LECTURE_50_ERECTILE_DYSFUNCTION_2.pptx.pdf
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Erectile dysfunction (ED) is a prevalent sexual dysfunction in men characterized by the inability to achieve or maintain an erection, often linked to psychological and physical causes. The document outlines various causes of ED, including cardiovascular issues, diabetes, lifestyle habits like smoking, and psychological factors, as well as the impact of treatments and surgeries on erectile function. It also discusses guidelines for evaluation, diagnosis, and treatment options, including lifestyle modifications, medications, and surgical interventions.
![CAUSES
• Diets high in saturated fat are linked to heart diseases, and men
with heart diseases are more likely to experience ED.
• By contrast, plant-based diets show a lower risk for ED.
• Prescription drugs (e.g., SSRIs, beta blockers, antihistamine
alpha-2 adrenergic receptor agonists,e.g clonidine, thiazides,
hormone modulators, and 5α-reductase inhibitors e.g Proscar
[finasteride 5 mg] )](https://image.slidesharecdn.com/lecture50erectiledysfunction2-240811205959-c4410b6b/85/LECTURE_50_ERECTILE_DYSFUNCTION_2-pptx-pdf-9-320.jpg)
![PATHOPHYSIOLOGY
• Erectile dysfunction generates from any process that
impairs either the neural or the vascular pathways that
contribute to erection.
• CLASSIFICATION
• Many classifications have been proposed for ED. Some are based
on the cause (diabetic, iatrogenic, traumatic) and some on the
neurovascular mechanism of the erectile process (failure to
initiate [neurogenic], failure to fill [arterial], and failure to store
[venous].](https://image.slidesharecdn.com/lecture50erectiledysfunction2-240811205959-c4410b6b/85/LECTURE_50_ERECTILE_DYSFUNCTION_2-pptx-pdf-14-320.jpg)
LECTURE_50_ERECTILE_DYSFUNCTION_2.pptx.pdf
- 1. ERECTILE DYSFUNCTION 2 DR. GORDON AMBAYO
- 2. INTRODUCTION • Erectile dysfunction (ED), also called impotence, is the type of sexual dysfunction in which the penis fails to become or stay erect during sexual activity. • It is the most common sexual problem in men. • Through its connection to self-image and to problems in sexual relationships, erectile dysfunction can cause psychological harm.
- 3. INTRODUCTION • In about 80% of cases, physical causes can be identified. • These include cardiovascular disease; diabetes mellitus; neurological problems, such as those following prostatectomy; hypogonadism; and drug side effects. • About 10% of cases are psychological impotence, caused by thoughts or feelings; here, there is a strong response to placebo treatment.
- 4. INTRODUCTION • Presence of erectile dysfunction due to atherosclerosis is a predictor of cardiac arrest two years after its onset. • This is because atherosclerosis affect all arteries of the body and the penile arteries are smaller than the cardiac arteries so they get blocked earlier. • Smoking is a major cause of erectile dysfunction.
- 5. INTRODUCTION • The sexual response cycle by Masters and Johnson are desire, arousal, orgasm, and resolution. • Erectile dysfunction (ED) can be conceptualized as an impairment in the arousal phase of sexual response
- 6. DEFINITION • Erectile dysfunction is the inability to get or sustain an erection necessary for satisfactory sexual intercourse. • What is satisfactory sexual intercourse. • For both men and women, in penile-vaginal intercourse and the consistency of being able to reach vaginal orgasm is associated with sexual satisfaction.
- 7. SIGNS OF FEMALE ORGASM • These are contractions in the vagina, pelvic lifting or thrusting, increased heartbeat, twitching of muscles, curling of the toes or fingers, and moaning. • The vagina becomes more lubricated due to squirting. • Squirting refers to the ejaculation of liquid other than urine from the vagina. Its sometimes called female ejaculation. • The woman will become much calm and relaxed after a noisy scream
- 8. SIGNS AND SYMPTOMS • ED is characterized by the regular or repeated inability to achieve or maintain an erection of sufficient rigidity to accomplish sexual activity. • It is defined as the "persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3 months.
