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Erectile dysfunction
“Man survives earthquakes, experiences the
horrors of illness, and all of the tortures of
the soul. But the most tormenting tragedy
of all time is, and will be, the tragedy of the
bedroom.”
Tolstoy
The consistent inability to achieve and/or
maintain an erection adequate for
satisfactory sexual intercourse.
“This definition is simple, but the condition is not”
Persistent or recurrent inability to attain, or to
maintain until completion of the sexual activity, an
adequate erection
The disturbance causes marked distress or
interpersonal difficulty
The erectile dysfunction is not better accounted for by
another Axis I disorder (other than a sexual dysfunction)
and is not due exclusively to the direct physiological
effects of a substance (e.g. a drug of abuse, a
medication) or a general medical condition
Erectile dysfunction
Normal Male Sexual Function requires:
1) An intact Libido
2) Detumescence
3) Ability to achieve and maintain penile Erection
4) Ejaculation
Parasympathetic nerves S2-4 mediate erection
Sympathetic nerves T11-L2 control ejaculation and
detumescence
Penile erection is a neurovascular event
modulated by psychological factors and
hormonal status. On sexual stimulation, there
is increased flow of blood into the lacunar
network. Subsequent compression of the
trabecular smooth muscle causes a closure of
the emissary veins and accumulation of blood
in the corpora. The corpora becomes non-
compressible and blood cannot escape.
Nerve impulses cause the
release of
neurotransmitters (NO)
from the cavernous nerve
terminals. Nitric oxide
diffuses into cavernosal
smooth muscle cells,
activates Guanylate
cyclase, which converts
GTP to cGMP resulting in
smooth muscle relaxation
in the arteries and
arterioles supplying the
erectile tissue and a
several fold increase in
penile blood flow.
At the same time, relaxation of the
trabecular smooth muscle increases
the compliance of the sinusoids,
facilitating rapid filling and expansion
of the sinusoidal system.
Flaccid Penis Erect Penis
The subtunical venular plexuses are thus
compressed between the trabeculae and the tunica
albuginea, resulting in almost total occlusion of
venous outflow.
These events trap the blood within the
corpora cavernosa and raise the penis from a
dependent position to an erect position, with
an intracavernous pressure of approximately
100 mm Hg (the phase of full erection).
Sexual impulse
Neurotransmitter
Release of NO & chemical substrates
Smooth muscle relaxation
Tumescence
Venous occlusion
Rigidity
Erection
Erectile dysfunction
It can be primary or secondary
 Primary means present from the first attempt
at intercourse or it may be secondary in which
person develop ED after a period of normal
function.
In situational male ED, a man is able to have
coitus in certain circumstances but not in others
More common in older than younger men (in
contrast to premature ejaculation)
Erectile dysfunction
Performance anxiety
Relationship problems/difficulties
Loss of attraction to partner
Depression and anxiety disorders
• Anxiety
• Depression
• Fatigue
• Guilt
• Stress
• Marital Discord
• Excessive alcohol consumption
Erectile dysfunction
Atherosclerosis
Hypertension
Trauma
Erectile dysfunction
Erectile dysfunction
Erectile dysfunction
Antihypertensive and antidepressant drugs
Antiandrogens
Alcohol abuse
Cigarette smoking
More likely to affect sexual function
Beta blockers(propranolol,atenolol)
Statins
Diuretics(thiazide)
Anti-
depressants(fluoxetine,sertraline,amitriptyline)
Anti-psychotics(chlorpromazine,risperidone)
Less likely to affect sexual function
Calcium channel blockers
ACE inhibitors
Sydney Men’s Health
Psychogenic
Sudden onset
Situational
Normal waking and nocturnal
erections
Normal erection with masturbation
Tumescence present
Relationship problems
Major Life event
Anxiety, fear, depression
Organic
Gradual onset
All situations
Reduced or absent waking and
nocturnal erections
No erection with masturbation
Lack of tumescence
Normal libido, normal ejaculation
Known Cardiovascular,
endocrinal,, neurological
conditions
Operations, radiotherapy, trauma
to testes/scrotum
Medications, smoking, alcohol
 Aging
 Chronic disease conditions
• Heart disease (1.8 times)
• HTN (1.6 times)
• DM (4.1 times)
• Peripheral vascular disease
(2.6 times)
 Smoking (24%)
 Alcohol use
 Obesity (22%)
 Lack of physical activity
 Depression (1.8 times)
 Elevated cholesterol (1.7 times)
Medical
Surgical
Psychiatric
Medication
Smoking
Alcohol
Recreational drug use
A thorough history (medical, sexual, and
psychosocial)
Has there been a previous period of normal
function?
