Downloaded 66 times
![Transient intracorporeal pressure increase
[smooth muscle contraction]
Pressure decrease slowly
[slow reopening of the venous channels]
Pressure decrease fast
[venous outflow capacity is fully restored]
Dr.Hassaan Ali 2014](https://image.slidesharecdn.com/erectiledysfunction-150115143440-conversion-gate02/85/Erectile-dysfunction-11-320.jpg)
Uploaded byAswan University | جامعة أسوان
Erectile dysfunction
The document discusses erectile dysfunction (ED), defining it as the persistent inability to obtain or maintain an erection necessary for satisfactory sexual performance, with prevalence affecting up to 52% of men aged 40-70. It outlines the causes, which include both organic and psychogenic factors, the physiological processes involved in erection, and various diagnostic and treatment options, emphasizing that many cases can be effectively managed. Additionally, it highlights the role of lifestyle factors and the efficacy of pharmacological treatments, particularly PDE-5 inhibitors, in the management of ED.
More Related Content
![Benign Prostatic Hyperplasia BPH [Dr. Edmond Wong]](https://cdn.slidesharecdn.com/ss_thumbnails/bphedmond-140716213908-phpapp02-thumbnail.jpg?width=640&height=640&fit=bounds)
![Erectile Dysfunction [Dr. Edmond Wong]](https://cdn.slidesharecdn.com/ss_thumbnails/ededmond-140716212750-phpapp02-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Erectile dysfunction
More from Aswan University | جامعة أسوان
Erectile dysfunction
- 1. Dr.Hassaan Ali 20142ndworkshop of ED and Penile Prostheses 1,2 Jan 2015 Aswan Egypt
- 2. Dr.Hassaan Ali 2014 ERECTILEDYSFUNCTION PRACTICAL VIEW
- 3. Definition of ED Epidemiology Anatomyand Physiology of erection Causes ED Examination of patient with ED Investigations Treatment Dr.Hassaan Ali 2014
- 4. Synonym: Impotence Persistent orrecurrent inability to obtain or maintain penile erection (or both) sufficient for satisfactory sexual performance, for more than 3-months duration(1). Dr.Hassaan Ali 2014
- 5. NO! Sexual function isan important component of quality of life and subjective well-being. Sexual problems affect adversely mood, well- being, and interpersonal functioning. Nearly every man can be successfully treated. Dr.Hassaan Ali 2014
- 6. Incidence and prevalenceis high worldwide Effects up to 52% of men (40-70yrs) Complete impotence from 5% of 40yr olds to 15% of 70yr olds Only 10-20% solely psychogenic Dr.Hassaan Ali 2014
- 7. Prevalence of EDby Age and Severity (%) Severe Moderate Mild or Mild/Moderate 100% 80% 60% 40% 20% 0% Dr.Hassaan Ali 2014
- 8.
- 9.
- 10. Dilatation arterioles&arteries expanding ofsinusoids compression of subtunical venular plexuses Emissary veins enclosed increasing of intracavernous pressure to raise the penis Dr.Hassaan Ali 2014
- 11. Transient intracorporeal pressureincrease [smooth muscle contraction] Pressure decrease slowly [slow reopening of the venous channels] Pressure decrease fast [venous outflow capacity is fully restored] Dr.Hassaan Ali 2014
- 12.
- 13.
- 14. Flaccid phase (1)Minimal arterial and venous flow; b Latent (filling) phase (2) Increased flow in the internal pudendal artery during both systolic and diastolic phases. Decreased pressure in the internal pudendal artery; unchanged intracavernous pressure. Some elongation of the penis. Tumescent phase (3) Rising intracavernous pressure until full erection is achieved. Penis shows more expansion and elongation with pulsation. The arterial flow rate decreases as the pressure rises.. Full erection phase (4) Intracavernous pressure can rise to as much as 80–90% of the systolic pressure. Pressure in the internal pudendal artery increases but remains slightly below systemic pressure. Arterial flow is much less than in the initial filling phase but is still higher than in the flaccid phase. approach those of arterial blood. Skeletal or rigid erection phase (5) As a result of contraction of the ischiocavernous muscle, the intracavernous pressure rises well above the systolic pressure, resulting in rigid erection.. Detumescent phase (6) After ejaculation or cessation of erotic stimuli, sympathetic tonic discharge resumes, resulting in contraction of the smooth muscles around the sinusoids and arterioles. This effectively diminishes the arterial flow to flaccid levels,. Dr.Hassaan Ali 2014
- 15. Supraspinal pathways [ hypothalamus,limbic system and cerebral cortex Parasympathetic nerves S2-4 mediate erection Sympathetic nerves T11-L2 control ejaculation and detumescence Smooth muscle relaxation Nitric oxide diffuses into cavernosal smooth muscle cells, activates Guanylate cyclase converts guanosine triphosphate to cGMP resulting in smooth muscle relaxation. Effect of cGMP stopped by Phosphodiesterase type 5 which exists primarily in corpora cavernosa Dr.Hassaan Ali 2014
- 16.
