Educational presentation for urology students

1. Male Sexual Dysfunction
SAYED M ELEWEEDY
PROF. AND CHIEF OF UROLOGY DEPARTMENT
UROLOGY DEPARTMENT
AL-AZHAR UNIVERSITY
CAIRO, EGYPT

2. Male Sexual Dysfunction
Classifications
1. Erectile dysfunction
• Primary impotence
• Secondary impotence
2. Ejaculatory dysfunction
• Premature ejaculation
• Ejaculatory incompetence
3. Libido quantification (hypoactive sexual desire disorder)
4. Priapism

3. Erectile Dysfunction

4. Erectile Dysfunction
ETIOLOGY
1. Psychogenic
2. Vasculogenic
3. Neurogenic
4. Endocrine
5. End-organ failure
6. Iatrogenic and drug induced

5. Erectile Dysfunction
PSYCHOGENIC IMPOTENCE
• One decade ago 80-90%
• Recently <30%

6. Erectile Dysfunction
PSYCHOGENIC IMPOTENCE
NORMAL SEXUAL FUNCTION REQUIREMENT
 Self-confidence
 Absence of anxiety
 Presence of arousal
 physical stimulations
 Ability to focus attention on sexual activity
PSYCHOGENIC DYSFUNCTION PRODUCE
 Exaggerated suprasacral inhibition
 Excessive sympathetic outflow

7. Erectile Dysfunction
ETIOLOGY
PSYCHOGENIC IMPOTENCE
LUE CLASSIFICATIONS
1. Anxiety and fear of failure
2. Depression (drug or disease induced)
3. Marital conflict strained relationship
4. Ignorance, misinformations , religious beliefs
5. Psychotic and personality disorder

8. Differentiation Between Psychogenic And
Organic Erectile Dysfunction

9. Erectile Dysfunction
ETIOLOGY
Psychogenic Impotence
Primary
• Sexually repressed patient from religiously family background
– Sex was not discussed
– sex was sinful and immoral
Secondary
• Poorly understood admixture of variable factors
– Emotional
– Familial
– Cognitive
– Cultural
– Maturational
– Biologic
– Temperamental

10. Erectile Dysfunction
ETIOLOGY
PSYCHOGENIC IMPOTENCE
• Desire Inhibition
• Excitement Inhibition

11. Erectile Dysfunction
ETIOLOGY
PSYCHOGENIC IMPOTENCE
Desire Inhibition
 Absence of desire
 Situation specific
 Partner specific
 Systemic illness
 Drugs
 Biologic disorders (klinefelter)

12. Erectile Dysfunction
ETIOLOGY
PSYCHOGENIC IMPOTENCE
Excitement Inhibition
Inability to maintain excitement initially present
Psychogenic impotence
 Treatable
 Sex therapy

13. VASCULOGENIC IMPOTENCE
Arterial
 Arterial narrowing
 Aortoiliac
 Pudendal
 Penile vessels
 Leriches syndrome
 Atherosclerosis
 Fibrosis
 Calcifications
 Obliteration
 Scarring

14. VASCULOGENIC IMPOTENCE
Arterial
 Aneurysmal dilatation
 Aging
 Progressive obliteration of cavernosal arteries
 Diabetic vasculopathy
 Other risk factors
 Hypertension
 Smoking
 Hyperlipidemia
 Blunt pelvic or perineal trauma
 Pelvic steal syndrome

15. VASCULOGENIC IMPOTENCE
Venoocclusive Dysfunction
 Presence of large and abnormal venous channels
CAUSES
 Degenerative disease
 Peyronies disease
 Structural changes in fibroelastic components
 Acquired shunts (treatment of priapism)

16. Erectile Dysfunction
Neurogenic Impotence
 Peripheral Neuropathy
 Spinal Cord Lesions
 Cerebral Hemisphere Lesions

17. Erectile Dysfunction
Neurogenic Impotence
Peripheral Neuropathy
 D.M
 Uremia
 Amyloidosis

18. Erectile Dysfunction
Neurogenic Impotence
Spinal Cord Lesion
 Trauma
 Herniated disk compression
 Multiple sclerosis
 Tabes dorsalis
 Syringomyelia
 Spina bifida
 Amyotrophic lateral sclerosis
 Tumors
 Lateral chordotomy
 Shy-dragger syndrome (Multiple System Atrophy with Orthostatic Hypotension)

