Erectile dysfunction (ED) is defined as the persistent inability to attain or maintain an erection sufficient for satisfactory sexual performance. It can be caused by physical or psychological factors. A thorough medical history, physical exam, and use of the International Index of Erectile Function questionnaire are used to evaluate patients. Treatment options include lifestyle changes, oral medications like sildenafil, counseling, penile injections, vacuum devices, and penile prostheses for severe cases. PDE5 inhibitors are generally well-tolerated but have drug interactions to consider. Proper treatment can help improve the lives of those suffering from ED.

1. ERECTILE
DYSFUNCTION

2. “Man survives earthquakes, experiences the
horrors of illness, and all of the tortures of
the soul. But the most tormenting tragedy
of all time is, and will be, the tragedy of the
bedroom.”
Tolstoy

3. The consistent inability to achieve and/or
maintain an erection adequate for
satisfactory sexual intercourse.
Definition of Erectile
Dysfunction(ED)
“This definition is simple, but the condition is not”

4. DSM-IV (American Psychiatric
Association, 2000)
Persistent or recurrent inability to attain, or to
maintain until completion of the sexual activity, an
adequate erection
The disturbance causes marked distress or
interpersonal difficulty
The erectile dysfunction is not better accounted for by
another Axis I disorder (other than a sexual dysfunction)
and is not due exclusively to the direct physiological
effects of a substance (e.g. a drug of abuse, a
medication) or a general medical condition

5. Anatomy of Penis

6. Normal Male Sexual Function requires:
1) An intact Libido
2) Detumescence
3) Ability to achieve and maintain penile Erection
4) Ejaculation
Parasympathetic nerves S2-4 mediate erection
Sympathetic nerves T11-L2 control ejaculation and
detumescence

7. Penile erection is a neurovascular event
modulated by psychological factors and
hormonal status. On sexual stimulation, there
is increased flow of blood into the lacunar
network. Subsequent compression of the
trabecular smooth muscle causes a closure of
the emissary veins and accumulation of blood
in the corpora. The corpora becomes non-
compressible and blood cannot escape.
Physiology Of Erection

8. Nerve impulses cause the
release of
neurotransmitters (NO)
from the cavernous nerve
terminals. Nitric oxide
diffuses into cavernosal
smooth muscle cells,
activates Guanylate
cyclase, which converts
GTP to cGMP resulting in
smooth muscle relaxation
in the arteries and
arterioles supplying the
erectile tissue and a
several fold increase in
penile blood flow.

9. At the same time, relaxation of the
trabecular smooth muscle increases
the compliance of the sinusoids,
facilitating rapid filling and expansion
of the sinusoidal system.

10. Sinusoidal engorgement of the
cavernosal tissues
Flaccid Penis Erect Penis

11. The subtunical venular plexuses are thus
compressed between the trabeculae and the tunica
albuginea, resulting in almost total occlusion of
venous outflow.

12. These events trap the blood within the
corpora cavernosa and raise the penis from a
dependent position to an erect position, with
an intracavernous pressure of approximately
100 mm Hg (the phase of full erection).

13. Sexual impulse
Neurotransmitter
Release of NO & chemical substrates
Smooth muscle relaxation
Tumescence
Venous occlusion
Rigidity
Erection
Normal pathway to erection

15. Types of Erectile Dysfunction
It can be primary or secondary
 Primary means present from the first attempt
at intercourse or it may be secondary in which
person develop ED after a period of normal
function.
In situational male ED, a man is able to have
coitus in certain circumstances but not in others
More common in older than younger men (in
contrast to premature ejaculation)

16. Causes of ED

17. Psychogenic
Performance anxiety
Relationship problems/difficulties
Loss of attraction to partner
Depression and anxiety disorders
• Anxiety
• Depression
• Fatigue
• Guilt
• Stress
• Marital Discord
• Excessive alcohol consumption

18. Psychogenic ED

19. Vasculogenic (arterial or
cavernosal):
Atherosclerosis
Hypertension
Trauma

20. Caused by other systemic
diseases and aging:
Old age
Diabetes mellitus
Chronic renal failure
Coronary heart disease

21. Neurogenic:
Stroke or Alzheimer’s disease
Spinal cord injury
Radical pelvic surgery
Diabetic neuropathy
Pelvic injury