- 17.
- 18. Organic I. Vasculogenic :Arteriogenic Cavernosal Mixed II. Neurogenic III. Anatomic IV. Endocrinology Psychogenic I. Generalized A. Generalized unresponsiveness 1. Primary lack of sexual arousability 2. Aging-related decline in sexual arousability B. Generalized inhibition 1. Chronic disorder of sexual intimacy II. Situational A. Partner-related 1. Lack of arousability in specific relationship 2. Lack of arousability owing to sexual object preference 3. High central inhibition owing to partner conflict or threat B. Performance-related 1. Associated with other sexual dysfunction/s (e.g., rapid ejaculation) 2. Situational performance anxiety (e.g., fear of failure) C. Psychological distress- or adjustment-related 1. Associated with negative mood state (e.g., depression) or major life stress (e.g., death of partner) Mixed Dr.Hassaan Ali 2014
- 19.
- 20. Vascular Diabetes Medication Pelvic Surgery, Radiation or Trauma NeurologicalCauses Endocrine Problems Other Vascular Diabetes Medication Dr.Hassaan Ali 2014
- 21. Hypertension Smoking Diabetes Hyperlipidaemia Peripheral vascular disease Bluntperineal or pelvic trauma Pelvic irradiation Dr.Hassaan Ali 2014
- 22. Central:Lesions of medialpreoptic nucleus, paraventicular nucleus, hippocampus Spinal trauma Myelodisplasia (spina bifida) Pelvic surgery/radiotherapy Multiple sclerosis Intervertebral disc lesion Peripheral neuropathies Alcohol Diabetes HIV Dr.Hassaan Ali 2014
- 23. Hypogonadism Low testosterone Raised SHBG RaisedProlactin Thyroid disease Hypothyroidism hyperthyroidism Dr.Hassaan Ali 2014
- 24. Peyronie’s disease Micropenis Penile anomalies(hypospadias etc Dr.Hassaan Ali 2014
- 25. Antihypertensives Thiazides B blockers Centrally acting drugs Antidepressants Tricyclics MAOinhibitors SSRI Anticholinergics Atropine Antipsychotics Phenothiazines Anxiolytics Benzodiazepines Psychotropic drugs Alcohol Opiates Amphetamines Cocaine Dr.Hassaan Ali 2014
- 26. I. Generalized A. Generalizedunresponsiveness 1. Primary lack of sexual arousability 2. Aging-related decline in sexual arousability B. Generalized inhibition 1. Chronic disorder of sexual intimacy Dr.Hassaan Ali 2014
- 27. II. Situational A. Partner-related 1.Lack of arousability in specific relationship 2. Lack of arousability owing to sexual object preference 3. High central inhibition owing to partner conflict or threat B. Performance-related 1. Associated with other sexual dysfunction/s (e.g., rapid ejaculation) 2. Situational performance anxiety (e.g., fear of failure) C. Psychological distress- or adjustment-related 1. Associated with negative mood state (e.g., depression) or major life stress (e.g., death of partner) Dr.Hassaan Ali 2014
- 28. History taking (includingdrug intake). physical examinations: testes, penis, signs of hypoandogenism. Investigation Dr.Hassaan Ali 2014
- 29.
- 30.
