ISLAMIC EMIRATE OF AFGHANISTAN

min MINISTRY OF PUBLIC HEALTH

5
0-2 Forensics directorate services
–2
time
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ate
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Erectile dysfunction

Prepared by : Dr. Muhibullah “Saifi” PGY2

Under supervision of : Trainer specialist Atiqullah “Atiq”
1402/11/10
Surprising health benefits of sex
Relieves stress
Lowers blood pressure
Boosts immunity
Provides exercise
Burns calories
Improves cardiovascular health
Boost self-esteem
Strengthens our well-being
Improves intimacy
Reduces pain
Reduces prostate cancer risk
Strengthens pelvic floor muscles
Helps you sleep better
 General Risks of Sex
Sexually transmitted infections (STIs)
Sexual activity directly cause death, particularly
due to coronary circulation complications, which is
sometimes termed coital death.
Sexual activity increases the expression of a gene
called Delta FosB.
Frequent engagement in sexual activity on a
regular(daily) basis can lead to the overexpression
of Delta Fosb, inducing an addiction to sexual
activity.
Anatomy of penis
 Blood supply(arterial supply)
Internal pudendal artery
4 branches
1. Dorsal artery – supplies penile skin and glans and
contributes to erectile function
2. Cavernosal artery – within the corpora , branches
into helicine arterioles
3. Bulbar artery
4. Scrotal artery
Blood supply(Venous drainage)
Both intra+extra cavernosal
 intra-cavernosal drains into – deep dorsal vein
Extra-cavernosal is via 3 routes:
1. Deep dorsal vein – drains distal corpora
2. Cavernosal and crural vein – drains proximal
corpora
3. Superficial dorsal vein – drains blood from penile
skin, glans and communicates with deep dorsal
vein.
 Nerve supply

Autonomic
Somatic
 Autonomic Nerve supply
Parasympathetic – S2-S4 – primarily controls
erectile function
Sympathtic – T11-L2 – control detumescene and
also contribute to ejaculation and emission.
 Somatic Nerve supply
Peripheral nerves(dorsal penile and pudendal
nerves) form sensory and motor element through a
reflex arc in the sacral spinal cord.

Peripheral nerves containing sensory elements are

also responsible for erectile functions, as they
innervates the ischio and bulbo cavernosus muscles of
the penis.
 Somatic Nerve supply
Central nervous system control is likely initiated in
the hypothalamus that integrates psychological and
tactile stimuli.
Physiology of Erection
 Types of Erection
Reflexogenic erection:

A genital stimulation leads to a reflexogenic

erection.
The relfexogenic erection is largely independent of
cortical influences, as this kind of erection can remain
intact after cervical and thoracic spinal cord injuries.
 Types of Erection
Psychogenic erection:

The cortical processing of sensory, visual, auditory

stimuli or fantasies are triggers for an erection.
The cortical centers influences the sacral erection
centers, which cause the erection.
 Types of Erection
Nocturnal erection:
Occurs during the REM sleeping phase and can be measured
during sleeping studies (Nocturnal penile tumescence = NPT)
NPT distinguish psychogenic ED from organic ED
Molecular physiology of penile
erection
cGMP is broken down by phosphodiesterase type 5 (PDE5)
When this occurs the Ca++ increases in concentration in the
cell, resulting in contraction of the smooth muscle cells and
detumescene.

Note: Sildenafil(Viagra) is a PDE5 inhibitor and allows for

erection to be maintained in response to stimuli, but does not
initiate erection.
 Erection Vs Detumescence
Parasympathetic – Nitric oxide (NO2) –
vasodilatation – Erection

Sympathetic – norepinephrine –
vasoconstriction – detumescene (flaccid).
 Phases of erection
Phases Term

0 Flaccid phase

1 Latent (filling phase)

2 Tumescent phase

3 Full erection phase

4 Rigid erection phase

5 Detumescence phase
Definition of Erectile dysfunction
or impotence

The persistent inability to achieve or maintain a

erection sufficient to permit satisfactory sexual
performance.

(NIH consensus conference on impotence 1993 and

AUA Guideline)
 Prevalence
Massachusetts male aging study (MMAS)
Men 40-70 years
52% have ED
Mild ED: 17%
Moderate : 25%
Complete ED: 10%
ED prevalence increases with age
50% at 50, 60% at 60, 70% at age of 70
Etiology of impotence or erectile
dysfunction

I.M.P.O.T.E.N.C.E mneumonic
Chordee disease(congenital penile
curvature)
 Types of Erectile dysfunction
Primary ED ( ex: the man has never been able to attain or
sustain erections) is rare and is almost always due to psychologic
factors(guilt, fear of intimacy , depression, severe anxiety) or
clinically obvious anatomic abnormalities.

Most often, ED is secondary( ex: a man who previously could

attain and sustain erections no longer can). Over 80% = have an
organic etiology.

However, in many men with organic disease, ED leads to

secondary psychologic difficulties that compound the problem.
 Psychogenic ED Organic ED
ED caused exclusively by Caused exclusively by vascular,
emotional stress or psychiatric neurologic, endocrine, or other
disease = 10% - 50% of all cases physical disease = 50% - 80%

In the majority of impotent men, erectile impairment has both a

psychological and an organic basis
How to diagnose & evaluate ED?

