Penis ed- management

MANAGEMENT OF
ERECTILE DYSFUNCTION
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

Moderators:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

NONSURGICAL MANAGEMENT
OF ERECTILE DYSFUNCTION
Nonspecific
lifestyle change,
psychosexual
therapy,
replacement of
offending
medication
oral
phosphodiesterase
type-5
(PDE5)inhibitors,
the vacuum
constriction device,
Specific
3
Dept of Urology, GRH and KMC, Chennai.

Lifestyle Change
Obesity
Physical activity
highest risk who remained sedentary
lowest who remained active
cigarette smoking increases impotence
Pelvic Floor Muscle Exercises-significant mean increases in
the erectile function
Long-distance bicycling is another risk factor .They have
genital numbness and ED.
4

Medication Change
Nonspecific α-adrenergic blockers
Older antihypertensive drugs, methyldopa and
reserpine,
Thiazide diuretics
spironolactone interferes with testosterone synthesis
Selective serotonin reuptake inhibitors (SSRIs) have
replaced tricyclic antidepressantsand monoamine
oxidase inhibitors as primary therapy for depression
because of equal or better efficacy and fewer adverse
effect
Switching patients to newer agents may reverse ED
in some patients 5

Herbal Supplements Alternative Therapies and
Commercially Available ED Supplements
Acupuncture.
Androstenedione/DHEA
Ginkgo biloba May have a blood-thinning
effect.
Korean red ginseng (Panaxginseng).
L-Arginine A precursor to nitric oxide.
Yohimbine Supplements benefit some with
psychogenic ED. Can cause serious
sideeffects. 6

Avena saliva (cholesterol and blood-pressure
reducers) and
Tribulus terrestris (precursor to DHEA) need clinical
trials.
Recent study of a Chinese herbal combination
demonstrated no impact on sexualfunction versus
placebo.
Antioxidants in combination with orally approved
FDAmedications Folic acid plus vitamin E may
enhance the response to sildenafil
7

Psychosexual Therapy
Basic treatment elements included an
emphasis on sensate focus exercises and
the elimination of performance anxiety.
Masters and Johnson recommended
beginning with nonsexual touching and
then, in a desensitization paradigm, moving
on to more genitally focused caressing.
By emphasizing the non demand nature of
the sensual exchange, they sought to
eliminate performance pressure.
8

Hormonal Therapy
limited to the treatment of hypogonadism
andhyperprolactinemia as they relate to ED
Testoderm as a scrotal patch (4 to 6 mg).
Testoderm TTS as a 5-mg patch to the arm, back, or
upper buttocks,
AndroGel 1% gel pack contains 50 mg, 75 mg, or 100
mg of testosterone; once daily in the morning over
the shoulders, upper arms, or abdomen.
Each Testopel pellet contains 75 mg of testosterone.
Dosage is two to six pellets (150 to 450 mg
testosterone) implanted subcutaneously every 3 to 6
months. 9

Oral
Metabolic inactivation requires oral dosing
to exceed 200 mg/day to maintain normal
serum levels
Large dosages of testosterone can lead to
hepatitis, cholestatic jaundice, hepatomas,
hemorrhagic liver cysts, and
hepatocarcinoma
Chemical modification to 17α-
methyltestosterone or fluoxymesterone
reduces the amount of testosterone
necessary to reach normal serum levels,
A dosage of 40 mg three times a day
provides adequate androgen replacement,
10

Potential Adverse Effects of
Androgen Therapy
Supraphysiologic levels of testosterone will suppress
LH andFSH production and result in infertility
breast tenderness and/or gynecomastia
Cardiovascular risks are increased
androgen replacement does not induce prostate
cancer in men with normal prostates, and
placebocontrolled studies show little difference in
prostate volume, PSA, and obstructiveSymptom
The presence of prostate or breast cancer is an
absolute contraindication to androgen
supplementation.
11

In patients with hyperprolactinemia with or
without hypogonadism, testosterone
therapy does notimprove sexual functionED.
If a pituitary adenoma is identified (usually
in patients with marked [10-fold] prolactin
elevation), the treatment of choice is
bromocriptine or surgical ablation.
12

Phosphodiesterase Type-5 Inhibitors.
Sildenafil (Viagra), vardenafil (Levitra) and
tadalafil (Cialis).
PDE-5 inhibitors do not increase the nitric
oxide level, but they potentiate nitric oxide's
effect to enhance erection.
Without sexual stimulation and resultant
nitric oxide release, these inhibitorsare
ineffective.
Eleven distinct families have been identified
(PDE-1 toPDE-11)
PDE-5 is present inhigh concentrations in
the smooth muscle of the penile corpora
cavernosa 13

all three PDE-5 inhibitors appear to have
equivalent efficacy in the treatment of ED.
All appear to be generally well tolerated and
have similar contraindications and
warnings.
vardenafil is the only PDE-5 inhibitor with a
cardiac conduction precaution
14