- 9. CAUSES • Diets high in saturated fat are linked to heart diseases, and men with heart diseases are more likely to experience ED. • By contrast, plant-based diets show a lower risk for ED. • Prescription drugs (e.g., SSRIs, beta blockers, antihistamine alpha-2 adrenergic receptor agonists,e.g clonidine, thiazides, hormone modulators, and 5α-reductase inhibitors e.g Proscar [finasteride 5 mg] )
- 10. CAUSES • Neurogenic disorders (e.g., diabetic neuropathy, temporal lobe epilepsy, multiple sclerosis, Parkinson's disease, multiple system atrophy) • Cavernosal disorders (e.g., Peyronie's disease) • Hyperprolactinemia (e.g., due to a prolactinoma) • Psychological causes: performance anxiety, stress,
- 11. CAUSES • Surgery (e.g., radical prostatectomy) • Ageing: after age 40 years, ageing itself is a risk factor for ED, although numerous other pathologies that may occur with ageing, such as testosterone deficiency, cardiovascular diseases, or diabetes, among others, appear to have interacting effects • Kidney disease: ED and chronic kidney disease have pathological mechanisms in common, including vascular and hormonal dysfunction, and may share other comorbidities, such as hypertension and diabetes mellitus that can contribute to ED.
- 12. CAUSES • Lifestyle habits, particularly smoking, which is a key risk factor for ED as it promotes arterial narrowing. • Due to its propensity for causing detumescence and erectile dysfunction, some studies have described tobacco as an anaphrodisiacal substance. • COVID-19: preliminary research indicates that COVID-19 viral infection may affect sexual and reproductive health[
- 13. CAUSES • ED is a common complication of treatments for prostate cancer, • including prostatectomy and destruction of the prostate by external beam radiation, although the prostate gland itself is not necessary to achieve an erection. • ED can also be associated with bicycling due to both neurological and vascular problems due to compression. • The increased risk appears to be about 1.7-fold
- 14. PATHOPHYSIOLOGY • Erectile dysfunction generates from any process that impairs either the neural or the vascular pathways that contribute to erection. • CLASSIFICATION • Many classifications have been proposed for ED. Some are based on the cause (diabetic, iatrogenic, traumatic) and some on the neurovascular mechanism of the erectile process (failure to initiate [neurogenic], failure to fill [arterial], and failure to store [venous].
- 15. Classification recommended by the International Society of Impotence Research ORGANIC CAUSES 1) Vasculogenic A. Arteriogenic B. Carvenosal C. Mixed. 2) Neurogenic 3) Anatomic 4) Endocrinology
- 16. Classification recommended by the International Society of Impotence Research PSYCHOGENIC 1) Generalised A) Generalized unresponsive 1) Primary lack of sexual arousal 2) Aging related decline in sexual arousal. Testosterone levels decline at the rate of 1% per annum from the age of 30 years. B) Generalized inhibition 1) Chronic disorders of sexual intimacy. 2) Situational A) Partner related a) Lack of arousal in specific relationships b) Lack of arousal owing to sexual object preference. c) High central inhibition owing to partner conflict or threat
- 17. Classification recommended by the International Society of Impotence Research SITUATIONAL (Cont.) Performance-related 1) Associated with other sexual dysfunction/s (e.g. rapid ejaculation) 2) Situational performance anxiety (e.g. fear of failure) C. Psychological distress- or adjustment-related 1) Associated with negative mood state (e.g. depression) or major life stress (e.g. death of partner).
- 18. PATHOPHYSIOLOGY - PSYCHOGENIC • Sexual behavior and penile erection are controlled by the hypothalamus, the limbic system, and the cerebral cortex. • Therefore, stimulatory or inhibitory messages can be relayed to the spinal erection centers to facilitate or inhibit erection. • Two possible mechanisms have been proposed to explain the inhibition of erection in psychogenic dysfunction: direct inhibition of the spinal erection center by the brain as an exaggeration of the normal suprasacral inhibition and excessive sympathetic outflow or elevated peripheral catecholamine levels, which may increase penile smooth muscle tone to prevent the relaxation necessary for erection.
