ERECTILE
DYSFUNCTION
Prof. Dr. T. KAMARAJ
M.B.B.S M.D., D.M.R.D., P.G.D.C.G., MCSEPI
Ph.D. (Sexual Medicine)
Ph.D. (Reproductive
Medicine)
“Persistent
inability to attain and/or maintain penile erection sufficient to permit
satisfactory sexual intercourse.”
Erection
Hardness -- Grades
• Penis
is larger, not hard
• Hard,
not enough for penetration
•
Hard
enough for penetration, not
complete
• Completely
hard and rigid
•
Prevalence
From
age 40 –
70yrs
Complete
ED
15%
Moderate
ED
34%
Mild
ED
17%
*Massachusetts Male Ageing Study (MMAS)
Incident
rates increased
with diabetes, treated heart
disease and treated hypertension
• For
diabetes---
50.7 cases/100 person yrs
• Treated
heart disease- 58.3
cases/100 person yrs
•
Treated
hypertension
42.5 cases/100 person yrs
Types
Of Erections
•
Central
•
Refluxogenic
•
Nocturnal
Central
•
Master of
sexual function—Brain
•
Whatever
the stimulus, eventually the brain that assigns an
erotic content to it.
Erectile
Dysfunction vasculogenic
•
Arteriogenic
– athero sclerotic disease
and trauma
•
venogenic
Vascular
•
SMALL
ED (penis) FOLOWED BY BIG ED (heart and brain)
•
BOTH
ARE DUE TO
ENDOTHELIAL DYSFUNCTIONS
•
COMMON
risk factors—age, diabetes
•
Smoking,alcohol,high
cholesterol,
•
Males
•
57% had
subsequently bye pass surgery
•
64% had
heart attack.
Endocrinology
•
Lower
serum testosterone
•
Hyperprolactinemia
•
Hyper
thyroid
•
Hypothyroid
Neurogenic
•
Stroke
•
Encephalitis
•
Temporal
lobe epilepsy
•
Parkinsonism
•
Alzheimer
•
trauma
Drug
Induced
•
Antipsychotic
and anti depressants
•
Clonidine,
methyl dopa
•
Antihypertensive-alpha,beta,calcium
channel blockers
•
Cimitidine
•
Cigarette
smoking
Alcohol
•
Small
quantity may improve –vasodilatation
,suppression
of anxiety and enhance
sexual drive
•
Large
quantity—suppression
of brain causes
poor
performance
• Chronic
alcoholism –increased
estrogen level ,poly neuropathy
Systemic
diseases
•
Diabetes
•
Hypertension
•
Chronic
renal failure
Psychological
causes of sexual dysfunction
Predisposing factors :
•
Restrictive
upbringing
•
Traumatic
early sexual experiences
•
Disturbed
family relationships
•
Early
insecurity in psychosexual role
•
Inadequate
sexual information
•
Socially
withdrawn personality type.
Precipitating
Factors
•
Infidelity
•
Unreasonable
expectation
•
Depression
& anxiety
•
Discord
in general relationship
•
Random
failure
•
Ageing
Maintaining
Factors
•
Performance
anxiety
•
Guilt
•
Loss of
attraction
•
Fear of
intimacy
•
Impaired
self image
•
Psychiatric
disorder.
•
Anticipation
of failure.
•
Inadequate
sexual information.
Diagnostic
Methods
•
CLINICAL
EXAMINATION
•
BASIC
BLOOD TESTS
•
RIGISCAN
•
COLOUR
DOPPLER
Rig
scan – normal sleeping erection
Impaired
sleeping erection
Treatment
•
Oral
drugs, vacuum suction and sex
therapy
•
Intracavernous
injection, MUSE (medicated
urethral system for erection)
•
Surgical
prosthesis
Oral
drugs
•
Sildenafil
VIAGRA PFIZER
•
Tadalafil
CIALIS
LILLY
•
Vardenafil
BAYER
To
relax the corpora smooth Muscle
•
Sinusoidal
enlargement
•
Helicine
artery dilatation
•
Emissary
vein compression
needs removal of
intra
cellular Ca++
via calcium channel,. -------------
requires energy.
