Erectile Dysfunction


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Erectile Dysfunction

  3. 4. The sumerians GALEN INTRODUCTION
  4. 5. Natural Impotence Supra Natural Impotence EGYPTIAN PAPYRI
  5. 6. Scythia Rich ( horse Rider ) Poor Hippocrates
  6. 7. Air Influx Hanged Man ARISTOLE Leonardo Da vinci
  7. 8. The penis does not obey the order of its master who tries to erect or shrink it at will. Instead the penis erects freely while its master is asleep , the penis must be said to have its own mind by any stretch of the imagination. The penis does not obey the order of its master who tries to erect or shrink it at will. Instead the penis erects freely while its master is asleep , the penis must be said to have its own mind by any stretch of the imagination.
  8. 9. <ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Treatment </li></ul></ul>ERECTILE DYSFUNCTION
  9. 10. 1) Vascular factors (DM,HTN,HLP) 2) Neurogenic factors (Autonomic dysfunction, peripheral neuropathy) 3) Psychogenic (Depression, Anxiety) 4) Endocrine factors (Test, FSH, LH, PRL , hyperthyroidism) 5) Pharmacologic factors (specially antihypertensives) 6) Other factors( Zn deficiency, hypoxemia) ETIOLOGY
  10. 11. American Women 30-50% Risk Factors same as males Psychogenic 10% Desire Arousal Orgasm Kaplan (1979) Excitement, Plateu, Orgasmic, Resolution. Master and Johnson (1966) Female Sexual Dysfunction
  11. 12. <ul><li>Anti-hypertensive drugs </li></ul><ul><ul><li>- All capable </li></ul></ul><ul><ul><li>- Common: thiazides and beta blockers </li></ul></ul><ul><ul><li>Uncommon: calcium channel blockers, alpha-adrenergic blockers, and ACE inhibitors </li></ul></ul>Causes of ED:
  12. 13. <ul><li>CNS drugs: </li></ul><ul><ul><li>- Antidepressants, tricyclics, SSRIs </li></ul></ul><ul><ul><li>- Tranquilizers </li></ul></ul><ul><ul><li>- Sedatives </li></ul></ul><ul><ul><li>- Analgesics </li></ul></ul><ul><li>H1 and H2 receptor blockers </li></ul>
  13. 14. <ul><li>- Anticholinergics </li></ul><ul><li>- LHRH agonists (Lupron, Zolladex) </li></ul><ul><li>- Alcohol </li></ul><ul><li>- Tobacco </li></ul><ul><li>- Drug abuse </li></ul><ul><li>- Estrogens </li></ul><ul><ul><li>Ketoconazole </li></ul></ul>
  14. 18. Erectogenic Nitric oxide (NO) Serotonin (5HT) Dopamine Vasoactive intestinal polypeptide (VIP) Histamine Oxytocin Pituitary adenylate cyclase activating peptide (PACAP) Calcitonin gene-related peptide (CGRP) Substance P Erectolytic Noradrenaline Neuropeptide Y Gamma-aminobutyric acid (GABA) Neurotransmitters involved in penile erection
  15. 19. Central Erection Pathway Schematic Central Stimulation (Stimulatory) Imagery (Inhibitory) Stress Anxiety Dopamine Receptors Oxytocin Seretonin Parabentricular Nucleus Midbrain Spinal Cord Cerebral Cortex ERECTION + -
  16. 20.  Physical examination & history (a)  Sildenafil citrate  Lab.(Ts,PRL,LH,FSH) (b)  Radiologic evaluation ( colour doppler ultrasonography,etc) a- Massry b- Chopp R.T ,Mendez R. EVALUATION & DIAGNOSIS
  17. 21. <ul><li>Sexual History </li></ul><ul><li>- Premature ejaculation </li></ul><ul><li>- Retarded ejaculation </li></ul><ul><li>- Painful intercourse </li></ul><ul><li>- Anorgasmia </li></ul><ul><li>- Decreased Libido </li></ul><ul><ul><li>Dissatisfaction with sex life </li></ul></ul>A Practical Evaluation of Men with ED
  18. 22. E.D Hx & P/E Depression, Vascul.,Medications NPT Ts & PRL NL ABNL Ts ,Bro,Clom. Succ. Fail
  19. 23. NPT NL ABNL Psychog. Doppler,ICI, PGE1 Psy Rx± Hor.Rx NL Succ. Fail AB NL Medications Fail Succ A.&V. Problem Surg Vacc Prosth
  20. 24. ED Hx & PE Sildenafil Response Cont. Sild. No Response Hb. Corr. Sex Hor. Drugs NPT
  21. 25. NPT ABNL NL ICI Doppler with ICI PGE ABNL NL Cont. ICI Corp. Cav. Bx NO Measurement Prosthesis
  22. 29. <ul><ul><li>Life Style Changes </li></ul></ul><ul><ul><li>Stay Sexually active </li></ul></ul><ul><ul><li>Kegel Exercise </li></ul></ul><ul><ul><li>Changing or reducing Medications </li></ul></ul><ul><ul><li>Psychotherapy and Behavioral therapy </li></ul></ul>TREATMENT
  23. 30. 1- Medical - Ts Replacement - PRL reduction - Zn replacement - Treatment of anemia - PDE5 inhibitors TREATMENT
  24. 31. <ul><li>PDE5 inhibitors </li></ul><ul><ul><li>Sildenafil citrate </li></ul></ul><ul><ul><li>Tadalafil </li></ul></ul><ul><ul><li>Vardenafil </li></ul></ul><ul><ul><li>SLX-2101 </li></ul></ul><ul><ul><li>Avanafil </li></ul></ul>New Horizons in ED Treatment
  25. 32. <ul><li>SLX-2101 (2-in-1 Erection Drug) </li></ul><ul><ul><li>A long and fast acting drug that acts well beyond 48 hours. </li></ul></ul><ul><ul><li>An oral PDE-5 inhibitor developed to treat endothelial dysfunction leading to smooth muscle relaxation </li></ul></ul><ul><ul><li>SLX-2101 improves erections not only in men with erectile dysfunction, but also in men already able to have erections. </li></ul></ul>New Horizons in ED Treatment