- 19. PATHOPHYSIOLOGY - PSYCHOGENIC • The stimulation of sympathetic nerves or systemic infusion of epinephrine causes detumescence of the erect penis. • Clinically, higher levels of serum norepinephrine have been reported in patients with psychogenic ED than in normal controls or patients with vasculogenic ED.
- 20. PATHOPHYSIOLOGY - NEUROGENIC • It has been estimated that 10 to 19% of ED is of neurogenic origin. • Because an erection is a neurovascular event, any disease or dysfunction affecting the brain, spinal cord, cavernous and pudendal nerves can induce dysfunction.
- 21. PATHOPHYSIOLOGY - NEUROGENIC • In men with a spinal cord injury, their erectile function depends largely on the nature, location, and extent of the spinal lesion. • In addition to ED they may also have impaired ejaculation and orgasm. • Reflexogenic erection is preserved in 95% of patients with complete upper cord lesions, whereas only about 25% of those with complete lower cord lesions can achieve an erection. • It appears that sacral parasympathetic neurons are important in the preservation of reflexogenic erection.
- 22. PATHOPHYSIOLOGY - NEUROGENIC • The introduction of nerve-sparing radical prostatectomy has reduced the incidence of impotence from nearly 100% to 30–50%
- 23. PATHOPHYSIOLOGY - ENDOCRINOGENIC • Hypogonadism is a frequent finding in the impotent population. • Androgens influence the growth and development of the male reproductive tract and secondary sex characteristics; their effects on libido and sexual behavior are well established. Studies report that: 1) testosterone enhances sexual interest; 2) testosterone increases frequency of sexual acts; and 3) testosterone increases the frequency of nocturnal erections.
- 24. PATHOPHYSIOLOGY - ENDOCRINOGENIC • A study correlating nocturnal erections and testosterone levels in men, reported that the threshold for normal nocturnal erections is about 200 ng/dl. • Men with lower serum testosterone levels often have abnormal nocturnal erection parameters compared to men with normal levels of testosterone. • However, exogenous testosterone therapy in impotent men with borderline low testosterone levels reportedly has little effect on potency.
- 25. PATHOPHYSIOLOGY - ENDOCRINOGENIC • Any dysfunction of the hypothalamic-pituitary axis can result in hypogonadism. • Hypogonadotropic hypogonadism can be congenital or caused by a tumor or injury; hypergonadotropic hypogonadism may result from a tumor, injury or surgery to the testis, or mumps orchitis.
- 26. PATHOPHYSIOLOGY - ENDOCRINOGENIC • Hyperprolactinemia, whether from a pituitary adenoma or drugs, results in both reproductive and sexual dysfunction. • Symptoms may include loss of libido, ED, galactorrhea, gynecomastia, and infertility. • Hyperprolactinemia is associated with low circulating levels of testosterone, which appear to be secondary to inhibition of gonadotropin-releasing hormone secretion by the elevated prolactin levels.
- 27. PATHOPHYSIOLOGY - ENDOCRINOGENIC • ED also may be associated with both the hyperthyroid and the hypothyroid state. • Hyperthyroidism is commonly associated with diminished libido, which may be caused by the increased circulating estrogen levels, and less often with ED. • In hypothyroidism, low testosterone secretion and elevated prolactin levels contribute to ED.
- 28. PATHOPHYSIOLOGY - ARTERIOGENIC • Atherosclerotic or traumatic arterial occlusive disease of the hypogastric-cavernous-helicine arterial tree can decrease the perfusion pressure and arterial flow to the sinusoidal spaces, thus increasing the time to maximal erection and decreasing the rigidity of the erect penis. • In the majority of patients with arteriogenic ED, the impaired penile perfusion is a component of the generalized atherosclerotic process.