Has the failure occurred with more than one
partner?
Does erection occur during foreplay?
Does erection occur on waking or in response to
masturbation?
Is there evidence of alcohol or drug abuse? (ask the
partner as well as the patient)
Are there possible effects of any medications?
Erectile dysfunction
Questions 1 2 3 4 5
1. How do you rate
your confidence that you could
get and keep an erection?
Very low Low Moderate High Very high
2. When you had erections with
sexual stimulation, how
often were your erections hard
enough for penetration?
Almost
never/never
A few times
(much less
than half the
time)
Sometimes
(about half the
time)
Most times
(much more
than half the
time)
Almost
always/always
3. During sexual intercourse, how
often were you able to maintain
your erection after you had
penetrated (entered) your
partner?
Almost
never/never
A few times
(much less
than half the
time)
Sometimes
(about half the
time)
Most times
(much more
than half the
time)
Almost
always/always
4. During sexual intercourse, how
difficult was it to maintain your
erection to completion of
intercourse?
Extremely
difficult
Very difficult Difficult Slightly
difficult
Not difficult
5. When you attempted sexual
intercourse, how often was it
satisfactory for you?
Almost
never/never
A few times
(much less
than half the
time)
Sometimes
(about half the
time)
Most times
(much more
than half the
time)
Almost
always/always
Over the Past 6 Months
The IIEF-5 score is the sum of the ordinal
responses to the 5 items.
22-25: No erectile dysfunction
17-21: Mild erectile dysfunction
12-16: Mild to moderate erectile dysfunction
8-11: Moderate erectile dysfunction
5-7: Severe erectile dysfunction
Blood pressure
Peripheral pulses, palpate for AAA
Testes size and consistency
Secondary sexual characteristics
Penis for Peyronie’s plaques, Phimosis
Serum Testosterone
Serum Prolactin
Screening Profile
•Sugars
•Lipids
•Thyroid Functions
It is normal for a man to have
five to six erections during sleep,
especially during rapid eye
movement (REM). Their absence
may indicate a problem with
nerve function or blood supply in
the penis. There are two methods
for measuring changes in penile
rigidity and circumference during
nocturnal erection: snap gauge
and strain gauge.
Nocturnal penile tumescence (NPT)
Erectile dysfunction
General Measures
Psychosexual Therapy
Drug Therapy
Vacuum devices
Surgical treatments
1st
line – lifestyle changes,
hormone issues
2nd
line – oral medication,
counseling
3rd
line – penile injections,
vacuum devices
4th
line – implants, vascular
surgery
Smoking cessation
Reduce alcohol
Weight loss
Exercise
Even if cause of ED is physical the patient
will develop psychosexual issues
Performance anxiety
Sensate focus exercises
Relationship counselling
 Oral agents:
• Phosphodiesterase type 5 inhibitors
• Oral phentolamine and apomorphine
• Yohimbine
 Intra-cavernosal
• Prostaglandin E1 Alprostadil
• Papaverine
 Intra-urethral:
• Alprostadil
Sildenafil (Viagra) 25mg, 50mg, 100mg
•1 hour before sexual activity
•4-6 hour window
•Absorption delayed by fatty meal
Tadalafil (Cialis) 5mg, 10mg, 20mg
•30 minutes before sexual activity
•36 hour window
•Absorption not affected by food
Vardenafil (Levitra) 5mg, 10mg, 20mg
•30-60 minutes before sexual activity
•4-6 hour window
•Absorption delayed by fatty meal
Sildenafil is a selective inhibitor of
phosphodiesterase type 5, which inactivates cyclic
GMP. When sexual stimulation releases nitric oxide
into the penile smooth muscle, inhibition of
phosphodiesterase type 5 by sildenafil causes a
marked elevation of cyclic GMP concentrations in
the glans penis, corpus cavernosum, and corpus
spongiosum, resulting in increased smooth-muscle
relaxation and better erection. Sildenafil has no
effect on the penis in the absence of sexual
stimulation, when the concentrations of nitric oxide
and cyclic GMP are low.
