Selected Clinical Topics in Urology

Selected Clinical Topics in Urology
This presentation was created with funding from Pfizer Inc.

Erectile Dysfunction Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function
Erectile Dysfunction (ED): General Considerations Evaluation of a Man Presenting with ED ED Treatments Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neuroanatomic considerations Sexual activity is initiated in the central nervous system The brain is the most poorly understood component of the sexual response, but is of great importance Some important areas that are known to contribute to sexual response include the medial preoptic nucleus and paraventricular nucleus, which reside near the hypothalamus The exact function and interaction of these structures are not known Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neuroanatomic considerations The most common sexual adverse effect of the frequently prescribed selective serotonin reuptake inhibitors (SSRIs) is anorgasmia although decreased libido and isolated erectile dysfunction may also occur Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neuroanatomic considerations Descending neural pathways controlling erection exit the brain and travel in the spinal cord to the level of S2-4, where they exit as peripheral parasympathetic nerves Activation of these parasympathetic nerves causes vascular changes that lead to erection The detumescence mechanism is under control of the sympathetic nervous system Ejaculation is a completely different neurological event from penile erection Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neuroanatomic considerations The locations of the sympathetic chain just lateral to the aorta and of the hypogastric plexus anterior to the aorta make these structures prone to surgical injury from aortic surgery or retroperitoneal lymphadenectomy for testis cancer Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Penile anatomy and vascular supply A. Penile arterial supply B. Venous drainage C. Cross section of penis showing corpora cavernosa, corpus spongiosum and their relationship to the vascular supply Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Penile anatomy and vascular supply The penile deep structures consist of 3 erectile bodies, 2 corpora cavernosa and a single corpus spongiosum Surrounding the entire package of erectile bodies is Buck’s fascia All 3 bodies contain erectile tissue Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Penile anatomy and vascular supply The corpus spongiosum surrounds the urethra and distally enlarges to become the glans penis Although the corpus spongiosum becomes engorged during sexual stimulation, it does not contain a tough fascial covering and thus cannot become rigid Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Penile anatomy and vascular supply The arterial blood supply to the penis is from the common iliac internal iliac (hypogastric) internal pudendal common penile artery Normal blood flow on one side is usually enough to keep things functioning properly However, there can be individual variation in the anatomy Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Penile anatomy and vascular supply In some men, only one side provides the majority of dorsal arteries may provide intracavernosal flow via perforating vessels more distally than normal This anatomic variation may have importance in planning Peyronie’s disease surgery, in which the neurovascular bundle is elevated blood Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Penile anatomy and vascular supply The venous drainage of the penis is redundant and plentiful The largest vein is the deep dorsal, originating at the glans and running deep to Buck’s fascia Circumflex veins coming up from the side and a few direct cavernosal perforators join the deep dorsal vein in its proximal course Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection In the flaccid state, there is very little blood flow into the penis The predominant basic neural tone is sympathetic The smooth muscle surrounding the lacunar spaces are held in a state of contraction from this sympathetic tone, and therefore, as each unit of space holds less blood, the penis as a whole contains less blood volume and is smaller The baseline sympathetic tone also keeps the blood supply in a vasoconstricted state Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection Blood flow increases fold through the cavernosal arteries Smooth muscle relaxation of the cavernosal smooth muscle surrounding the lacunar spaces also occurs, creating a permissive increase in blood volume stored in each space The increase in penile size is checked by the limitation of stretch of the tunica albuginia surrounding the corpus cavernosum Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection The smooth muscle relaxation is controlled by well known neurochemical cascades The major control system is the nitric oxide/cyclic GMP (NO/cGMP) system NO is released by nitrergic end-neurons and endothelial cells in the cavernosal tissue in response to sexual stimulation Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection Production of NO causes the conversion of GTP into cGMP by the action of guanylate cyclase Interaction of cGMP with protein kinase G causes calcium shifts and resultant smooth muscle relaxation Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection Cyclic nucleotides of all types are broken down by phophodiesterases (PDEs) in the body The most important PDE in the penile tissue is PDE5, which is present in high concentration, is specific for cGMP and plays a central role in inactivation of the NO/ cGMP pathway Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection Although PDE5 is clearly the predominant PDE in the penis, and its relative