22. Hormonal:
Hypogonadism
Hyperprolactinemia

23. Drug-induced:
Antihypertensive and antidepressant drugs
Antiandrogens
Alcohol abuse
Cigarette smoking

24. Medications & ED
More likely to affect sexual function
Beta blockers(propranolol,atenolol)
Statins
Diuretics(thiazide)
Anti-
depressants(fluoxetine,sertraline,amitriptyline)
Anti-psychotics(chlorpromazine,risperidone)
Less likely to affect sexual function
Calcium channel blockers
ACE inhibitors

25. Causes of ED
Sydney Men’s Health

26. Clues differentiating psychogenic
from organic causes
Psychogenic
Sudden onset
Situational
Normal waking and nocturnal
erections
Normal erection with masturbation
Tumescence present
Relationship problems
Major Life event
Anxiety, fear, depression
Organic
Gradual onset
All situations
Reduced or absent waking and
nocturnal erections
No erection with masturbation
Lack of tumescence
Normal libido, normal ejaculation
Known Cardiovascular,
endocrinal,, neurological
conditions
Operations, radiotherapy, trauma
to testes/scrotum
Medications, smoking, alcohol

27. Risk factors for ED
 Aging
 Chronic disease conditions
• Heart disease (1.8 times)
• HTN (1.6 times)
• DM (4.1 times)
• Peripheral vascular disease
(2.6 times)
 Smoking (24%)
 Alcohol use
 Obesity (22%)
 Lack of physical activity
 Depression (1.8 times)
 Elevated cholesterol (1.7 times)

28. History
Medical
Surgical
Psychiatric
Medication
Smoking
Alcohol
Recreational drug use

29. Assessment
A thorough history (medical, sexual, and
psychosocial)
Has there been a previous period of normal
function?
Has the failure occurred with more than one
partner?
Does erection occur during foreplay?
Does erection occur on waking or in response to
masturbation?
Is there evidence of alcohol or drug abuse? (ask
the partner as well as the patient)
Are there possible effects of any medications?

30. The International Index of
Erectile Function (IIEF-5)
Questionnaire

31. Questions 1 2 3 4 5
1. How do you rate
your confidence that you could
get and keep an erection?
Very low Low Moderate High Very high
2. When you had erections with
sexual stimulation, how
often were your erections hard
enough for penetration?
Almost
never/never
A few times
(much less
than half the
time)
Sometimes
(about half the
time)
Most times
(much more
than half the
time)
Almost
always/always
3. During sexual intercourse, how
often were you able to maintain
your erection after you had
penetrated (entered) your
partner?
Almost
never/never
A few times
(much less
than half the
time)
Sometimes
(about half the
time)
Most times
(much more
than half the
time)
Almost
always/always
4. During sexual intercourse, how
difficult was it to maintain your
erection to completion of
intercourse?
Extremely
difficult
Very difficult Difficult Slightly
difficult
Not difficult
5. When you attempted sexual
intercourse, how often was it
satisfactory for you?
Almost
never/never
A few times
(much less
than half the
time)
Sometimes
(about half the
time)
Most times
(much more
than half the
time)
Almost
always/always
Over the Past 6 Months

32. The IIEF-5 score is the sum of the ordinal
responses to the 5 items.
 22-25: No erectile dysfunction
 17-21: Mild erectile dysfunction
 12-16: Mild to moderate erectile dysfunction
 8-11: Moderate erectile dysfunction
 5-7: Severe erectile dysfunction
Scoring System

33. Examination
Blood pressure
Peripheral pulses, palpate for AAA
Testes size and consistency
Secondary sexual characteristics
Penis for Peyronie’s plaques, Phimosis

34. Investigations
Serum Testosterone
Serum Prolactin
Screening Profile
•Sugars
•Lipids
•Thyroid Functions

35. Test for erections during
REM sleep
It is normal for a man to have
five to six erections during sleep,
especially during rapid eye
movement (REM). Their absence
may indicate a problem with
nerve function or blood supply in
the penis. There are two methods
for measuring changes in penile
rigidity and circumference during
nocturnal erection: snap gauge
and strain gauge.
Nocturnal penile tumescence (NPT)

36. Treatment of Erectile
Dysfunction

37. General Measures
Psychosexual Therapy
Drug Therapy
Vacuum devices
Surgical treatments

38. ED treatment algorithm
1st line – lifestyle changes,
hormone issues
2nd line – oral medication,
counseling
3rd line – penile injections,
vacuum devices
4th line – implants, vascular
surgery

