Penis ed- overview

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

2. 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

3. ERECTILE DYSFUNCTION
 ED defined as the consistent or
recurrent inability to attain and/or
maintain penile erection sufficient for
sexual performance .
3
Dept of Urology, GRH and KMC,
Chennai.

4. EPIDEMIOLOGY
 Incidence - 25.9 cases per 1000 man-years.
 Annual incidence rates increased with each decade
(per 1000 man-years):
• 12.4 cases for 40 to 49 years,
• 29.8 cases for 50 to 59 years, and
• 46.4 cases for 60 to 69 years.
Massachusetts Male Aging Study (MMAS )-1709 -men
40- 70 yrs , first surveyed 1987 - 1989 and resurveyed
1995 - 1997 .
4
Dept of Urology, GRH and KMC,
Chennai.

5. An Erection Requires a Coordinated
Interaction of Multiple Organ Systems
 Psychological
 Endocrine
 Vascular
 Neurologic
5
Dept of Urology, GRH and KMC,
Chennai.

6. C /S of Penis
6
Dept of Urology, GRH and KMC,
Chennai.

7. 7
Dept of Urology, GRH and KMC,
Chennai.

8. NEURO ANATOMY
8
Dept of Urology, GRH and KMC,
Chennai.

9. Mechanism of
Smooth Muscle Relaxation
9
Dept of Urology, GRH and KMC,
Chennai.

10. 10
Dept of Urology, GRH and KMC,
Chennai.

11. RISK FACTORS
 Heart disease
 Hypertension
 Diabetes
 Chronic renal failure
 Hepatic failure
 Multiple Sclerosis
 Severe depression
 Other (vascular disease, low HDL, high
cholesterol)
11
Dept of Urology, GRH and KMC,
Chennai.

12. FUNCTIONAL CLASSIFICATION OF ED
12
Dept of Urology, GRH and KMC,
Chennai.

13. NEUROGENIC
 10% to 19% of ED is neurogenic .
 Parkinson's disease
 MULTIPLE SCLEROSIS
 Stroke
 Encephalitis
 Temporal lobe epilepsy
 Tumors
 Dementias
 Alzheimer's disease
 Shy-Drager syndrome
 Trauma.
13
Dept of Urology, GRH and KMC,
Chennai.

14. ENDOCRINOLOGIC
 Testosterone : enhances sexual interest, ↑
frequency of sexual acts, and ↑ frequency
of nocturnal erections.
 Men receiving long-term androgen
ablation therapy
 Hyperprolactinemia- pituitary adenoma or
drugs
 hyper- and hypothyroidism.
 DM.
14
Dept of Urology, GRH and KMC,
Chennai.

15. ARTERIOGENIC
 Atherosclerotic or traumatic arterial
occlusive disease of hypogastric-
cavernous-helicine arterial tree .
 Risk factors HT, hyperlipidemia,
cigarette smoking, DM, blunt
perineal or pelvic trauma, and pelvic
irradiation.
15
Dept of Urology, GRH and KMC,
Chennai.

16. CAVERNOUS (VENOGENIC)
 Tunical changes- degenerative changes
(Peyronie's disease, old age, and DM) or
traumatic injury to T.A (penile # )
 Fibroelastic structural alterations,
 Insufficient trabecular smooth muscle
relaxation,
 Venous shunts. (priapism)
16
Dept of Urology, GRH and KMC,
Chennai.

17. DRUG INDUCED
 Anti HT- thiazide diuretics, non sel β blockers,
clonidine, methyl dopa.
 Psychotropic - all anti dep except trazodone &
bupropion.
 Antiandrogen - bicalutamide, LHRH agonist ,
estrogen, ketoconazole, cyproterone.
 MISC -digoxin, cimitidine, tobacco & alcohol -ED.
17
Dept of Urology, GRH and KMC,
Chennai.

18. PRIMARY ED
 Lifelong inability to initiate /maintain
erections, or both.
 Begins with first sexual attempt .
 Most cases due to psychologic factors,
 Physical cause - maldevelopment of penis
or blood and nerve supply .
18
Dept of Urology, GRH and KMC,
Chennai.