- 31. International Index ofErectile Function questionnaire (IIEF) most common questionnaire addresses erectile function, orgasmic function, desire, intercourse satisfaction, overall satisfaction Erectile function 1,2,3,4,5,15 Intercourse satisfaction 6,7,8 Orgasmic function 9,10 Sexual desire 11,12 Overall satisfaction 13,14 Dr.Hassaan Ali 2014
- 32. International Index ofErectile Function 5-item version for quick office evaluation Score of 5-7 sever ED Score of 8-11 moderate Score of 12-16 mild to moderate Score of 17-21mild Score of 22- 25 no ED Dr.Hassaan Ali 2014
- 33. Gradual onset Normal ejaculation Normallibido Medical risk factor Trauma/surgery/radiotherapy to pelvis Current medication Lifestyle Dr.Hassaan Ali 2014
- 34. Sudden onset Early collapseof erection Self stimulated or waking erections Premature ejaculation or inability to ejaculate Problems/change in relationship Major life event Psychological problems Dr.Hassaan Ali 2014
- 35. Genitourinary examination Testes sizeand consistency Secondary sexual characteristics Penis for Peyronie’s plaques, Pulses (femoral), BP Rectal examination Dr.Hassaan Ali 2014
- 36. Laboratory Investigation complete bloodcount, urinalysis, renal function, lipid profile, fasting blood sugar, thyroid function. Routine endocrinologic testing remains controversial Dr.Hassaan Ali 2014
- 37. 1-Young patients whohave always had difficulty in obtaining and/or sustaining an erection 2-Patients with a history of trauma 3-Where an abnormality of the testes or penis is found on examination. 4-Patients unresponsive to medical therapies that may desire surgical treatment for ED. Dr.Hassaan Ali 2014
- 38. 1-Nocturnal penile tumescenceand rigidity (NPTR) 2-vascular studies: Combined intracavernous injection & stimulation (CIS) Duplex ultrasound Dynamic infusion cavernosometry & cavernosography (DICC) Selective penile angiography 3-neurological studies (e.g. bulbocavernosus reflex latency,nerve conduction studies); 4-endocrinological studies; 5-specialised psycho diagnostic evaluation. Dr.Hassaan Ali 2014
- 39. 3 B . 4 B 4B GRLERecommendations for the diagnostic work-up B3Clinical use of a validated questionnaire related to ED may help assess all sexual function domains and the effect of a specific treatment modality. B3Physical examination is needed in the initial assessment of ED to identify underlying medical conditions associated with ED B4Routine laboratory tests, including glucose-lipid profile and total testosterone, are required to identify and treat any reversible risk factors and modifiable lifestyle factors. B4Specific diagnostic tests are indicated by only a few conditions. Dr.Hassaan Ali 2014
- 40. Total tumescence time20% of night at puberty Adults – 27 minutes/nigh RigiScan - 1985 Monitors radial rigidity, tumescence, number, duration of erectile events Portable – can use at home Can record 3 different nights up to 10 hrs each Results Radial rigidity >70% = good erection <40% = flaccid penis Normal = 3-6 erections/night, 10-15 minutes per episode NEVA device Uses electrobioimpedance to assess volumetric changes in penis during nocturnal erections Undetectable alternating current from glans to hip electrodes Penile base electrode measures impedance & changes in penile length Mean volume change in controls = 213% increase (14.4 mL) Dr.Hassaan Ali 2014
- 41. Inject vasodilator, stimulate, Bypassesneurologic & hormonal influences to evaluate vascular status Use: alprostodil 10-20ug papaverine & phentolamine (Bimix 0.3 mL) Trimix 0.3 mL 27 or 29g needle, compress for 5 min after injection Normal results = normal venous occlusion False negative up to 20% w/ borderline arterial flow Dr.Hassaan Ali 2014
- 42. Penile blood flowstudy (CIS & blood flow measurement by US) is most reliable & least invasive evidence based assessment of ED Red = towards probe Blue = away from probe Can visualize dorsal & cavernous arteries in real time Can diagnose high flow priapism Technique Measure flow velocities 5-10 min after injection Rate erectile quality Look at both cavernous arteries & diameters Asymmetric cavernous arterial flow >10cm/s or reversal of flow across a collateral may mean atherosclerotic lesion Dr.Hassaan Ali 2014