  26. 33. <ul><li>Avanafil </li></ul><ul><ul><li>Faster, Shorter-Acting Erection Drug </li></ul></ul><ul><ul><li>Highly selective PDE5 inhibitor </li></ul></ul><ul><ul><li>Reaches its maximum blood concentrations 35 minutes after it is taken, it has a half-life of 90 minutes (compared with four hours for Levitra and viagra and 17.5 hours for Cialis). </li></ul></ul><ul><ul><li>Due to its shorter acting time, it could be used in men who take nitrate-based heart drugs (such as Nitrostat, Isordil, and Imdur). </li></ul></ul>New Horizons in ED Treatment
  27. 34. 2- Gene therapy TREATMENT
  28. 35. NITRIC OXIDE ( NO) Neuronal (n NOS) Endothelial (e NOS) Inducible (i NOS) Genes and ED
  29. 36. L- Arginine L-Citrulline NO synthase NITRIC OXIDE
  30. 38. NITRIC OXIDE <ul><ul><li>Nitric oxide is a gas released, each time we breath by endothelial cells of the blood vessels. This relaxes the tiny smooth muscles in the arterial walls in the penis causing erection. </li></ul></ul><ul><ul><li>Smoking and excess weight reduces NO production as they impair breathing. </li></ul></ul><ul><ul><li>Exercising, losing weight and quitting smoking may overcome the condition. </li></ul></ul>
  31. 39. Penile variant of nNOS (Pn NOS) is a reasonable candidate for gene therapy .
  32. 40. <ul><li>hMaxi-K </li></ul><ul><ul><li>It is a form of gene therapy called naked DNA, which forces the cells to make a protein that tells smooth muscles to relax. </li></ul></ul><ul><ul><li>Its effects remain for as long as 6 months. </li></ul></ul><ul><ul><li>The drug lets individuals get normal erections whenever they are aroused. </li></ul></ul>New Horizons in ED Treatment
  33. 41. <ul><li>hMaxi-K </li></ul><ul><ul><li>A single subtherapeutic intracavernous injection of the human recombinant Maxi-K ion channel gene via a &quot;naked DNA&quot; plasmid vector (hMaxi-K) is safe in men with moderate to severe erectile dysfunction (ED). </li></ul></ul><ul><ul><li>The hMaxi-K injection increases the expression of the Maxi-K channel in a small percentage of penile smooth muscle cells, whose signal for smooth muscle relaxation upon neural stimulation is amplified by gap junctions. </li></ul></ul><ul><ul><li>The primary function of K channels is to modulate Ca++ influx through Ca-channels. The amount of Ca++ that enters the cell through these channels is a major determinant of the free intracellular calcium levels inside the smooth muscle cell, which in turn determines the degree of smooth muscle cell contraction. </li></ul></ul><ul><ul><li>Increased Maxi-K channel activity is associated with smooth muscle cell relaxation, resulting in penile erection and detrussor muscle relaxation. </li></ul></ul>New Horizons in ED Treatment
  34. 43. hMaxi-K hMaxi-K isn't just for getting erections; it may also be effective in other ailments including overactive bladder, asthma, irritable bowel syndrome, benign prostatic hyperplasia, premature labor, and premenstrual syndrome. New Horizons in ED Treatment
  35. 44. 3 -I.C.I 4 -Penile prosthesis (risk of infection) 5 - Surgery (poor response) TREATMENT
  36. 46. Penile Prosthesis Indications: - Patients who have failed other therapies - Peyronie’s disease - Severe vasculogenic disease
  37. 47. Malleable Prosthesis - Easy for patient and partner to use - Few mechanical parts - Same-day surgery usually possible - Least expensive type of prosthesis
  38. 48. Two-Piece Inflatable Prosthesis - Small inflation pump provides comfort and ease - Fast and easy one-step deflation procedure - Better conceal ability when flaccid than with malleable or self-contained devices
  39. 49. Three-Piece Inflatable Prosthesis - Most closely approximates the feel of a natural erection - Cylinders expand in girth - Some cylinders have the potential to expand in length - When inflated, it feels more firm and more full than other prosthetic erections - When deflated, it feels softer and more flaccid with better conceal ability than with other prosthetic devices
  40. 59.  Careful evaluation is needed to point out the underlying cause of the main problem.  The treatment must be based on aetiologic factor(s)  PDE5 inhibitors are safe medications for ED; however, new drugs have shown promising results in the ongoing clinical trials. Conclusions
  41. 60. <ul><ul><li>Avanafil (PDE5 inh.) is a good choice in individuals taking nitrite-based medications. </li></ul></ul><ul><ul><li>Gene therapy is another effective treatment for ED patients. </li></ul></ul>Conclusions