Group 3

43076140

43076173

43076199

Erectile Dysfunction
Meaning :

The inability to achieve and maintain a penile erection satisfactory for sexual intercourse (Does not include ejaculation disorders)

History
The first description of erectile dysfunction, about 2000 B.C., was set down on Egyptian. Hippocrates concluded that too much horseback riding was the cause of disease. Aristotle, air influx into penis.

Anatomy of the penis

Tunica Albuginea Corpora Cavernosa -- Sinusoid Corpus Spongiosum -- Sinusoid Glans Penis Artrial supply Venous drainage Nerve

Arterial Supply
Internal iliac artery internal pudendal artery [main]
Dorsal artery Bulbourethral artery Cavenous artery

External iliac, Obturator, vesical and femoral artery. [accessory]

Venous drainage
Emissary veins, transformed from peripheral sinusoids Deep dorsal vein [main] Bulbourethral vein, Cavernous vein [ accessory]

Mechanism of erection :
Dilatation arterioles&arteries expanding of sinusoids compression of subtunical venular plexuses Emissary veins enclosed increasing of intracavernous pressure to raise the penis

Mechanism of Detumescence
Transient intracorporeal pressure increase

[smooth muscle contraction]

Pressure decrease slowly [slow reopening of the venous channels]

Pressure decrease fast [venous outflow capacity is fully restored]

Neuroanatomy of penile erection

Sympa, - NE release Parasym, + NO & Ach release Somatic, +Ach release

Peripheral pathways

autonomic [ C. Cavenosa & C. Spongiosum] somatic [ Glans Penis & C. Spongiosum]

Neuroanatomy of penile erection

Supraspinal pathways
[ hypothalamus, limbic system and cerebral cortex]
dopaminergic & adrenergic recepters promotes sexual drive
inhibits sexual drive

serotonin recepters

Classification of Erectile Dysfunction

Psycogenic Neurogenic Endocrinologic Arteriogenic Cavernosal (Venogenic) Drug-induced Erectile dysfunction associated with aging, systemic disease & others

Cause of Erectile Dysfunction

Alcohol Abuse Anxiety or Depression Coronary Artery Disease Diabetes Hormonal Abnormalities Hypertension Peripheral Vascular Disease Renal or Hepatic Failure Anemia Smoking Surgery(Pelvic or Perineal) Trauma to pelvic or spine Medication : AntiHT, Antidepressant, Antiarrhythmic,Antipsychotics Diuretics, Anticonvulsants, Antiandrogen, Narcotics

Treatments of
Erectile Dysfunction

Treatments of Erectile Dysfunction

Drug Therapy : Orally Administration Intracarvernous Injection MUSE or Intraurethral Suppository Vacuum Devices Horrmone Replacement Therapy Surgery Others

Treatments of Erectile Dysfunction

Drug Therapy : Orally Administration

Yohimbine Phentolamine Apomorphine Sildenafil

Treatments of Erectile Dysfunction

Drug Therapy : Orally Administration

Yohimbine
alpha 2 -antagonist

Side effect : anxiety, , tachycardia,

arterial pressure

Treatments of Erectile Dysfunction

Drug Therapy : Orally Administration

Phentolamine

vasoactive Drug
Side effect : orthostatic hypotension,

tachycardia

Treatments of Erectile Dysfunction

Drug Therapy : Orally Administration

Apomorphine (Sublingual)
Stimulate brain dopaminergic mechanism
Side effect : nausea, vomit, yawn

Treatments of Erectile Dysfunction

Drug Therapy : Orally Administration

Sildenafil
Phosphodiesterase Inhibitor
Side effect : headache, flushing, dyspepsia

visual disturbance
Contraindication : co-administration with nitrate MI, CHF

Treatments of Erectile Dysfunction

Intracavernous Injection

vasoactive agents corpora cavernosa penis erection

Vasoactive Agent Papaverine Phentolamine Alprostadil

Treatments of Erectile Dysfunction

Intracavernous Injection

Side effect : priapism, small nodule, subcutaneous hemorrhage, pain, trauma, scar *combination therapy monotherapy * oral alpha-blocker (Doxazosin)

Treatments of Erectile Dysfunction

Intraurethral suppositories

MUSE (Medicated urethral system for erection)

alprostadil urethra 8-10 :

