Erectile Dysfunction
Dr. S. Ram Gopal
MBBS (Osm), M.Ch (Russia)
EPOR Model
Historical Aspects
 The first description of erectile dysfunction
dates from about 2000 B.C. and was set
down on Egyptian papyrus
 Hippocrates described many cases of male
impotence among the rich inhibitions of Scythia
and concluded that too much horseback riding
was the cause. (The poor were not affected
because they travelled on foot)
 Various theories : arterial polsters (Receptors)
(Von Ebner, 1900; Kiss, 1921), arterial and venous
polsters (Conti, 1952), the sluice theory (Deysach,
1939), an arteriovenous shunt (Newman et al, 1964;
Newman and Northrup, 1981; Wagner et al 1982),
and contraction of the cavernous smooth muscles
(Goldsterin et al, 1982)
 Among these, Conti’s hypothesis that arterial and
venous polsters regulate penile blood flow is the
most frequently quoted.
 Nitric oxide (NO) as the major neurotransmitter
involved in erection.
Incidence and Epidemiology
 In older men, alterations in the vascular
supply, hormonal changes, neurologic
dysfunction, medication, and associated
systemic diseases are the main causes
 The prevalence of complete impotence
tripled from 5% to 15%
Autonomic Pathways
 Eleventh thoracic to the second lumbar
 Cavernous nerves
 4 to 7 mm lateral to the sphincter
 Stimulation of the pelvic plexus and
the cavernous nerves induces erection,
whereas stimulation of the hypogastric
nerve or the sympathetic trunk causes
detumescence
 When parasympathetic centers are injured.
In man, many patients with sacral spinal cord
injury retain psychogenic erectile ability even
though relexogenic erection is abolished
 No psychogenic erection occurs in patients
with lesions above T9
 Contraction of the ischiocavernosus muscles
produces the rigid erection phase. Rhythmic
contraction of the bulbocavernosus muscle is
necessary for ejaculation
Pathophysiology of Erectile
Dysfunction
 Psychogenic
 Neurogenic
 Arteriogenic
 Endocrines
 Drug induced
Psychogenic
 Increased central sympathetic tone may be one of
the causes of psychogenic erectile dysfunction and
may explain why some patients respond poorly to
injection therapy with no evidence of vascular or
neurogenic disorders
 A subclassification of psychogenic erectile
dysfunction has been proposed recently (Lue,
1994a):
 Type 1 anxiety, fear of failure (widower’s syndrome,
sexual phobia, performance anxiety, and so on)
 Type 2 depression (including drug or disease induced
depression)
 Type 3 marital conflict, strained relationship
 Type 4 ignorance & misinformation (e.g, about normal
anatomy, sexual function, or aging), religious scruples
 Type 5 obsessive compulsive personality (anhedonia,
sexual deviation, psychotic disorders)
Neurogenic
 Sensory input from the genitalia is essential
in achieving and maintaining reflexogenic
erection, and the input becomes even more
important when older people gradually lose
the capability of psychogenic erection :
circumcision decrease performance.
Endocrinologic
 Hyperprolactinemia, symptoms may include loss of
libido, erectile dysfunction, galactorrhea, gynecomastia,
and infertility.
 Erectile dysfunction may also be associated with both
hyperthyroidism and hypothyroidism. Hyperthyroidism is
commonly associated with diminished libido, which may
be due to the increased circulating estrogen levels and
less often with erectile dysfunction. In hypothyroidism,
low testosterone secretion and elevated prolactin levels
contribute to erectile dysfunction.
Arteriogenic
 In the majority of patients with arteriogenic erectile
dysfunction, the impaired penile perfusion is a component
of the generalised atherosclerotic process. Common risk
factors associated with arterial insufficiency include
hypertension, hyperlipidemia, cigarette smoking, diabetes
mellitus, blunt perineal or pelvic trauma, & pelvic irradiation
(Goldstein et al 1984; Levine et al 1990; Rosen et al 1990)
 Diabetic men and older men
 Intimal proliferation, calcification and luminal stenosis
 Nicotine may adversely affect erectile function not only
by decreasing arterial flow to the penis but also by
blocking corporeal smooth muscle relaxation, thus
preventing normal venous occlusion (Junemann et al
1987; Rosen et al 1991)
 Hypertension is another well-recognised risk factor for
arteriosclerosis; a prevalence of about 45% has been
noted in one series of impotent men (Rosen et al 1991)
Drug - Induced
 Centrally acting sympatholytics
 Peripheral sympatholytic
 Alpha-adrenergic blocking
 Selective alpha-adrenergic
 Beta-adrenergic blockers
 Major tranquilizers or antipsychotics
 Alcohol in small amounts improve erection and
sexual drive because of its vasodilatory effect and
suppression of anxiety; however, large amounts
can cause central sedation, decreased libido, and
transient erectile dysfunction. Chronic alcoholism
may result in liver dysfunction, decreased
testosterone and increased estrogen levels, and
alcoholic polyneuropathy which also affects
penile nerve (Miller and Gold, 1988)
 Cimetidine, a histamine H2 receptor antagonist,
act as an antiandrogen, prolactin level.
