Electrical stimulation for erectile dysfunction, physiotherapy

1. Electrical Stimulation
For
Erectile Dysfunction
Aditya Johan Romadhon, Sst.Ft, M.Fis

2. Erectile Dysfunction
“The consistent or recurrent
inability to attain and/or
maintain a penile erection
sufficient for sexual satisfaction”
WHO-ISIR. 1st
International
Consultation on
ED, 1999

3. How would you
describe yourself?
Always, usually,
sometimes or never
able to get and keep an
erection good enough
for sexual intercourse
The subjects answering
‘always’ were classified
as normal
Those whos answering
“usually, sometimes or
never” were classified
as having mild,
moderate or complete”

4. Pathologic processes in these regions, such as Parkinson’s disease, stroke, encephalitis, or temporal lobe
epilepsy, are often associated with ED
The MPOA, the paraventricular nucleus, and the hippocampus have been regarded as important
integration centers for sexual drive and penile erection
Because an erection is a neurovascular event, any disease or dysfunction affecting the brain, spinal cord,
cavernous and pudendal nerves can induce dysfunction
Some are based on the cause (diabetic, iatrogenic, traumatic) and some on the neurovascular mechanism of
the erectile process failure to initiate [neurogenic], failure to fill [arterial], and failure to store [venous]
Many classifications have been proposed for ED.
doi: 10.1016/j.ucl.2005.08.007

5. In men with a spinal cord injury, their erectile function depends
largely on the nature, location, and extent of the spinal lesion
It appears that sacral parasympathetic neurons are important
in the preservation of reflexogenic erection
Reflexogenic erection is preserved in 95% of patients with
complete upper cord lesions, whereas only about 25% of those
with complete lower cord lesions can achieve an erection
Because of the close relationship between the cavernous nerves
and the pelvic organs, surgery on these organs is a frequent
cause of impotence
In cases of pelvic fracture, ED can be a result of cavernous
nerve injury or vascular insufficiency or both.

6. Prevalence of erectile dysfunction and associated factors among
men without concomitant diseases: a population study
• Nicolosi et al (2005) interviewed a population sample of 2412 men aged 40–70 y in
Brazil, Italy, Japan and Malaysia about medical history, lifestyle habits and sexual
behavior
• Of the 2513 subjects interviewed, 2412 answered the ED question and gave their
medical history
• 200 (8.3%) reported heart disease
• 540 (22.3%) hypertension,
• 223 (9.2%) diabetes
• 183 (7.6%) prostate diseases or surgery
• 164 (6.8%) depression
• 295 (12.2%) gastric or duodenal ulcer
• 29 (1.2%) hormonal treatment

7. Prevalence of mild, moderate and complete ED by age
group among men without concomitant diseases

8. Prevalence of moderate or complete ED among diseased
and healthy men by age group and risk of ED (OR)

9. Penile Erection
Penile erection is initiated after central
processing and integration of tactile, visual,
olfactory, and imaginative stimuli
Final response is mediated
by coordinated spinal
activity in the autonomic
pathways to the penis and
in the somatic pathways to
the perineal striated
muscles
https://doi.org/10.1111/j.1743-6109.2009.01624.x

10. • The central mechanisms controlling erection include supraspinal as well as spinal pathways
• Central dopaminergic neurons project to the medial preoptic area and the paraventricular
nucleus
• Dopaminergic neurons have been identified that travel from the caudal hypothalamus to
innervate the autonomic and somatic nuclei in the lumbosacral spinal cord

11. Central Pathways
A series of neurotransmitters are
involved in the central regulation
of erection
Facilitate erectile function
(dopamine, nitric oxide,
glutamate, acetylcholine,
oxytocin, hexarelin peptide,
ACTH, MSH and pro-VGF).
Inhibit erectile function (e.g.
noradrenaline, enkephalins,
GABA and endocannabinoids)
https://doi.org/10.1111/bcpt.12653

12. Dopaminergic neurons have been
identified that travel from the caudal
hypothalamus to innervate the autonomic
and somatic nuclei in the lumbosacral
spinal cord
Dopamine, thought to be of importance for
erectile function, is localized in the MPOA
and the PVN of the hypothalamus and the
nucleus accumbens
Dopamine leads to the activation of
oxytocinergic neurons by increasing
intracellular calcium followed by the
activation of neuronal nitric oxide
synthase (nNOS) through
parasympathetic nerves
Activation of dopamine receptors in the
lumbosacral part of the spinal cord and in
the erectile tissue are also involved in the
erection.

