Penis Structural Importance in order to Maintain

Erection Physiology

TUTOR 24:
Ainun Alifah Rizky (130110180235)
Anis Rohmasari (130110180269)
Annisa Ramadhanti (130110180128)
Farruqi Wirawan (130110180152)
Indrinovie Utama (130110180209)
Haifa Tuffahati (130110180244)
Jihan Ananda Salsabila (130110180045)
Muhammad Kahfi Erbi Putra (130110180228)
Satya Nasti Parodharma (130110180185)
Tatyana Millenia (130110180202)
Timoty Krisna Sukoco (130110180226)
Ulfa Afina (130110180080)

UNIVERSITAS PADJADJARAN
FAKULTAS KEDOKTERAN
JATINANGOR
2020
Anatomy of Penis
The penis contains the urethra and also a passage for semen ejaculation and urine
excretion. Penis shape is cylindrical and consists of a body, glans penis, and a root. The body of
the penis consists of three cylindrical tissue masses, each surrounded by a fibrous tissue called
the​ tunica albuginea​.
Two dorsolateral masses are termed the corpora cavernosa penis. Meanwhile, the smaller
midventral mass is the corpus spongiosum penis, which contains the spongy urethra and
maintains it open during ejaculation. These three masses are enclosed by skin and subcutaneous
layers. Erectile tissue is composed of several blood sinuses (vascular spaces) which are lined by
endothelial cells and surrounded by smooth muscle and elastic connective tissue.
In the distal end of the ​corpus spongiosum is a region called glans penis, which is slightly
enlarged and acorn-shaped. This is where the distal urethra enlarges within the glans penis and
forms an opening, called the external urethral orifice. In an uncircumcised penis, there is a
loosely fitting prepuce or foreskin covering the glans.
The root of the penis is the portion of penis that is attached to the body directly. It
consists of the bulb of the penis, continuation of the base of the corpus spongiosum and the crura
of the penis. The bulb of the penis is attached to the
perineum deep muscles and enclosed by the
bulbospongiosus muscle. This muscle aids
ejaculation.

Two ligaments support the penis and are

continuous with the fascia of the penis. The
fundiform ligament arises from the inferior part of
the linea alba and the suspensory ligament arises
from the pubic symphysis.

Arterial supply of penis is supplied by deep, dorsal,

and bulbar arteries of the penis, branches of the
internal pudendal arteries. Numerous veins drain
blood to the internal pudendal and internal iliac
veins. Innervation of penis supplied by autonomic
and somatic nerves. Stimulation of
parasympathetic nerves leads to filling the spongy
erectile tissue with blood, which is caused by dilation of arterioles and constriction of veins. In
results, they increase blood flow into the penis and obstruct outflow. The penis becomes
engorged and erects.
Histology of Penis
The penis is made up of the penile urethra and three columns of erectile tissue : two
corpora cavernosa lie next to each other on the dorsal side and one corpus spongiosum lies
between them on the ventral side which also surrounds the urethra. At its end the corpus
spongiosum expands, forming the glans. Most of the penile urethra is lined with pseudostratified
columnar epithelium except in the glans, it becomes stratified squamous epithelium continuous
combine with the thin epidermis covering the glans surface. Along the length of the penile
urethra or spongy urethra, urethral glands are founded. In uncircumcised men the glans is
covered by the prepuce or foreskin, a retractable fold of thin skin with sebaceous glands on the
internal surface. The epithelium of the glans is keratinized squamous epithelium, but after
circumcision the epithelium becomes nonkeratinized. The lamina propria consists of a 1- to
3-mm layer of loose connective tissue containing small vessels, lymphatics, nerves , and sporadic
Vater-Pacini corpuscles.
 The corpora cavernosa are each surrounded by a dense fibroelastic layer called the tunica
albuginea. All three erectile tissues consist of many venous cavernous spaces lined with
endothelium and separated by trabeculae with smooth muscle and connective tissue continuous
with the surrounding tunic.
 The central arteries in the branches of the cavernous bodies form nourishing arterioles
and small coiling helicine arteries, which lead to the cavernous vascular space for erectile tissue.
The arteriovenous shunt lies between the central artery and the dorsal vein. Penile erection,
which involves blood filling the cavities of the caverns in three parts of the erectile tissue.
Triggered by external stimuli from the central nervous system, erections are controlled by
autonomic nerves in the walls of these blood vessels. Parasympathetic nerve stimulation relaxes
the smooth muscle of the trabeculae and expands the spiral arteries, thereby increasing blood
flow and filling the cavernous spaces. This enlarges the cavernous bodies and causes them to
compress the dorsal veins against the dense tunica albuginea, thus blocking venous outflow and
causing tumescence and stiffness in the erectile tissue. Since the start of ejaculation, sympathetic
stimulation causes the helical arteries and trabecular muscles to contract, reducing blood flow to
the cavity. reduces pressure in the cavity, and allows the vein to draw most of the blood from the
erectile tissue.