Sexuality Facts
Anatomy Drawings
Male
1. Vas deferens
2. Bladder
3. Prostate gland
4. Urethra
5. Penis
6. Testicle
7. Scrotum
Female - Internal
8. Fallopian tube
9. Ovary
10. Uterus (womb)
11. Cervix
12. Vagina
Female - External
13. Clitoris
14. Labia majora
outer lips
15. Urethra (opening)
16. Labia minora
(inner lips)
17. Vagina (opening)
18. Anus (opening)
Diagnosis of Dysfunction
 Symptoms
 Medical and Psychosexual history
 Physical examination
 Laboratory testing
Symptoms
Verbal
 Weakness
 Not strong
 Not working
 Nervous weakness
Non Verbal
Medical and Psychosexual History
 Early morning erection and erectile quality
 A history of peripheral vascular or coronary artery
disease, diabetes, renal failure, tobacco and
alcohol use, psychologic, neurologic, or chronic
debilitating disease can direct further evaluation
 Radical pelvic surgery (prostatectomy,
abdominoperineal resection), radiotherapy, pelvic
trauma are often associated with impotence
Psychometry and
Psychologic Interview
Organic / Psychogenic
Characteristic
Organic
Psychogenic
Onset
Gradual
Sudden
Circumstances
Always
Situational
Course
Constant
Varying
Noncoital erection
Poor
Rigid
Partner problem
Same
Specific to the partner
Anxiety and fear
+
+
Physical Examination
 Extensibility of the flaccid penis
 Sensation
 Bulbocavernosus reflex
 Axial rigidity
Laboratory Testing
 Renal insufficiency, diabetes
 Hyperprolactinemia ( Thyroid)
 Generally serum testosterone
and prolactin
 Serum lipids
 Platelet aggregation
 Special tests
– CIS test
– X-ray cavernosography
– Rigi scan
– Doppler study
– Penile plethysmography
Nocturnal Penile Tumescence
Testing
 NPT - associated with REM sleep
 Normal parameters
4-5 / night
> 30 mts
> 30 mm at base
> 20 mm at the tip
RIGI scan not measure axial
rigidity (500 gm)
Axial Rigidity
 A bucking resistance of 500 to 550 g
is considered minimum for vaginal
penetration
 Penile tumescence may not always
correlate with penile rigidity sufficient
for vaginal penetration
50 gm
CIS Test
 Inhibitory effect on phosphodiesterase
 Calcium channels
 Papaverine 7.5 - 60 mg
 Tanaka (1990) measured systemic papaverine
levels after intracavernous injection and found
significantly higher peripheral blood levels in
patients with poor erectile response suggestive
of veno-occlusive dysfunction
Sexual Stimulation
(Audiovisual and Vibratory)
 The triple drug combination :
Papaverine, Phentolamine and PGE2
 Contraindications : Sickle cell anemia,
schizophrenia or a severe psychiatric
disorder, severe nenous incompetence,
or systemic disease
Neurologic Testing
Somatic
Autonomic
Autonomic Nervous System
 Heart rate variability and
sympathetic skin response
Platelet Aggregation
 Biochemical study : It has been suggested that
penile hypercoagulability predisposes the patient
to penile vascular changes and impotence.
 Thromboxane A2 is a potent vasoconstrictor and
a stimulus of platelet aggregation, which may
contribute to hypercoagulability.
 Contrarily, prostaglandin I2 has exactly the
opposite effect
Penile Brachial Pressure Index
 A normal PBI connot be relied upon to exclude
arterigogeic impotence. Indeed, attempts to
correlate PBI and other more established
techniques have been disappointing.
 Penile plethysmography (Penile pulse volume
recording). This test is performed by connecting a
2.5 or 3 cm cuff to an air plethysmograph. The cuff
is inflated to a pressure above brachial systolic
pressure, which is then decreased by 10 mm Hg
increments, and tracings are obtained at each level.