14. Phosphodiesterase 5 Inhibitor
The current standard of care
for ED consists of lifestyle
changes such as
management of diet,
diabetes, hypertension, and
weight loss, along with
pharmacotherapies
The current gold standard
treatment is the use of
phosphodiesterase 5
inhibitors such as sildenafil
citrate
As previously mentioned,
phosphodiesterase 5 (PDE-
5) is responsible for the
breakdown of cGMP within
the corpora cavernosa and
the initiation of
detumescence
PDE-5 inhibitors prevent
this breakdown of cGMP
and subsequently promote
the erectile response

15. Spinal Pathways
Spinal dopaminergic pathway is
also of importance for erectile
function
Fibres immunoreactive to
dopamine are present in the
thoracolumbar sympathetic chain
and also in the lumbosacral
parasympathetic nucleus
strong dopamine D2 receptor
expression was found in the
lumbosacral parasympathetic
neurons

16. Pudendal and Cavernous nerves
The penis has both somatic and autonomic (i.e.,
sympathetic and parasympathetic) innervation
The pudendal nerve supplies the somatic
innervation, which is responsible for the sensation of
the penis and the contraction of the bulbospongiosus
and ischiocavernosus muscles
The chain ganglia from T11 to L2 supply the
sympathetic innervation, which is responsible for
vascular smooth muscle contraction of the penis
The sympathetic fibers travel through the spinal
cord and exit as the superior hypogastric plexus
These nerves end terminally in the pelvic plexus
and as cavernous nerves
The sympathetic innervation is responsible for the
baseline tonic contraction of the helicine arteries
and trabecular smooth muscle, maintaining a flaccid
state

17. the intermediolateral nuclei of the S2
supply the parasympathetic innervation
to S4 sacral spinal cord segments
The parasympathetic fibers are pro-
erectogenic and responsible for vascular
smooth muscle relaxation of the penis
The preganglionic fibers provided by the
parasympathetic nuclei of the spinal cord
pass through the pelvic nerves and join
the sympathetic nerves from the superior
hypogastric plexus at the pelvic plexus
and cavernous nerves.

18. This clearly implies that the sacral
parasympathetic input is responsible
for tumescence and the
thoracolumbar sympathetic pathway
is responsible for detumescence

19. The penis consists of three cylindrical
chambers: the paired corpora cavernosa
and the corpus spongiosum
The hemodynamics of the corpus
spongiosum and glans penis are somewhat
different from those of the corpora
cavernosa
During erection, the arterial flow increases
in a similar manner
however, the pressure in the corpus
spongiosum and glans is only one third to
one half of that in the corpora cavernosa
In the rigid erection phase, the
ischiocavernosus and bulbocavernosus
muscles forcefully compress the
Spongiosum and penile veins

20. Penile erection is initiated by inhibition of
the sympathetic nerves and activation of
parasympathetic pelvic nerves
Leading to penile arterial dilatation and
relaxation of the erectile smooth muscle cells
of the corpora cavernosa
Allows blood filling of the cavernous
sinusoids and restriction of the venous out-
flow, with entrapment of pressurized blood in
the corpora cavernosa
Release of nitric oxide from the
parasympathetic nerves plays an important
role for the relaxation, and the increase in
blood inflow to penis during the erection
Dopamine and dopaminergic agonists induce
relaxation by opening of large-conductance
calcium-activated potassium channels

21. Flaccid State
The cavernous smooth
musculature and the smooth
muscles of the arteriolar and
arterial walls, plays a key
role in the erectile process
The flaccid penis is in a
moderate state of
contraction, tonically
contracted, allowing only a
small amount of arterial flow
for nutritional purposes
The blood partial pressure of
oxygen (PO2) is about
35mmHg range
doi: 10.1016/j.ucl.2005.08.007

22. Erect State
An increase in PO2 (to about 90
mmHg) and intracavernous pressure
(around 100 mm Hg), which raises the
penis from the dependent position to
the erect state (the full-erection phase)

23. Ischiocavernosus and Bulbocavernosus
muscles
• In the rigid erection phase, the ischiocavernosus and bulbocavernosus muscles forcefully
compress the Spongiosum and penile veins (force blood distally to aid in erection)

24. Erectile dysfunction can be due to
vasculogenic, neurogenic, hormonal,
veno-occlusive, psychogenic and/or
pharmacogenic factors

