ERECTILE DYSFUNCTION.

(ED)
• TYPES OF ERECTION
• CAUSES OF ED
• INVESTIGATION
• MANAGEMENT
TYPES OF ERECTION.

1.Reflexogenic erection:
• A genital stimulation leads to a reflexogenic erection. Afferent signal
pass via the nerve to the sacral erection center, this sends the efferent
signal via the inferior hypogastric plexus to the penis.
• The reflexogenic erection is largely independent of cortical influences,
as this kind of erection can remain intact after cervical or thoracic
spinal cord injuries.
• Explains why spinal cord injury may not affect erection.
2.Psychogenic erection:
• The cortical processing of sensory, visual, auditory stimuli or fantasies
are the triggers for an erection.
• The cortical centers influence the sacral erection centers, which
cause the erection via activation of the inferior hypogastric plexus.
3.Nocturnal erection:
• Occurs during the REM sleeping phase and can be measured during
sleeping studies (Nocturnal penile tumescence = NPT).
• Typical for the psychogenic impotence is the existence of NPT, in
contrast to serious vascular erectile dysfunction.
• Sympathetic centers mediate nocturnal erections, the existence of
NPT still cannot rule out damage to the sacral parasympathetic
erection center
Physiology of erection.
• Excitatory stimuli from the CNS produce erections through a variety of
neurotransmitters.
• Many neurotransmitters including acetylcholine (ACh) and vasoactive intestinal
polypeptide (VIP) contribute to erectile function.
• The most important neurotransmitter in the corpora cavernosa is nitric oxide (NO).
• Following sexual stimulation, acetyl choline triggers the release of nitric oxide from
endothelial cells, and diffuses into the corporal smooth muscle.
• Nitric oxide (NO) is a gas that acts as a vasodilating agent, inducing smooth
relaxation via (guanylate cyclase) the cGMP system.
• Therefore, NO cause arteries dilate to fill the corpora spongiosum and cavernosa
with blood resulting into an erection.
SO WHAT IS IMPOTENCE OR ERECTILE DYSFUNCTION?

• The persistent inability to achieve or maintain a penile erection sufficient for

sexual intercourse
• ED affects about 10% of men aged 40-70 years, and prevalence increases
with age
• Primary ED (ie, the man has never been able to attain or sustain erections) is
rare and is almost always due to psychologic factors (guilt, fear of intimacy,
depression, severe anxiety) or clinically obvious anatomic abnormalities.
• Most often, ED is secondary (ie, a man who previously could attain and
sustain erections no longer can). Over 80% have an organic etiology.
However, in many men with organic disease, ED leads to secondary
psychologic difficulties that compound the problem.
CAUSES OF ED
• I.M.P.O.T.E.N.C.E
• Inflammatory: Prostatitis, urethritis
• Mechanical: injury (castration).
• Psychological: Depression, performance anxiety, stress, relationship difficulties.
• Occlusive vascular disease: Hypertension, smoking, hyperlipidemia, DM., peripheral vascular
disease Ven: venous occlusion due to anatomical or degenerative changes
• Trauma: Pelvic fracture, SC inj, penile trauma ( penile fracture)
• Endocrine: Hypogonadism, hyperprolactinemia, hypo + hyperthyroidism
• Neurologic: Parkinsons, multiple sclerosis, spina bifida, pelvic surgery, peripheral neuropathy
• Chemical: Anti-HTN, anti-arrhythmics, antidepressants, anxiolytics, anti-androgens,
anticonvulsants, alcohol, marijuana, anti-parkonson drugs, LHRH analogues
• Extra factors: Prostatectomy, old age, Chronic Renal Failure, cirrhosis.
• Most significant social implication of ED is its increasingly recognized
status as an early marker of vascular disease
• ED is a marker of significantly increased risk of CardioVascular
Disease, coronary artery disease (CAD), stroke and all-cause mortality
• Erectile dysfunction commonly occurs in the presence of silent CAD
• Time window between ED onset and a CAD event is usually 2 to 5
years
Risk factors for ED
1.Sedentary lifestyle
2. Obesity
3. Smoking
4. Hypercholesterolemia
5. Metabolic syndrome
6. Diabetes mellitus
(Shared risk factors with CVD)
• Vascular Causes
• 1. CVD
• 2. Atherosclerosis
• 3. Hypertension
• 4. Diabetes
• 5. Hyperlipidemia
• 6. Smoking
• 7. Trauma
• Central nervous causes
1. Parkinson’s , Stroke ,. Tumours spinal disease/injury
Peripheral causes
1. Peripheral neuropathy
2. Diabetes
3. Alcoholism
4. Uraemia
5. Pelvic surgery
• HORMONAL CAUSES
1. Hypogonadism
2. Hyperprolactinaemia
3. Thyroid disease
4. Cushing’s disease
ANATOMICAL CAUSES
1. Peyronie’s disease
2. Micropenis
3. Penile anomalies.
• DRUGS
1. Antihypertensives (Beta blockers, Diuretics)
2. Antidepressants (Tricyclic and SSRIs)
3. Antipsychotics (Phenothiazines, Risperidone)
4. Anticonvulsants (Phenytoin, Carbamazepine)
5. Antihistamines
6. H2 antagonists (Cimetidine, Ranitidine)
7. Recreational drugs (Tobacco and Alcohol)
• ED is more prevalent among patients with atherosclerotic peripheral
vascular disease, hypertension, diabetes mellitus (75% of diabetic
pts), hypercholesterolemia, and heart disease and among men who
smoke cigarettes.
• In the majority of impotent men, erectile impairment has both a
psychological and an organic basis.
• Psychogenic ED: caused exclusively by emotional stress or psychiatric
disease = 10% - 50% of all cases
• Organic ED: Caused exclusively by vascular, neurologic, endocrine, or
other physical disease = 50% - 80.
Diagnosis
Sexual history
• 1. Lifelong: The disturbance has been present since the individual became sexually
• active.
• 2. Acquired: The disturbance began after a period of relatively normal sexual
• function.
• 3. Generalized: Not limited to certain types of stimulation, situations, or partners.
• 4. Situational: Only occurs with certain types of stimulation, situations, or partners.
Specify current severity:
• 1. Mild: Evidence of mild distress over the symptoms in Criterion A.
• 2. Moderate: Evidence of moderate distress over the symptoms in Criterion A.
• 3. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.
Diagnosis