Comparison of Three PDE-5 Inhibitors Currently
Available in the United States
Sildenafil Vardenafil Tadalafil
Cmax(Max
plasma concen)
(ng/mL)
450 20.9 378
Tmax (hr) 0.8 0.7-0.9 2
Onset of
action
15 min to 1
hr
15 min to 1
hr
15 min to
2 hr
Half-life
dose
3-5 hr
25,50,100m
4-5 hr
5,10,20mg
17.5 hr
5,10,20m
15

Side effects
Headache, dyspepsia, facial flushing
Backache, myalgia Blurred/blue
vision
Contraindicated with nitrates
16

Effect of PDE-5 Inhibitors in Difficult-to-Treat Patients
Sildenafil, vardenafil, and tadalafil have all
been shown to be effective in diabetic men
with ED,
.
After surgery or radiation with prostate
cancer, ED is a well-known side effect.
treatment with each of the PDE-5 inhibitors
results in significant improvements
For men with low testosterone levels who
did not respond to sildenafil, adjunctive
testosterone“rescue” therapy (testosterone
gel) has been used successfully
17

WARNINGS
Myocardial infarction within the previous 90
days
Unstable angina or angina occurring during
sexual intercourse
New York Heart Association class II or
greater heart failure in the previous 6
months
Uncontrolled arrhythmias, hypotension
(>90/50 mm Hg), or uncontrolled
hypertension (>170/100 mm Hg)
Stroke within the previous 6 months
Known hereditary degenerative retinal
18

PDE-5 Inhibitors and
Cardiovascular Safety
The Low-Risk Patient
Mild, stable angina pectoris
Post revascularization
Past myocardial infarction (>6 to 8 wk)
Mild valvular disease
Left ventricular dysfunction (NYHA class I)
Other cardiovascular conditions
(pericarditis, mitral valve prolapse, or
atrial fibrillation with controlled ventricular
response)
19

The Intermediate- or Indeterminate-Risk
Patient
Moderate, stable angina pectoris
History of myocardial infarction (>2 wk,
<6 wk)
Left ventricular dysfunction/congestive
heart failure (NYHA class II)
Noncardiac sequelae of atherosclerotic
disease
20

The High-Risk Patient
Unstable or refractory angina pectoris
Uncontrolled hypertension
Congestive heart failure (NYHA class III or
IV)
Recent myocardial infarction (<2 wk)
High-risk arrhythmia
Obstructive hypertrophic cardiomyopathy
Moderate-to-severe valve disease,
particularly aortic stenosis
21

22

vardenafil contraindicated in patients
type-1A antiarrhythmics (e.g.,
quinidine or procainamide) or type-3
antiarrhythmics (e.g., sotalol or
amiodarone) or in patients with
congenital prolonged QT syndrome.
Nitrates are absolutely
contraindicated in patients taking
PDE-5 inhibitors
23

Intracavernous Injection
Papaverine, an alkaloid isolated from the opium
poppy,
exerts an inhibitory effect on PDE,
leading to increased cyclic AMP and cyclic GMP in
penile erectile tissue.
Dose 7.5-60mg
The advantages
low cost and stability at room temperature.
The major disadvantages
priapism (up to 35%) and corporeal fibrosis (1%
to 33%),
24

Phentolamine methylate (Regitine) is a competitive
α-adrenoceptor antagonist.
side effects.
Systemic hypotension, reflex tachycardia, nasal
congestion, andgastrointestinal upset
It has a short plasma half-life (30minutes). When
injected intracavernously alone, it increases
corporeal blood flow
Alprostadil (Prostaglandin E1).
(i.e., alprostadil refers to the exogenous form, PGE1
to the endogenous compound). It causes smooth
muscle relaxation, vasodilation, and inhibition of
platelet aggregation through elevation of
intracellular cyclic AMP
25

Alprostadil is metabolized by the enzyme
prostaglandin-15-hydroxydehydrogenase,
which is active in human corpus cavernosum
After intracavernous injection, 96% of alprostadil is
locally metabolized within 60 minutes
The clinical dose ranges from 2 to 40 mcg.
advantages
lower incidences of prolonged erection, systemic side
effects, and fibrosis.
disadvantages include a
high painful erection and higher cost, and,
refrigeration needed
26

