ERECTILE
DYSFUNCTIO
N
Sherine Hosny Ahmed
Prof. of Dermatology, Andrology and
Venereology
1. Define ED
2. Understands the anatomy of penis and the physiology of
erection
3. Recognize sex cycle in both male and female
4. Recall different types of erections
5. List causes of ED, how to differentiate and treat
6. Know, how to take a history, general examination in ED
case.
ERECTILE
DYSFUNCTIO
N (ED)
It is also known as
impotence
Definition: It is the inability
to obtain or maintain erection
of sufficient quality for
satisfactory vaginal
penetration.
Anatomy of the penis
The penis is covered by three layers of fascia:
superficial fascia, deep fascia and tunica
albuginea.
The weight of the penis is supported by two
ligaments: the fundiform and the suspensory
ligaments.
The penis receives innervation from
sympathetic (T11-L2), parasympathetic (S 2-
S4) and somatic nerves (pudendal nerve).
NEUROPHYSIOLOGY AND
NEUROANATOMY
The Penis is supplied by
Autonomic (sympathetic and parasympathetic)
through cavernous nerves and somatic through
pudendal nerve
Sympathetic (T11-L2) norepinephrine
VC ( flaccid state)
Parasympathetic (S2-S4) provide vasodilating
innervation to the cavernosal tissue (erection)
The pudendal pathway, responsible for the
contraction of the perineal striated muscles, enhances
an already present erection
NEUROPHYSIOLOGY AND
NEUROANATOMY
NANC nerves innervating the corpus cavernosum is thought to be
nitroxidergic (nitrergic) nerves which liberate nitric oxide (NO).
Liberated NO activates soluble guanylate cyclase (sGC) in cavernous
smooth muscle cells which increase intracellular cyclic (c) GMP
dilates cavernous smooth muscle induces penile erection.
Nitroxidergic (nitrergic) vasodilator nerves also innervate cavernous
arteries and veins which regulate the blood volume in the corpus
cavernosum.)
SEXUAL
DYSFUNCTI
ON
SEX CYCLE IN MALES AND
FEMALES
Definition: The sexual response cycle is
the sequence of physical and emotional
changes that occur as a person becomes
sexually aroused and participates in
sexually stimulating activities, including
intercourse and masturbation
SEX
CYCLE IN
MALES
AND
FEMALES
TYPES OF ERECTION
Reflexog
Nocturnal
enic
Psychogenic
Psychog Reflexog
enic enic
Tactile stimuli to genital organ
Audiovisual stimuli or fantasy
Send impulses to spinal erection
centers
Impulses from the brain
Ascending tract
To spinal erectile centers (S2-S4) Reflexogenic erectile centers, which
send messages through cavernous
parasympathetic nerves in the penis
Induce erection
Leading to erection
N.B: This type is preserved in upper
spinal cord injury
NOCTURNAL PENILE TUMESCENCE (NPT).
Erections during sleep or upon waking up are known as nocturnal
penile tumescence (NPT).
Absence of NPT is commonly used to distinguish between
organic and psychological causes of erectile dysfunction.
Latent
Tumescence
5 PHASES OF
ERECTION Erection
Rigidity
Detumescence
PHYSIOLOGY OF
ERECTION
It’s a vascular mechanism controlled or influenced by
Psychological,
Neurological &
Endocrinal mechanisms.
Erectile dysfunction
(ED)
Psychogen
Organic
ic
50-80%
20-30%
Organic
causes of
ED
(impotence)
I) Predisposing risk factors
Decrease blood flow &
Hypertension & atherosclerosis antihypertensive drugs
Endocrinal dysfunction, Diabetic
Diabetes Mellitus angiopathy, autonomic neuropathy,
Psychogenic
Hypertension & Decrease blood flow &
atherosclerosis antihypertensive drugs
I) Predisposing risk factors Endocrinal dysfunction, Diabetic
Diabetes Mellitus angiopathy, autonomic
neuropathy, Psychogenic
Hypertension or antihypertensive
therapy, Endocrinal malfunction
Renal failure (hyperprolactinemia and low
testosterone), Uremic neuropathy
Smoking Nicotine causes VC of A &V
Drugs
CONT. PREDISPOSING RISK
FACTORS
Drugs:
o Psychotropic drugs, antihypertensive drugs, cardiac drugs, antihistamines,
H2 receptor antagonist and antiandrogens.
o Drugs of abuse: long term use of narcotics causes decreased libido, erection
and disturb ejaculation.
o Alcohol may initially increase libido, but it will impair erection, ejaculation
and orgasm.
