DR. Krishna Govind Lodha

Definition: The consistent inability to obtain and maintain

penile erection sufficient to complete satisfactory sexual performance

Estimated to affect 152millions men worldwide

Non-diabetic men 0.1-18.4% prevalence

In a study of 541 diabetic males◦ 35% in diabetic men◦ 5.7% in 20-24 year olds◦ 52.4% in 55-59 years olds

ED is a growing problem◦ Massachusetts Male Aging Study estimate an 11% world increase by 2015

◦ Phimosis

◦ Penile fibrosis

◦ Tumours

◦ Trauma

Historical Perspective

Public health Significance

Management Principals

Diagnostic Evaluation

Specialized Evaluation and Testing

Treatment Consideration

Future Direction

The value of properly assessing and managing ED relates not only to affected individuals and their partners but also to society as a whole, and its scope encompasses physical and mental wellness aspects related to addressing (or failing to address) the sexual dysfunction, concurrent

disease management issues, and socioeconomic burden.

1.Early Detection : patients with identifiable ED risk factors likely experience the sexual dysfunction currently or will eventually develop it at sometime. Clinical screening of such patients based on these indications may allow advantageous opportunities to diagnose and treat ED.

The basic aim of goal-directed management is to allow the patient or couple to make an informed selection of the preferred therapy for sexual fulfillment on the basis of a sound understanding of all treatment options after completing a thorough discussion with the treating clinician.

The approach recognizes that patients vary in their acceptance of their sexual disorders and in their interest to pursue management. Their decisions accordingly follow individual preferences, needs, and expectations regarding management options.

The “Process of Care Model for Erectile Dysfunction” was proposed as a stepwise methodology, combining processes, actions, and outcomes in the management of the ED patient (Process of Care Consensus Panel, 1999).

It specified an algorithm for therapeutic decision making that takes into account patient needs and preferences (goal-directed management), it was also based on specific criteria such as ease of administration, reversibility, relative invasiveness, and cost of therapies.

This algorithm presented a strategy of staged therapy (i.e., first-, second-, and third-line interventions), which ranged from lifestyle modification to surgery.

An informed decision-making process should dictate the best therapeutic option. It follows a balanced and thorough discussion led by the clinician of all treatment options, both medical and nonmedical, and their expected advantages and disadvantages. Perceived risks and benefits, which may be influenced by the individual clinical situation, should be weighed.

Indications are failure of initial treatment,

Urologist; younger patients with a history of pelvic or perineal trauma, significant penile deformity (e.g., Peyronie disease, congenital chordee),

Endocrinologist; complicated endocrinopathies (e.g., secondary hypogonadism, pituitary adenoma),

Psychiatrist;; complicated psychiatric hypoactive sexual desire),

Vascular surgeon or neurosurgeon, respectively;

vascular or neurosurgical intervention (e.g., aortic aneurysm, lumbosacral disc disease.

Primary basis is to ensure continual success with the therapeutic outcome. It has been shown that treatment discontinuation occurs at high rates among patients who are not reassessed regularly (Albaugh et al, 2002).

Patient’s description of the problem

Patient’s and partners expectations

Duration

Speed of onset

Intermittent/progressive?

History of sexual partners

Nocturnal erections?

Libido

PMH◦ Glycaemic control

◦ Vascular/neurological disease

◦ Urological

◦ Pelvic surgery and trauma

Drug history◦ Anti- hypertensive's

◦ Androgen antagonists

◦ Sedatives

◦ Drugs that cause hyperprolactinaemia (phenolthiazides)

◦ Alcohol

Psychological assessment

General

Vascular

Neurological

Genitalia

DRE

Serum chemistries

CBC

LIPID PROFILE

Diabetic: fasting glucose ,PPBS

Endocrine◦ 9am Testosterone

◦ Thyroid function tests

◦ Pituitary hormones (LH,FSH,PRL)

◦ PROLACTIN

Serum PSA

URINE FOR glycosuria

Goal to improve diagnostic accuracy and direct successful therapy on the

basis of the specific diagnosis.

Aim to arterial impairment and veno occlusive dysfunction.

Combined intracavernous injection and stimulation (CIS): First line evaluation of penile blood flow.

The test involves the intracavernous injection of a vasodilator drug or drugs as a direct pharmacologic stimulus ,combined with genital or audiovisual sexual stimulation , and the erectile response is observed and rated by an independent assessor.

The test is designed to bypass neurologic and hormonal influences involved in the erectile response and allows the clinician to evaluate the vascular status of the penis directly and objectively.

It is the most reliable and least invasive diagnostic modality for assessing ED.