In 1991, Bennett and coworkers introduced
a threedrug mixture containing 2.5 mL
papaverine (30
mg/mL), 0.5 mL phentolamine (5 mg/mL),
and 0.05 mL alprostadil (500 μg/mL) for
intracavernous Injection
the triple-drug combination has been shown
to be as effective as alprostadil alone, or
more so, and has a much lower incidence of
painful erection. It is generally reserved for
men in whom PGE1 or
papaverine/phentolamine therapy has failed
or who have significant penile pain with
PGE1.
27

Intraurethral Therapy
Alprostadil, the synthetic formulation of
PGE1,for management by both
intracavernous and intraurethral routes.
The medicated urethral system for erection
(MUSE;)consists of a very small semisolid
pellet administered into the distal urethra (3
cm) by a proprietary applicator
65% had successfulintercourse
The reported penile pain rate was up to
10.6%
hypotension and syncope have been noted
in 1% to 5.8%, mandating the office setting
for initialadministration. 28

Vacuum Constriction Device
The vacuum constriction device consists of a
plastic cylinder connected directly or by
tubing to a vacuum-generating source
(manual or battery-operated pump).
After the penis is engorged by the negative
pressure, a constricting ring is applied to
the base to maintain the erection.
To avoid injury, the ring should not be left in
place for longer than 30 minutes.
29

The device can be used
successfully by men with a malfunctioning
penile prosthesis in place.
In men with severe vascular insufficiency,
combining intracavernous injection with the
vacuum constriction device may enhance
the erection
Complications include penile pain and
numbness, difficult ejaculation, ecchymosis,
and petechiae.
Patients taking aspirin or warfarin
(Coumadin) should exercise caution
30

Prosthetic Surgery for Erectile Dysfunction
Most men with ED are initially offered
systemic therapy with a phosphodiesterase
type 5 (PDE-5) inhibitor. When that fails,
second- and third-line therapies should be
discussed.
When these fail or are rejected, penile
prosthesis implantation is usually
appropriate.
First-line therapy PDE-5 inhibitors
Second-line therapy VCDs,
Third-line therapy Intracavernous injections
Fourth-line therapy Penile prosthesis
implantation
31

.
Prosthesis Type American Medical
Systems
Mentor Corporation
Semirigid rod AMS Malleable 600
AMS Malleable 650
Acu-Form
Positionable Dura II
Two-piece
inflatable
AMS Ambicor
Three-piece
inflatable
AMS 700 CX
AMS 700 CXM
AMS 700 CXR
AMS 700 Ultrex
Alpha I
Titan
Titan Narrow Base
32

Malleable prostheses are semirigid devices
with a central core that allows the penis to
be bent down for dressing and bent
upward for coitus.
most men this malleable core does not
maintain these positions very well.
advantage very low mechanical failure
rates and ease of use.
Disadvantages constant penile rigidity and
an increased risk of erosion
33

The postionable penile prosthesis
(Dura II) is a semirigid device with a
central series of articulating
segments held together with a spring
on each end.
This device, compared with malleable
prostheses, is better able to maintain
its upward and downward positions.
34

The two-piece inflatable penile prosthesis
(AMS Ambicor) consists of two cylinders
connected to a small scrotal pump
Squeezing this pump transfers a small
volume of fluid from the rear tip reservoirs
of the cylinders into a nondistensible central
chamber, producing rigidity comparable to
that of a malleabledevice.
When the device is deflated, the central
chamber partially collapses, providing better
flaccidity than a malleable implant. The two-
piece prosthesis has as its primary
advantage ease of implantation because
there is no third piece (abdominal fluid
reservoir).
A disadvantage compared with malleable
devices is the increased risk of mechanical
35

36

The ideal prosthesis would provide as
closely as possible normal penile flaccidity
and erection.
Only three-piece inflatable devices that
transfer a large volume of fluid into the
penile cylinders for erection and out of the
cylinders for flaccidity 37

38

SURGERY
under SA or GA on an OP
with discharge on the same or the next day
When an abdominal fluid reservoir is placed,
no strenuous activity and heavy lifting for
4 weeks.
nonstrenuous work after one week.
Coitus in 4 to 6 weeks.
39

Implantation preserves orgasm and
ejaculation if present but does not restore
them if they are absent.
The patient should be informed about
complete removal of the implant if infetion
occur
mechanical failure is possible and correcting
it requires device revision or replacement.
40

Surgical approaches
subcoronal (used only for implantation of
malleable or positionable devices),
infrapubic, and
penoscrotal
41

Comparison of Infrapubic and Penoscrotal Implant Approaches
Infrapubic
Approach
Penoscrotal Approach
Advantages Reservoir
placement under
direct vision
Better corporeal
exposure
No dorsal nerve
injury
Pump fixation
possible
Disadvantages Limited
corporeal
exposure
Possible dorsal
nerve injury
Inability to
anchor pump
Blind reservoir
placement
42

