This document discusses erectile dysfunction (ED), including the anatomy and physiology of erection, evaluation of ED, and treatment options. It covers the arterial supply and venous return in the penis, nervous control by the sympathetic, parasympathetic, and somatic pathways, and the neurophysiological and psychogenic mechanisms of erection. Evaluation of ED involves history, physical exam, rigiscan, penile artery/vein evaluation. Treatment includes medications like sildenafil, injections, vacuum devices, surgery. Premature ejaculation is also discussed, with causes like malconditioning or anxiety and treatments like reassurance, drugs, sex therapy, anesthetics.

1. Erectile Dysfunctions
Ahmed Afify, MD
Assistant professor of Dermatology,
Venereology and Andrology
Ain Shams University

2. Anatomy of the Penis

3. Arterial Supply

4. Venous Return

5. *The superficial dorsal vein is separated
from the deep dorsal
bundle(vein,artery,nerve)by Buck’s fascia.
*The corpora cavernosa are traversed by
the deep penile arteries(cavernosal
arteries).
*The corpus spongiosum is traversed by the
penile urethra & urethral arteries.

6. Nervous Control

7. Nervous Control
sympathetic T11,T12,L1,L2
Autonomic
parasympathetic S2,S3,S4
sensory
Somatic(Pudendal nerve S2,S3,S4
motor

8. The Sympathetic Pathway
Spinal cord roots T11 to L2 white rami
sympathetic chain lumbar splanchnic
nerve inferior mesenteric plexus
superior hypogastric plexus
hypogastric nerves pelvic plexus
cavernous nerve.

9. The Parasympathetic Pathway
Spinal cord roots S2 to S4 pelvic
nerve(nervi erigentes) pelvic plexus
cavernous nerve.

10. The Somatic Pathway
S2,S3,S4
A.Sensory B.Motor

11. Physiology of Erection
It’s a vascular mechanism controlled or
influenced by psychological,neurological &
endocrinal mechanisms.

12. Neurophysiological Mechanism
*Reflexogenic erection
*Psychogenic erection

13. Reflexogenic Erectile Mechanism
Afferent Limb:
Receptors in the skin of glans,prepuce & penis dorsal
penile nerve pudendal nerve.
Nuclei of S2,S3,S4
Efferent Limb:
Pelvic nerve Pelvic plexus Cavernous nerve
Erectile tissue.

14. Psychogenic Erectile Mechanism
Thalamic nuclei(somatosensory) Hypothalamic
visuosensory nuclei
Rhinocephalon(olfactory) mid brain
Limbic system(memory)
emotion
symp.nuclei T11-L2
pons&medulla erectile tissue
parasymp.nuclei S2-
S4

16. Erectile Dysfunction
Impotence
Inability to obtain or maintain erection
sufficient for vaginal penetration.

17. Etiology
1.Organic
-vasculogenic(arterial insufficiency+/- venous leakage)
-neurogenic
-mixed
2.Psychogenic
Intra or interpersonal

18. Evaluation of Erectile Dysfunction
A.History
1.Personal:age,marital status,work,special habits,sleep pattern
2.Sexual:development,sex education,masturbation,phobias…….
3.History of ED:onset,course,duration
Desire,Arousal
Erection(morning,masturbation,situational)
Rigidity(easy intromission,manual help)
*Medical:coronary,vascular,hepatic,renal,neurologic,pelvic
trauma,op.,medication)
*History of partner:attitude & orientation

19. Evaluation of ED (cont.)
B.Examination
1.General:
-2ry sex characters -signs of systemic diseases
-breast enlargement -femoral & LL pulsation
-neurological examination in diabetes or neurogenic complaints
2.Genital:
Penis:size,cordee,pyeronie’s balanitis,urethritis,ulcers
Testis:size,consistency,sensation,varicocele
P/R:prostate,S.V,anal sphincter tone,smear
Genital & Perianal sensation & reflexes

20. Evaluation of ED (cont.)
C.Rigiscan
Measures circumfrential changes & rigidity during
sleep
D.Evaluation of penile arteries
Doppler,Duplex U/S,ICI
E.Evaluation of penile venous system
Cavernosometry,Cavernosography

21. Nocturnal Penile Tumescence
(NPT)
During sleep
Erection during REM
Detumescence during non REM

22. Doppler Examination

24. Cavernosography

25. Rigiscan

26. Treatment of ED
*Medical
-Control of diabetes
-Avoid drug induced ED
-Yohimbine
-Androgen
-Bromocriptine
-Sildenafil Citrate (Viagra)

28. Treatment of ED (cont.)
*ICI
-Papaverine
-Bimix:Papaverine/Phentolamine
-PGE1
-Trimix:Papaverine/Phentolamine/PGE1
-Quadmix:Papaverine/Phentolamine/PGE1/Atropine

29. Treatment of ED (cont.)
*Vacuum device
*Surgery
-Penile prosthesis
-Re-vascularization

33. Premature Ejaculation
*Definition:
The inability of the male to control ejaculation long
enough to satisfy his partner in at least 50% of
their sexual encounters,when there is no female
orgasmic dysfunction.
*Etiology:
1.Mal-conditioning
2.Anxiety
3.Organic causes (rare)

34. Premature Ejaculation (cont.)
*Treatment:
1.Reassurance of the couple and explanation of
the problem to correct any sexual false ideas.
2.Drugs:e.g
Thioridazine(Meleril),Clomipramine(Anafranil)
and Selective Serotonin Reuptake
Inhibitors(SSRI).
3.Sex Therapy
4.Local anesthetics and condoms.

35. Questions

36. 1-Branches of pudendal artery in male include all
except:
a)Bulbar artery
b)Urethral artery
c)Cavernosal artery
d)Cremasteric artery
e)Dorsal artery of the penis

37. 2-PDE inhibitors induces erection through:
a)Release of nitric oxide
b)Inhibition of conversion of GTP to cGMP
c)Inhibition of conversion of cGMP to GTP
d)Inhibition of alpha1 adrenergic receptors

38. 3-Hyperprolactinemia is treated by:
a)Yohimbine
b)Bromocriptine
c)Sildenafil citrate
d)Cyproterone acetate

39. THANK YOU