PDE5 Inhibitors
Facial flushing
Headache
Nasal congestion
Dizziness
Dyspepsia
Visual disturbance (blue halo)
Priapism
Non-arteritic anterior ischaemic optic
neuropathy
Recent cardiovascular event
Nitrates
Hypotension
Anatomical deformity
•Angulation,
•Cavernosal fibrosis
•Peyronie’s disease
Predisposition to prolonged erection
•Sickle cell disease
•Multiple myeloma
•Leukaemia
Nitrates
•Glyceryl trinitrate, isosorbide mono or dinitrate
•Chest pain after taking Sildenafil/Vardenafil no
nitrates 24 hours, Tadalafil no nitrates 48 hours
•Recreational amyl nitrate (Poppers)
Cytochrome P450 inhibitors
•Protease inhibitors especially Ritonavir use very
small dose
•Cimetidine, Ketoconazole, Erythromycin
Alpha blockers
Erectile dysfunction
Alprostadil (Caverject, Viridal) 5-40 mcg
•Independent of intact nervous system
•Manual dexterity, adequate vision, training
•Contraindicated: bleeding disorders, sickle cell
anaemia, multiple myeloma, leukaemia
•Side effects: peno-scrotal pain, haematoma,
fibrosis at injection sites, priapism
Papaverine, Phentolamine, Aviptadil (vaso-intestinal
peptide) been used sole or with Alprostadil
Erectile dysfunction
Alprostadil (Muse) 125mg, 250mg, 500mg, 1g
•Pellet inserted with applicator
•Massage penis to aid absorption
•Side effects: Penile pain, dizziness,
priapism rare
Erectile dysfunction
Blood trapped in intracorporal and
extracorporal compartments of penis
Constricting ring at base of penis
Cyanosis, oedema, cold
Pivots at base below ring
Maximum time 30 minutes
Erectile dysfunction
Semi-rigid rods
2 piece inflatable prosthesis
3 piece inflatable prosthesis with abdominal
reservoir
Risks
•Infection
•Destroys corpora cavernosa
•Erosion and extrusion
•Mechanical failure
Erectile dysfunction
®
THANK YOU

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Erectile dysfunction

  • 2. “Man survives earthquakes, experiences the horrors of illness, and all of the tortures of the soul. But the most tormenting tragedy of all time is, and will be, the tragedy of the bedroom.” Tolstoy
  • 3. The consistent inability to achieve and/or maintain an erection adequate for satisfactory sexual intercourse. “This definition is simple, but the condition is not”
  • 4. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection The disturbance causes marked distress or interpersonal difficulty The erectile dysfunction is not better accounted for by another Axis I disorder (other than a sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition
  • 6. Normal Male Sexual Function requires: 1) An intact Libido 2) Detumescence 3) Ability to achieve and maintain penile Erection 4) Ejaculation Parasympathetic nerves S2-4 mediate erection Sympathetic nerves T11-L2 control ejaculation and detumescence
  • 7. Penile erection is a neurovascular event modulated by psychological factors and hormonal status. On sexual stimulation, there is increased flow of blood into the lacunar network. Subsequent compression of the trabecular smooth muscle causes a closure of the emissary veins and accumulation of blood in the corpora. The corpora becomes non- compressible and blood cannot escape.