importance in the penis compared to the rest of the body is substantial allowing an oral agent to be given to get an effect in the penis without exaggerated systemic adverse events Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection Although less important than the cGMP system, a parallel cAMP systemis present in the penile tissue, as well. cAMP is degraded by several cAMP specific PDEs (not PDE5, which is cGMP-specific) When present, cAMP also causes smooth muscle relaxation via protein kinase A and calciumflux in much the same way as cGMP Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection Both cyclic nucleotide systems can be manipulated by non-specific PDE inhibitors, such as papaverine Injection of this drug into the penis causes prolonged smooth muscle relaxation by preventing the degradation of both cGMP and cAMP However, oral administration cannot achieve a targeted response in the penis without insurmountable systemic adverse effects of PDE inhibition Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Neurovascular changes of erection Following sexual activity, activation of the sympathetic supply to the penis results in arterial vasoconstriction, contraction of lacunar smooth muscle, defeat of the venoocclusive mechanism as intrapenile pressure decreases, and reversal of the changes mentioned above This results in return to the baseline flaccid state Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Physiology of ejaculation
After a period of sexual stimulation, coordination of psychic and physical stimulation results in climax and ejaculation The brain component of this stimulation is poorly understood Sensory input into the reflex is mostly from the glans and is carried via the dorsal nerves of the penis, which enter the cord at levels S2-4 Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Physiology of ejaculation
Sacral input into the reflex causes contraction of the periurethral muscles and proprioception from these muscles may give further to promote reaching climax Following high pressure contraction of the pelvic/periurethral muscles, ascending pathways meet those descending from the brain at the thoracolumbar junction at levels T10-L From there, sympathetic nerves exit the cord and course via the route above, culminating in the ejaculatory organs Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Normal Sexual Function Physiology of ejaculation Since ejaculation is a separate neurological event from penile erection, climax and ejaculation can occur in the absence of an erection Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Erectile Dysfunction (ED): General Considerations Epidemiology of ED ED should be defined as: “Inability of the male to attain and maintain erection of the penis to permit satisfactory sexual intercourse Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Erectile Dysfunction (ED): General Considerations Epidemiology of ED The dysfunction should be recurrent or persistent The ability either to obtain and/ or maintain an erection may be affected It is important that sexual function and expectation is not homogeneous across a patient population, so the definition of dysfunction must add in an element of patient expectation/satisfaction Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Erectile Dysfunction (ED): General Considerations Epidemiology of ED Sexual dysfunction was positively correlated (Selvin study) with age, hypertension and presence of preexisting cardiovascular disease Diabetics have a particularly high rate of problems with a crude incidence rate of > 50% Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Erectile Dysfunction (ED): General Considerations Epidemiology of ED Men with ED are also at risk for developing manifestations of cardiovascular disease when followed over time, suggesting that ED represents the first manifestation of the generalized condition Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Arteriogenic:
Erectile Dysfunction (ED): General Considerations General types of ED Arteriogenic: If one cannot increase blood flow the fold that is necessary to fill the penis, inadequate blood supply will be the cause of ED This can be due to atherosclerotic disease, diabetic small vessel disease, or trauma, which may either be a major pelvic injury or chronic compression, such as that seen in bicycle riders Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Veno-occlusive dysfunction:
Erectile Dysfunction (ED): General Considerations General types of ED Veno-occlusive dysfunction: Blood trapping is an essential part of the erectile process Lack of smooth muscle relaxation in the cavernosal bodies, due to tissue degeneration from ischemia, trauma, inadequate neurotransmitter release (diabetic microneuropathy), or Peyronie’s Disease can cause ED, even in the face of normal arterial inflow Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Neurogenic:
Erectile Dysfunction (ED): General Considerations General types of ED Neurogenic: Conditions such as diabetic or alcoholic neuropathy, multiple sclerosis, spinal cord injury, or radical prostatectomy can lead to a situation where the signal to cause vascular changes never gets to the penile tissues Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Hormonal:
Erectile Dysfunction (ED): General Considerations General types of ED Hormonal: Testosterone deficiency has been shown in multiple animal models to result in decreased production of nitric oxide synthase, NO and cGMP production, and worsened erectile function It is clear now that in addition to effects on libido, testosterone deficiency may result in an unfavorable change in penile tissue function Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Anatomic:
Erectile Dysfunction (ED): General Considerations General types of ED Anatomic: Peyronie’s Disease can lead to sexual difficulty due to deformity, decreased flexibility of the penile tissue or from the development of venoocclusive dysfunction Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Drug-induced:
Erectile Dysfunction (ED): General Considerations General types of ED Drug-induced: Many drugs can lead to erectile dysfunction, and the list is too long to print here The most commonly implicated drugs are antihypertensives and antidepressants, due to the CNS effects CNS: Central Nervous System Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Psychogenic:
Erectile Dysfunction (ED): General Considerations General types of ED Psychogenic: Although with our current understanding of ED we believe that 90% of cases have a predominantly organic cause, there remains a large subset of patients with a psychogenic source Differentiation of these cases is usually by history, but other testing may be necessary Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED The evaluation of a man with ED follows the typical model for most medical evaluations, history, physical examination, basic lab tests, specialized testing, and finally, treatment The goal-oriented approach to erectile dysfunction treatment is a widely accepted concept One must remember that consensus panels on the definition of ED have focused on putting the definition in terms of “satisfactory” sexual activity, and the goal-oriented treatment approach follows along that same line Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED History The history is essential in determining whether the ED appears predominantly organic or psychogenic Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED History
Components of the ED history that would support the diagnosis of organic ED include Older age Presence of organic risk factors, such as diabetes or hypertension Gradual onset and progressive worsening Pelvic or retroperitoneal surgery, such as radical prostatectomy Consistent dysfunction—no difference between intercourse and masturbation Sleep erections and morning erections are absent or significantly diminished in quality Orgasm present, even without penile tumescence Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED History Conversely, components of the history that should make the clinician suspect psychogenic source include: Younger age Absence of risk factors Abrupt onset, especially in relation to a psychologically traumatic event Inconsistent and varying dysfunction, with differences between sexual situations Sleep and morning erections present Orgasm absent Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED History Individuals with psychogenic ED should be identified in the history, so that they may receive proper psychological treatment Drug interactions are possible with ED treatments, and it is important to have a complete list of patient medications Previous surgeries, such as prostatectomy, can lead to ED Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Evaluation of the person’s cardiovascular risk and risk reduction program is important The other cardiac history that is necessary in the urologist’s office is whether the patient can tolerate the physical rigors of sexual activity If he is then given a method to have an erection, he may be at risk for a cardiac event during sex. Questions regarding ability to successfully perform activities of about 3-5 MET will predict success with sexual activity Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED History The Princeton Guidelines is a good reference that allows the stratification of men into certain cardiac risk classes When a man presents with ED, a clinical assessment of risk factors allows him to be placed into low, intermediate and high risk groups Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Princeton Guidelines algorithm for interaction between erectile dysfunction treatment and cardiac risk Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED History The history should include queries about what the patient’s goals are in treatment of erectile dysfunction This may change the choice of treatment plan Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Physical examination The degree of virilization should be noted, and if abnormal, may make the clinician suspect hypogonadism Peripheral pulses should be palpated If abnormal, there may an increased likelihood of vasculogenic ED Neurological examination can tip off CNS disease or peripheral neuropathies that may be the cause of the dysfunction Detailed examination of the penis for hypospadias, disproportion of the corporal bodies, and plaque is performed CNS: Central Nervous System Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Basic laboratory testing A testosterone level should be performed in all men presenting with ED because of the potential effects on libido and also penile tissue function Whether or not to obtain a total testosterone (low cost) or free testosterone (more accurate) is controversial It is probably best to obtain the level in the morning, especially if the patient is a younger man, as there is a diurnal variation with peaks in the morning Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Basic laboratory testing In men with hypogonadism on initial testing, further evaluation should include a prolactin level, and LH In men without good prior medical care, assessment for cardiovascular risk factors with blood testing is recommended These include lipid profile and assessment for diabetes with either fasting blood glucose or hemoglobin A1C LH: Luteinizing Hormone Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing Nocturnal penile tumescence (NPT) monitoring: Men will have several erections during sleep This is related to sleep pattern, and not to sexual