- 43. Peak Systolic Velocity(PSV) PSV < 25 correlates with abnormal pudendal arteriography Severe unilateral arterial insufficiency >10 cm/s asymmetry Severe vascular ED, diameter increase is <75%, diameter rarely exceeds 0.7 mm High systolic flow (>25 cm/s) Persistent end-diastolic flow (EDV) (>5 cm/s) Resistive Index (RI) RI = PSV – EDV/PSV Measure 20 min after injection & stimulation RI > 0.9 normal RI < 0.75 venous leakage Dr.Hassaan Ali 2014
- 44. Intracavernosal injection withcolor duplex Doppler ultrasound Most informative diagnostic test Least invasive for vascular ED, high vs. low flow priapism, Peyronie’s plaque Useful measurements PSV, cavernous artery diameter, EDV, RI PSV <25 = severe cavernous artery insufficiency PSV >35 = normal inflow Negative relationship between age & PSV Dr.Hassaan Ali 2014
- 45. Cavernous arterial occlusionpressure Basically penile blood pressure measurement – 1989 Technique Inject vasodilator infuse saline into corpora to get pressure > systolic BP apply Doppler to penile base Pressure when cavernous arterial flow becomes detectable is cavernous artery systolic occlusion pressure (CASOP) Gradient between cavernous & brachial artery pressure <35 & equal pressure on L & R is normal Pharmacologic Arteriography Technique Inject vasodilator Cannulate internal pudendal artery Inject contrast Look at anatomy of iliac, internal pudendal, penile arteries Aberrant anatomy in 50% of normal volunteers Useful for anatomy, not function Indication: Young pt w/ ED due to traumatic arterial disruption or perineal compression injury. Essential for planning reconstruction Dr.Hassaan Ali 2014
- 46. Pharmacologic Cavernosometry & Cavernosography Cavernosometry Salineinfusion while monitoring intracavernous pressure Assesses penile outflow Cavernosography Infusion of contrast into corpora after vasodilator induced erection Good for young men who may be candidates for penile vascular operations Dr.Hassaan Ali 2014
- 47. Penile Brachial PressureIndex Inaccurate Penile Plethysmography Penile pulse volume recording Infrared Spectrophotometry Radioisotopic Penography MRA Cavernous Smooth Muscle Content Dr.Hassaan Ali 2014
- 48. Only certain typesof ED have the potential to be cured with specific treatments: General Measures Smoking cessation Reduce alcohol Weight loss Exercise Hormonal: testosterone failure – give testosterone contraindicated in men (prostate carcinoma or with symptoms of prostatism.) Post-traumatic arteriogenic: surgical penile revascularization has a 60-70% long-term success Psychogenic: underlying problem, sex therapy/counselling, phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil) Dr.Hassaan Ali 2014
- 49. PDE-5 inhibitors potentiateNO’s effect Do not increase NO levels Need sexual stimulation for PDE-5 inhibitors to work Sildenafil (Viagra) FDA approved 1998 Vardenafil (Levitra) FDA approved 8/2003 Tadalafil (Cialis) FDA approved 11/2003 Dr.Hassaan Ali 2014
- 50. TadalafilVardenafilSildenafil 15 min –2 hr15 min – 1 hr 15 min - 1 hr Onset of Action 17.5 hr4-5 hr3-5 hrHalf-life Not tested15%40%Bioavailability No effect↓↓ Absorption ↓↓ Absorption Fatty Food YesYesYes HA, flushing, dyspepsia YesRareRareBachache, Myalgia RareRareYesBlurred/Blue vision NoYesNo Precaution w/ antiarrhythmics YesYesYes Contraindication w/ Dr.Hassaan Ali 2014
- 51. Newer agents Avanafil Post RadicalProstatectomy Diabetes Acts 15 min No effect with food Dr.Hassaan Ali 2014
- 52. 25-50% placebo response Acupuncture– psychogenic ED Androstenedione – may benefit men w/ low testosterone, lowers HDL 10% Ginko biloba – may have blood- thinning effect Korean red ginseng – may benefit L-Arginine – precursor to Nitric Oxide, may lower BP Yohimbine – most supplements contain little or none, can have serious side effects Zinc – good if low zinc, can be immunosuppressive Dr.Hassaan Ali 2014
- 53. Plastic cylinder connectedto vacuum generating source place constriction ring after engorgement Remove ring within 30 min Satisfaction rate 68-83% Adverse effects: pain, petechiae, bruising, numbness Dr.Hassaan Ali 2014
- 54. Papaverine Phentolamine (alpha1 &alpha2-antagonist) Alprostadil (Caverject & Edex 2-40mcg) - Prostaglandin E1 Combinations Papaverine + Phentolamine Papaverine + Phentolamine + Alprostadil Dr.Hassaan Ali 2014
