1. ERECTILE DYSFUNCTION By
Dr. Umar M.T

2. Outline Introduction Epidemiology Anatomy and Physiology of erection
Pathophysiology of erectile dysfunction
Classification
Causes
Clinical features
Investigations
Management
Prognosis
Conclusion

3. Introduction
Definition: Erectile dysfunction (ED) is defined as the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance.
NIH Consensus Development Conference in recommended the use of erectile dysfunction as the preferred term to impotence.
ED though not life threatening condition, has the potential to spoil relationships, and break marriages.
It has a significant impact on the quality of pts and their partners.

4. Introduction cont’d Phases of normal male sexual function Libido
Erection
Ejaculation
Detumiscence

5. Introduction cont’d
“Man survives earthquakes, experiences the horrors of illness, and all the tortures of soul. But the most tormenting tragedy of all time is, and will be, the tragedy of bedroom.” by Leo Tolstoy

6. Epidemiology
It was estimated in 1995, that over 152 million men worldwide experienced ED.
The prevalence is predicted to be approximately 322 million in 2025 worldwide.
ED generally affects 10% of men and more than 50% of men by age 70years
The severity, prevalence and incidence of ED increase with age

7. Epidemiology cont’d
Erectile dysfunction (ED) is the commonest form of sexual dysfunction and prevalence rates in diabetes vary from 35 to 75%.
Olarinoye et al, found 74% of patients with type 2 DM had some degree of erectile dysfunction, whilst the prevalence of moderate to severe forms was 51%
Study done in Benin city by Unadike, Eregie, and Ohwovoriole found 58% prevalence of sexual dysfunction among diabetic pts.

8. Anatomy of erection

10. Physiology of erection
Penile erection is a complex process
1. Psychological
2. Neural
3. Vascular
4. Hormonal factors.
5. Molecular/cellular level

11. Physiology of erection cont’d
Nocturnal erection
Seen during REM sleep
Mediated by pontine reticular formation and amygdalae
Androgens have modulating role

12. Molecular physiology of erection

13. Pathophysiology of ED
ED occurs one when there is one or more of the following
Neurological damage
Arterial insufficiency
Venous incompetence
Androgen deficiency
Penile abnormalities
Decrease libido

14. Classification of erectile dysfunction
1. Primary
2. Secondary
Secondary
Psychogenic
Organic
mixed

15. Causes of ED
Vascular
Neurogenic
Endocrine
Psychogenic
Drugs

16. Vascular causes of ED Hypertension Smoking Diabetes Dyslipidaemia
Peripheral artery disease
Peyronie’s disease
Priapism

17. Neurologic causes of ED
Peripheral neuropathies e.g Alcohol, Diabetes, HIV, CKD
Lesions of medial preoptic nucleus, paraventicular nucleus, hippocampus
Multiple sclerosis
Parkinson's dx
Disc prolapse
Spinal trauma
Spina bifida
Pelvic surgery/radiotherapy

18. Endocrine and Psychogenic causes of ED
Hypogonadism
Primary
Secondary
Hyperprolactinaemia
Thyroid dysfunction
Cushing’s syndrome
Andropause
Psychogenic
Anxiety
Depression
Psychosis
Loss of attraction to partner
Relationship difficulties
Stress

19. Drugs associated with ED
Antihypertensives
Thiazides
B blockers
Centrally acting drugs
Antidepressants
TCA
MAO inhibitors
SSRI
Anticholinergics
Atropine
Antipsychotics
Phenothiazines
Anxiolytics
Benzodiazepines
Psychotropic drugs
Alcohol
Opiates
Amphetamines
Cocaine

20. Causes of ED Vascular Diabetes Medication
Pelvic Surgery, Radiation or Trauma
Medication
Vascular
Vascular
Neurological Causes
Endocrine Problems
Other
Diabetes
4. Goldstein I. Male sexual circuitry. Working Group for the study of central mechanisms in erectile dysfunction. Sci Am., Aug 2000;283(2):70-75

21. Clinical features History Duration of ED Medical Hx
Insidious or sudden onset
Early morning/nocturnal erection
Normal or decreased libido
Pain or curvature of erection
( Peyronie’s dx)
Medical Hx
Chronic systemic dxs
Surgical Hx
Drug Hx
Social Hx

22. Clinical features cont’d
Examination
Vascular - BP, Dorsalis pedis pulsation
Neurological – Bulbocarvanosus reflex
Endocrine
-Secondary sexual xtics
-Neck examination
- Testicular size
Penile examination

23. Clinical features cont’d
Severity of ED
International Index of Erectile Function (IIEF) questionnaire
Erectile Dysfunction Index of Treatment Satisfaction (EDITS)
Arizona Sexual Experience Scale (ASEX)
Androgen Deficiency in Aging Males (ADAM) questionnaire