II) ENDOCRINAL CAUSES OF
ED
A) Androgens and Sexual Response
In men androgens are necessary for sexual desire and ejaculation, but
erection and orgasm are not androgen dependent
B) Prolactin
Men with hyperprolactinemia experience loss of libido and ED.
Hyperprolactinemia is associated with decrease of serum testosterone level.
III) VASCULOGENIC CAUSES OF
ED
A) Arterial insufficiency: Commonly seen in cases of
Atherosclerosis, arterial spasm, tumors, trauma and stricture.
Patients with mild to moderate arterial insufficiency will need longer time
to initiate erection while patients with severe arterial insufficiency cannot
initiate erection.
B) Venogenic Causes
A careful balance between blood flow into and out of the erectile bodies is
essential in providing erection.
IV) NEUROGENIC CAUSES OF ED
A. Cerebral disorders: cerebral lesions that affect the hypothalamus,
thalamus or limbic system (e.g. brain surgery, trauma, tumors or
inflammation) may result in impairment of erection, ejaculation or penile
sensation.
B. Spinal cord lesions: the effect on sexual function will depend on the site of
lesion.
C. Peripheral lesion: most peripheral lesions are either traumatic or
iatrogenic.
Psychogen
ic causes
of
ED
(impotenc
e)
PSYCHOGENIC CAUSES OF ED
A) Personal Causes of ED B) Inter-Personal Causes
1. Religious orthodoxy. 1. Lack of attraction of the
2. Gender identity disorders. partner.
3. Fear of loss of control during 2. Poor sexual skills of the
the sexual act. partner.
4. Masked sexual deviation.
3. Ignorance about the pattern
5. Fear of pregnancy.
of female orgasm.
6. Widowers syndrome.
4. Marital conflicts.
7. Depression.
Histor
y
DIAGNOSIS Clinica
OF ED l
exami
na-
tion
I] 1-PERSONAL &
2-SEXUAL HISTORY
ۖ ﴿ ِنَس اُؤ ُكْم َح ْر ٌث َّلُكْم َف ْأُتوا َح ْر َثُكْم َأَّنٰى ِش ْئُتْم
1a) Personal history َأ 1b) Sexual history
َو َق ِّدُم وا َأِلنُف ِس ُكْم ۚ َو اَّتُق وا الَّلَه َو اْعَلُم وا َّنُكم
Age Sexual development
﴾ ُّم اَل ُق وُه ۗ َو َبِّش ِر اْلُم ْؤ ِم ِنيَن
Marital status Sexual education
]223[ :سورة البقرة
Occupation Psychological disorder
Sleep disorder
I] 3-HISTORY OF ED
Onset, course, duration Ejaculation (normal, premature,
Desire retrograde)
Orgasm (present, absent, or
Arousal
pleasureless)
Erection (NPT, Masturbation)
Rigidity
I] 4-MEDICAL &
5-SURGICAL HISTORY
CHD ( hypertension, atherosclerosis, Prostatitis
dyslipidemia)
Pelvic trauma
DM
Pelvic operation
Renal failure
( prostatectomy)
Malignancy
Neurological diseases
I] 6-
HISTORY
ABOUT WIFE
Complete sexual
history of the wife
sexual attitude and
orientation
II]1- GENERAL II] 2- LOCAL
EXAMINATION EXAMINATION
2ary sexual characters ( hypogonadism) Penis ( size , inflammation)
Breast ( gynecomastia or discharge)
Testes (size, consistency,
temperature or any atrophic changes
varicocele, sensation)
Neurological examination in DM and
PR to test for prostatic size,
neurodegenerative disorders for
peripheral neuropathy tenderness
III]
RIGISCAN
It is a small computer that
measures circumferential &
rigidity of the penis during
sleep
Normal rigiscan is
suggestive of psychogenic
ED.
III] EVALUATION OF
PENILE ARTERIES
Doppler,
Penile duplex U/S
ICI ( intracorporal injection) to differentiate
between organic and psychogenic erectile
dysfunctions, normally erection is obtained 10
minutes after injection and is sustained for 30
minutes.