- 29. PATHOPHYSIOLOGY - ARTERIOGENIC • Common risk factors associated with arterial insufficiency include hypertension, hyperlipidemia, cigarette smoking, diabetes mellitus, blunt perineal or pelvic trauma, and pelvic irradiation.
- 30. ARTERIOSCLEROSIS
- 31. ATHEROSCLEROSIS
- 32. GUIDELINES – AMERICAN UROLOGICAL ASSOCIATION • Evaluation and Diagnosis: 1. Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history; a physical examination; and selective laboratory testing. 2. For the man with ED, validated questionnaires are recommended to assess the severity of ED, to measure treatment effectiveness, and to guide future management. 3. Men should be counseled that ED is a risk marker for underlying cardiovascular disease (CVD) and other health conditions that may warrant evaluation and treatment. 4. In men with ED, morning serum total testosterone levels should be measured. 5. For some men with ED, specialized testing and evaluation may be necessary to guide treatment.
- 33. GUIDELINE 6 6. For men being treated for ED, referral to a mental health professional should be considered to promote treatment adherence, reduce performance anxiety, and integrate treatments into a sexual relationship. • When the man’s presenting concern is ED, a comprehensive evaluation and targeted physical exam should be performed.
- 34. GUIDELINE 6 • Given that many men are uncomfortable broaching sexual concerns with a physician, it is critical that the physician initiate the inquiry. • Validated questionnaires may provide an opportunity to initiate a conversation about ED; examples include the Erection Hardness Score and the Sexual Health Inventory for Men. • General medical history factors to consider when a man presents with ED are age, comorbid medical and psychological conditions, prior surgeries, medications, family history of vascular disease, and substance use.
- 35. TREATMENT GUIDELINE 6 & 7 7. Clinicians should counsel men with ED who have comorbidities known to negatively affect erectile function that lifestyle modifications, including changes in diet and increased physical activity, improve overall health and may improve erectile function. • The presence of ED indicates the likely presence of other comorbid conditions and risk factors, particularly cardiovascular risk factors and obesity.
- 36. GUIDELINES 8&9 8. Men with ED should be informed regarding the treatment option of oral phosphodiesterase type 5 inhibitor (PDE5i), including discussion of benefits and risks/burdens, unless contraindicated. 9. When men are prescribed an oral PDE5i for the treatment of ED, instructions should be provided to maximize benefit/efficacy.
- 37. GUIDELINE 10 10. For men who are prescribed PDE5i, the dose should be titrated to provide optimal efficacy. • The most commonly used oral phosphodiesterase type 5 inhibitors (PDE5i) for management of ED in Kenya include sildenafil, tadalafil, vardenafil, and avanafil. • Studies report that, men with diabetes and men who are post-prostatectomy have more severe ED at baseline and respond less robustly to PDE5i.
- 38. GUIDELINE 10 • The most frequently reported adverse events (AEs) in men using PDE5i are dyspepsia, headache, flushing, back pain, nasal congestion, myalgia, visual disturbance, and dizziness. • The use of nitrate-containing medications in combination with a PDE5i can cause a precipitous drop in blood pressure. As such, men taking nitrates regularly should not use PDE5i medications.
- 39. GUIDELINE 10 • In men with mild to moderate hepatic or renal impairment or men with spinal cord injury, PDE5i should be used with caution at least initially at lower doses given the potential for delayed metabolism. • In men with severe renal or liver disease, use of PDE5i is generally not recommended.
- 40. GUIDELINE 10 • Given that incorrect use of PDE5i (e.g., lack of sexual stimulation, medication taken with a large meal) accounts for a large percentage of treatment failures, men who are prescribed a PDE5i should be carefully instructed in the appropriate use of the medication. • In particular, it should be explained that sexual stimulation is necessary and that more than one trial with the medication may be required to establish efficacy.
- 41. GUIDELINE 11 11. Men who desire preservation of erectile function after treatment for prostate cancer by radical prostatectomy (RP) or radiotherapy (RT) should be informed that early use of PDE5i post-treatment may not improve spontaneously.