24. Differentiating psychogenic from organic causes of ED
Sudden onset
Occasional
Waking and nocturnal erections
Normal erection with masturbation
Relationship problems
Anxiety/depression
Organic
Gradual onset
Most times
Absent waking and nocturnal erections
No erection with masturbation
No relationship problems
Features of organic disorders

25. Investigations Blood glucose Lipid profile Serum testosterone, LH, FSH
Prolactin
TFT
EUCr
FBC
PSA
Postage stamp test
Nocturnal penile tumescence (RigiScan plus device)
Intracarvanosal injection of vasodialator
Penile doppler sonography
Penile brachial pressure index
Carvanosography
Angiography

26. Postage stamp test

27. Nocturnal penile tumescence (RigiScan plus device)

28. Penile Doppler Sonography

29. Carvanosography

30. Screen all men with DM for ED
Screen for hypogonadism (Testosterone level)
PDE-5 inhibitors2
Urology Referral
Consider Testosterone replacement3
PDE-5 inhibitor
Modify risk factors1
Present
None
Normal
Low
Contraindication or ED persists
ED Present

31. Management Psychosexual therapy Medications Vacuum devices
Prosthesis/Surgery

32. Psychosexual therapy Usually for those with psychogenic ED e.g
Depression
Anxiety
Relationship problems

33. Medications Treat the underlying cause of ED if possible
b) Drugs for ED
1. Oral agents
Phosphodiesterase type 5 inhibitors
Centrally acting (Apomorphine and Dopamine)
2. Intra-cavernosal
Prostaglandin E1 Alprostadil
3. Intra-urethral
Alprostadil

34. PDE5 inhibitors 1. Sildenafil (Viagra) 25mg, 50mg, 100mg
1 hour before sexual activity
4-6 hour duration of action
2. Tadalafil (Cialis) 5mg, 10mg, 20mg
30 minutes before sexual activity
36hour duration of action
Absorption not affected by food
3. Vardenafil (Levitra) 5mg, 10mg, 20mg
30-60 minutes before sexual activity

35. PDE5 Inhibitors Side Effects and Drug Interactions
Facial flushing
Headache
Nasal congestion
Dizziness
Dyspepsia
Visual disturbance
Priapism
PDE5 Drug Interactions
Nitrates
- Isosorbide mono or dinitrate
Cytochrome P450 inhibitors
-Protease inhibitors
-Cimetidine
-Ketoconazole

36. PDE5 Contraindications
Recent cardiovascular event
Nitrates
Hypotension
Anatomical deformity
-Angulation, cavernosal fibrosis, Peyronie’s
Predisposition to prolonged erection
-SCA, MM, Leukaemia

37. Intracavernosal Injections
1. Alprostadil (Caverject, Viridal) 5-40 mcg
Independent of intact nervous system
Adequate vision, trained pt
Contraindications: bleeding disorders, SCA, MM, leukaemia
Side effects: Pain, haematoma, fibrosis at injection sites, priapism
2. Papaverine, Phentolamine in combination with Alprostadil
3. Testosterone (Hypogonadism)

39. Intraurethral suppositories
Alprostadil (Muse) 125mg, 250mg, 500mg,1g
Pellet inserted with applicator
Massage penis to aid absorption
Side effects: Penile pain, dizziness, priapism (rare)

41. Vacuum Devices
Blood trapped in intracorporal and extracorporal compartments of penis
Constricting ring at base of penis
Cyanosis, oedema, cold
Pivots at base below ring
Maximum time 30 minutes

43. Penile Prostheses Semi-rigid and inflatable rods
2 piece inflatable prosthesis
3 piece inflatable prosthesis with abdominal reservoir
Risks
Infection
Destroys corpora cavernosa
Erosion and extrusion
Mechanical failure

45. Reconctructive surgery
Revascularization ( using inferior epigastric artery)
Ligation of dorsal veins

46. Newer technology ED1000 machine Shock Wave Therapy
Approach to vasculogenic and DM ED
Stimulate neovascularization
Trials in Europe and LUTH

47. Gene therapy (Future research)
Future treatment option
Focused on molecules that regulate corporal smooth muscle relaxation or increase neovascularization e.g
-Penile-inducible nitric oxide synthase gene
-VIP gene
-Maxi-e channel gene
-Brain neurotrophic gene

48. Prognosis Depends on Aetiology of ED Duration of ED Severity of ED
Comorbidities
Age of pt

49. Conclusion ED is a common problem Impact on patient and partner
Overlap of psychological and organic causes
May be initial presentation of diabetes or coronary artery disease
If YOU don’t ask, patient may be too embarrassed to tell you

50. THANKS
NAGODE