ERECTILE

DYSFUNCTION
“Man survives earthquakes, experiences the
horrors of illness, and all of the tortures of
the soul. But the most tormenting tragedy
of all time is, and will be, the tragedy of the
bedroom.”

Tolstoy
Definition of Erectile
Dysfunction(ED)

The consistent inability to achieve and/or

maintain an erection adequate for
satisfactory sexual intercourse.

“This definition is simple, but the condition is not”

DSM-IV (American Psychiatric
Association, 2000)
Persistent or recurrent inability to attain, or to
maintain until completion of the sexual activity, an
adequate erection

The disturbance causes marked distress or

interpersonal difficulty

The erectile dysfunction is not better accounted for by

another Axis I disorder (other than a sexual dysfunction)
and is not due exclusively to the direct physiological
effects of a substance (e.g. a drug of abuse, a
medication) or a general medical condition
Anatomy of Penis
Normal Male Sexual Function requires:
1) An intact Libido
2) Detumescence
3) Ability to achieve and maintain penile Erection
4) Ejaculation

Parasympathetic nerves S2-4 mediate erection

Sympathetic nerves T11-L2 control ejaculation and

detumescence
Physiology Of Erection
Penile erection is a neurovascular event
modulated by psychological factors and
hormonal status. On sexual stimulation, there
is increased flow of blood into the lacunar
network. Subsequent compression of the
trabecular smooth muscle causes a closure of
the emissary veins and accumulation of blood
in the corpora. The corpora becomes non-
compressible and blood cannot escape.
Nerve impulses cause the
release of
neurotransmitters (NO)
from the cavernous nerve
terminals. Nitric oxide
diffuses into cavernosal
smooth muscle cells,
activates Guanylate
cyclase, which converts
GTP to cGMP resulting in
smooth muscle relaxation
in the arteries and
arterioles supplying the
erectile tissue and a
several fold increase in
penile blood flow.
At the same time, relaxation of the
trabecular smooth muscle increases
the compliance of the sinusoids,
facilitating rapid filling and expansion
of the sinusoidal system.
Sinusoidal engorgement of the
cavernosal tissues

Flaccid Penis Erect Penis

The subtunical venular plexuses are thus
compressed between the trabeculae and the tunica
albuginea, resulting in almost total occlusion of
venous outflow.
These events trap the blood within the
corpora cavernosa and raise the penis from a
dependent position to an erect position, with
an intracavernous pressure of approximately
100 mm Hg (the phase of full erection).
Normal pathway to erection
Sexual impulse
Neurotransmitter
Release of NO & chemical substrates
Smooth muscle relaxation
Tumescence
Venous occlusion
Rigidity
Erection
Types of Erectile Dysfunction
It can be primary or secondary

 Primary means present from the first attempt

at intercourse or it may be secondary in which
person develop ED after a period of normal
function.

In situational male ED, a man is able to have

coitus in certain circumstances but not in others

More common in older than younger men (in

contrast to premature ejaculation)
Causes of ED
Psychogenic
Performance anxiety
Relationship problems/difficulties
Loss of attraction to partner
Depression and anxiety disorders
• Anxiety
• Depression
• Fatigue
• Guilt
• Stress
• Marital Discord
• Excessive alcohol consumption
Psychogenic ED
Vasculogenic (arterial or
cavernosal):

Atherosclerosis
Hypertension
Trauma
Caused by other systemic
diseases and aging:
Old age
Diabetes mellitus
Chronic renal failure
Coronary heart disease
Neurogenic:
Stroke or Alzheimer’s disease
Spinal cord injury
Radical pelvic surgery
Diabetic neuropathy
Pelvic injury
Hormonal:
Hypogonadism
Hyperprolactinemia
Drug-induced:
Antihypertensive and antidepressant drugs
Antiandrogens
Alcohol abuse
Cigarette smoking
Medications & ED
More likely to affect sexual function
Beta blockers(propranolol,atenolol)
Statins
Diuretics(thiazide)
Anti-
depressants(fluoxetine,sertraline,amitriptyline)
Anti-psychotics(chlorpromazine,risperidone)

