Lecture name: Erectile dysfunction.
Time: 1 hr.
Dr.Salam A. ALmosawi.
Aims and goals of the lecture:At the end of the lecture , the students are able to:
1-Identify the main causes of erectile dysfunction.
2-Deal and manage cases of erectile dysfunction.
3-Discuss the new modalities of management of erectile dysfunction.
Introduction:Erectile dysfunction is one of the commonest problems that face the
urologist in his practice.
From 1970 till now,there is rapid evolution in the methods of diagnosis
and treatment of erectile dysfunction .
Contents:Physiology and pathophysiology of erection and erectile dysfunction:
Classification of erectile dysfunction.
Diagnosis and evaluation of patient with erectile dysfunction.
Management of erectile dysfunction.
Physiology and pathophysiology of erection and erectile
dysfunction:
*Erection is a complex phenomenon that require intact neurological,
arterial and venous system of the penis with psychological stability.
*There are 3 types of erection :- sexualy induced , reflexogenic and
fantasy or visualy stimulated erection.
*The sacral parasympathetic (S2-S4) is responsible for tumescence while
the thoracolumbar sympathetic (T10-L2) is responsible for
detumescence.
*The higher central nervous system play a role in tumescence and
detumescence by integration of signals with release of central
neurotransmitters that affect the penis these are:- (nitrous oxide and
acetyle choline) stimulate erection while (norepinephrine) cause
detumescence.
*The main peripheral neurotransmitter responsible for erection is
nitrous oxide that release from the nerve endings and from the
endothelial cells of the penile vessels.
Sexual arousal → nitrous oxide release → diffusion into the
vasculature and cavernous smooth muscles→ stimulate smooth
muscles relaxation → dalitation of the arterioles and cavernous
sinuses which full (engorge) with blood → entrapment of blood in
the penis by closure of the venous return of the penis (emissiary
veins) → erection.
Risk factors for erectile dysfunction:1-Diabetes mellitus.
2-Hypertension.
3-Deterioration in the general health status.
4-Psychological disorders or psychiatric diseases.
5-Smoking.
6-Obesity.
7-Drugs: as: beta- blockers , anti-androgens ,cemitidine ,…..etc.
Causes and classification of E.D.:1-Organic E.D.:-
1.Vasculogenic
2-Psychogenic.
2.Neurogenic
3.Anatomic
3-Mixed.
4.Endocrinologic
Evaluation of patients with E.D.:
1/ History: concentrate on :
-Medical hx.
–Treatment hx.
–Psychological hx.
-Sexual hx.(face to face): Variety of SAQ. As IIEF.
2/ Physical examination:
Complete physical examination needed with special attention for:
- Examination of the external genitalia: for any anatomic abnormalities
or any diseases of the external genitalia.
-Neurological examination.
3/ Lab. Ix.:
Depending on the hx. And physical examination and may include:
FBS.,B.urea,S.creatinine,hormonal assay…..etc.
Treatment of E.D.:
1) General measures: as:
Decrease weight, stop smoking, modify physical activities
and stop or change medications which have high risks for E.D
2) Psychosexual treatment:
3) Pharmacological treatment: which includes:
a- Hormonal treatment: indicated mainly for those with
hormonal deficiencies and include:
-Testosterone preperations:as (inj., transdermal, pellet, or oral)
-DHT gel.
-HCG.
b- Peripherally acting agents: includes:
1. PDE-5 inhibitors:as(Sildenafil, Vardenafil, Tadalafil)
They are ineffective without sexual stimulation.
They are absolutely C.I. in patients taking nitrates.
Special care in pt. with M.I. in previous 90 days, stroke with in
6 monthes, uncontrolled arrythemia and those with tendency
to develop priapism.
2. Adrenoceptor antagonist: as oral Phentolamines.
3. Intracavernous injections: include (Papaverine,
Phentolamines and/or Alprostadil ).
4. Intrauretheral therapy.
c- Centrally acting drugs: as
1. Yohimbine: alpha 2 adrenocepters antagonist.
2. Apomorphine: dopaminergic agonst.
3. Trazadone.
4) Vacuum constrictor device:
It consist of plastic cylinder connected directly or by tubes to
vacuum generating source.
It should be used with caution in those taking Aspirin or
Warfarin.
5) Surgical treatment (penile prostheses)