  • 8. Nerve impulses cause the release of neurotransmitters (NO) from the cavernous nerve terminals. Nitric oxide diffuses into cavernosal smooth muscle cells, activates Guanylate cyclase, which converts GTP to cGMP resulting in smooth muscle relaxation in the arteries and arterioles supplying the erectile tissue and a several fold increase in penile blood flow.
  • 9. At the same time, relaxation of the trabecular smooth muscle increases the compliance of the sinusoids, facilitating rapid filling and expansion of the sinusoidal system.
  • 11. The subtunical venular plexuses are thus compressed between the trabeculae and the tunica albuginea, resulting in almost total occlusion of venous outflow.
  • 12. These events trap the blood within the corpora cavernosa and raise the penis from a dependent position to an erect position, with an intracavernous pressure of approximately 100 mm Hg (the phase of full erection).
  • 13. Sexual impulse Neurotransmitter Release of NO & chemical substrates Smooth muscle relaxation Tumescence Venous occlusion Rigidity Erection
  • 15. It can be primary or secondary  Primary means present from the first attempt at intercourse or it may be secondary in which person develop ED after a period of normal function. In situational male ED, a man is able to have coitus in certain circumstances but not in others More common in older than younger men (in contrast to premature ejaculation)
  • 17. Performance anxiety Relationship problems/difficulties Loss of attraction to partner Depression and anxiety disorders • Anxiety • Depression • Fatigue • Guilt • Stress • Marital Discord • Excessive alcohol consumption
  • 23. Antihypertensive and antidepressant drugs Antiandrogens Alcohol abuse Cigarette smoking
  • 24. More likely to affect sexual function Beta blockers(propranolol,atenolol) Statins Diuretics(thiazide) Anti- depressants(fluoxetine,sertraline,amitriptyline) Anti-psychotics(chlorpromazine,risperidone) Less likely to affect sexual function Calcium channel blockers ACE inhibitors
  • 26. Psychogenic Sudden onset Situational Normal waking and nocturnal erections Normal erection with masturbation Tumescence present Relationship problems Major Life event Anxiety, fear, depression Organic Gradual onset All situations Reduced or absent waking and nocturnal erections No erection with masturbation Lack of tumescence Normal libido, normal ejaculation Known Cardiovascular, endocrinal,, neurological conditions Operations, radiotherapy, trauma to testes/scrotum Medications, smoking, alcohol
  • 27.  Aging  Chronic disease conditions • Heart disease (1.8 times) • HTN (1.6 times) • DM (4.1 times) • Peripheral vascular disease (2.6 times)  Smoking (24%)  Alcohol use  Obesity (22%)  Lack of physical activity  Depression (1.8 times)  Elevated cholesterol (1.7 times)
  • 29. A thorough history (medical, sexual, and psychosocial) Has there been a previous period of normal function? Has the failure occurred with more than one partner? Does erection occur during foreplay? Does erection occur on waking or in response to masturbation? Is there evidence of alcohol or drug abuse? (ask the partner as well as the patient) Are there possible effects of any medications?