Less likely to affect sexual function

Calcium channel blockers
ACE inhibitors
 Causes of ED

Sydney Men’s Health

Clues differentiating psychogenic
from organic causes
Psychogenic Organic
Sudden onset Gradual onset
Situational All situations
Normal waking and nocturnal Reduced or absent waking and
erections nocturnal erections
Normal erection with masturbation No erection with masturbation
Tumescence present Lack of tumescence
Relationship problems Normal libido, normal ejaculation
Major Life event Known Cardiovascular,
Anxiety, fear, depression endocrinal,, neurological
conditions
Operations, radiotherapy, trauma
to testes/scrotum
Medications, smoking, alcohol
Risk factors for ED
 Aging
 Chronic disease conditions
• Heart disease (1.8 times)
• HTN (1.6 times)
• DM (4.1 times)
• Peripheral vascular disease
(2.6 times)
 Smoking (24%)
 Alcohol use
 Obesity (22%)
 Lack of physical activity
 Depression (1.8 times)
 Elevated cholesterol (1.7 times)
History
Medical
Surgical
Psychiatric
Medication
Smoking
Alcohol
Recreational drug use
Assessment
A thorough history (medical, sexual, and
psychosocial)
Has there been a previous period of normal
function?
Has the failure occurred with more than one
partner?
Does erection occur during foreplay?
Does erection occur on waking or in response to
masturbation?
Is there evidence of alcohol or drug abuse? (ask
the partner as well as the patient)
Are there possible effects of any medications?
The International Index of
Erectile Function (IIEF-5)
Questionnaire
 Over the Past 6 Months
Questions 1 2 3 4 5
1. How do you rate Very low Low Moderate High Very high
your confidence that you could
get and keep an erection?

2. When you had erections with Almost A few times Sometimes Most times Almost
sexual stimulation, how never/never (much less (about half the (much more always/always
often were your erections hard than half the time) than half the
enough for penetration? time) time)

3. During sexual intercourse, how Almost A few times Sometimes Most times Almost
often were you able to maintain never/never (much less (about half the (much more always/always
your erection after you had than half the time) than half the
penetrated (entered) your time) time)
partner?

4. During sexual intercourse, how Extremely Very difficult Difficult Slightly Not difficult
difficult was it to maintain your difficult difficult
erection to completion of
intercourse?

5. When you attempted sexual Almost A few times Sometimes Most times Almost
intercourse, how often was it never/never (much less (about half the (much more always/always
satisfactory for you? than half the time) than half the
time) time)
Scoring System
The IIEF-5 score is the sum of the ordinal
responses to the 5 items.

 22-25: No erectile dysfunction

 17-21: Mild erectile dysfunction
 12-16: Mild to moderate erectile dysfunction
 8-11: Moderate erectile dysfunction
 5-7: Severe erectile dysfunction
Examination

Blood pressure
Peripheral pulses, palpate for AAA
Testes size and consistency
Secondary sexual characteristics
Penis for Peyronie’s plaques, Phimosis
Investigations

Serum Testosterone
Serum Prolactin
Screening Profile
• Sugars
• Lipids
• Thyroid Functions
Test for erections during
REM sleep
It is normal for a man to have
five to six erections during sleep,
especially during rapid eye
movement (REM). Their absence
may indicate a problem with
nerve function or blood supply in
the penis. There are two methods
for measuring changes in penile
rigidity and circumference during
nocturnal erection: snap gauge
and strain gauge.
Nocturnal penile tumescence (NPT)
Treatment of Erectile
Dysfunction
General Measures
Psychosexual Therapy
Drug Therapy
Vacuum devices
Surgical treatments
ED treatment algorithm
1st line – lifestyle changes,
hormone issues

