament relaxation and sinusoids fill </li></ul>
  14. 20. treatments <ul><li>Penile injections ( smooth muscle relaxants) </li></ul><ul><li>Converts cGTP to cGMP  </li></ul><ul><li>Calcium levels  relaxed sinusoids </li></ul><ul><li>Viagra and other ED meds. Inhibit cGMP degradation ( maintains erection) </li></ul><ul><li>Phosphodiesterase 5 is the chemical which degrades cGMP…ending the erection </li></ul>
  15. 21. Name a famous drug? <ul><li>A phosphodiesterase type 5 inhibitor, often shortened to PDE5 inhibitor, is a drug used to block the degradative action of phosphodiesterase type 5 on cyclic GMP in the smooth muscle cells lining the blood vessels supplying the corpus cavernosum of the penis. These drugs are used in the treatment of erectile dysfunction, and were the first effective oral treatment available for the condition </li></ul>
  16. 22. Does Viagra need an intact apparatus? <ul><li>Needs penile blood flow </li></ul><ul><li>Intact nerves and sensory impulses </li></ul><ul><li>NO production </li></ul><ul><li>Sexual stimulation </li></ul>
  17. 26. Epidemiology <ul><li>Estimated to affect 152m men worldwide </li></ul><ul><li>Non-diabetic men 0.1-18.4% prevalence </li></ul><ul><li>In a study of 541 diabetic males </li></ul><ul><ul><li>35% in diabetic men </li></ul></ul><ul><ul><li>5.7% in 20-24 year olds </li></ul></ul><ul><ul><li>52.4% in 55-59 years olds </li></ul></ul><ul><li>ED is a growing problem </li></ul><ul><ul><li>Massachusetts Male Aging Study estimate an 11% world increase by 2015 </li></ul></ul>
  18. 27. Aetiology <ul><li>Vascular </li></ul><ul><li>Neurological </li></ul><ul><li>Endocrine </li></ul><ul><li>Psychological </li></ul><ul><li>Pharmacological </li></ul><ul><li>Penile tissue abnormalities </li></ul><ul><li>Others </li></ul>
  19. 28. Vascular <ul><li>Arterial insufficiency </li></ul><ul><ul><li>Endothelial dysfunction (up to 95%) </li></ul></ul><ul><ul><li>Discrete lesions </li></ul></ul><ul><li>Venous leakage </li></ul><ul><ul><li>Failure of venule constriction </li></ul></ul>
  20. 29. Neurological <ul><li>Damage to autonomic nervous system </li></ul><ul><ul><li>Predominant parasympathetic damage </li></ul></ul>
  21. 30. Endocrine <ul><li>Hypogonadism </li></ul><ul><ul><li>Most commonly primary testosterone deficiency </li></ul></ul><ul><ul><li>Secondary hypogonadism </li></ul></ul><ul><li>Hypothyroidism </li></ul><ul><li>Hyperprolactinaemia </li></ul>
  22. 31. Other causes of ED <ul><li>Penile </li></ul><ul><ul><li>Balinitis </li></ul></ul><ul><ul><li>Phymosis </li></ul></ul><ul><ul><li>Penile finrosis </li></ul></ul><ul><ul><li>Tumours </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><li>Pharmacoloical </li></ul>
  23. 32. <ul><li>PMH </li></ul><ul><ul><li>Glycaemic control </li></ul></ul><ul><ul><li>Vascular/neurological disease </li></ul></ul><ul><ul><li>Urological </li></ul></ul><ul><ul><li>PSH and trauma </li></ul></ul><ul><li>DH </li></ul><ul><ul><li>Anti-hypertensives </li></ul></ul><ul><ul><li>Androgen antagonists </li></ul></ul><ul><ul><li>Sedatives </li></ul></ul><ul><ul><li>Drugs that cause hyperprolactinaemia (phenolthiazides) </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><li>Psychological assessment </li></ul>
  24. 33. Oral therapies <ul><li>Phosphodiesterase V inhibitors </li></ul><ul><ul><li>Sildenafl ( Viagra) 4hr </li></ul></ul><ul><ul><li>Tadalafil ( Cialis) 17hrs </li></ul></ul><ul><ul><li>Vardenafil (Levita) 4 hrs </li></ul></ul><ul><li>Side effects </li></ul><ul><ul><li>flushing, headache and GI disturbance </li></ul></ul><ul><li>Contraindications - nitrates </li></ul>
  25. 37. Efficacy of PDE-V inhibitors <ul><li>Hundreds of studies internauinally </li></ul><ul><li>Improved erections and increased successful episodes of sexual intercourse vs placebo (15 RCTs) </li></ul>
  26. 38. PDE V inhibitor prescribing <ul><li>Following conditions </li></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>PD, MS, polyiomyelitis </li></ul></ul><ul><ul><li>Pinal cord injuries, spina bifida </li></ul></ul><ul><ul><li>Radical prostatectomy </li></ul></ul>
  27. 39. Vacuum devices <ul><li>Can improve erection </li></ul><ul><li>Messy and user dependent </li></ul><ul><li>Satisfaction varies 35-80% </li></ul>
  28. 40. Intracavernosal injections <ul><li>Intracavernosal injections with prostaglandins </li></ul><ul><ul><li>Alprostadil (prostaglandin E1) </li></ul></ul><ul><li>One large RCT found increased rate of satisfactory erections when alprostadil injected compared to placebo </li></ul><ul><li>Side effects – pain, priapism </li></ul>
  29. 41. Testosterone replacement <ul><li>Improves erectile function and libido </li></ul><ul><li>Preparations </li></ul><ul><ul><li>Topical (testim gel) </li></ul></ul><ul><ul><li>Im testosterone </li></ul></ul><ul><ul><li>Long-acting depots </li></ul></ul>
  30. 42. Penile implant <ul><li>Inflatable </li></ul><ul><li>Malleable </li></ul>
  31. 43. Psychosexual counselling <ul><li>Talking therapies for men and couples </li></ul>
  32. 44. Summary <ul><li>ED </li></ul><ul><ul><li>Common </li></ul></ul><ul><ul><li>Marker for other forms of neurovascular complications in diabetes </li></ul></ul><ul><ul><li>Psychologically damaging </li></ul></ul><ul><ul><li>Treatable </li></ul></ul><ul><ul><li>Treat associated hormonal deficiencies </li></ul></ul>
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