stimulation Because men with a psychogenic source of ED will continue to have such sleep pattern-related erections, this test represents an opportunity to differentiate men with organic from those with predominantly psychogenic problems The men with organic ED will have poor responses noted during sleep, in concert with their organic dysfunction Men with psychogenic problems will have a discrepancy between sleep and conscious erections Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing NPT testing can be done in a supervised sleep laboratory or in an ambulatory setting The disadvantages of the laboratory setting are cost and difficulty sleeping in a strange surrounding The advantage of the lab is the ability to monitor for rapid eye movement (REM) sleep by lab personnel Absence of such sleep may lead to false positive testing Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing Many urologists utilize the RigiScan ambulatory NPT monitor Advantages include low cost and the ability of patient to sleep in his own surroundings Another advantage is the ability of the machine to measure penile rigidity Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing REM sleep is not measured in the ambulatory setting and false positive tests may be encountered There are many standards for what constitutes a normal test, but most would consider 2-3 erectile events per night, duration of >15 minutes per event and rigidity of 50%-60% a normal test Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing A. Normal Rigiscan study showing several episodes of prolonged tumescence during a night of sleep B. Abnormal Rigiscan study with short-lived episodes of tumescence; the tip does not have adequate rigidity Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing Duplex doppler ultrasonography: This has uniformly replaced other gross screening tests for penile blood flow used in the past, such as determination of the penile brachial index Advantages include ability to visualize the artery being measured identification of Peyronie’s plaques and direct measurement of blood flow in response to pharmacologic injection Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing Injection of a vasoactive drug into the penis is essential to glean useful information from the test It is the increase in blood flow that needs to be measured to assess for arteriogenic erectile dysfunction There are a wide number of protocols for type and dose of injected medicines, including micrograms of prostaglandin E1, mg of papaverine, and combinations of papaverine, phentolamine and prostaglandin E1 Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing If during such a test, the patient notes that the erection obtained is much poorer than his normal baseline erection, the test may be a false-positive Epinephrine that is released in response to the penile injection activates the detumescence mechanism and may be the cause A patient with sufficient anxiety can also create a false-positive test Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Cavernosometry/ cavernosography:
Evaluation of a Man Presenting with ED Specialized testing Cavernosometry/ cavernosography: The test is invasive, with 2 needles in the penis, 1 for infusion of medications and saline, and the other for pressure measurements A pharmacologic agent is injected to achieve full smooth muscle relaxation, and saline infusion is begun Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Evaluation of a Man Presenting with ED Specialized testing In men whom veno-occlusive dysfunction is suspected, this test can give more specific information but is rarely carried out, as specific treatment of such dysfunction is rarely performed Poor durability of the results Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Penile arteriography:
Evaluation of a Man Presenting with ED Specialized testing Penile arteriography: Specific arteriography of the internal pudendal system is reserved for those individuals in whom penile revascularization is being considered The arteriogram is performed under pharmacologically stimulated erection Penile arterial supply, as well as patency of potential donor arteries (usually inferior epigastrics) is carefully examined Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Sex Therapy After identification of a psychogenic source for ED, referral to a therapist with expertise in treating sexual dysfunction is in order Organic treatments may be used in conjunction with the therapist’s recommendations, but they should have a good safety profile, so as to not put the patient at undue risk Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Yohimbine Yohimbine is a supplement that has a historical place in the treatment of ED Its proposed role in the treatment of ED is to increase parasympathetic and decrease sympathetic activity In high enough doses it can lead to diaphoresis, palpitations and elevated heart rate Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Yohimbine The AUA does not recommend yohimbine for the treatment of ED Patients with a history suggestive of cardiovascular disease should be cautioned against these supplements Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments PDE5 inhibitors
This class of drug is considered first line therapy for those men presenting with ED without a contraindication to their administration Administration results in inhibition of PDE throughout the body, but due to the relative importance of the enzyme in the penile tissue, a favorable environment in the penile tissue of prolonged cGMP effect is seen without major change in systemic homeostasis This is due to direct inhibition of the breakdown of cGMP produced by the NO/cGMP system Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Drugs available include