  • 31. Questions 1 2 3 4 5 1. How do you rate your confidence that you could get and keep an erection? Very low Low Moderate High Very high 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always/always 3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always/always 4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Extremely difficult Very difficult Difficult Slightly difficult Not difficult 5. When you attempted sexual intercourse, how often was it satisfactory for you? Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always/always Over the Past 6 Months
  • 32. The IIEF-5 score is the sum of the ordinal responses to the 5 items. 22-25: No erectile dysfunction 17-21: Mild erectile dysfunction 12-16: Mild to moderate erectile dysfunction 8-11: Moderate erectile dysfunction 5-7: Severe erectile dysfunction
  • 33. Blood pressure Peripheral pulses, palpate for AAA Testes size and consistency Secondary sexual characteristics Penis for Peyronie’s plaques, Phimosis
  • 34. Serum Testosterone Serum Prolactin Screening Profile •Sugars •Lipids •Thyroid Functions
  • 35. It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. Nocturnal penile tumescence (NPT)
  • 37. General Measures Psychosexual Therapy Drug Therapy Vacuum devices Surgical treatments
  • 38. 1st line – lifestyle changes, hormone issues 2nd line – oral medication, counseling 3rd line – penile injections, vacuum devices 4th line – implants, vascular surgery
  • 40. Even if cause of ED is physical the patient will develop psychosexual issues Performance anxiety Sensate focus exercises Relationship counselling
  • 41.  Oral agents: • Phosphodiesterase type 5 inhibitors • Oral phentolamine and apomorphine • Yohimbine  Intra-cavernosal • Prostaglandin E1 Alprostadil • Papaverine  Intra-urethral: • Alprostadil
  • 42. Sildenafil (Viagra) 25mg, 50mg, 100mg •1 hour before sexual activity •4-6 hour window •Absorption delayed by fatty meal Tadalafil (Cialis) 5mg, 10mg, 20mg •30 minutes before sexual activity •36 hour window •Absorption not affected by food Vardenafil (Levitra) 5mg, 10mg, 20mg •30-60 minutes before sexual activity •4-6 hour window •Absorption delayed by fatty meal
  • 43. Sildenafil is a selective inhibitor of phosphodiesterase type 5, which inactivates cyclic GMP. When sexual stimulation releases nitric oxide into the penile smooth muscle, inhibition of phosphodiesterase type 5 by sildenafil causes a marked elevation of cyclic GMP concentrations in the glans penis, corpus cavernosum, and corpus spongiosum, resulting in increased smooth-muscle relaxation and better erection. Sildenafil has no effect on the penis in the absence of sexual stimulation, when the concentrations of nitric oxide and cyclic GMP are low.
  • 45. Facial flushing Headache Nasal congestion Dizziness Dyspepsia Visual disturbance (blue halo) Priapism Non-arteritic anterior ischaemic optic neuropathy
  • 46. Recent cardiovascular event Nitrates Hypotension Anatomical deformity •Angulation, •Cavernosal fibrosis •Peyronie’s disease Predisposition to prolonged erection •Sickle cell disease •Multiple myeloma •Leukaemia
  • 47. Nitrates •Glyceryl trinitrate, isosorbide mono or dinitrate •Chest pain after taking Sildenafil/Vardenafil no nitrates 24 hours, Tadalafil no nitrates 48 hours •Recreational amyl nitrate (Poppers) Cytochrome P450 inhibitors •Protease inhibitors especially Ritonavir use very small dose •Cimetidine, Ketoconazole, Erythromycin Alpha blockers
  • 49. Alprostadil (Caverject, Viridal) 5-40 mcg •Independent of intact nervous system •Manual dexterity, adequate vision, training •Contraindicated: bleeding disorders, sickle cell anaemia, multiple myeloma, leukaemia •Side effects: peno-scrotal pain, haematoma, fibrosis at injection sites, priapism Papaverine, Phentolamine, Aviptadil (vaso-intestinal peptide) been used sole or with Alprostadil
  • 51. Alprostadil (Muse) 125mg, 250mg, 500mg, 1g •Pellet inserted with applicator •Massage penis to aid absorption •Side effects: Penile pain, dizziness, priapism rare
  • 53. Blood trapped in intracorporal and extracorporal compartments of penis Constricting ring at base of penis Cyanosis, oedema, cold Pivots at base below ring Maximum time 30 minutes
  • 55. Semi-rigid rods 2 piece inflatable prosthesis 3 piece inflatable prosthesis with abdominal reservoir Risks •Infection •Destroys corpora cavernosa •Erosion and extrusion •Mechanical failure
  • 57. ®