Cavernous arterial insufficiency is suggested when PSV is less than 25 cm/sec; a PSV[peak systolic velocity] consistently greater than 35 cm/sec defines normal cavernous arterial inflow.

Indicated for select patients who have a site-specific vasculogenic leak due to perineal or pelvic trauma or who have had life-long ED (primary ED).

for corrective penile vascular surgery.

The existence of venoocclusive dysfunction is indicated by the failure to increase intracavernous pressure to the level of the mean systolic blood pressure with saline infusion or the demonstration of a rapid drop of intracavernous pressure after cessation of saline infusion.

Cavernosography follows Cavernosometry evaluation and is intended to reveal the site of venous leakage

Reserved for the young patient with ED secondary to a traumatic arterial disruption or the patient with a history of penile compression injury,

Penile Tumescence and Rigidity Monitor:

Nocturnal penile tumescence and rigidity (NPTR)

Recommended criteria for normal NPTR include four to five erectile episodes per night, mean duration longer than 30 minutes, an increase in circumference of more than 3 cm at the base and more than 2 cm at the tip, and maximal rigidity above 70% at both base and TIP.

Rigiscan: An automated, portable device used for NPTR,

ED is associated with anxiety, depression, low degrees of self-esteem, negative outlook on life, self-reported emotional stress, and a history of sexual coercion.

In the absence of organic risk factors, a primary psychogenic ED causation may be suspected. Further support for the diagnosis may follow the confirmation of noncoital erections (i.e., masturbatory, nocturnal or on awakening).

Target sites for evaluation include peripheral, spinal, and supraspinal centers, as well as both somatic and autonomic pathways involved in this biologic response.

Tests : SOMATIC Nervous system;

Biothesiometery : affrent sensory function

Evoked Response-Bulbocavernosus reflux latency: >30-40msec indicate neuropathology.

Dorsal nerve conduction velocity

Genitocerbral evoked potential

Autonomic nervous system: Heart rate variability and sympathetic skin responses

Penile thermal sensory testing

Copus cavernous EMG

Serum testosterone measurement : The best indicator of androgen status is the calculated bioavailable testosterone (free testosterone and albumin-bound testosterone).

The typical reference range for the total testosterone measurement is 280 to 1000 ng/dl.

Serum Gonadotropin : Measurement of serum gonadotropins will help to localize the source of the hypogonadism

Serum Prolactin : Hyperprolactinaemia causes hypogonadism by suppression of gonadotropins-releasing hormone from the hypothalamus, which impairs pulsatile LH secretion required for serum testosterone production by the gonads.

Serum Thyroid function :Hyperthyroidism is associated with ED, possibly by increasing aromatization of testosterone into estrogen (which raises levels of SHBG) (Morales et al, 2004) or by increasing adrenergic tone (which causes smooth muscle contractile effects or exerts psycho-behavioral effects

Life style modification:

• Quit smoking

• Regular exercise

• Weight control

Medication change:

Psychosexual therapy: A variety of interventions are used: systematic anxiety reduction/ desensitization, sensate focus, interpersonal therapy, cognitive-behavior therapy, sex education, couples’ communication and sexual skills training.

ORAL Therapy: Phosphodiesterase V inhibitors◦ Sildenafl (Viagra) 4hr

◦ Tadalafil (Cialis) 17hrs

◦ Vardenafil (Levita) 4 hrs

PDE5 inhibitors: increases cGMP in the smooth muscle

of the corpus cavernosum, causing prolongedvasodilation and a firmer, longer-lasting erection.

PDE5 inhibitors have been shown to be effective in men with diabetes, hypertension, coronary artery disease, peripheral vascular disease, and spinal cord injury, as well as after coronary artery bypass surgery, transurethral prostatectomy (TURP), and radical prostatectomy.

The poorer the blood supply, the more damaged the nerves (such as from surgery), and the more prolonged the dysfunction, the poorer the response.

Unlike injection therapy, PDE5 inhibitors require sexual stimulation for an erection to occur.

concomitant use of nitrates is an absolutecontraindication PDE5 inhibition potentiates thehypotensive effects of nitrates.

The use of alpha adrenergic blockers also increasesthe risk for hypotension and generally should beavoided.

Relative contraindications include MI, stroke, ordysrhythmia within the past 6 months; poorlycontrolled hypertension or hypotension;uncompensated cardiac failure; unstable angina; apredisposition to priapism; and retinitis pigmentosa.

The most common side effects reported includeheadache, flushing, dyspepsia, and nasal congestion.The inhibition of phosphodiesterase 6 in the retina bysildenafil may cause altered color vision–usually a bluetinge—or increased sensitivity to light in some men.

