Erectile Dysfunction

Prof. Dr Syed Azhar Syed Sulaiman

Introduction
 Testosterone levels diminish with age, as both testosterone
production and metabolic clearance decrease.

 These hormonal alterations lead to loss of libido, decreased

muscle strength, alterations in memory, diminished energy
and well-being, and possibly osteoporosis.

 Testosterone appears to influence the frequency of nocturnal

erections; however, low testosterone levels do not affect
erections produced by erotic stimuli.
Introduction- ED
 (Impotence)
 The inability to develop and sustain an erection
sufficient for satisfactory sexual intercourse in 50%
or more attempts at intercourse.
 Once a rarely discussed topic, erectile dysfunction is
now a topic of general conversation. Awareness and
openness have been driven in large part by the
availability of new treatments and the coverage of
these treatments by the media.
Introduction
 Erectile dysfunction may occur from time to time at
any age for a variety of reasons. However, the
incidence of persistent erectile dysfunction increases
with age.

 The prevalence is about 52% among men aged 40 to

70 and even greater among older men. The
prevalence is nearly 95% among men > 70 who have
certain medical disorders such as diabetes
Etiology and Pathogenesis
 Vascular disorders

 Neurologic disorders

 Endocrine disorders

 Structural abnormalities
Drug induced ED
 About 25% of cases of erectile dysfunction
are caused by drugs especially :
 antihypertensives (most notably reserpine, -
blockers, guanethidine, and methyldopa),
 alcohol, cimetidine, antipsychotics,
 antidepressants, lithium, sedative-hypnotics,
 leuprolide, and hormones such as estrogen and
progesterone.
Drug induced ED
 In addition, many drugs can impair sexual function
in men, especially elderly men, by :
 altering libido (eg, cimetidine, diazepam),
 inhibiting ejaculatory function (eg, most tricyclic
antidepressants such as amitriptyline, clomipramine,
doxepin, nortriptyline),
 or delaying or inhibiting orgasm (eg, selective serotonin
reuptake inhibitors such as fluoxetine).
 Trazodone has been found to improve libido and
facilitate erectile function
 Treatment

 Sildenafil (50 to 100 mg given 1 hour before a sexual

encounter) helps produce erections, but only when the
patient is sexually stimulated.

 Sildenafil has relative selectivity for inhibition of type V

phosphodiesterase, which inhibits breakdown of cyclic
guanosine monophosphate, resulting in vasodilation.

 However, inhibition of type III and type VI

phosphodiesterase may occur, which can affect cardiac
function and vision, especially color vision.
 Treatment
 Because sildenafil can cause severe
hypotension when nitrates are used
concurrently, it is contraindicated in patients
who take nitrates to relieve angina and in
those with significant heart disease.

 Sildenafil can also cause headaches, flushing,

and dyspepsia
Treatment
 Second oral medicine, vardenafil hydrochloride
(Levitra).
 Taken an hour before sexual activity, Viagra
and Levitra work by enhancing the effects of
nitric oxide, a chemical that relaxes smooth
muscles in the penis during sexual stimulation
and allows increased blood flow.
 The recommended dose for Viagra is 50 mg,
and the physician may adjust this dose to 100
mg or 25 mg, depending on the patient.
Treatment
 The recommended dose for Levitra is 10 mg,
and the physician may adjust this dose to 20
mg if 10 mg is insufficient.

 Lower doses of 5 mg and 2.5 mg are available

for patients who take other medicines or have
conditions that may decrease the body's ability
to use Levitra
Treatment
 Neither Viagra nor Levitra should be used more
than once a day. Men who take nitrate-based
drugs such as nitroglycerin for heart problems
should not use either drug because the
combination can cause a sudden drop in blood
pressure.

 Also, Levitra should not be taken with any of the

drugs called alpha-blockers, which are used to
treat prostate enlargement or high blood
pressure.
Treatment
 What is Cialis (tadalafil)?
Cialis is in a class of medications known as PDE-5
inhibitors, which are used to treat cases of male
impotence.

 How does Cialis (tadalafil) work?

Cialis acts in the same way as Viagra, by blocking an
enzyme called phosphodiesterase-5, or PDE-5.

 Cialis helps the smooth muscles in the penis relax and

widen, which allows for more blood to entergain
erections faster and easier
Treatment
 Oral testosterone can reduce ED in some men
with low levels of natural testosterone, but it is
often ineffective and may cause liver damage.

 Patients also have claimed that other oral

drugs—including yohimbine hydrochloride,
dopamine and serotonin agonists, and
trazodone—are effective, but the results of
scientific studies to substantiate these claims
have been inconsistent.
Treatment
 Many men achieve stronger erections by injecting drugs into the
penis, causing it to become engorged with blood.

 Drugs such as papaverine hydrochloride, phentolamine, and

alprostadil (marketed as Caverject) widen blood vessels.

 These drugs may create unwanted side effects, however,

including persistent erection (known as priapism) and scarring.

 Nitroglycerin, a muscle relaxant, can sometimes enhance

erection when rubbed on the penis.
Treatment
 Alprostadil (prostaglandin E1) can be given by
intraurethral pellet or intracavernosal injection with
or without papaverine phentolamine.

 Alprostadil causes vasodilation via smooth muscle

relaxation and thus improves blood flow, leading to
erection.

 About 5 to 20 minutes after insertion of the pellet or

injection, the patient should initiate sexual activity.
Treatment
 Under ideal conditions, an erection can last up to 60
minutes.
 Common adverse effects include a penile burning
sensation and aching.
 Priapism can occur but is less common when the
drug is given by intraurethral pellet.
 Priapism lasting longer than 4 to 6 hours can result
in penile ischemic necrosis and fibrosis
Treatment
 Drugs such as yohimbine have not been
shown to be more efficacious than placebo in
randomized controlled trials, and use of this
drug is not recommended.

 Testosterone therapy may benefit some men

whose erectile dysfunction is due to
hypogonadism or when libido is at issue.
Nonpharmacologic measures
 Constriction rings, which are made of
rubber, slow venous outflow at the base of the
penis and may be useful for men who can
obtain erections but cannot sustain them
 Vacuum tumescent devices increase penile
engorgement by creating a vacuum or
negative pressure, which draws blood into the
penis
Nonpharmacologic measures
 Permanent penile prostheses or implants may be
helpful when erectile dysfunction does not respond
to other treatment modalities
 Penile revascularization surgery (especially
arterial) is relatively experimental and has not been
found to have high success rates

 Traditional Massage – Jelq and Kegel techniques

Surgery
 Surgery usually has one of three goals:
 to implant a device that can cause the penis
to become erect
 to reconstruct arteries to increase flow of
blood to the penis
 to block off veins that allow blood to leak
from the penile tissues