Advanced methods of erectile dysfunction

1. Advanced methods for detection of erectile dysfunction / impotence
CHAIR PERSON
(PROF).DR BISWAJIT SUKUL
HEAD OF THE DEPARTMENT
FORENSIC AND STATE MEDICINE
PRESENTER
DR.SRUTHI S KUMAR
1st YEAR PGT
Dept of fsm

2. OBJECTIVES
 Definition of Erectile Dysfunction
 Causes and Risk factors of Erectile Dysfunction
 Diagnostic evaluation of ED
 Advanced Methods for detection of Erectile Dysfunction

3.  Erectile dysfunction is the inability to achieve or maintain an
erection for sexual intercourse.
 The prevalence of erectile dysfunction is estimated at 35% in
men over age of 60 and in some studies as high as 50 %
 It is estimated that globally the number of patients with ED will
exceed 300 million by 2025
ERECTILE DYSFUNCTION

4. INCIDENCE AND EPIDEMIOLOGY
 35 % of married men aged 60 years and old suffer from erectile dysfunction
 MMAS (Massachusettsmale Aging Study) study between the ages of 40
and 70 years, the probabilityof
 Complete ED was from 5.1 to 15 %
 Moderate ED was from 17 % to 34% and mild ED was about 17%
 NHSLS (Nationalhealth and social life survey)study revealedthe
prevalence of ED at
 7 % for age 18-29 years, 9% for age 30-39
 11 % for age 40-49 years, 18% for age 50-59

5. RISK FACTORS FOR ED
 Diabetes mellitus
 Psychiatric or psychological disorders
 Cardiovascular disease
 Smoking
 Medications
 Vascular (most common)
 Neurological factors

6. Causes of ED

9. VASCULAR EVALUATION
 PENILE PLETHYSMOGRAPHY ( Penile pulse volume Recording ) : vasculogenic ED , waveform – slow upstroke ,
low rounded peak, slow downstroke ,no dicrotic notch
 CIS( COMBINED INTRACAVERNOUS INJECTION AND STIMULATION TEST) : Most commonly performed
diagnostic procedure , first line evaluation of penile blood flow

10. contd…
 Intracavernousinjection of vasodilator–genital/ audiovisualsexual stimulation,and
assesementof erection by observer.
 It bypass neurologic and hormonal influences, evaluate vascularstatus of penis directly
 Trimix 0.3 ml-(papaverine, phentolamine , alprostadil) are commonly used
 27 to 29 gauge is inserted at the lateral base of the penis directly into corpus cavernosum
 Manual compression is applied to the injection site for 5 minutes to prevent local hematoma
formation
 A rigid erection lasting > 10 minutes is indicative of normal venous function

11. CONTD….

12. CONTD…
 DUPLEXULTRASONOGRAPHY
 Duplex ultrasoundof penis after CIS represents second line evaluationof penile blood flow
 Most reliableand least invasive diagnosticmodality for assessingED
 Uses high resolution(7.5 to 12 MHZ) ultrasonographyand color pulsed doppler which helps visualize
the dorsal and cavernous arteries selectively
 Flow velocities are measured at baseline before injection and commonly every 5 minutes up to 20
minutes
 Cavernousarterial insufficiency is suggested when PSV is less than 25 cm/s (normal PSV is >30 cm/s)
 Veno- occlusive dysfunction is suggested when persistenthigh PSV , high EDV
 Resistiveindex =PSV-EDV/PSV ; RI < 0.75 associate with Veno-occlusive dysfunction(normal >0.9)

14. contd…
 DYNAMICINFUSIONCAVERNOSOMETRY-CAVERNOSOGRAPHY
 3rd line for vascular integrity of penis
 Indication-pelvic/perinealtrauma/life long ED- suspectedsite specific leak
 Intracavernosal injection 2 needles placed –simultaneous saline infusionand potent
vasodilatorcombination (papaverine+ phentolamine + alprostadil) & intracavernosal pressure
monitoringto asses the penile outflow
 Flow rate requiredto maintain erection at intracavernous pressureof >100 mmHg is <3 to 5
ml/min

15. DICC….

16.  PHARMACOLOGICCAVERNOSOGRAPHY
 Cavernosography done after Cavernosometry
 Opacificationof corpora cavernosa but minimal/ no visualizationof veins or corpus spongiosum
is normal
 Indication –pelvic/perinealtrauma / lifelong ED

17. contd…
 PENILEARTERIOGRAPHY
 Best indicationin young patient with ED secondary to traumatic disruptionor perineal
compressioninjury
 Intracavernousinjection of vasodilatoragent (papaverine, papaverine + phentolamineor
alprostadil)followed by selective cannulationof internal pudendalartery
 Anatomy and radiographicappearance of internal pudendal and penile arteries are evaluated