Raising acetylcholine from the parasympathetic nerves causes vascular endothelial cells
from the vane arteries and cavernous tissue to release nitric oxide (NO) at an early stage. NO
diffuses into the surrounding smooth muscle cells and activates the guanylate cyclase to produce
cyclic gMP, which causes these cells to relax and increases blood flow to the erection. Diabetes,
anxiety, vascular disease, or nerve damage during prostatectomy can cause erectile dysfunction
or impotence. The drug sildenafil can overcome this problem by inhibiting phosphodiesterase,
which can reduce cyclic GMP in spirochetal artery smooth muscle cells and erectile tissue.
Higher levels of cgMP further promote relaxation of these cells and increase the function of
nerves that produce or maintain an erection.

Physiology of Erection
Erection or hardening of the normally flaccid penis is a part of male sex act, engorgement of the
penis with blood makes the penis erect and it will permit its entry into the vagina. The penis
consists mostly of ​erectile tissue​ which is made up of three columns or cords of sponge-like
vascular spaces extending the length of the organ.

When there’s no sexual excitation, the erectile tissues contain little blood because the
constriction of arterioles that supply these vascular chambers. This makes the penis remains
small and flaccid. When there’s sexual arousal, these arterioles reflexly dilate and the erectile
tissue fills with blood, making the penis to enlarge both in length and in width, also become
more rigid. This engorgement and expansion of the vascular spaces compress the veins that drain
the erectile tissue which reduces venous outflow and thereby contributing even further to the
buildup of blood, also called ​vasocongestion. T​ hese vascular responses will transform the penis
into a hardened and elongated organ that is capable of penetrating the vagina.
An erection may be produced due to psychogenic or somatogenic stimuli. Psychogenic stimuli
cause stimulation of efferent nerves to the penis via the limbic system from sensory where
somatogenic stimuli cause this same stimulation but through sensation such as touching the
penis.
Phases of Erection
Phase 0 - Flaccid Phase
In this Phase, the dominant sympathetic influences make the terminal arterioles and
cavernosal smooth muscle contracted. This will limit the blood flow to minimal level, only for
nutritional purpose. There are also free venous outflow of the penis.
Phase 1 - Latent (Filling) Phase
This Phase begin to occur when sexual stimulation exists. In this phase, parasympathetic
stimulation dominates. The blood flow through internal pudendal arteries and cavernous arteries
begin to increase. Dilation of Cavernosal and helicine arteries also reduce the peripheral
resistance in penis. Even though there are increased blood flow and decreased peripheral
resistance, the intracavernosal pressure still remain unchanged in this phase. As the final result,
the penis begin to elongate.
Phase 2 - Tumescence Phase
In this Phase, there is a rapid increase in intracavernosal pressure due to blood influx. The
trabecular smooth muscle also relaxes, which markedly enhances the compliance of the caverna,
causing penile engorgement and erection. The arterial flow rate decrease in the end of this phase.
Phase 3 - Full Erection Phase
The expansion of relaxed trabecular smooth muscle alongside with increased blood
volume will compress subtunical venules against tunica albuginea. This venocclusive mechanism
will reduce the venous outflow from the penis, and also contributes to the increase in
intracavernosal pressure until close to systolic pressure. The arterial flow to penis is reduced, but
still higher than the flow in flaccid phase.
Phase 4 - Skeletal or Rigid Erection Phase
Because of voluntary and also reflexogenic contraction of the ischiocavernosus and
bulbocavernosus muscle, the intracavernous pressure in this phase is increased, even higher than
the systolic pressure. This results in a rigid erection. There is no flow through the cavernous
artery at this stage. But, because of the venocclusive mechanism, blood also can’t get out from
the penis, so that the erection can be maintained.
Phase 5 - Transition Phase
Increased activity in the sympathetic nervous system leads to increased tone in the
helicine arteries and contraction of the trabecular smooth muscle. Arterial flow is resumed at a
low level, and the venocclusive mechanism is still activated.
Phase 6 - Initial Detumescence Phase
There is a moderate decline of intracavernous pressure, indicating a reopening of the
venous outflow channels and a decreasing arterial flow.
Phase 7 - Fast Detumescence Phase
The intracavernous pressure declines rapidly, the venocclusive mechanism becomes
inactivated, arterial flow decreases to its prestimulation level, and the penis returns to the flaccid
state.
ANATOMY, HISTOLOGY, AND PHYSIOLOGY RELATED TO ERECTION

What happened in the erection problem in ​sexual dysfunction?​

In men, The normal sexual response involves three processes: ​erection, emission,
and ejaculation. S​ exual dysfunction is the impairment of all this processes. ​Impairment can
be caused by a number of physiologic and psychologic factors.
The causes of organic sexual dysfunction include:
(1) vascular, endocrine, and neurologic disorders;
(2) chronic disease, including renal failure and diabetes mellitus;
(3) penile diseases and penile trauma; and
(4) iatrogenic factors, such as surgery and pharmacologic therapies. Most of these
disorders cause erectile dysfunction.