History
Examination
Investigation
 History
Sexual
Some symptoms suggest psychogenic ED, and others
suggest organic disease
A psychogenic cause is suggested by the sudden onset of
ED or the presence of ED under some circumstances but
complete erection at other times.
In contrast, gradual deterioration of erectile quality over
months or years with preservation of libido suggests organic
disease.
Psychological evaluation.
 History
Medical
Inquiries should be made about: DM, HTN, smoking,
hypercholesterolemia, and hyperlipidemia as well as about
liver, renal, vascular, neurologic, psychiatric, and endocrine
disease.
Surgical history
Abdominal, pelvic, perineal
Drug history
Androgenic substances are associated with decreased
serum testosterone levels and decreased libido.
 physical examination
External Genitalia
Penis: phimosis, penile lesions
Testis: size, consistency
DRE
 Investigation
LAB:
Recommended: Fasting glucose, lipid profile,
hormonal profile
Others: thyroid, PSA, prolactin
 Principles of treatment
The primary goal in the management of strategy of a patient
with ED is to determine the etiology of the disease and treat it
when possible, and not to treat the symptom alone.

Modifiable or reversible factors, including lifestyle or drug-

related factors should be modified first.
As a rule, ED can be treated successfully but cannot be cured,
the only exceptions are psychogenic ED, post-traumatic
arteriogenic ED in young patients, and hormonal causes.
 Treatment
1. lifestyle modification
2. Treatment of curable E.D
3. Therapy for assisted erection
First line therapy
Oral drugs (PDE5 and apomorphine)
Topical pharmacotherapy
Intra-urethral alprostadil
Second line therapy
Vaccum constriction devices
Intra-cavernous injections
Third line therapy
Penile prosthesis
 Lifestyle modification
Avoid smoking
Maintain ideal body weight
Regular exercise
Stop alcohol abuse
Consider alternative for medication that contribute
to ED
Optimize management of DM, HTN and heart
diseases
 Curable causes of ED
1. hormonal:

Testosterone replacement therapy (intramuscular, oral or

transdermal) is effective, but should only be used after other
endocrinological causes for testicular failure have been
excluded.
(Greenstein et al 2005)
 Curable causes of ED
2. post-traumatic arteriogenic ED in young patients:

In young patients with pelvic or perineal trauma, surgical

penile revascularization has a 60-70% long-term success rate
(Rao DS and Donatucci CF, 2001)
 Curable causes of ED

3. psychosexual counseling:

For patients with a significant psychological

problem, psychosexual therapy may be given
either alone or with another therapy for assisted
erection.
Therapy for assisted erection

First line therapy:

PDE5 inhibitors:
It is recommended as first line therapy
according to the AUA guidelines.
 Treatment
Blocks the breakdown of cGMP, thus maintaining erection

Sexual stimulation is still needed to initiate erection

Adverse effects: headache, flushing, dyspepsia, nasal

congestion and dizziness

Abnormal vision with sildenafil and vardenafil

Back pain and myalgia with tadalafil only.
 Drug interaction
1. Nitrates: totally contra-indicated with PDE5 inhibitors
2. Anti-hypertensive drugs: may result in small additive
drops in blood pressure, which are usually minor.
3. Alpha blocker: fear of profound hypotension.
 Dosage adjustment
 Drugs that inhibit the CYP34A – will inhibit the
metabolic breakdown of PDE5 inhibitors.
(Ketoconazole, itraconazole, erythromycin,
clarithromycin and HIV protease inhibitors(ritonavir,
saquinavir). Such agents may increase blood levels of
PDE5 inhibitors, so that lower doses of PDE5 inhibitors
are necessary.
 Drugs that induce the CYP34A pathway – will enhance
the breakdown of PDE5 inhibitors. (Rifampin,
phenobarbital, phenytoin and carbamazepine). So that
higher doses of PDE5 inhibitors are required.
 Severe kidney and hepatic dysfunction.
 Causes of failure of PDE5
inhibitors (PDE5 non-responders)
1. Incorrect usage of the drugs( Timing, dose or lack of
sexual stimulation)
2. Inadequate patient education
3. Unidentified hypo-gonadism
4. Anxiety of performance
5. Co morbidities
6. Psychosocial factors
7. Severe ED at presentation

(Chelsea et al 2006)
Management of non-responders
1. Patient education
2. Improved of related co morbid conditions
3. Normalizing testosterone level
4. Switching PDE5 inhibitors
5. Daily or continuous use of PDE5 inhibitors
6. Psychosocial counseling
7. Combined therapy
Medicated urethral system for
erection
 Intra-urethral alprostadil
 Introduced in 1990
 Mechanism: activate adenylate cyclase
 Erection starts 5-20min after administration
 Contra-indication: 1.distal urethral stricture 2. significant
angulation or fibrosis 3. balantitis or urethritis 4. sexual
activity with pregnant female
 Side effects: pain, bleeding, priapism and hypotension
 Intra-cavernous injection
 Introduced in 1990
 Side effect: priapism, fibrosis , pain and hypotension
Vacuum constriction devices
 Mechanically create negative pressure surrounding penis
 Engorge penis with blood
 Ring to prevent venous leakage
 Penile prosthesis
 The third line therapy after failure of other lines
 Has the highest satisfaction rates (70-87%) among
treatment options for ED.
(EUA Guidelines 2009)
 the 2 main complications of penile prosthesis
implantation are mechanical failure and infection.
 Reference

• Current medical diagnosis and treatment 2016

• Internet
• Thank You