19. Erectile Dysfunction
Neurogenic Impotence
Cerebral Lesions
 Frontal lobotomy
 Parkinson's disease
 Stroke
 Huntington's chorea
 Electrocortical shock therapy (ECT)

20. Erectile Dysfunction
Endocrine And Metabolic Disorders
 D.M
 Hypergonadotrophic hypogonadism
 Hypogonadotrophic hypogonadism
 Hyperprolactinemia
 Thyroid disorders
 Chronic renal failure

21. Erectile Dysfunction
Endocrine And Metabolic Disorders
D.M
• 50% of diabetic patients
• ED not correlelate with the severity of the disease or
the adequacy of control
• Duration of the disease is a greater risk
• Mechanism is complex
– Vascular microangiopthy
– Accelerated atherosclerosis
– Peripheral neuropathy
– Endocrine

22. Erectile Dysfunction
Endocrine And Metabolic Disorders
Hypergonadotrophic Hypogonadism
• Klinefelter
• Chemotherapeutic agents
• Radiation
Hypogonadotrophic Hypogonadism
• Kallmanns (hypogonadism and almost invariably infertility and anosmia)
• Prader-Willi (low muscle tone, short stature, incomplete sexual development, cognitive disabilities, problem
behaviors, and a chronic feeling of hunger that can lead to excessive eating and life-threatening obesity)
• Laurence-Moon-Biedl (obesity, retinitis pigmentosa, polydactyly, hypogonadism, and renal failure)

23. Erectile Dysfunction
Endocrine And Metabolic Disorders
 Hyperprolactinemia
Drug induced
Prolactine secreting tumor
 Thyroid disorders
 Chronic renal failure

24. Erectile Dysfunction
End Organ Factors
 Extrophy/epispadias complex
 Microphallus
 Fusiform megalourethra
 Severe penile chordee
 Peyronies disease
 Priapism (corporal scarring)
 Prostatitis and seminal vesiculitis

25. Erectile Dysfunction
Iatrogenic
 Vascular surgical procedures
 Radical pelvic surgery
 Abdominoperineal resections
 Simple prostatectomy
 Perineal 29%
 Suprapubic 13%
 TURP 5%
 Surgery for priapism
 Pelvic irradiation
 Trauma to lower urinary tract
 Certain procedures on spinal cord or brain

26. Erectile Dysfunction
Drug-induced
 25% of ED
 Alcohol
 Recreational drugs
 Antihypertensives
 Psychotropics
 Histamine H2 receptor agonist (Cimetidine)
 Hyperlipidemia (colifibriate)

27. Erectile Dysfunction
Drug-induced
Antihypertensives
Most Of Antihypertensives Are Associated With ED
• Diuretics And Vasodilators (Rarely Cause ED)
• Sympatholytics (Usually associated With ED)
 Methyldopa
 Clonidine
 Reserpine
• Alpha Adrenergic Blockers (Affect Emission And Ejaculation)
 Phentolamine
 Prazocin
 Phenoxybenzamine
• Beta blockers

28. Erectile Dysfunction
DRUG-INDUCED
Psychotropics
 Antidepressants
 Tricyclic antidepressant
 Monoamine oxidase inhibitors
 Tranquilizers
 Benzodiazepines
 Meprobamate
Anticholinergic
Abused substances
Alcohol
Amphetamines
Barbiturates
Cocaine
Marijuana
Narcotics
Cannabis

29. Erectile Dysfunction
ALCOHOL
 Initially increase sexual activity
 High level depress sexual arousal
 Depress serum testosterone level

30. Erectile Dysfunction
ETIOLOGY

31. MALE SEXUAL DYSFUNCTION
EVALUATION
HISTORY
PHYSICAL EXAMINATION
LAB INVESTIGATIONS
SPECIAL STUDIES

32. Erectile Dysfunction
HISTORY
Carful History And Physical Examination Are The Most
Important Part Of Overall Evaluation
 Specify type of sexual dysfunction
 Onset of dysfunction
 Duration
 Situation
 Morning erection
 Risk factors
 Medications

33. Erectile Dysfunction
Physical Examination
Attention to identifying vascular, neurologic, hormonal,
and genital abnormalities

34. Erectile Dysfunction
Physical Examination
General
Cardiovascular system
Femoral and peripheral pulses
Abdomen and femoral areas bruit
Endocrine diseases
Gynecomastia
Hair distribution
Abdominal
External genitalia
Focused neurological exam
Peripheral and genital sensation
Anal sphincter
Bulbocavernosus reflex