Vascular disorders can prevent erection​. Some arterial diseases diminish or interrupt
circulation to the penis. This ​prevents engorgement of erectile tissues in the corpora
cavernosa and corpus spongiosum. Rarely, excessive venous drainage of the corpora cavernosa
prevents erection.
Neurologic disorders can interfere with the important sympathetic, parasympathetic, and
CNS mechanisms required for erection, emission, and ejaculation.
Priapism causes fibrosis of trabeculae (erectile tissues) within the corpora
cavernosa, making erection difficult. The penile curvature caused by Peyronie disease does not
make erection impossible but may make it extremely painful and intercourse impossible. Penile
trauma can damage the erectile tissue, disrupt the posterior urethra, and disrupt the pudendal
arteries or nerves.

Other factors/etiologies may cause erection problem in ​sexual dysfunction

Endocrine disorders that ​reduce testosterone production ​affect sexual function and
libido. The reduction may be caused by inadequate secretion of the gonadotropins caused by
pituitary dysfunction or hyperprolactinemia. Testicular atrophy from any cause also decreases
testosterone levels and contributes to sexual dysfunction.
Emotional and psychological response to chronic illness​, such as anxiety, depression,
and loss of self-esteem, can affect sexual functioning. In other chronic conditions, sexual
dysfunction is associated with low energy levels and loss of libido. The pathophysiologic
mechanisms responsible for such changes are not known.
Iatrogenic factors, including drugs and surgery, have a significant effect on erectile
function. The following surgical procedures carry the risk of erectile dysfunction: radical pelvic
surgery; radical prostatectomy; transurethral, suprapubic, or simple retropubic prostatectomy;
and aortoiliac surgery. Erectile dysfunction is caused by the severing of small nerve branches
that are essential for erection. Aortoiliac surgery, retroperitoneal lymphadenectomy, and
sympathectomy cause the loss of ejaculation capacity in some individuals.
Components of penis and the function during erection

Corpora cavernosa Supports the corpus spongiosum and glans

Tunica albuginea - Contains and protects erectile tissue

- Giving rigidity to Corpora Cavernous
- Participate on veno occlusive mechanism

Smooth muscle Regulates inflow and outflow on sinusoids

Musculus Ischiocavernosus - Pumps blood to harden erection

- Provides additional rigidity when erection
(supportive)

Musculus Bulbocavernosus Helps ejection of sperm during ejaculation

Apply pressure and constrict the lumen of the

Corpus Spongiosum urethra to helps sperm ejection

Penis Glans
- Works as a cushion during copulation
- Provides sensory input for help the erection
process
 Correlation between Vascularization of penis and Erection Physiologic

The penis receives blood flow from the internal pudendal artery. Furthermore, this artery
branches into the cavernous artery or central artery, the dorsal artery of the penis and the
bulbo-urethral artery. The central artery enters the cavernous cavity and then branches to become
arteriole helicin, which then arteriole will fill blood into the sinusoids.

Venous blood from the sinusoid cavity is drained through the plexus located under the
tunica albuginea. This plexus combines to form the emisaria venule and then penetrates the
tunica albuginea to drain blood to the dorsal vein of the penis.

Sexual stimulation causes an increase in parasympathetic nerve activity which results in

dilatation of the arterioles and venule constriction so that inflow (blood flow to the corpora)
increase while the outflow (blood flow leaving the corpora) decrease. Causes increase in blood
volume and the pressure on the corpora increase so that the penis becomes erect.

Correlation between Innervation of penis and Erection Physiologic

ERECTION REFLEX

The erection reflex is a spinal reflex triggered by stimulation of highly sensitive

mechanoreceptors located in the glans penis, which caps the tip of the penis. An
erection-generating center lies in the lower spinal cord. Tactile stimulation of the glans reflexly
triggers, by means of this center, increased parasympathetic vasodilator activity and decreased
sympathetic vasoconstrictor activity to the penile arterioles. The result is rapid, pronounced
vasodilation of these arterioles and an ensuing erection.
As long as this spinal reflex arc remains intact, erection is possible even in men paralyzed
by a higher spinal-cord injury. This parasympathetically induced vasodilation is the major
instance of direct parasympathetic control over blood vessel diameter in the body.
Parasympathetic stimulation brings about
relaxation of penile arteriolar smooth muscle by nitric oxide, which causes arteriolar vasodilation
in response to local tissue changes elsewhere in the body. Arterioles are typically supplied only
by sympathetic nerves, with increased sympathetic activity producing vasoconstriction and
decreased sympathetic activity resulting in vasodilation. Concurrent parasympathetic stimulation
and sympathetic inhibition of penile arterioles accomplish vasodilation more rapidly and in
greater magnitude than is possible in other arterioles supplied only by sympathetic nerves.
Through this efficient means of rapidly increasing blood flow into the penis, the penis can
become completely erect in as little as 5 seconds. At the same time, parasympathetic impulses
promote secretion of lubricating mucus from the bulbourethral glands and t he urethral glands in
preparation for coitus.
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