Nonsurgical Treatment of
Erectile Dysfunction
 Lifestyle change
 Change of medication
 Pelvic floor muscle exercise
 Hormonal therapy
 Oral agents
 Transdernal and intrauretheral
medications
 Intracavernous injection
 Vacuum constriction device
Lifestyle Changes
 Exercise, Diet, Smoking and Alcohol
 In rabbit experiments, the deleterious effect
of a high-cholesterol diet on the cavernous
smooth muscle was reversed several weeks
after cholesterol was eliminated from the diet
 Long-distance bicycle riding is another risk
factor that should be discussed
Changes of Medication
 Methyldopa and reserpine
 Calcium channel blockers or
angiotensin-converting
 Trazodone
Pelvic Floor Muscle Exercise
 Electrical stimulation of the ischiocavernosus
muscle, graded pelvic floor exercises with muscle
training, and a home exercise program for lying,
sitting, and standing positions for 4 months.
The root of the penis. The corpora are
shown in transverse section
Sex Therapy
 In the 1970s, Masters and Johnson (1970)
developed a sensate focus exercise program for
sex therapy and treatment performance anxiety,
inhibition, and guilt. Kaplan (1974, 1983) added
personal or interpersonal conflicts.
Vacuum Constriction Device
 The blood oxygen level in the corpus cavernosum
is less
 Proximal to the ring is not rigid, which may
produce a pivoting effect
 The penile skin may be cold and dusky, and
ejaculation may be trapped by the constricting ring
 The ring can be uncomfortable or even painful
Pharmacology of Penile Erection
 Increase the libido of patients
(LADY PANT)
 Suppress mating behavior
Suppressors
( prolactin)
 Phenothiazine
 Opiates
 Tricyclic antidepressents
 Clonidine
 Haloperidol
 Prazocin
 Methyldopa
 Serotonin
 Reserpine
 Fenfluramine
 Meprobomate
 Estrogens and drugs with antiandrogenic
action, such as ketoconazole & cyproterone
acetate. Many anticancer drugs.
Erection Inducing Drugs
 Papaverine
 Nitroglycerine
 Phentolamine
 Phenoxy Benzamine
 Moxy Sylyte
 Verapamil
 Trazodone
 PGE
LADY PANT
 L-Dopa
 Amphetamine
 Deprinyl
 Yohimbine
 Pergolide
 Apomorphine
 Nomifensine
 Trazodone
Hormonal Therapy
 The long acting forms, testosterone
cypionate and enanthate, are the drugs of
choice for replacement therapy (Sustanon)
 The recommend dose is 200 mg
intramuscularly every 2 to 3 weeks.
 Parenteral testosterone is given if free
testosterone < 9 ng/dl
Serotonergic Drugs
 Trazodone is a commonly prescribed mild
antidepresant with a rare incidence of priapism
 A combination of trazodone and yohimbine
 Better nocturnal erections after trazodone.
Sexual activity in the morning when the
sedative effect is no longer a problem.
Transdermal and Intrauretheral
Medications
 Nitroglycerin paste
 Penile shaft (nitroglycerin) or glans penis (minoxidil & placebo)
 Increases in diameter and rigidity were measured with the
Rigiscan divice, and arterial flow was evaluated by conventional
Doppler sonography
 Minoxidil was shown to be more effective than nitroglycerin
 Treatment with yohimbine ointment was reported to be effective
in patients with impotence of recent onset who had no major
vascular alterations
Sildenafil
Mode of action
 Type 5 (PDE5)
 By selective inhibition of PDE5, sildenafil
enhances cyclic GMP activity in the erectile
tissue. It amplifies the vasodilatory effect of nitric
oxide, which is produced naturally in the erectile
tissue in response to sexual stimulation. Without
sexual stimulation, therefore, sildenafil has no
effect on erections
 Peak plasma concentration at 30-120 minutes
 The improvement in erectile function was
dose related, with men on 100 mg doses
scoring 100% higher
 Sildenafil gave a significant improvement
in erectile ability and success at intercourse
increased fourfold : this benefit was
conferred for at least 6 months
Indications
 Sildenafil restores erectile ability,
but has not demonstrable effect
on sexual desire or ejaculation
Contraindications
 Severe hepatic impairment; a recent myocardial
or cerebral infarction; blood pressure below 90/50
mmHg; hereditary degenerative retinal disorders,
such as retinitis pigmentosa.
 Cardiac condition in whom the heart is so
decompensated that it will not stand the effort of
sexual exertion.