26. Percutaneous Perineal Electrostimulation Induces
Erection: Clinical Significance in Patients With Spinal Cord
Injury and Erectile Dysfunction
The probe was applied to the perineum in the area between the anal orifice and the bulb of corpus spongiosum
participant lying in the lithotomy position and the scrotum elevated and strapped to the abdomen
PESP was performed by means of the same probe used in rectal electroejaculation
Percutaneous electrostimulation of the perineum (PESP) was performed, and penile erection was evaluated by
recording the intracorporeal pressure
Duration of erectile dysfunction (ED) was 9 to 16 years (mean 11.6 6 2.2 y)
28 healthy volunteers (age 36.3 ± 7.4 y) and 18 patients (age 36.6 ± 6.8 y) with complete neurogenic erectile dysfunction
(NED)

27. The probe was connected to an electrical
stimulator, and current was delivered in a
sine wave summation fashion
Average maximal voltages and number of
stimulations delivered per session were 15
to 18 volts and 15 to 25 stimulations
he stimulation period varied from 15 to 20
minutes each time
The intracavernosal pressure (ICP) was
measured by means of a 27-gauge butterfly
needle that was inserted into one corpus
cavernosus (CC)
The measurements were started 20
minutes after needle insertion into the CC
to ensure that the CC had adapted to the
inserted needle

28. The ICP measured prior
to PESP (basal) recorded
a mean of 7.3 ± 1.2
cmH2O
PESP using the
parameters effected an
increase of the ICP to a
mean of 94.6 ± 8.5
cmH2O (P , 0.0001)
The ICP started to
increase 2 to 3 seconds
(2.6 ± 0.2 s) after the
start of PESP
The ICP reached its
maximum after 26 to 40
seconds (mean 32.4 ±
5.3 s)
The elevated ICP was
maintained as long as
PESP was continuous
After cessation of PESP,
the ICP remained
elevated for a mean
period of 38.2 ± 6.8
seconds (range 22–46 s)

29. • The intracavernosal pressure of a patient with neurogenic erectile dysfunction (a) at rest and
(b) on percutaneous perineal electrostimulation
• The latent period recorded a mean of 14.6 ± 2.2 seconds (range 12–18 s)

31. Functional electrical
stimulation (FES)
therapy has shown a
high regenerative
capacity for smooth
muscle cells
FES can be a beneficial
treatment option when
the cause of ED is
related to degeneration
of cavernous smooth
muscle
We randomized 22
patients, aged 40 to 65
years, with known ED
(defined as a score of
less than 22 on the
IIEF-5)
Participants were
randomly assigned to
two groups:
intervention (IG) or
control (CG)

32. Erectile function was assessed by the validated International Index of Erectile Function (IIEF-5) and Erection Hardness Score
(EHS) and quality of life, by the WHOQOL questionnaire.
CG participants were treated with placebo FES and followed the same routine as the IG
Both groups attended sessions twice a week for a period of 4 weeks, for a total of 8 FES sessions
Sessions lasting 15 min each, with intensity lower than the motor threshold.
One electrode was placed at the base of the penis, while the second was attached 2 cm below the first one
Two self-adhesive electrodes measuring 3 cm each were used
IG participants underwent FES therapy (50 Hz/500 µs) for a total of 4 weeks

36. The study included 30 male
patients with bladder and
erectile dysfunction after
traumatic partial spinal cord
injury above the level of T12
within 6–18 months after
injury
Patients were randomly
divided into two equal groups
The study group was
subjected to TENS and pelvic
floor exercises and the control
group was subjected to Pelvic
floor biofeedback (PFBFB)
training in addition the
exercises
Taught how to tighten and lift
the pelvic floor muscles, as if
they were interrupting the
flow of urine midstream
Initial contractions were
performed for 5–10 s with
10–20 s rest, with 12–20
repetitions
Endurance exercise focused
on maintaining muscle
contraction at 65–75% of
maximum strength and
holding for 20–30s with 8–10
repetitions

37. TENS session
• This technique was carried out with an empty bladder, with two surface electrodes placed directly
over the skin of S3
• Stimulator was adjusted to a frequency of 50 Hz, duration of 30 min, 250 μs pulse width, and
biphasic continuous rectangular waveform

38. PFBFB training session
They were asked to look at the screen of the computer to watch the EMG biofeedback activities
during muscle contraction, and also the patient was asked to listen to the sound caused by
contraction of the pelvic floor muscles
The site of negative electrode (black) was marked at the bulk of pelvic-floor muscles, especially
ischiocavernosus and bulbospongiosus muscles, about 3 cm from the positive electrode site
With the EMG Biofeedback Device, the site of positive electrode (red) was marked with a marker at
the base of the penis
This exercise was performed with an empty bladder, and contraction of the pelvic floor muscles was
performed in the fowler lying position

40. THANKS