•
1 .cAMP
mediated by PGE2.
•
2 .cGMP
mediated by NO.
•
By
inhibiting the degradation
, these energy sources
can
be potentiated.
•
cAMP(active)-----PDE-----5”AMP(inactive)
•
cGMP(active)-----PDE-----5”GMP(inactive)
•
cGMP(active)-----PDE-----cGMP(active)
•
Sildenafil
(PDE5 inhibitor)
•
Papaverine
blocks PDE2----cAMP
•
Since
active metabolite of sildenafil
is excreted in
the
feaces (80%) and urine(13%) 25 mg starting
dose is regimented for >60yrs, hepatic , renal
insufficiancy.
•
Small
amount of PDE5 is found in
vascular
endothelium it can
potentiate the hypotensive
effects
of nitrates.
ED
is predictive factor for IHD
•
Death
or other incidents are more related to physical exertion
sexual activity.
Low
risk
•
Asymptomatic,
less than 3 risk factors
•
Controlled
hypertension
•
Mild ,
stable angina
•
Uncomplicated
post MI (>6-8 weeks)
•
Mild
valvular disease
•
CCF
NYHA class 1
Intermediate
risk
•
More
than 3 risk factor of CAD
•
Moderate
stable angina.
•
Recent
MI or CVA (>2,<6
weeks)
•
CCF
NYHA (class ii)
•
Arrhythmia
of unknown cause
High
Risk
•
Unstable
or refractory angina
•
Uncontrolled
hypertension.
•
CCF
NYHA ( class iii, iv)
and
cardiomyopathy
•
Recent
MI , CVA (less than 2
weeks)
•
High
risk arrythmias
•
Hyper
tropic cardio myopathies
•
Moderate
/ severe valvular disease.
•
Inject
agent directly into the proximal
corpor
•
Apply
gentle local pressure for 2 min to
injection site Sexual stimulation following
injection
•
Comfortable,
unstressful environment
•
In
unsuccessful, repeat attempt at slightly
higher dose in 2-3 days time;
increase
dose until recommended maximum
achieved
•
Inadequate
dose
•
Injection
into wrong location
•
Leakage
of agent prior to injection
•
Inadequate
sexual stimulation
•
Premature
ejaculation
•
Stress
•
Review
injection technique
•
Reassess
dose and increase until a
reasonable therapeutic response is
achieved
•
Evaluate
timing of injection in relation to
sexual stimulation
•
Change
to more potent agent, if at
maximum recommended dose
•
If
pain is a limiting factor, use
combination therapy
•
Involve
partner and reassure
Vascular
Surgeries
Penile
prosthesis
•
Urinate
prior to placement of pellet
•
Advance
device into proximal urethra gently
deliver
vasoactive agent
•
Check
device to see that pellet has dislodged
•
Massage
penis for 2-5 min in standing position with penis slightly elevated
•
Sexual
stimulation with partner
•
If
unsuccessful at initial 500 microgram dose, increase to 1000 microgram
BEHAVIOUR
THERAPY
•
Behaviour
therapy focuses on specific tasks and attention to resistances in the
completion
of those tasks.
•
Technique such
as systematic desensitization in this case would include teaching the
man
relaxation techniques and gradually to have him engage in approximations of the
sexual
behaviors that he has avoided due to his anxiety.
GENE
THERAPY
Previous priapism with
vasoactive drug use
Severe
penile fibrosis
Visual
acuity which limits needle delivery
Monoamine
oxidase inhibitors (would limit use of phennlephrine for potential priapism)
Administration
of highly potent specific vasoactive agents
Delivery
of long term pharmacological agents altering smooth-muscle tone
Applicatoin
of vascular endothelial growth factors directly into the penile circulation
Neural
enhancement agents
Delivery
of gene based erectile dysfunction approaches
Alteration
of ion channels
Upregulation
of guanylate cyclase
Increased
synthesis of nitric oxide