- 55. Isolated from opiumpoppy Inhibitory effect on PDE, increased cAMP & cGMP, blocks calcium channels 1-2 hr half-life Good Low cost Stable at room temp Bad Priapism (up to 35%) Corporal fibrosis (1-33%) due to acidity <55% effective Not FDA approved Dr.Hassaan Ali 2014
- 56. alpha1 & alpha2-antagonist Sideeffects Hypotension Reflex tachycardia Nasal congestion GI upset 30 min half-life Increases corporal blood flow, but does not cause significant increase in intracavernous pressure Dr.Hassaan Ali 2014
- 57. (Caverject & Edex2-40mcg) - Prostaglandin E1 Exogenous form of a naturally occurring fatty acid Causes smooth muscle relaxation, vasodilation, inhibition of platelet aggregation by elevating cAMP Metabolized by prostaglandin-15-hydroxydehydrogenase in corpora cavernosa 96% locally metabolized after 60 min Side effects Pain at injection site or during erection Hematoma Priapism Much lower incidence of fibrosis Once reconstituted into liquid from powder, has shortened half-life if not refrigerated Dr.Hassaan Ali 2014
- 58. Papaverine + Phentolamine Papaverine+ Phentolamine + Alprostadil Lower incidence of painful erection As effective as alprostadil alone Good for failed therapy or painful erection w/ PGE1 Serious side effects Priapism Fibrosis Contraindications Sickle cell Schizophrenia Other severe psychiatric disorders Severe systemic illness Dr.Hassaan Ali 2014
- 59. Intraurethral suppositories “MUSE” (Medicatedurethral system for erection Alprostadil (125mg, 250mg, 500mg,1g Dr.Hassaan Ali 2014
- 60. Types Malleable prosthesis ADV: LowMechanic Failure / Ease of use DISADV: Constant rigidity / ▲ Erosion Risk Positional prosthesis SemiRigid – Articulating Segments Better to maintain up/down positions 2 – piece inflatable prosthesis ADV: Ease of implantation DISADV: ▲ Mechanical Failure Risk Dr.Hassaan Ali 2014
- 61. 3 – pieceinflatable penis Most closely resembles natural flaccidity and erection Provide penile girth expansion and rigidity Dr.Hassaan Ali 2014
- 62.
- 63.
- 64. Subcoronal – malleableor positional Infrapubic - reservoir placement under direct vision Penoscrotal – better corporeal exposure, no dorsal nerve injury, pump fixation possible Dr.Hassaan Ali 2014
- 65.
- 66. Foley removed nextday Antibiotic for 1 week Oral narcotic used for 1 week Restrict lifting activities if reservoir present Have pts practice pumping 1 month after sx Dr.Hassaan Ali 2014
- 67. INFECTIONS – Nosignificant illness, but to eradicate infection, removal of prosthesis is required. To avoid it: -Delay implanation if UTI or cutaneous inf -Shave day of surgery -Prevent by 10 minute skin prep -Gent vancomycin -Silicone has a sterile charge and should be irrigated Dr.Hassaan Ali 2014
- 68. Infections occur either 1stfew weeks - gram negative After 6 months – gram positive Staph epi Role of diabetes is controversial as related to infection probability EARLY INFECTIONS Swelling, erythema, tenderness, drainage Occasional fever LATE INFECTIONS Skin may be adherent to pump Erosion is evidence of infection REMOVE ALL COMPONENTS Dr.Hassaan Ali 2014
- 69. Re-Implant? To minimize scarringof corporeal dilation, perform as soon as possible to PREVENT SCARRING AND PENILE SHORTENING Rifampin/Minocycline coated prosthesis showed less infection rate than hydrophilic coated devices. IF mechanical failure, usually after 5 years Dr.Hassaan Ali 2014
- 70. If dilator perforatesproximal corpora, use a larger dilator & allow perforation to heal If dilator perforates urethra, ABANDON PROCEDURE; place catheter 7-10 days Can avoid by keeping tip of dilator under dorsolateral surface of corpus cavernosum If erosion of one cylinder: REMOVE THAT CYLINDER. OK w/ one Dr.Hassaan Ali 2014
- 71. “Concorde” type glansafter placement b/c of undersized, or inadequate dilation SST DEFORMITY Oversized cylinders cause pain and can erode Dr.Hassaan Ali 2014
- 72. Peyronie’s disease Scarring intunic albuginea Corporoplasty likely needed if length and girth expanders used If relaxing incision are done and gap is greater than 1 cm, must cllose to prevent herniation of cylinders Dr.Hassaan Ali 2014
- 73.