39. Treatment of ED General
Measures
Smoking cessation
Reduce alcohol
Weight loss
Exercise

40. Psychosexual therapy
Even if cause of ED is physical the patient
will develop psychosexual issues
Performance anxiety
Sensate focus exercises
Relationship counselling

41. Drugs for ED
 Oral agents:
• Phosphodiesterase type 5 inhibitors
• Oral phentolamine and apomorphine
• Yohimbine
 Intra-cavernosal
• Prostaglandin E1 Alprostadil
• Papaverine
 Intra-urethral:
• Alprostadil

42. PDE5 inhibitors
Sildenafil (Viagra) 25mg, 50mg, 100mg
•1 hour before sexual activity
•4-6 hour window
•Absorption delayed by fatty meal
Tadalafil (Cialis) 5mg, 10mg, 20mg
•30 minutes before sexual activity
•36 hour window
•Absorption not affected by food
Vardenafil (Levitra) 5mg, 10mg, 20mg
•30-60 minutes before sexual activity
•4-6 hour window
•Absorption delayed by fatty meal

43. Most commonly usedPDE5
Inhibitor-Sildenafil
Sildenafil is a selective inhibitor of
phosphodiesterase type 5, which inactivates cyclic
GMP. When sexual stimulation releases nitric oxide
into the penile smooth muscle, inhibition of
phosphodiesterase type 5 by sildenafil causes a
marked elevation of cyclic GMP concentrations in
the glans penis, corpus cavernosum, and corpus
spongiosum, resulting in increased smooth-muscle
relaxation and better erection. Sildenafil has no
effect on the penis in the absence of sexual
stimulation, when the concentrations of nitric oxide
and cyclic GMP are low.

44. PDE5 Physiology
PDE5 Inhibitors

45. PDE5 Inhibitors Side Effects
Facial flushing
Headache
Nasal congestion
Dizziness
Dyspepsia
Visual disturbance (blue halo)
Priapism
Non-arteritic anterior ischaemic optic
neuropathy

46. PDE5 Inhibitor Contraindications
Recent cardiovascular event
Nitrates
Hypotension
Anatomical deformity
•Angulation,
•Cavernosal fibrosis
•Peyronie’s disease
Predisposition to prolonged erection
•Sickle cell disease
•Multiple myeloma
•Leukaemia

47. PDE5 Inhibitors Drug
Interactions
Nitrates
•Glyceryl trinitrate, isosorbide mono or dinitrate
•Chest pain after taking Sildenafil/Vardenafil no
nitrates 24 hours, Tadalafil no nitrates 48 hours
•Recreational amyl nitrate (Poppers)
Cytochrome P450 inhibitors
•Protease inhibitors especially Ritonavir use very
small dose
•Cimetidine, Ketoconazole, Erythromycin
Alpha blockers

48. Comparision of the 3 Major
PDE5 Inhibitors

49. Intracavernosal Injections
Alprostadil (Caverject, Viridal) 5-40 mcg
•Independent of intact nervous system
•Manual dexterity, adequate vision, training
•Contraindicated: bleeding disorders, sickle cell
anaemia, multiple myeloma, leukaemia
•Side effects: peno-scrotal pain, haematoma,
fibrosis at injection sites, priapism
Papaverine, Phentolamine, Aviptadil (vaso-intestinal
peptide) been used sole or with Alprostadil

50. Intracavernosal Injections

51. Intraurethral
Alprostadil (Muse) 125mg, 250mg, 500mg, 1g
•Pellet inserted with applicator
•Massage penis to aid absorption
•Side effects: Penile pain, dizziness,
priapism rare

52. Intraurethral Alprostadil

53. Vacuum Devices
Blood trapped in intracorporal and
extracorporal compartments of penis
Constricting ring at base of penis
Cyanosis, oedema, cold
Pivots at base below ring
Maximum time 30 minutes

54. Vacuum Devices

55. Penile Prostheses
Semi-rigid rods
2 piece inflatable prosthesis
3 piece inflatable prosthesis with abdominal
reservoir
Risks
•Infection
•Destroys corpora cavernosa
•Erosion and extrusion
•Mechanical failure

56. Penile Prosthesis

57. ®

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