19. MINIMAL DIAGNOSTIC WORK UP
 C/O ERECTILE DYSFUNCTION
 MEDICAL&PSHCHOSEXUAL H/O
(IDENTIFY CAUSE/REVERSIBLE RISK FACT/PSHCOSOCIAL STATUS)
 FOCUSED PHYSICAL EXAMINATION
(PENILE DEFORMITIES/SIGNS OF HYPOGONADISM/PROSTATIC/CV-NEURO
STATUS)
 LABORATORY TEST
(GLUCOSE/LIPID PROFILE/HORMONAL)
19
Dept of Urology, GRH and KMC,
Chennai.

20. SEXUAL QUESTIONNAIRES
 International Index of Erectile Function (IIEF) ,
 Brief Male Sexual Function Inventory (BMSFI)
 Dysfunction Inventory for Treatment Satisfaction
(EDITS) ,
 Male Sexual Function Scale.
 Major drawback is reliance on self-assessment.
20
Dept of Urology, GRH and KMC,
Chennai.

21. SEXUAL HISTORY
 Interview conducted face-to-face.
 Ensure pt trust, comfort, and openness.
 Ascertain severity, onset, and duration of problem, as well
as presence of concomitant medical or psychosocial factors.
 Determine presenting complaint is primary sexual problem
or other aspects (desire, ejaculation, orgasm) are involved.
21
Dept of Urology, GRH and KMC,
Chennai.

22. MEDICAL HISTORY
 Evaluate role of underlying medical conditions
(e.g., atherosclerosis, DM) and comorbidities.
 Assess potential role of medication.
 Past H/O: Prostatectomy, APR, Pelvic trauma.
 Differentiate potential organic and psychogenic
causes .
22
Dept of Urology, GRH and KMC,
Chennai.

23. Characteristic
Organic Psychogenic
Onset Gradual Acute
Circumstances Global Situational
Course Constant Varying
Noncoital erection Poor Rigid
Psychosexual problem Secondary Long history
Partner problem Secondary At onset
Anxiety and fear Secondary Primary
23
Dept of Urology, GRH and KMC,
Chennai.

24. PSYCHOSOCIAL HISTORY
 Assess pt's past & present partner relationships.
 Sexual dysfunction may affect pt's self-esteem
and coping ability, social relationships and
occupational performance.
 Ensure pt is involving in monogamous,
heterosexual relationship.
 Organic and psychogenic factors often coexist.
24
Dept of Urology, GRH and KMC,
Chennai.

25. PHYSICAL EXAMINATION
 Screening for medical risk factors or sec sexual
characteristics,
 Assessment of CVS, CNS, and genital systems.
 Obvious cause (e.g., micropenis, chordee,
Peyronie's plaque.
 Test for genital & perineal sensation and
bulbocavernosus reflex (BCR) useful in assessing
possible neurogenic impotence .
25
Dept of Urology, GRH and KMC,
Chennai.

26. LAB TESTS
 Fasting glucose, RFT, lipids & testosterone.
 Optional : indicated by history & P/E .
( Prolactin, LH, FSH, Thyroid function.)
 PSA measured >50 yrs age ,F/H ca prostate, if
hormonal replacement planned.
26
Dept of Urology, GRH and KMC,
Chennai.

27. EVALUATION OF COMPLEX PATIENT
 Indications for specialized evaluation
• Failure of initial treatment
• Peyronie's disease
• Primary ED
• H/O pelvic/perineal trauma
• Vascular or neurosurgical intervention
• Complicated endocrinopathy
• Complicated psychiatric disorder
• Complex relationship problems and
• Medicolegal concerns .
27
Dept of Urology, GRH and KMC,
Chennai.

28. EVALUATION
28
Dept of Urology, GRH and KMC,
Chennai.

29. VASCULAR
-CAVERNOUS ARTERIAL OCCLUSION PRESSURE
-DYNAMIC INFUSION CAVERNOSOMETRY
AND CAVERNOSOGRAPHY (DICC)
-PHARMACOLOGIC CAVERNOSOGRAPHY
-PHARMACOLOGIC ARTERIOGRAPHY
-COMBINED INTRACAVERNOUS INJECTION
AND STIMULATION (CIS)
29
Dept of Urology, GRH and KMC,
Chennai.