ED Treatments PDE5 inhibitors Drugs available include sildenafil citrate (25, 50 and 100 mg), vardenafil hydrochloride (5, 10 and 20 mg) and tadalafil (5, 10 and 20 mg for demand dosing, and 2.5 or 5 mg for daily use) All are highly specific for PDE5, and all are efficacious in promoting penile erection capability in men with ED Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments PDE5 inhibitors Success rates for improvement of erection is ~ 70%-80%, and improvement to the point where the drugs are suitability for monotherapy of ED is seen in ~ 60% of cases Choice of agent must take into consideration the sexual pattern of the patient, without the physician making assumptions about such things The advent of daily tadalafil presents the option for continuous treatment for ED, equivalent to that of other organic diseases, without suffering a decline in erectile improvement due to the lower dose Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments PDE5 inhibitors Because these agents inhibit the PDE5 systemically, it is essential they NOT be given in conjunction with organic nitrates Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments PDE5 inhibitors Advantages of PDE5 inhibitors include oral administration, safety and effectiveness Disadvantages include cost, systemic administration as opposed to local effect, potential for interaction with nitrates, and poor efficacy in men with severe ED Cost is becoming an issue as well, as some insurance companies offer extremely limited coverage for any ED medications Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Penile injection therapy Many vasoactive agents have been used for ED therapy Only alprostadil (PGE1) has been approved by the FDA for this indication Alprostadil, when introduced into the corpus cavernosum, actives the cAMP system, leading to calcium flux and smooth muscle relaxation Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Mechanical devices Mechanical devices are similar to semirigids in that they are in a fixed degree of penile girth, so erection quality is a complaint of these devices Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Mechanical devices
Malleable penile prosthesis Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

2-piece inflatable devices were designed To meet the advantages of inflatables, as far as girth expansion and rigidity, while allowing flaccidity and concealment, while also capitalizing on the advantages of semirigid—lack of the need for a reservoir implantation There is only one 2-piece inflatable available on the market It has 2 cylinders which are filled in the center, allowing for fluid insertion just under the surface of the cylinders Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

2-piece inflatable penile prosthesis Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Mechanical devices 3-piece inflatable devices are most reported in series in the literature They consist of 2 cylinders, a reservoir in the pelvis and a pump in the scrotum They are the most complicated devices and require a larger surgical procedure to implant the device However, they give the best flaccidity and the best rigidity of all the devices available Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

3-piece inflatable penile prosthesis with paired cylinders, reservoir and scrotal pump Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Surgical approaches for penile implants There are a variety of ways to place a penile prosthesis, but most surgeons utilize the infrapubic or penoscrotal approaches Advantages of the infrapubic approach include avoidance of the urethra, and ability to directly open the abdominal fascia for reservoir placement Disadvantages include longer operative time, abdominal fascial incision pain, and possibility of dorsal neurovascular bundle injury Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction Advantages of the penoscrotal approach include
ED Treatments Surgical approaches for penile implants Advantages of the penoscrotal approach include decreased operative time, decreased postoperative pain due to no fascial incision, and better access to the corporal bodies for dilation Disadvantages include the possibility of bladder or vascular injury during blind reservoir placement Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Surgical approaches for penile implants Complications of penile prosthesis surgery include infection, erosion and mechanical failure, necessitating re-operation Erosion is thought to be due to subclinical infection in nearly all cases With current improvement in coating of prosthetic devices, the infection rate should be <1% Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Surgical approaches for penile implants One can never be faulted for removing a device to treat infection Fibrosis and shrinkage seen following explantation dictates that one considers a salvage operation in such cases If mechanical malfunction is seen in a prosthesis, the entire device should be replaced with a new one Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Erectile Dysfunction ED Treatments Penile Revascularization
Revascularization of the penis to correct erectile difficulty is uncommonly performed due to the stringent criteria for patient selection, including a young age, a history of significant pelvic/perineal trauma, and no preexisting erectile complaints Angiography is a prerequisite to the surgery Because ED in older men coexists with other comorbidities and involves some degree of venous leak, revascularization is not an option Ohl A. D, Quallich A. S, Sønksen J. Erectile Dysfunction. In: The American Urological Association Educational Review Manual in Urology. 2nd Edition 2010; Chapter 28:

Selected Clinical Topics in Urology

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