Treatments of Erectile Dysfunction

Vacuum Devices

Pump cylinder penis elastic band

Treatments of Erectile Dysfunction

Hormone Replacement Therapy :

Testosterone sexual function

Treatments of Erectile Dysfunction

Surgery
- Paired rod

corpora cavernosa
- repair arteries

obstruction

Treatments of Erectile Dysfunction

Others
: Alprostadil gel glans penis penile rigidity

Comparision of Treatments
Oral Medication Intracarvenous Injection MUSE Vacuum Device HRT Surgery

Use :

AUA guildline :
1st Line(Now)

AUA guildline :
1st Line(Old)

Injection
alternatives

Oldest
Treatment

Andropause Last choice

or Arterial revascularize and venous ligament in younger pt. Or prosthetic penile implantation

effective in effective in definable & definable & undefinable cause undefinable cause

Comparision of Treatments
Oral Medication Intracarvenous Injection MUSE Vacuum Device HRT Surgery

Agents :

Sildenafil
Yohimbine Phentolamine Apomorphine

Alprostadil
Papaverine Phentolamine

Alprostadil

Testosterone

Effective : Silden. 65-93% Monotherapy 70-74% Others is lower Combined 90 %

40-65%

90 % up

61 %

Comparision of Treatments
Oral Medication Intracarvenous Injection MUSE Vacuum Device HRT Surgery

Advantage

Comfortable,
Non invasive

High effective,
no death evidence

Less
Invasive than inj. and no death evidence

High effective Maintain

BMD Improve sex fn.,mood & emotion Increase muscle strength

High effective

Comparision of Treatments
Oral Medication Intracarvenous Injection MUSE Vacuum Device HRT Surgery

Dis
Advantage

Have Death evidence data

lower effective in some case as DM

50 % reject the
long term treatment cause : decrease in response less interest in sex problem of self inj. Penile pain(11%) priapism (0.5-5%)

Penile pain Patients and

urethral bleeding More expensive than Partners

Use only
in

Expensive,
uncomfort.

satisfation andropause less than inj. long term : Anemia, increase bl. Viscosity CI in Prostate CA

injection

Comparision of Drug Therapy

Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine Apo morphine

Mechanism Phosphodiesterase inhibitors

Phosphodies- Alpha 1,2Stimulate terase inhibitors alpha-adrenagic Alprostadil adrenergic Brain : increase NO : Inhibit smooth blocking agent receptor dopaminergic : increase cGMP muscle :Carvenous smooth blocking mechanism contraction muscle relax :Dilate arterial that effect Syn. PG. E Like
:Arterioles smooth muscle relax 65-93% avg. 75 % 40-65% 40-60 % vessel :inh. Symp. 40-45 % 65% erection

Effective

Monotherapy 70-74% Combined 90 %

Comparision of Drug Therapy

Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine Apo morphine

Admin.
route

oral

intracarvenous
injection

Intraurethral intracarvenous
suppository by applicator injection

oral or
Intracarvenous injection 40-80 mg

sublingual

usual dose

25-100 mg

5-20 mcg

50-1000 mcg Single 10-60mg Combine 3-5mg (Papa+Phento or Papa+Alpro)

Comparision of Drug Therapy

Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine Apo morphine

Use in
case

Definable and
undefinable such as DM, Olderly with HT spinal cord injury depression - pt. Use nitrate, Heart Disease, Renal&Hepatic Impairments

Definable and
undefinable such as DM, Olderly with HT spinal cord injury depression Predisposition to priapism eg anemia,leukemia Anatomical deformation of penis

Alprostadil like alprostadil

injection alternative

like
alprostadil

Psychogenic
Type

Contra indication

Ab. Penile Anatomy Urethritis risk of priapism

Heart Disease

NA.data

NA.data

Comparision of Drug Therapy

Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine Apo morphine

ADR

16% Headache
10% Flushing 7% Dyspepsia 3% Visual Disturb

35 % Penile Pain 30 % Penile

2% Priasism or Fibrosis Pain 5% Urethral bleeding 6% Drowsiness sweating,Hypot.

Papa + Phentolamine
0.4 % Penile Pain 8% Priapism and fibrosis

Nausea
Vomit Yawn

Dis Advantage

Have Death
evidences

only Alprostadil has approved in USA

Phentolamine has carcinogenic potential effect in rat

The End