30. DUPLEX ULTRASONOGRAPHY
 CIS & blood flow measurement by duplex U/S .
 Evaluates veno occlusive dysfunction.
30
Dept of Urology, GRH and KMC,
Chennai.

31. NEUROLOGIC
 Nerve conduction velocity
studies, biothesiometry,
 bulbocavernosus EMG,
 corpus cavernosus EMG
 Penile thermal sensory testing
31
Dept of Urology, GRH and KMC,
Chennai.

32. PSYCHOPHYSIOLOGIC
 Nocturnal penile tumescence (NPT) monitoring
 Stamp test
 Snap gauges:3 individual, differently colored
bands secured at base of penis , break under
progressive radial forces.
 Sleep laboratory nocturnal penile tumescence
and rigidity (NPTR)
 RigiScan
 NPT electrobioimpedance .
32
Dept of Urology, GRH and KMC,
Chennai.

33. NPTR
• Suspected sleep disorder
• Obscure cause of ED
• No response to therapy
• Planned surgical treatment
• Legally sensitive case
• Measurement of drug effects in placebo-controlled trials
• Suspected psychogenic cause
 Advantages - freedom from psychologic influences, ability
to detect sleep-related abnormalities.
 Disadvantages of NPT evaluation - it is age dependent and
costly, ideally done with RigiScan in a sleep center.
33
Dept of Urology, GRH and KMC,
Chennai.

34. RIGISCAN
 First automated, portable NPTR recording.
 Combines monitoring of radial rigidity, tumescence, no &
duration of erectile events with portable sys -used at home.
 Collect data 3 separate nights for maximum of 10 hrs/night
 Consist of two loops: one is placed at base of penis & other
at coronal sulcus. By constricting the loops, device records
penile tumescence & radial rigidity at penile base and tip.
 Measurement (initialization) first done in office 15- 20 mts.
34
Dept of Urology, GRH and KMC,
Chennai.

35. MANAGEMENT OF
ERECTILE DYSFUNCTION
35
Dept of Urology, GRH and KMC,
Chennai.

36. NONSURGICAL MANAGEMENT OF ERECTILE
DYSFUNCTION
 Specific Nonspecific
lifestyle change
psychosexual
therapy
replacement of
offending medication
hormonal therapy
oral PDE5-inhibitors,
vacuum constriction
device
Intra cavernous
injection
36
Dept of Urology, GRH and KMC,
Chennai.

37. Lifestyle Change
 Physical activity
 cigarette smoking increases
impotence
 Long-distance bicycling is another
risk factor .
37
Dept of Urology, GRH and KMC,
Chennai.

38. Medication Change
 Anti hypertensive drugs
- Nonspecific α-adrenergic blockers, methyldopa
and reserpine,
Thiazide diuretics,Spironolactone-ED
Switching patients to newer agents- calcium-
channel blockers and angiotensin-converting
enzyme inhibitors,
 Antidepressants -
Tricyclic antidepressantsand monoamine
oxidase inhibitors
Selective serotonin reuptake inhibitors (SSRIs)
Treatment - substitution , drug holidays, SSRI
dosage reduction, watchful waiting, and PDE-5
inhibitors
38
Dept of Urology, GRH and KMC,
Chennai.

39. Psychosexual Therapy
 Basic treatment –
emphasis on sensate focus exercises and
the elimination of performance anxiety.
Masters and Johnson- beginning with
nonsexual touching and then, moving on to
more genitally focused caressing.
 Recent approaches –
-cognitive-behavioral interventions -
correcting maladaptive cognitions,
-desensitization and assertiveness
exercises,
- family-of-origin and psychodynamic
explorations
39
Dept of Urology, GRH and KMC,
Chennai.