The transverse
penoscrotal
incision extended
in an inverted-T
fashion to provide
nearly complete
corporeal exposure
43

• A 4-cm transverse incision 1
cm below the penoscrotal junction.
The transverse incision is carried
down through dartos fascia..
Allis clamps are placed on the
lower margin of the fascia, and the
underside of dartos fascia is
dissected off theurethra and the
proximal corpora (crura).
ring retractor placed
so that exposure may be
maintained by a combination of
hook stays and retractor blades 44

Two-centimeter corporotomies are
made,
Two horizontal mattress sutures of 2-
0 polydioxanone,
are placed on each side of the
corporotomy
These are used as
guide sutures during corporeal
dilation and measurement, and to
close the corporotomy
after the cylinders are placed
Dilation starts with an 8-mm Hegar
dilator and proceeds to
16 mm proximally and to 14 mm
distally. 45

Using a sizing instrument, the distal measurement is taken from
the distal end of the corporotomy and the proximal measurement
is taken from the proximal end of the corporotomy
46

After corporeal measurements
the appropriate cylinder size is
selected
Adjustments between these sizes are
made by the addition of rear tip
extenders (1, 2, or 3 cm).
47

Distal cylinder insertion is aided by use of
the Furlow cylinder inserter .
If rear tip extenders needed they are added
now,
and then proximal portion of the cylinder is
manually inserted
If the cylinder fit is proper, the rounded
visible portion of the cylinder lies flatly in
the open
corporotomy 48

49

The cylinder, which has been correctly sized, lies
flat within the corpus caverno
50

For pump placement, a second incision is
made in the dartos fascia in scrotal septum.
A deep septal pouch is developed
The pump is placed in this pouch with the
reservoir tube in front and the two cylinder
tubes in back.
A right angle clamp is used to route each
pump tube through three separate stab
incisions through the back wall of the pouch
After this all three tubes from the pump are
transposed to the area exposed by the first
transverse dartos incision
51

52

For reservoir insertion into the retropubic space,Bladder is
emptied by foley catheter
The surgeon introduces a finger into the incision and
moves it up to the external inguinal ring on either side..
Metzenbaum scissors is used to perforate the transversalis
fascia
If all layers of the fascia are perforated, the surgeon's
index finger enters the retropubic space.
Correct entry is confirmed by the symphysis pubis and the
balloon in the empty bladder are palpated.
A nasal speculum is substituted for the finger; this
maintains the fascial opening.
The empty reservoir is introduced into the retropubic
space
53

The AMS reservoirs are available in
two sizes: 65 mL and 100 mL. The
former is recommended for all
except for the 18- and 21-cm Ultrex
cylinders, which require the 100 mL
reservoir size
54

To avoid autoinflation, the fluid pressure in
the
reservoir should be zero even when
pressure is applied to the suprapubic area.
To achieve zero pressure, a 50-mL syringe
without a plunger is attached to the
reservoir tubing and held at the bladder
(reservoir) level.
Manual suprapubic pressure is then applied,
allowing fluid to escape from the reservoir
This maneuver should leave 50 to 55 mL in a
65-mL reservoir and 80 to 85 mL in a 100-
55

56

A long right angle clamp is introduced through the
incision to the inguinal area on the side of the
reservoir.
stab incision is made, and through this a closed
suction type of drain is introduced. The drain is
brought downto the base of the penis,
Dartos fascia is then closed transversely with
running 3-0 Dexon.
The skin is closed with running subcuticular 4-0
Vicryl.
57

POSTOPERATIVE CARE
The urethral catheter and the closed suction
drain are removed the next morning.
patient is instructed to keep his penis up on
the lower abdomen pointing to the
umbilicus to avoid ventral curvature of the
penis
The patient is given permission to begin
coitus whenever inflation can be
accomplished without discomfort
Retarded ejaculation (failure to reach
orgasm) may occur when men first use their
prosthesis for coitus. To avoid this, the
couple is counseled to have adequate
foreplay
58

COMPLICATIONS
Infection,
to eradicate the infection, removal of all components
of the prosthesis is almost always required.
Perforation and Erosion
Perforation is an event that occurs intraoperatively;
whereas erosion is an event that occurs or is
recognized only postoperatively
If urethra perforation occurs, the implant procedure
should be abandoned and a urethral catheter should
be left in for 7 to 10 days
59

Erosion of the distal cylinder lateral
to the distal corpus cavernosum is
usually most effectively corrected by
a technique described by Mulcahy
60

If erosion of one cylinder into the meatus or
the glans, this cylinder should be removed
as soon as possible.
After the cylinder is removed, an
implantable plug (supplied by the device
manufacturer) is placed
many men are able to have coitus with only
one inflatable cylinder
61

THANKYOU
62

Penis ed- management

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