2nd line – oral medication,

counseling

3rd line – penile injections,

vacuum devices

4th line – implants, vascular

surgery
Treatment of ED General
Measures
Smoking cessation
Reduce alcohol
Weight loss
Exercise
Psychosexual therapy

Even if cause of ED is physical the patient

will develop psychosexual issues
Performance anxiety
Sensate focus exercises
Relationship counselling
Drugs for ED
 Oral agents:
• Phosphodiesterase type 5 inhibitors
• Oral phentolamine and apomorphine
• Yohimbine

 Intra-cavernosal
• Prostaglandin E1 Alprostadil
• Papaverine

 Intra-urethral:
• Alprostadil
PDE5 inhibitors
Sildenafil (Viagra) 25mg, 50mg, 100mg
• 1 hour before sexual activity
• 4-6 hour window
• Absorption delayed by fatty meal
Tadalafil (Cialis) 5mg, 10mg, 20mg
• 30 minutes before sexual activity
• 36 hour window
• Absorption not affected by food
Vardenafil (Levitra) 5mg, 10mg, 20mg
• 30-60 minutes before sexual activity
• 4-6 hour window
• Absorption delayed by fatty meal
Most commonly usedPDE5
Inhibitor-Sildenafil
Sildenafil is a selective inhibitor of
phosphodiesterase type 5, which inactivates cyclic
GMP. When sexual stimulation releases nitric oxide
into the penile smooth muscle, inhibition of
phosphodiesterase type 5 by sildenafil causes a
marked elevation of cyclic GMP concentrations in
the glans penis, corpus cavernosum, and corpus
spongiosum, resulting in increased smooth-muscle
relaxation and better erection. Sildenafil has no
effect on the penis in the absence of sexual
stimulation, when the concentrations of nitric oxide
and cyclic GMP are low.
PDE5 Physiology

PDE5 Inhibitors
PDE5 Inhibitors Side Effects
Facial flushing
Headache
Nasal congestion
Dizziness
Dyspepsia
Visual disturbance (blue halo)
Priapism
Non-arteritic anterior ischaemic optic
neuropathy
PDE5 Inhibitor Contraindications
Recent cardiovascular event
Nitrates
Hypotension
Anatomical deformity
• Angulation,
• Cavernosal fibrosis
• Peyronie’s disease
Predisposition to prolonged erection
• Sickle cell disease
• Multiple myeloma
• Leukaemia
PDE5 Inhibitors Drug
Interactions
Nitrates
• Glyceryl trinitrate, isosorbide mono or dinitrate
• Chest pain after taking Sildenafil/Vardenafil no
nitrates 24 hours, Tadalafil no nitrates 48 hours
• Recreational amyl nitrate (Poppers)
Cytochrome P450 inhibitors
• Protease inhibitors especially Ritonavir use very
small dose
• Cimetidine, Ketoconazole, Erythromycin
Alpha blockers
Comparision of the 3 Major
PDE5 Inhibitors
Intracavernosal Injections
Alprostadil (Caverject, Viridal) 5-40 mcg
• Independent of intact nervous system
• Manual dexterity, adequate vision, training
• Contraindicated: bleeding disorders, sickle cell
anaemia, multiple myeloma, leukaemia
• Side effects: peno-scrotal pain, haematoma,
fibrosis at injection sites, priapism
Papaverine, Phentolamine, Aviptadil (vaso-intestinal
peptide) been used sole or with Alprostadil
Intracavernosal Injections
Intraurethral
Alprostadil (Muse) 125mg, 250mg, 500mg, 1g
• Pellet inserted with applicator
• Massage penis to aid absorption
• Side effects: Penile pain, dizziness,
priapism rare
Intraurethral Alprostadil
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
Vacuum Devices
Penile Prostheses
Semi-rigid rods
2 piece inflatable prosthesis
3 piece inflatable prosthesis with abdominal
reservoir
Risks
• Infection
• Destroys corpora cavernosa
• Erosion and extrusion
• Mechanical failure
Penile Prosthesis
®
THANK YOU