 Men under 18 years (Legal)
Drug Interactions
 Cimetidine
 Erythromycin by 182%. If sildenafil is taken
with one of these drugs, it is advisable to
start the patient on half the standard dose.
 There is no known interaction between
sildenafil and alcohol, antidepressants
or antihypertension medication.
Side-effect
Frequency (%)
 Headaches
12.8
 Flushing
10.4
 Dyspepsia
4.6
 Dizziness
1.2
 Nasal congestion
1.1
 Green blue tingeing of vision
 Increased sensitivity to light
 Blue red vision
Muscle aches have been reported in patients who
used more than recommended one dose a day
Dosage and administration
 The standard dose of sildenafil is 50 mg, one hour before
intended sexual activity. The dose can be increased to a
maximum of 100 mg or reduced to 25 mg, depending on
efficacy and toleration in the individual
 Safe, effective and easy-to-administer treatments, such as
sildenafil, are not a panacea
 Patient’s partners should be involved in the decision, and
the treatment should be prescribed with psychotherapeutic
support. Erectile dysfunction is a multifactorial problem
and a comprehensive approach is the key to management
Definition
 Inability to maintain until penetration
are ejaculation sooner than desired
either before or after penetration
Test
Intra vaginal latency period
Treatment
 Paroxetine (Paxitil) 10-40 mg
20 mg / OD / daily is the best Rx
 Fluox (Fludac, Prozac) 20 mg
 Chlomipramine 10 mg / 4 hrs prior
or 25 mg daily / 1 year
 Verapamil, Trazadone
Early Ejaculation (PME)
 PME treatment - Medical treatment
 Pelvic exercises - Muscle stimulator
Surgical Treatment
 Penile implants
 Leu’s surgery
50 Watts 50/60 Hz
Kamasutra
Mallanath Vatsayana
Nagera (South Gujarat) 350 AD
 Situational
 Constitutional : Ahar, Vihar, Aushad
 What is good for the whole body is
good for sex
 Education : Whom, When, Why
 Whom “A Sapthathi Yavvana”
 When : “Prag yavvana”
 Why : Dharma, Artha, Kama, Moksha
 Samyak Bhoga = Sambhoga
 Sama bhog = Equal enjoyment
by both the partners
 Anand (orgasm) = Bliss
 Vajroli mudra, Ashwin mudra
(Pubococcygeous exercises)
 Foreplay - Verbal, body
 Masturbation (Upa mardan)
 Pani (Hand) Manthan (Movement)
 Oral sex (Aupershtaka) for elderly, obese
 Anal sex : Adho rut (S2 S3 Vagina, Rectum)
 Apadravya or Prathima (Dilldos, Dolls)
 Artificial penis
Partner Satisfaction
 Masturbation, oral sex, artificial penis
 Lesbian / Homo : Venus and Saturn in
the same house
 Multiorgasm
What are the points to be
noted in the case sheet of FS ?
How does differs from the male case sheet ?
Female Sexuality
 Desire
S. grounding
 Lubrication in
arousal
= erection in
 Case sheet
Female
Male
 Desire
Desire
 Lubrication
Erection
 Penetration
Penetration
 Orgasm
Orgasm
orgasm
What is to be asked the history ?
 Dislike to wards partner
 History of surgery especially
Bilateral Oophorectomy
What are the signs ?
Exclusion of several pelvic diseases
What investigations ?
 Prolactin
 Estrogen
 Progesterone
What are the treatments ?
 Hymenectomy if needed
 Psychotherapy
 Desire
F.lobe tumors, Prolactin , Androgen after
bilateral oophorectomy, dislike of partner
 Lubrication inadequate foreplay, infection, endocrinal
(E ) P
 Penetration no penetration, partial penetration
painful penetration, hymen, vaginismus.
 Partial penetration : vaginal anatomy, position - faulty
 Painful penetration : superficial, deep, scars, wounds,
infection
 Orgasm = enough and nothing more
 Cerebrally encoded neuromuscular
response at the peak of sexual arousal
 Early, delayed, impaired, absent
(My husband is using me as a sleeping pill)
(Wo to na ha kar chalgaye, mai thadapthi rohi)
 Multi orgasms : Physiological in
Acquired art in
 Prof. Kothari Ji : Orgasm cannot be explained
but must be experienced (like a sneeze)
 One must try to posess acceptable,
respectable sexual behavior.
EPOR Model
EPOR Model
 Excitement phase
 Plateau phase
 Orgasmic phase
 Resolution phase - short absolute
refractory period in the male during
which rearousal is not possible
Thank you