40. Hormonal Treatment
Testosterone Preparations
Oral
• Methyltestosterone (Metandren) 10-30 mg Sublingual Daily
• Testosterone undecanoate (Andriol) 120-160 mg Oral Daily
Buccal
 Striant 30 mg Buccal q 12 hr
Transdermal Patches
 Testoderm TTS 5 mg Skin Daily
Transdermal Gel
 Androgel 1% 5 g Skin Daily
 Testim 1% 5 g Skin Daily
Intramuscular
 Cypionate (Depo-testosterone) 150-300 mg IM q 2-4 wk
 Enanthate (Delatestryl) 150-300 mg IM q 2-4 wk
Pellet - Testopel 150-450 mg SC q 3-6 mo
40
Dept of Urology, GRH and KMC,
Chennai.

41. Adverse Effects of Androgen Therapy
 Supraphysiologic levels of testosterone - suppress LH
andFSH production and result in infertility, breast
tenderness and/or gynecomastia
 Cardiovascular risks are increased
 prostate safety -mean increase in PSA from 1.7 to 2.5
ng/L after 3 months of testosterone therapy
every 6 months-periodic hemoglobin/hematocrit levels,
liver function tests, cholesterol, and lipid profile , rectal
examination and serum PSA testing
 prostate or breast cancer -absolute contraindication
digital rectal examination and serum PSA level,
ultrasound-guided biopsy before androgen therapy .
41
Dept of Urology, GRH and KMC,
Chennai.

42. Pharmacological therapy
 Peripherally acting agents
Sildenafil ,vardenafil and tadalafil
M.O.A-
nitric oxide's effect to enhance erection.
S/E-
 visual disturbances-Blurred/blue vision
 headaches, flushing, slight lowering of blood
pressure, dyspepsia
 nonarteritic anterior ischemic optic neuropathy
 vardenafil - cardiac conduction precaution.
 C/I-CVS risk and on nitrates.
42
Dept of Urology, GRH and KMC,
Chennai.

43. 43
Dept of Urology, GRH and KMC,
Chennai.

44. 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
44
Dept of Urology, GRH and KMC,
Chennai.

45. Common Intracavernous
Agents
Drug Dose Range Advantages SideEffect
Papaverine 7.5-60 mg Low cost
Stable at room temp Fibrosis,priapism
Elevation of liver
enzymes
Papaverine +
Phentolamine 0.1-1 ML More potent Fibrosis, priapism
Alprostadil 1-60 μg Metabolized in penis Priapism
Painfulerection
Requires
refrigeration
Relatively
expensive
Moxisylyte 10-30 mg Priapism rare
Less potent
Papaverine +
phentolamine +
alprostadil 0.1-1.0 mL Most potent Requires refrigeratio
45
Dept of Urology, GRH and KMC,
Chennai.

46. Intraurethral Therapy
 Alprostadil- hypotension and syncope have been
noted in 1% to 5.8%.
 The medicated urethral system for erection
(MUSE;)
alprostadil in very small semisolid pellet
administered into the distal urethra (3 cm)
-absorbed by the corpus spongiosum and
transported to the corpus cavernosum through
venous channels -through circumflex and
emissary veins perforating the tunica albuginea
side effects- penile pain - 10.6%
hypotension and syncope -I-5%
46
Dept of Urology, GRH and KMC,
Chennai.

47. Transdermal Therapy
transglanular monotherapy
Topiglan (Macrochem), Alprox-
TD
- mixture of a PGE1 gel (0.5 to 2.5
mg) and a proprietary
transdermal permeation
enhancer (SEPA).
- Topical alprostadil was well
tolerated.
- adverse event - urogenital pain
47
Dept of Urology, GRH and KMC,
Chennai.

48. Vacuum Constriction Device
 The vacuum constriction device -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.
 portion of the penis proximal to the ring is not rigid,
which may produce a pivoting effect.
 The penile skin may be cold and dusky, and
ejaculation may be trapped by the constricting ring.
48
Dept of Urology, GRH and KMC,
Chennai.

49.  Indications-
- severe proximal venous leakage
- arterial insufficiency,
- fibrosis secondary to priapism, or
- prosthesis-the device may not produce
adequate erection.
severe vascular insufficiency, combining
intracavernous injection with the vacuum
constriction device may enhance the erection
Complications-
penile pain and numbness, difficult ejaculation,
ecchymosis, and petechiae.
Patients taking aspirin or warfarin (Coumadin)
should exercise caution
49
Dept of Urology, GRH and KMC,
Chennai.

