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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
Peripheral pathways

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

Sympa, - NE release
Parasym, + NO & Ach release
Somatic, +Ach release
Neuroanatomy of penile erection
Supraspinal pathways
[ hypothalamus, limbic system and cerebral cortex]

dopaminergic & adrenergic recepters promotes sexual
drive

serotonin recepters inhibits sexual
drive
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

Drug Therapy : Orally Administration


Yohimbine
Phentolamine
Apomorphine
Sildenafil
Treatments of Erectile Dysfunction
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
Drug Therapy : Orally Administration
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
Treatments of Erectile Dysfunction
Comparision of Treatments
Oral
Medication
Intracarvenous
Injection
Vacuum
Device
HRT Surgery
MUSE
Use :
AUA guildline :
1st Line(Now)
effective in
definable &
undefinable cause
Injection
alternatives
Oldest
Treatment
Andropause Last choice
or Arterial
revascularize
and venous
ligament in
younger pt.
Or prosthetic
penile
implantation
AUA guildline :
1st Line(Old)
effective in
definable &
undefinable cause
Comparision of Treatments
Oral
Medication
Intracarvenous
Injection
Vacuum
Device
HRT Surgery
MUSE
Agents : Sildenafil
Yohimbine
Phentolamine
Apomorphine
Alprostadil - Testosterone - Alprostadil
Papaverine
Phentolamine
Effective : Silden. 65-93%
Others is lower
Monotherapy 70-74%
Combined 90 %
40-65% 90 % up 61 % -
Comparision of Treatments
Oral
Medication
Intracarvenous
Injection
Vacuum
Device
HRT Surgery
MUSE
Advantage Comfortable,
Non invasive
Less
Invasive
than inj.
and
no death
evidence
Maintain
BMD
Improve
sex fn.,mood
& emotion
Increase
muscle
strength
High effective,
no death evidence
High effective High effective
Comparision of Treatments
Oral
Medication
Intracarvenous
Injection
Vacuum
Device
HRT Surgery
MUSE
Dis
Advantage
Have Death
evidence data

lower effective
in some case
as DM

Penile pain
urethral
bleeding

More
expensive
than
injection
Use only
in
andropause
long term :
Anemia,
increase
bl. Viscosity
CI in
Prostate CA
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%)
Patients and
Partners
satisfation
less than inj.
Expensive,
uncomfort.
Comparision of Drug Therapy
Sildenafil Alprostadil Papaverine Phentolamine
Apo
morphine
MUSE Agents
Phosphodiesterase
inhibitors
: increase NO
: increase cGMP
Like
Alprostadil
Phosphodies-
terase inhibitors
: Inhibit smooth
muscle
contraction
Alpha 1,2-
adrenergic
receptor
blocking
:Dilate arterial
vessel
:inh. Symp.

Stimulate
Brain
dopaminergic
mechanism
that effect
erection

Syn. PG. E
alpha-adrenagic
blocking agent
:Carvenous smooth
muscle relax
:Arterioles smooth
muscle relax
Mechanism
65-93%
avg. 75 %

Monotherapy 70-74%
Combined 90 %
40-65% 40-60 % 65% Effective 40-45 %
Comparision of Drug Therapy
Sildenafil Alprostadil Papaverine Phentolamine
Apo
morphine
MUSE Agents
oral Intraurethral
suppository
by
applicator
intracarvenous
injection

oral or
Intracarvenous
injection


sublingual

intracarvenous
injection
Admin.
route
25-100 mg 5-20 mcg 50-1000 mcg Single 10-60mg
Combine 3-5mg
(Papa+Phento
or
Papa+Alpro)
- usual dose 40-80 mg
Comparision of Drug Therapy
Sildenafil Alprostadil Papaverine Phentolamine
Apo
morphine
MUSE Agents
Definable and
undefinable
such as DM,
Olderly with HT
spinal cord injury
depression
Alprostadil
injection
alternative
like alprostadil

like
alprostadil


Psychogenic
Type

Definable and
undefinable
such as DM,
Olderly with HT
spinal cord injury
depression
Use in
case
- pt. Use nitrate,
Heart Disease,
Renal&Hepatic
Impairments
Predisposition to
priapism eg
anemia,leukemia
Anatomical
deformation of penis
Ab. Penile
Anatomy
Urethritis
risk of
priapism
Heart Disease
Contra
indication
NA.data NA.data
Comparision of Drug Therapy
Sildenafil Alprostadil Papaverine Phentolamine
Apo
morphine
MUSE Agents
16% Headache
10% Flushing
7% Dyspepsia
3% Visual Disturb
Papa + Phentolamine
0.4 % Penile Pain
8 % Priapism and
fibrosis

Nausea
Vomit
Yawn

35 % Penile Pain
2% Priasism or
Fibrosis
ADR
Have Death
evidences
only Alprostadil has approved in USA

Phentolamine has carcinogenic potential effect in rat
Dis
Advantage
30 % Penile
Pain
5% Urethral
bleeding
6% Drowsiness
sweating,Hypot.
The End