1. 男性性功能障礙
Huang Guan-lin M.D. / YC Shen M.D.

2. 司馬奕 桓溫

4. Why erectile dysfunction matters
2007 taiwan EDCAT
N=990 male (40~89)
The average ED rate would is 26% by IIEF5 score
However,
the rate of ED is only 13% by self report

6. 2007 Taiwan EDCAT ED prevalence
16.09
24.38
41.92
52.87
5.27
15.44
23.98 25.27
40-49 50-59 60-69 70+
0
10
20
30
40
50
60
¦Û-z
¶qªí
%
age (yr)

7. The anatomy and physiology
of ED

8. Ext. iliac artery
Helicine a.

9. Neuro control
MPOA, PVN, hippocampus, mygdala,PAG, ventral tegmentum
AUTONOMIC CONTROL CENTER
T11-L2, S2-S4
Pelvic plexus → cavernous n. stimulation
SOMATIC CONTROL CENTER
S2-S4
Bulbocavernous m. /ischiocavernous m.

10. The use of PDE5 is to inactivate the following?
1. C-GMP 2. 5-GMP 3. Guanylyl cyclase 4. GTP

12. Hemodynamic physiology
1. Flaccid phase
2. Filling phase, P→ F↑
3. Tumescence phase, P↑
4. Full erection phase
5. Rigid erection phase
6. Detumescence phase
More than 30cm!!!

14. Classification of ED
33%33%
33%
PSYCHOGENIC
ORGANIC
MIXED
1.Lack of arousability
2.Partner problem
3.Performance problem
4.Mood problem
1.Neurogenic
2.Hormonal
3.Arterial
4.cavernosal/ vein
5.Drug
6.Systemic Dz

15. Organic ED
• Neurogenic
– Brain: AD, parkinsonism, trauma
– Neuron: OP/RT, Alcohol/DM → cavernosal n.
• Hormone
– Hypothalamus/pituitary gland
– Hyper/hypothyroidism
• Artery
– Trauma
– HTN, hyperlipidemia, DM, smoking

16. Organic ED
• Vein
– Veno-occlusive dz
– Peyronie dz, albugenia injury, shunt
• Drug
– SSRI
– antipsychotics
– Diuretics: thiazide/ spirolactone
– B-blocker
– Antiandrogen
• Systemic DZ
– CKD, DM…

17. Risk factors
Age
DM
SMOKING
Cholesterol
CKD
HTN
Obesity/metabolic syndrome
Bicycling?

18. How to approach the ED pts?

19. Evaluate the ED severity
Erection hardness score: simple, easy to screen

20. 分數
5-7 嚴重
8-11 中度
12-16 輕度到中度
17-21 輕度

21. DD psychogenic / organic
表徵 器質性ED 心因性ED
發生時間 漸進性 突然發生
情境 全都一樣 某些情況出現
過程 無差別 有起伏變化
無關性交的勃起 差 有
性生理問題 續發性 出現一段時間
與性伴侶問題 續發性 開始就有
對性行為焦慮害怕 續發性 開始就有

22. HISTORY TAKING
• Underlying dz
• OP history?
• Medication?
• Morning erection?

23. Lab and examination
• Sugar, cholesterol, TG, testosterone
– Gonadal hormone if need
• Most patients do not need further examination
 Penis vascular Doppler
 Penis arterial angiography
 Cavernosography
 Nocturnal penile tumescence/rigid scan
 Psycho-evaluation
 Hormone (testosterone, LH, prolactin, SHBG, FSH)

24. angiography

25. Cavernosography

26. Rigid scan

27. Treatment
Oral medication
Injection
Operation
1
2
3
轉
介
泌
尿
科

28. Common side effect:
1.Flush
2.Headache
3.Dyspepsia
4.BLUE visual field

29. Common side effect:
1.Flush
2.Headache
3.Dyspepsia
4.BLUE visual field

30. PDE5 inhibitor Sildenafil Vardenafil Tadalafil
商品名 威而鋼 樂威壯 犀利士
上市劑型(mg) 25,50,100 5,10,20 5,10,20
Tmax
達到血液最高濃度
60min 40min 120min
半衰期 3-5hrs 4-5hrs 17.5hrs
有效作用期 4-8hrs 2-8hrs 24-36小時
食物影響 高脂食物 高脂食物 無
價格 NTD300(100mg) NTD300(20mg) NTD400-
450(20mg)

31. 如何選擇此三種藥物?
威而鋼:
單次使用,市場舖貨最廣,
臨床試驗最齊全
樂威壯:
單次使用,最強結合效力,
適用於困難治療病人
犀利士:
周末狂歡,CP值高

32. 注意事項
• PDE5 inhibitor:治療勃起功能障礙，非春藥
• 坊間及網路假藥甚多，請轉介醫師處方
• 使用有機硝酸鹽類為絕對禁忌症
– NTG, isosorbide mononitrate,
isosorbide dinitrate

34. Other oral medications
• Apomorphine(Uprima)
– Central neuro-control D1,D2 receptor
• Yohimbine
– ɑ2 adrenoceptors blocker
• Trazodone
– SSRI with ɑ blocker effect
– Psychogenic ED prefer

35. Injection/suppository ,PGE1
Caverjet
MUSE

37. Complications
• Priapism
• Fibrosis
• Hematoma
• Infection

38. Operation
OP
REVASCULARIZATION ARTIFICIAL PENIS
INFLATBLEMALLEABLE

39. EASY USE
EASY PLACEMENT
CHEAP
PHYSIOLOGY
INFLATION↓

40. MECHNICAL FAILURE
EXPENSIVE
LESS LONG TERM DURABILITY