50. Progressive Treatment Model
Osteoarthritis Erectile
Dysfunction
First-line NSAIDs PDE-5
inhibitors
Second-line Joint injections VCDs, IUD
Third-line Arthroscopic surgery
Intracavernous inj.
Fourth-line joint replacement Penile
prosthesis
50
Dept of Urology, GRH and KMC,
Chennai.

51. .
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
51
Dept of Urology, GRH and KMC,
Chennai.

52. 52
Dept of Urology, GRH and KMC,
Chennai.

53. 53
Dept of Urology, GRH and KMC,
Chennai.

54. Surgical approaches
 subcoronal (used only for implantation of
malleable or positionable devices),
 infrapubic, and
 penoscrotal
54
Dept of Urology, GRH and KMC,
Chennai.

55. 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
55
Dept of Urology, GRH and KMC,
Chennai.

56. The transverse
penoscrotal
incision extended
in an inverted-T
fashion to provide
nearly complete
corporeal exposure
56
Dept of Urology, GRH and KMC,
Chennai.

57. • 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
57
Dept of Urology, GRH and KMC,
Chennai.

58. Two-centimeter corporotomies
are made,
Two horizontal mattress
sutures of 2-0 polydioxanone,
are placed on each side of the
corporotomy
Dilation starts with an 8-mm
Hegar dilator and proceeds to
16 mm proximally and to 14
mm distally.
58
Dept of Urology, GRH and KMC,
Chennai.

59. 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
59
Dept of Urology, GRH and KMC,
Chennai.

60. 60
Dept of Urology, GRH and KMC,
Chennai.

61. The cylinder, which has been correctly sized, lies
flat within the corpus caverno
61
Dept of Urology, GRH and KMC,
Chennai.

62. 62
Dept of Urology, GRH and KMC,
Chennai.

63.  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
63
Dept of Urology, GRH and KMC,
Chennai.

64. 64
Dept of Urology, GRH and KMC,
Chennai.

65. COMPLICATIONS
1-Infection
-removal of all components of the prosthesis.
-prosthesis reimplantation
2-Perforation and Erosion
- Perforation is an event that occurs
intraoperatively
-erosion is an event that occurs or is recognized
only postoperatively
3-Pump Complications
upward pump migration
Autoinflation with physical activity-
4-Poor Glans Support
SST deformity -supersonic transport (Concorde)
nose appearance 65
Dept of Urology, GRH and KMC,
Chennai.

66. Penile vascular surgery
overall goal -to bypass obstructive arterial lesions
in the hypogastric-cavernosal arterial bed.
increase the cavernosal arterial perfusion
pressure and blood inflow in patients with
vasculogenic erectile dysfunction secondary to
pure arterial insufficiency.
Penile venous surgery can still be indicated in
patients who have congenital venous
abnormalities of drainage of the corpora
cavernosa tissue
66
Dept of Urology, GRH and KMC,
Chennai.

67. 67
Dept of Urology, GRH and KMC,
Chennai.

68. 68
Dept of Urology, GRH and KMC,
Chennai.

69. PENILE VENOUS SURGERY
 Selection Criteria
1. complaint by a patient of short-duration erections or
tumescence only with sexual stimulation;
2. failure to obtain or to maintain an erection from the use
of oral sildenafil or intracavernous injection on multiple
trials with different agents with sexual stimulation;
3. normal cavernous arteries on color duplex Doppler
studies or the second phase of dynamic infusion
cavernosometry and cavernosography
4. faulty veno-occlusive mechanism as determined by
infusion pump or gravity pharmacocavernosometry that is
amenable to surgery (no massive venous leakage);
5. location of the site of venous leakage from the corpora
cavernosa on pharmacocavernosography
6. no medical contraindication to surgery;
7. complete elimination of tobacco use;
69
Dept of Urology, GRH and KMC,
Chennai.

70. 70
Dept of Urology, GRH and KMC,
Chennai.