- 42. GUIDELINES 12 &13 • 12. Men with ED and testosterone deficiency (TD) who are considering ED treatment with a PDE5i should be informed that PDE5i may be more effective if combined with testosterone therapy. • 13. Men with ED should be informed regarding the treatment option of a vacuum erection device (VED), including discussion of benefits and risks/burdens.
- 43. GUIDELINES 14 • 14. Men with ED should be informed regarding the treatment option of intraurethral (IU) alprostadil, including discussion of benefits and risks/burdens.
- 44. GUIDELINE 15 • 15. For men with ED who are considering the use of IU alprostadil, an in-office test should be performed. • Intraurethral (IU) medication involves the insertion of a delivery catheter into the meatus and depositing an alprostadil (prostaglandin E1) pellet in the urethra to induce an erection sufficient for intercourse. • IU alprostadil is a treatment option for men for whom PDE5i are contraindicated, for men or partners who prefer to avoid oral medication, and/or for men or partners who prefer not to use the needles required for ICI medications.
- 47. GUIDELINE 16 • 16. Men with ED should be informed regarding the treatment option of intracavernosal injections (ICI), including discussion of benefits and risks/burdens. • Intracavernosal injection (ICI) therapy refers to direct injection of a vasodilatory medication or combination of medications into the corpus cavernosum to induce an involuntary erection
- 49. GUIDELINE 17 • 17. For men with ED who are considering ICI therapy, an in-office injection test should be performed. • ICI medications are administered by injecting alprostadil, papaverine, phentolamine, and/or atropine into the corpus cavernosum of the penis to produce an erection. Only alprostadil is FDA-approved in the U.S. for ICI injection, and it is the only medication typically used as a single agent.
- 50. GUIDELINE 17 • The three other medications with established efficacy for ED are typically used in combination with one another (e.g., papaverine + phentolamine, alprostadil + papaverine + phentolamine; alprostadil + papaverine + phentolamine + atropine). • Men should be thoroughly counseled regarding the potential differential risk profiles of the various ICI substances. The most serious AE associated with ICI medications is priapism with lowest rates of priapism (mean 1.8%) reported in studies using alprostadil.
- 51. GUIDELINE 18, 19,20 • 18. Men with ED should be informed regarding the treatment option of penile prosthesis implantation, including discussion of benefits and risks/burdens. • 19. Men with ED who have decided on penile implantation surgery should be counseled regarding post-operative expectations. (Clinical Principle) • 20. Penile prosthetic surgery should not be performed in the presence of systemic, cutaneous, or urinary tract infection.
- 52. GUIDELINE 18, 19,20 • Men and their partners should be thoroughly counseled regarding the benefits and potential risks of penile implant surgery to ensure appropriate choice of device, realistic post-operative expectations, and potential for high satisfaction. • Men and their partners should be counseled regarding AEs in the peri- and post-operative period, including penile edema or hematoma, corporeal injury, urethral injury, and acute urinary retention.
- 53. • These AEs are rarely serious and generally resolve with supportive care or minimal intervention. Infection is a serious AE that typically occurs within the first three months after surgery and usually requires removal of the prosthesis. • Given the invasive and essentially irreversible nature of penile prosthesis implantation surgery, counseling regarding short- and long-term postoperative expectations is essential.
- 54. GUIDELINE 21 • 21. For young men with ED and focal pelvic/penile arterial occlusion and without documented generalized vascular disease or veno-occlusive dysfunction, penile arterial reconstruction may be considered. • Penile arterial reconstruction surgery may be considered for the man with ED who is young and who does not have veno-occlusive dysfunction or any evidence of generalized vascular disease or other comorbidities that could compromise vascular integrity.
- 55. GUIDELINE 22 • 22. For men with ED, penile venous surgery is not recommended. • Penile venous surgery is not recommended because of the lack of compelling evidence that it constitutes an effective ED management strategy in most men. Randomized trials of men who underwent various versions of penile venous ligation surgery indicate that penile venous ligation surgery is unlikely to result in long- term successful management of ED for the overwhelming majority of men and delays treatment with other more reliable options such as penile prosthesis surgery.