• Some symptoms suggest psychogenic ED, and others suggest organic

disease.
• A psychogenic cause is suggested by the sudden onset of ED or the
presence of ED under some circumstances but complete erection at
other times.
• In contrast, gradual deterioration of erectile quality over months or
years with preservation of libido suggests organic disease.
Psychological Evaluation
PSYCHOGENIC ERECTILE
DYSFUNCTION
• Immediate causes :
1. Performance anxiety
2. Lack of adequate stimulation
3. Relationship conflicts
Remote causes :
1. Childhood sexual trauma
2. Sexual identity issues
3. Unresolved partner or parental attachments
4. Religious or cultural taboos
Chain of events for developing ED
• Precipitating events
↓
• One episode of erectile failure
↓
• Performance anxiety
↓
• Another episode of erectile failure
↓
• More performance anxiety
• Decreased frequency of sexual initiation ↓
• Changes in the sexual equilibrium ↓
• Established pattern of ED with partner.
 Medical
• Inquiries should be made about: DM, HTN, smoking,
hypercholesterolemia, and hyperlipidemia as well as about liver,
renal, vascular, neurologic, psychiatric, and endocrine disease.
Surgical History
• Abdominal, pelvic, perineal
Drug History
Androgenic substances are associated with decreased serum
testosterone levels and decreased libido.( Negative feedback).
LAB
1. Testosterone level (consider peak 8 am and trough 8 pm when
evaluating result, can be 30% difference)
2. Prolactin level
3. TSH
4. Hematology
5. Hepatic and kidney function
6. Hemodynamic evaluation
7. Nerve conduction studies.
INVESTIGATION

• Labaratory
• Recommended: Fasting glucose, lipid profile, hormonal profile
• Thyroid, PSA, prolactin.
• Specialized Evaluations: Primary ED history of surgery/trauma,
complicated endocrine or neuropsychiatric disorder.
• A. Vascular Evaluation B
• . Neurologic Evaluation
• C. Psychologic Evaluation
• D. Hormonal Evaluation
MANAGEMENT
• The Patient centered care outlines six phases:
• 1. Establishing the diagnosis
• 2. Discussing the initial findings, discussing referral, beginning the
education process
• 3. Modifying reversible causes of erectile dysfunction
• 4. Implementing first-line treatment: Psychotherapy, oral erectogenic
agents, vacuum constriction devices
• 5. Implementing second-line treatment: self-injection therapy, transurethral
therapy
• 6. Implementing third-line treatment: implantation of a penile prosthesis
• Pharmacotherapy is useful in treatment of erectile dysfunction of
various causes
• Drugs explored in the treatment of ED are:
• 1. Nitric oxide enhancers/ PDE 5 Inhibitors (phosphodiesterasetype-5)
• 2. Oral prostaglandin
• 3. Alprostadil
• 4. Injectable phentolamine
• 5. Transurethral alprostadil
• Oral phentolamine (Vasomax)
1. Has proved effective as a potency enhancer
2. Useful for men with cardiac problems as sildenafil is
contraindicated for men using organic nitrates
3. Not currently approved by the FDA
• Apomorphine
Being tested as an oral remedy for erectile dysfunction
• Alprostadil
• Injectable and transurethral alprostadil act locally on the penis
• Can produce erections in the absence of sexual stimulation
• Self-injection Of Papaverine And Phentolamine In The Treatment Of
Psychogenic ED:
1. Self-injections four times monthly has a 94% success rate
2. Increase in frequency of intercourse and sexual satisfaction