35. Erectile Dysfunction
Lab Investigations
• Multiple blood chemistries
 Renal function tests
 Liver function tests
 Blood sugar level
 lipid profile
• Hormonal profile
 Testosterone,
 Prolactine
 LH
• Urinalysis

36. Erectile Dysfunction
Special Studies
• Psychological tests
• Nocturnal penile tumescence test
• Assessment of penile blood flow
– Doppler study
– Angiography
• Dynamic infusion cavernometry and Cavernosography
• Neurologic testing
• Cavernous tissue biopsy

37. Erectile Dysfunction
Special Studies
Psychological Tests
 Beck depression inventory test
 Minnesota multiphasic personality inventory test
 Abnormalities require more psychological evaluation

38. Erectile Dysfunction
Special Studies
Nocturnal Penile Tumescence Test
• Normally occurs at REM sleep
• 3-5 episodes
• Psychogenic ED have positive test
• Negative test does not indicate organic ED
• Test at home or in sleep lab
• Measures tumescence not rigidity
• Not commonly used routinely

40. Erectile Dysfunction
Special Studies
Assessment Of Penile Blood Flow
• Penile-brachial index (PBI)
– Penile systolic bl.P/brachial systolic bl.P
– Normal >0.7
– Vasculogenic arterial ED <0.7
• USE 10mhz Doppler probe
• Abandoned test
– Doppler signal is not specific
– Difficult to specify the exact vessel
– Study in flaccid penis
– Operator dependant

41. Erectile Dysfunction
Special Studies
Assessment Of Penile Blood Flow
Penile Doppler study
• Doppler study pre and after vasoactive ICI
• It is the commonly used test
• Rigid erection after ICI indicate normal arteries
 Peak systolic velocity
 End-diastolic velocity
 Diameter of cavernosal arteries

43. Erectile Dysfunction
Special Studies
Assessment Of Penile Blood Flow
ANGIOGRAPHY
 Selective bilateral internal iliac arteries
 Selective bilateral internal pudendal arteries
 Invasive
 Expensive
 With significant risk
Prior for revascularization procedures only

45. Erectile Dysfunction
Special Studies
Dynamic Infusion Cavernometry And
Cavernosography
 Confirm diagnosis of venogenic ED
 Infusion of warmed heparinized saline at a flow rate to achieve
erection
 Infusion of contrast for Cavernosography
 Record of flow rate required to maintain erction

46. Erectile Dysfunction
Special Studies
Neurologic Testing
Patient with high index of suspicion of Neurogenic ED
1. Pelvic parasympathetic nerves evaluation
Cystometry
2. Somatic pudendal nerve evaluation
Perineal EMG
Bulbocavernosus reflex latency test
3. Suprasacral afferent pathway evaluation
Genitocerebral evoked response

47. Erectile Dysfunction
Special Studies
Cavernous Tissue Biopsy
• Cavernosal smooth muscle biopsy
• Controversy
• Rare indication
• Prior to highly reconstructive vascular surgery

48. TRATMENT
1. Nonsurgical
 Psychotherapy and sexual counseling
 Drug therapy
 Oral drugs
 Hormonal therapy
 Intracorporeal injection therapy
 Intraurethral therapy
 Vacum-constriction device
2. Surgical

49. Erectile Dysfunction
NONSURGICAL
Psychotherapy And Sexual Counseling
• Reassurance
• Education
• Marriage counseling
• Sexual therapy
• Psychoanalysis

50. Erectile Dysfunction
NONSURGICAL
Hormonal Therapy
Testosterone Administration
 Low or low normal testosterone level
 Affect libido rather than erectile function
 Contraindicated in patients with prostate CA
 Orally administered alkylated testosterone
 Not preferable
 Poor GIT absorption
 liver toxicity
 Intramuscularly administered estirified testosterone
 Recommended
 Transdermal route

51. Erectile Dysfunction
Nonsurgical
Pharmacological Therapy
ORAL DRUGS
 Centrally acting drugs
 Yohimbine
 Apomorphine
 Trazadone
 Ginsing roots
 Peripherally acting drugs
 Phosphodiesterase inhibitors
 Sildenafil
 Tadalafil
 Verdenafil

