Sexual dysfunctions in men
Sources – 1. Smith’s general urology -17th edition
2. Clinical manual of Sexual medicine –
editors- T. Lue, F. Giuliano, S. Khoury, R. Rosen
Presented by - Giorgi Changashvili
CONTENTS
1. Erectile dysfunction
Basic considerations (Anatomy, Physiology, Cellular molecular process, Endocrine
factors of ED, Pathophysiology of erection)
diagnostic assessment and prevalence ( basic evaluation, selected optional
tests, diagnosis and evaluation algorithm, prevalence)
treatment ( oral therapy, intracorporeal pharmacological therapy, intraurethral
and intrameatal therapy, androgen replacement therapy, vacuum tumescence
device, vascular surgery, penile prothesis, psychosexual and couple therapy,
treatment strategy)
2. Ejacualtion and orgasmic disorders
3. Peyronie’s disease
4. priaprism
Anatomy of
penis
arterial supply
Anatomy of the penis
venous drainage
Innervation
Autonomic somatosensory
Sexual cycle in men
Types of erection
Psychogenic erection
Reflexogenic erection
Vascular events during erection
۰smooth muscle
relaxation
۰Increase of arterial
inflow.
۰restriction of venous
outflow
Peripheral control of erection
Neuronal relaxing factors endothelial relaxing factors
Acetylcholine 1. Nitric oxide (NO)
Nitric oxide (NO) 2. Prostanoids (e.g. PGE1)
Vasoactive intestinal polypeptide
Intracellular molecular
process
relaxation
Phosphodiesterase 5
Intracellular
molecular process
contraction
gap junctions
Endocrine factors and ED
Pathophysiology of erectile disfunction
Causes
• Organic cause
• Psychogenic cause
• Mixed cause
Vasculogenic erectile dysfunction
Psychogenic erectile dysfunction
Primary psychological erectile dysfunction – the cause
is found in the patient’s past ( social situation, sexual
abuse, education, etc.)
Secondary psychological erectile dysfunction – is
mainly due to specific situations, such as performance
anxiety, depression an partner relationship problems.
The neurological mechanisms of this dysfunction are
complex and have not been fully elucidated:
1. Psychogenic signal may inhibit activation of NO-
mediated parasympathetic nerves.
2. Excessive sympathetic outflow in an anxious man may
increase the constriction effect on penile smooth
muscle tone and maintain penile flaccidity.
Endocrine erectile dysfunction
Endocrine abnormalities
Mainly Hypogonadism may lead to ED. Hyperprolactinemia
and thyroid disorders are a rare cause od sexual dysfunction.
Hypogonadal men have decreased sexual interest and desire,
but do not necessarily lose erection, which is nevertheless
reduced in terms of both rigidity and duration.
Hyperprolactinemia
A significant rise in serum prolactin ( generally a prolactin-
secreting pituitary tumor) may result in ED, reduced libido,
infertility and galactorrhea. The mechanism may be due to
secondary hypogonadism. Prolactin causes decreased GBRH
secretion by the hypothalamus leading to decreased LH and FSH
and testosterone. It also appears to interfere with peripheral
testosterone metabolism.
Hypothyroidism and hyperthyroidism
Can rarely cause ED by a negative action on androgen and
Neurogenic Erectile disfunction
Events that disrupt central neural networks or the peripheral
nerves involved in sexual functions can cause neurogenic ED.
10% to 20 % of cases of ED are due to a neurogenic cause. Other
causes of ED may also coexist, such as in the case of diabetes.
Eiology
Neurogenic ED can be classified as:
Supraspinal
Spinal: sacral and suprasacral
peripheral
Neurogenic Erectile disfunction
Supraspinal lesions
Various brain lesions may induce ED. In these cases, erectile dysfunction is of the a symptom of the
imbalance between pro-erectile and anti-erectile stimuli and the clinical presentation can be vary
heterogenous.
Spinal lesions
The degree of completeness and the level of the lesion determine the extent of erectile dysfunction.
Lesions above the sacral erection center
Reflexogenic erection is generally maintained. In these patients, minimal tactile stimulation can trigger
erection, which is however of short duration requiring continuous stimulation to maintain erection. Patients
with an incomplete lesion can receive input from psychogenic erection and maintain erectile function.
Lesions affecting the sacral erection center
Patients with a lesion of the sacral erection center do not have reflexogenic erection and do not respond
to psychogenic stimulation.
Peripheral lesions
Peripheral lesions can be secondary to disruption of the sensory afferent nerves carrying information from
the penis to the central nervous system or disruption of efferent nerves that mediate arterial and trabecular
smooth muscle dilation
Iatrogenic erectile disfunction
Surgical ED
Surgery can cause ED, generally by damaging the nerves and/or arteries that are
essential for erection.
Damage to neural control: Brain and spinal surgery.
Damage to pelvis nerves: radical pelvic surgery ( Bladder, prostate, rectum).
Damage to penile vasculature: Aorto-iliac surgery, surgery for priapism, Peyronie’s
disease, urethroplasty.
Erectile dysfunction after radical pelvic surgery
Usually due to a neurological lesion of the pelvic plexus or cavernous nerves located in
the postero-lateral aspect of the prostate.
Incidence of ED after radical bladder or prostate surgery, was virtually 100% in past, but
has been improved with the introduction of nerve-sparing procedures.
Maintenance of erectile capacity with these techniques varies between 35% and 70%
depending on the surgical technique, the clinical and pathological staging of the tumor
and the patient’s age.
Erectile function can be slowly recovered over a period of 12 to 18 months after radical
pelvic surgery. Early treatment improves the probability of recovering erectile function (
penile rehabilitation).
Iatrogenic erectile disfunction
Drug-induced
Various kinds of drugs can induce ED.
Radiotherapy of pelvic organs
Radiotherapy may cause vasculitis which leads to radiation damage to small
cavernosal vessels and nerves.
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