Inability to attain/maintain penile erection sufficient for satisfactory sexual performance
ED
52% of men over __ y/o have some degree of ED
40
What are the 2 processes of normal erection?
- Relaxation of smooth muscles of cavernosal artery –> increased inflow of blood to corpora cavernosa
- Increased venous outflow resistance –> decreased outflow
Normal physiology of erections
- Relaxation of smooth muscles of cavernosal arterial wall
- ______ nerves release _____
- Increased ____ and ____ in cells of smooth muscle surrounding cavernosal arteries
- Decreased intracellular ____
- Smooth muscle relaxation, vasodilation
- Wider diameter of artery
- Greater inflow of blood into _____ of penile shaft
- Parasympathetic / nitric oxide (NO)
- cyclic-GMP & cyclic-AMP
- calcium
- corpora cavernosa
Normal physiology of erections
- Increased venous outflow resistance
- High inflow into corpora cavernosa causes corpora cavernosa to expand & compress the _______
- Decreased outflow of blood via the ____ from the penis –> erection occurs and is sustained
- venous sinuses
- venous system
6 etiologies of ED
- Vasculogenic
- Neurogenic
- Psychogenic
- Endocrine
- Medication induced
- Disease states
What are the 2 vasculogenic problems?
- Arterial inflow problem
- Venous outflow problem
Cause of neurogenic ED
Prostatectomy
(prostate removed, nerves are taken with it)
4 psychogenic causes of ED
- Depression
- Stress
- Anxiety
- Psychiatric disorders
“PADS” bc psychos need padded room
4 endocrine causes of ED
- Hyperprolactinemia
- thyroid disorder
- SHBG (sex hormone binding globulin)
- Hypogonadism
3 main types of meds which cause ED
- antihypertensives
- antidepressants & antipsychotics
- meds which reduce testosterone
What are the 4 antihypertensives which cause ED?
- Beta Blockers
- Thiazides
- Clonidine
- Methyldopa
4 antidepressants/antipsychotics which cause ED
- Tricyclic antidepressants
- MAO-I
- Lithium
- Phenothiazines (thorazine, compazine)
6 meds that can reduce testosterone
- Cimetidine
- Spironolactone
- Ketoconizole
- LHRH agonists (leuprolide)
- Non-steroidal anti-androgens (flutamide, bicalutamide)
- Estrogens (DES) = Diethylstilbestrol
What are 5 “other meds/drugs” which cause ED?
- Sedatives
- Phenytoin
- Anticholinergics
- Alcohol
- Tobacco smoking
3 disease states which cause ED
- Medical
- Surgical
- Traumatic
4 medical disease states causing ED
- Chronic renal insufficiency
- DM
- Chronic hepatic disease
- Neurologic, atherosclerotic disease, endocrine
2 surgical disease states which cause ED
- Prostatectomy & Cystectomy
2 traumatic disease states which cause ED
- Pelvic fx
- Penile fx
(fascia tear)
What scale is used?
International Index of Erectile Function
(IIEF Scale)
5 PE components of ED
- Circulation
- Gynecomastia
- Galactorrhea
- Visual field defects (caused by prolactinoma)
- External genitalia exam (penis & testes)
3 ways to eval ED
- Testosterone
- if pt has decreased libido / physical findings
- total testosterone
- bioavailable testosterone
- highest from 7a-11a
- Prolactin
- Nocturnal penile tumescence (postage stamp) if it falls off pt had a night time erection
2 imaging studies for ED
- Penile duplex dopper sonography
- tests for arterial insufficiency
- cavernosal injection w/ vasoactive med
- Arterial flow measured
- Arterial diameter measured
- Cavernosometry / Cavernosography
- tests for venous leak
- cavernosal injection w/ vasoactive med
- cavernosal needle for inflow of saline
- measures rate of inflow of saline required to maintain erection
Which test?
- tests for venous leak
- cavernosal injection w/ vasoactive med
- cavernosal needle for inflow of saline
- measures rate of inflow of saline required to maintain erection
Cavernsometry / Cavernosography