Other Oral Agent Yohimbine is an oral alpha-2 adrenergic-

receptor blocker that may improve erectile function better than placebo, particularly in psychogenic impotence.

Studies remain ongoing for the use ofphentolamine, apomorphine, dopaminergic, andmany other agents.

Testosterone replacement

Improves erectile function and libido

Preparations◦ Topical (testim gel)

◦ Im testosterone

◦ Long-acting depots

Intracavernosal injections with prostaglandins◦ Alprostadil (prostaglandin E1),PHENTOLAMINE, PAPAVERIN

One large RCT found increased rate of satisfactory erections when Alprostadil injected compared to placebo

Side effects – pain, priapism

Contraindicated : psychologic instability

history of priapism

severe coagulopathy

unstable cardiovascular disease

Alprostadil via urethral channel

Response rate ~50%

s/e local urogenital pain , urethral bleed ,hypotension dizziness

Effective but requires sufficient training

Drugs used are :nitroglycerin papevarin alprostadil etc.

The principle of vacuum erection device therapy is to mechanically create negative pressure surrounding the penis in order to engorge it with blood and then restrain blood egress from the organ to maintain the erection-like effect.

Efficacy rates in achieving satisfactory erections of 67% to 90% have been reported for ED associated with various severities and etiologies, but satisfaction rates with the device are lower, ranging from 34% to 68%

Can improve erection

Messy and user dependent

Satisfaction varies 35-80%

Complications

Minor complications include penile pain and numbness, difficult ejaculation, ecchymosis, and petechiae.

Major complications (e.g., penile skin necrosis, urethral varicosities, Fournier gangrene) are infrequent. Patients receiving anticoagulant therapy (e.g., aspirin, warfarin) and patients with bleeding disorders should use the device with caution.

Which are made of rubber, slow venous outflow at the base of the penis and may be useful for men who can obtain erections but cannot sustain them.

Constriction rings can produce local discomfort and, if too tight, difficulty

with ejaculation.

They are applied in the face of penile injury resulting from genital or pelvic trauma, penile structural deformity occurring in association with Peyronie disease, or possibly cavernosal fibrosis secondary to prolonged ischemic priapism or infection. They are also considered when medical therapy for ED is contraindicated, unsuccessful, or undesirable.

A permanent penile prosthesis may help a patient with an otherwiseuntreatable potency problem. Such a prosthesis is irreversible and thereforeshould be used only as a last resort.

Penile implants can be noninflatable (positionable or semirigid rodprosthesis) and inflatable.

Contraindications to this treatment include psychiatric problems such aspsychosis and untreated depression.

Complications include infection, mechanical failure, and penile fibrosis.

The ideal prosthesis would its recipient with a penis that resembles as closely as possible normal penile flaccidity and erection. Only three-piece inflatable devices that transfer a large volume of fluid into the penile cylinders for erection and out of the cylinders for flaccidity approach this ideal.

•Inflatable

•Malleable

Longitudinal penoscrotal incision with longitudinal dividation of superficial dartose fascia

Deep layers opened transversely

This providedartos flap to burry tube

2cm corporotomies made and two horizontal mattress suture of 2-0 PDS on each side of corporotomy used as guide during dilatation and measurement as well as closure of colopotomy

Dilatation start with 8mm hegar dilator and up to 16 mm proximally and 14mm distally

It is important to size cylinders exactly to fill the entire corpora. Cylinders should be neither too short, producing the supersonic transporter (SST) deformity (Ball, 1980), nor too long, producing bucking within the corpora. We do not include the 2-cm corporotomy in the measurement because we believe that surface sizing with a rigid measuring tool introduces a 2-cm measuring error (Montague et al, 2003).

Pinoscrotal IncisionIdentification of urethra and erection chamber

Left erection chamber opened dilated and measured for cylinder placement

Right erection chamber opened dilated and measured for cylinder placement

Cylinder inserted into prepared erection chamber

Reservoir placement in a scrotal pouch

Reservoir filled with saline and connected to pump

Pump installed between the testicles at bottom of scrotum and skin is closed

INFECTION

PERFORATION and Erosion

POOR GLANS support =supersonic transporter deformity

Pump complication

Autoinflation

Mechanical failure

Arterial surgery is relatively experimental . inclusion criteria should be

met to select patients for arterial surgery:

Age younger than 55 years, nonsmoker, nondiabetic,

Absence of venous leakage, and radiographic confirmation

of stenosis of the internal pudendal artery (Hellstromet al, 2010).

The highest success rates are reported in young men (younger than

30 years of age) with isolated arterial stenosis following perineal or pelvic trauma

VENOUS surgery are in experimental phase

THANK YOU