18. NEUROLOGIC EVALUATION
 Neurologicalevaluationis recommended in the case of selected cases to
1. Uncover reversibleneurologic disease such as dorsal neuropathy secondary to long distance
bicycling
2. To asses the extent of neurologicaldeficit from a known neurological disease such as diabetes
mellitus or pelvic Injuiry
3. To determine whether a referral to neurologistis necessaryin the case of spinal cord tumor
 Nerve conduction study , Biothesiometry , bulbocavernosus reflex latency, Penile thermal sensory
testing are some of the test used but these are not well standardizedand lack of validity,
reproducibilityand comparabiliity

19. CONTD…
 BIOTHESIOMETRY : This test is to measure the sensoryperception threshold to various amplitude of
vibratory stimulationproduced by a hand - held electro magnetic device placed on the both side of
penile shaft and glans penis
 Bulbocavernosus reflex latency : This test is performed by placing 2 electrodes around the penis,
concentric needles are present in the right and left bulbocavernosusmuscle and impulse is
recorded. Abnormal BCR indicate high probabilityof neuropathology

20. contd…
 PENILETHERMALSENSORYTESTING
 It quantify conductance of small sensory nerve fibers which can indirectly reflect autonomic
disturbances in diffuse neuropathies such as diabetic poly neuropathy
 It strongly correlates with the clinical evaluation of erectile dysfunction
 It is a promising tool for the diagnosis of neurogenic ED

21. NOCTURNAL PENILE TUMESCENCE TEST
 Nocturnal erections , 80 % of which occur during REM sleep , average of 3-5 episodes occur at
night ranging from 30 to 60 minutes
 NPT has been measured by severalmethods including stamp test (Ring of postage stamps
placed around the base of penis at night
 The conventionalapproach is to perform monitoring in conjunction with- EEG , Electro-
oculography ,EMG, with nasal airflow and oxygen saturationto document REM sleep and
presence/absence of hypoxia ( OSA)
 Now a days NPTR is performed with simple outpatient devices such as RIGISCAN
 NPT is originally designed to differentiate Psychogenicfrom Organic ED

22. RIGISCAN
 First Automated , portable NPTR recording
 Combines the monitoring of penile rigidity , tumescence ,number & duration of erectile events
 The device consists of two loops , one placed at base of penis & other at tip , by constricting the loops , device
records penile tumescence & rigidity at base and tip of penis
 Rigidity > 70% -non buckling erection
 Rigidity of <40 % represent flaccid penis
 Normal NPTR :4-5 erection episodes/night , mean duration is > 30 mts

23. Contd…

24. PSYCHOLOGIC EVALUATION
 Diagnostic mainstay of evaluation
 Current sexual problem and its history
 Deeper causes of sexual dysfunction
 Relationships & psychiatric problems
 Immediate causes
 Fear of failure
 Performance anxiety
 Loss of attraction
 Relationship conflicts

25. contd…
 Minnesota Multiphasic Personality Inventory (MMPI)-2is a valuable tool for assessing patient
personality & its relevance to sexual dysfunction
 BeckDepression Inventory is a self reported test score above 18 considered indicative of
significant clinical depression
 Short Marital Adjustment Test ( for Married couples) to determine overall relationship quality

26.  Erectile dysfunction / impotence is the most common problem facing nowadays by men
between the age of 40 and 70
 Common etiologies of ED are vascular , psychogenic,neurologic factors
 Risk factors includes Diabetic , Hypertension, Smoking ,trauma to penis / perineum and pelvic
radiation
 Different methods of evaluationinclude injection therapy,plethysmography, Duplex
ultrasonography, Rigiscan

27. ACKNOWLEGEMENT
 I would like to thank all Faculties and Senior Resident of this Department for their
Guidance and valuable suggestions in the preparation of seminar
 I would like to thank all Senior PGTS of this Department for all the help and
coordinationand supervision.
 I would like to thank all Staffs of this Department for their support in carrying out
this seminar.

28. REFERENCES
 1. Anil Aggarwal , Textbook of forensic medicine and toxicology. impotence and sterility: Avichal publishing
company. 2nd edt. 2021 ; 419-20
 2.Emil A Tanagho, Jack WM ,Smiths general urology .Male sexual dysfunction :a Lange medical book.17 th ed
2008; 519-30
 3. Montorsi F, Adaikan G, Becher E, et al.: Summary of the recommendations on sexual dysfunctions in men. J
Sex Med. 2010;7(11):3572–88. 10.
 4. Derogatis LR, Burnett AL: The epidemiology of sexual dysfunctions. J Sex Med. 2008;5(2):289–300.
 5. Ayta IA, McKinlay JB, Krane RJ: The likely worldwide increase in erectile dysfunction between 1995 and
2025 and some possible policy consequences.BJU Int. 1999;84(1):50–6.
 6. Litwin MS, Saigal CS, Yano EM, et al.: Urologic diseases in America Project: analytical methods and
principal findings. J Urol. 2005;173(3):933–7.