52. Erectile Dysfunction
Nitric Oxide
• Released from noncholinergic nonadrenergic nerves
• Stimulate guanylate cyclase enzyme
• Increase production of cGMP
• Cavernous smooth muscle relaxation
• Tumescence and erection
• Phosphodiesterase convert cGMP into GMP
• Sildenafil inhibits type 5 PDE leading to enhancing NO
relaxant effect

53. Erectile Dysfunction
Nonsurgical
Phosphodiesterase 5 Inhibitors
1. SILDENAFIL
2. TADALAFIL
3. VARDENAFIL
4. AVANAFIL

54. Erectile Dysfunction
Nonsurgical
Avanafil
• Is a potent selective phosphodiesterase type 5 (PDE5)
inhibitor newly developed for treating (ED).
• Preclinical and clinical phase I studies showed that
avanafil had :
– Enhanced selectivity
– Faster onset of action
– Favourable side-effect profile relative to currently available PDE5 inhibitors.
• As the result of phase III clinical trial for the efficacy and
safety of avanafil treatment (100 and 200 mg), taken as
needed over a period of 12 weeks, in Korean patients with
ED, avanafil is an effective and well-tolerated therapy for ED
of broad-spectrum aetiology and severity.

55. Erectile Dysfunction
Nonsurgical
Phosphodiesterase 5 Inhibitors
SILDENAFIL CITRATE
• FDA approval in 1998
• Significant advance in medical therapy of ED
• Success rate of 65-80%
• Intact neural input is necessary
• Sexual stimulation is required

56. Erectile Dysfunction
NONSURGICAL
SILDENAFIL CITRATE
Absolute contraindication
Use of organic nitrates
Side effects
1. Nasal congestion
2. Visual color tinge
3. Dyspepsia and diarrhea

57. Erectile Dysfunction
Intraurethral Drug Therapy
• PGE1 Urethral suppository
• Activate adenylate cyclase
• Increasing cAMP level
• Smooth muscle relaxation
• Success rate < 50%
• Side effects
– Penile pain
– Hypotension
– Dizziness
– Syncope
– UTI

58. Erectile Dysfunction
Nonsurgical
Intracavernous Injection Therapy
Diagnostic and therapeutic tool
 Papaverine
 Phentolamine
 PGE1
Single or combination
Direct smooth muscle relaxation

59. Erectile Dysfunction
NONSURGICAL
Intracavernous Injection Therapy
• Candidates
 Neurogenic impotence
 Refractory psychogenic impotence
 Minimal Vasculogenic impotence
• Side effects
 Pain
 Fibrosis
 Priapism

60. Erectile Dysfunction
Nonsurgical
Other Therapeutic Options
1. Neurostimulation
– Electrical stimulation of sacral nerves
– Investigational
2. Corporeal dilation
– Papaverine induced erection
– Heparinized saline infusion
– Sustained intracorporea pressure
– Monthly therapy for 6-12 months
– Investigational
3. Gene therapy
4. Stem cell therapy

61. Erectile Dysfunction
Nonsurgical
Vacume Constriction Device
• Device creates negative pressure
• Filling of sinusoidal spaces
• Engorgement producing erection
• Erection is maintained by rubber ring
• Success rate 40-50%
• Complications
– Pain
– Eccymosis
– Swelling
– Petichiae

62. VACUME CONSTRICTION DEVICE

63. Erectile Dysfunction
SURGICAL
1. Penile prosthesis surgery
 Malleable or semirigid prosthesis
 Inflatable prosthesis
2. Vascular procedures
 Proximal arterial lesions
 Distal arterial lesions
 Venous lesions

64. Erectile Dysfunction

65. Erectile Dysfunction

66. Erectile Dysfunction

67. Erectile Dysfunction

69. Erectile Dysfunction
SURGICAL
Vascular Procedures
Penile Revascularization
Venous Ligation Procedures
 Proximal arterial lesions
 Distal arterial lesions
 Venous lesions

70. Erectile Dysfunction
SURGICAL
Arterial Revascularization
 Iliac to Hypogastric artery graft
 Hypogastric endarterectomy
 Balloon angioplasty
 Inferior epigastric artery to corpus cavernosum
anastomosis
 Inferior epigastric artery to dorsal artery of the penis

71. Erectile Dysfunction
SURGICAL
Venous Vascular Surgery
 Dorsal vein ligation
 Inferior epigastric artery to deep dorsal vein

72. THANK YOU