Papverine
PGE1
Trimix
III] EVALUATION OF
PENILE VENOUS
SYSTEM
Cavernosometry is used to evaluate the venous
system and diagnose veno-occlusive disorders.
Cavernosography
TREATMENT
OF
ORGANIC ED
Detect the cause and
treat accordingly
Lifestyle changes and
risk factors
modification
Provide education &
counseling to
patients and partners
1ST LINE OF
TREATMENT
(ORAL THERAPY)
Phosphodiesterase (PDE5) inhibitors e.g.
Sildenafil,
Tadalafil and
Vardenafil
PDE5 inhibitors inhibit the degradation of
cGMP by PDE5, increasing blood flow to
the penis during sexual stimulation.
This mode of action means that PDE5
inhibitors are ineffective without sexual
stimulation.
1ST LINE OF
TREATMENT Assess
(ORAL THERAPY) therape
utic
outcome
Others:
Yohimbine Erection
Side Satisfact
effects ion
L-arginine
Bromocriptine ( in cases of
prolactinemia) Inadequacy
2ND LINE OF Intracorporeal injection
TREATMENT
Vacuum erection device
Inadequacy
3RD LINE OF Penile prothesis implantation
TREATMENT
(SURGERY)
Arterial reconstruction
In cases of penile insufficiency
TREATMENT OF ORGANIC
ED
Surgery
Vacuum erection
device
Oral OR
ICI
WHAT IS
EJACULATION?
Ejaculation is the process by
which sperms moves from
epididymis via vas deferens to
urethra and finally expelled
out through the urethral
meatus by the contraction of
smooth muscles.
A normal antegrade
ejaculation consists of
emission, expulsion
(ejection), and orgasm
Emission: 1st stage of ejaculation
Under sympathetic control
Bladder neck closure
Deposition of seminal fluid into post
urethra
Expulsion:
To propel semen through the urethra
and out the meatus
Under somatic ( pudendal nerve)
causing
Relaxation of external urethral
sphincter
Colonic contraction of ischio-
cavernous, bulbo-cavernous, levator
ani & transverse perineal muscles
Orgasm
Is a CNS phenomenon ( purely
cerebral and emotional cortical
occurrence)
Distinct entity from ejaculation
Coincides with ejaculation
Associated with powerful &
highly pleasurable pelvic
muscles contraction (ischio-
cavernous, bulbo-cavernous)
along with rectal sphincter
contraction
N.B Low level of androgen will
cause weaker orgasm (e.g.
hypogonadism & old people)
INTRODUCTION
OF PE
Premature ejaculation (PE) is a common sexual
problem encountered by men in day-to-day
clinical practice affecting 20-30% of men in the
sexually active age group leading to
Psychological stress and
Loss of self-esteem,
Resulting in significant adverse effects on the
quality of life, of both the patient and the partner.
DEFINITION OF
PREMATURE
EJACULATION
The inability of the male to
control ejaculation long
enough to satisfy his partner
in at least 50% of their
sexual encounters, provided
that the female is normal.
Other factors that can play a role
PSYCHOLOGI include:
CAL CAUSES • Erectile dysfunction. Being anxious
about getting and keeping an erection
might form a pattern of rushing to
•Early sexual experiences ejaculate.
• Anxiety. It's common for premature
•Sexual abuse ejaculation and anxiety to occur together.
The anxiety may be about sexual
•Poor body image performance or related to other issues.
•Depression • Relationship problems. Relationship
issues can contribute to premature
ejaculation.
•Worrying about premature ejaculation
•Guilty feelings that can cause you to
rush through sex
ORGANIC COMPLICATIO
CAUSES (RARE) NS
•Stress and relationship problems.
Genito-urinary tract infections
(urethritis, prostatitis).
Neurogenic causes (peripheral • Fertility problems: This may happen
neuritis). if ejaculation doesn't occur in the
Drugs. vagina
Coitus interruptus.
TREATMENT OF PREMATURE
EJACULATION
1. Selective serotonin reuptake inhibitors (SSRIs):They inhibit the effects of
serotonin on the central ejaculatory reflex.
2. Techniques to help the patient to control his ejaculation:
a. Squeeze technique: squeezing the glans penis by the partner shortly
before ejaculation.
b. Start-stop technique: coital movement is stopped shortly before
ejaculation.
3. Alleviation of hypersensitivity: local anesthetics, double condoms, distraction.
4. Increasing the frequency of intercourse.