Yohimbine In Treatment Of Psychogenic Impotence:

1. Yohimbine is a safe treatment for psychogenic ED
2. As effective as sex and marital therapy for restoring satisfactory sexual
functioning
3. Response to yohimbine is unrelated to the cause of impotence
TREATMENT

• Psychosexual therapy.
• Aims to understand and address the underlying psychological issues following
proper evaluation
• Instructs the patient on information regarding sex education, partner
communication and sexual behavioral therapy.
• Oral Medication PDE5 (phosphodiesterasetype-5) inhibitors (eg. Sildenafil=
viagra, tadalafil = cialis, vardenafil = levitra)
• MoA Blocks the breakdown of cGMP, thus maintaining erection .
Sexual stimulation is still needed to initiate erection
Adverse Effects: headache, visual disturbance
Contraindication: pts on nitrates, recent MI, recent stroke, unstable angina
• Androgen Replacement Therapy:
• indicated for hypogonadism.
• Available in oral, IM, patch & gel forms.
• In older men, PSA must be checked before and during treatment.
• Intraurethral pellet therapy: using a synthetic PGE-1 pellet administered
into the urethra.
• Intracavernosal therapy: Alprostadil (synthetic PGE1) enhances cavernosal
smooth muscle relaxation. The needle is inserted at right angles into the
corpus cavernosum on the lateral aspect of the penile shaft.
• Adverse Effects : priapism, pain, hematoma.
• Alternative therapy
• Vacuum erection device: uses vacuum chamber, pump and
constriction device to increase blood flow into the penis and maintain
rigidity via constriction band
• Prosthesis
• Asanteni
PREMATURE EJACULATION ( PE)
• EVOLUTIONARY PERSPECTIVE
• The control of the ejaculatory reflex represents an evolutionary and
cultural advance for human sexuality
• In the primates the rapid deposition of semen protects the animal
from extended exposure to predators
• Men have learnt to control ejaculation to enhance their partner’s
enjoyment
• PE has a profound effect on relational and psychological health
DEFINITION OF PE
PE : “Persistent or recurrent ejaculation with minimal sexual stimulation
before, on, or shortly after penetration and before the person wishes it”
“The inability to control ejaculation sufficiently for both partners to enjoy
sexual interaction” and
“an inability to delay ejaculation sufficiently to enjoy lovemaking”
EFFECTS
1. Reduced sexual satisfaction
2. Personal distress
3. Partner distress
4. Interpersonal or relationship distress
RISK FACTORS

1. Older age( >42)

2. current anxiety and depression
3. Financial debt
MANAGEMENT
• Before beginning treatment it is essential to discuss the patient's
expectations thoroughly
• It is important to treat ED first if present
• In lifelong PE:
• 1. Behavioural techniques are not recommended for firstline
treatment
• 2. They are time-intensive
• 3. Require the support of a partner and can be difficult to perform
• 4. Long-term outcomes of behavioural techniques for PE are unknown
BEHAVIORAL
• Behavioural strategies mainly include:
• 1. The ‘stop-start’ programme developed by Semans
• 2. The ‘squeeze’ technique proposed by Masters and Johnson

• In the ‘stop-start’ programme, the partner stimulates the

penis until the patient feels the urge to ejaculate
At this point, he instructs his partner to stop, waits for the sensation to
pass and then stimulation is resumed
• The ‘squeeze’ technique is similar but the partner applies manual
pressure to the glans just before ejaculation until the patient loses his
urge
• Both these procedures are typically applied in a cycle of three pauses
before proceeding to orgasm
PHARMACOLOGICAL THERAPY

• DAPOXETINE:
• Dapoxetine hydrochloride is a short-acting SSRI
• It is approved for on-demand treatment of PE
• In RCTs dapoxetine 30 mg or 60 mg 1-2 hours before
intercourse was effective from the first dose on:
• 1. increased ejaculatory control
• 2. Decreased distress
• 3. Increased satisfaction
• Paroxetine was found to be superior to fluoxetine, clomipramine
and sertraline
. Efficacy of clomipramine was not significantly different from
• fluoxetine and sertraline
• TRAMADOL:
• Tramadol has shown a moderate beneficial effect with a similar
efficacy as dapoxetine
• Efficacy and tolerability of tramadol would have to be confirmed in
more patients and longer-term
• Lidocaine-prilocaine cream (5%) is applied for 20-30 minutes prior to
intercourse

• END