Sexual function and dysfunction in men

Transcription

1 Georges A. de Boccard,, M.D. Consultant Urologist F.E.B.U. Sexual function and dysfunction in men Geneva Foundation for Medical Education and Research Training Course in Reproductive Health / Sexual Health Research Geneva 2006

2 The physical pathways of a normal erection? After erotical stimulation And physical stimulation visual tactile genital

3 1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments

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5 Pituitary & gonadic physiology - - Testostérone E(?) LH + GnRH + Hypothalamus Anterior pituitary FSH Testosterone behaviour prostate bones T E(?) + Testis

6 Anatomy UrologyHealth.org Anatomical Drawings

7 Anatomy UrologyHealth.org Anatomical Drawings

8 Neurophysiology Cavernous Nerves Parasympathetic nitrergic Sympathetic adrenergic control of the blood flow (rigidity- flaccidity) Pudendal Nerves Sensitive (positive feed-back) motors : contraction of perineal muscles (ischio- and bulbocavernous)

9 Functional neuroanatomy of erection Cortex Hypothalamus Limbic System Thalamus Medulla Oblongata Autonomic nuclei in Reticular Formation Systemic effects Sympathetic Chain Ganglia T11-L2 S2-S4 Pelvic Nerve Superior Hypogastric Plexus Hypogastric Nerve Pelvic Plaxus Pudendal Nerve Cavernous Nerve Dorsal Nerve of the Penis P Hedlund

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11 Penile anatomy

12 Vascularisation

13 Anatomy of corpus cavernous Flaccidity Erection

14 Erectile physiology cgmp Ca ++ NO

15 NO - cgmp relaxation of the cavernous smooth muscle inducing erection

16 1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments

17 Incidence of erectile dysfunction in Europe ,3 % (%) ,7 % Total 12,8 % 1,7 % ,6 % ,6 % >70 S.I.M.G. Epidemiologic Study, 1997

18 1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments

19 Causes of erectile dysfunctions 18% psychogenic 43% physical 57% 82% 39% mix

20 Causes of erectile dysfunctions Hormonal disorders 6% Medical treatment 8% Drug addiction 7% Vascular diseases 33% Neurological affection 11% Radical surgery in the pelvis 10% Diabetes 25% Stief et. Al, Zeitgemäße Therapie der erektilen Dysfunktion, Springer Verlag

21 Causes of erectile dysfunctions Role of the vascular endothelium Any condition that induces a lack of NO production from the vascular endothelium may be a cause of erectile dysfunction. Since NO secretion is centrally modulated (brain), any relational disturbance will negatively affect the corpus cavernous, The same way as a vascular or neurological disorder.

22 Causes of erectile dysfunctions NO GTP 5 GMP Guanylate cyclase Ca 2+ Ca 2+ Ca 2+ Ca 2+ PK cgmp Ca 2+ Ca 2+ Ca 2+ Inhibitors PDE5 Muscle relaxation - erection

23 Hormones and aging Pituitary GH LH / FSH ACTH = IGF-1 Somatopause E 2 / T Menopause / Androclysis DHEA Adrenopause

24 Day-night testosterone level Testosterone level (ng/ml) Age 25 y. Age 71 y time Bremner et al, J Clin Endocrinol Metab 1983; 56: 1278

25 1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments

26 Diagnostic tools Special investigations Duplex sonography with pharmacostimulation Intra cavernous injection test Lab. Blood and hormonal status Physical examination History

27 History Onset, nature, duration Rigidity, shape of the penis External factors (psych. or prof.. stress) Associated diseases Former therapies Expectations regarding the treatment.

28 Physical examination General condition Blood pressure, pulsations External genitals Inflammatory diseases (teeth) DRE Neurological evaluation

29 Lab tests Fasting glycaemia (HbA1c) Lipidic profile Blood formula Liver enzymes Hormones Testosterone (free) (PRL TSH T4) PSA % free PSA Urine

30 Specific tests Duplex sonography + intracavernosal prostaglandin Nocturnal penile tumescence test Vascular imaging Neurological testing

31 Duplex sonography PGE1 injection Art.flow>30cm/s Venous leakage

32 NPT REM sleep phases History

33 Vascular radiology arteriography cavernosography Anxiety / fibrosis

34 1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments

35 Hormonal treatment Testosterone injection Testosterone oral Testosterone transdermal testosterone undecanoate testosterone enanthate Testosterone gel

36 PDE5 inhibitors Sildenafil Tadalafil Vardenafil CH 3 O CH 3 N H H H O CH 3 N N O O O S N O HN N N N CH3 HCl N O O H 3 C Viagra Pfizer Cialis Lilly-Icos Levitra GSK-Bayer

37 PDE5 inhib.. preferences 40% 43% 17% (34/86) (15/86) Levitra 20mg Viagra 100mg Cialis 20mg Sommer et al. (2003), ESSM, Istanbul

38 Yohimbini Tadalafil (Cialis) N H H H O CH3 N N O O O

39 MACA (lepidium Meyenii) Gonzales G. & al Effect of Lepidium Meyenii (MACA) on sexual desire and its absent relationship with serum testosterone levels in adult healthy men. Andrology 34,

40 PDE5 inhibitors, what dosage? Occasional treatment 1 tabl.. 30 to 60 min before planned intercourse Long term treatment Tadalafil (Cialis): x 20 mg per week during 2-88 weeks Vardenafil (Levitra): 2-3x 2 5 or 10 mg per week during weeks Sildenafil (Viagra): 2-3x 2 25 or 50 mg per week during weeks

41 PDE5 inhibitors, tips It is important to separate the intake of the pill from the intercourse in order to avoid a medically generated performance anxiety. The medication shall not necessarily induce a rigid erection It should facilitate an erection following a normal love process.

42 PDE5 inhibitors: warning Simultaneous treatments with NO donors (nitroglycerine etc) that will induce a possibly dangerous hypotension Contra indication to sexual activity Cardiovascular diseases like Recent myocardial infarction or angina Ictus Arrhythmia, uncontrolled hypertension

43 Muse Alprostadil

44 MUSE Alprostatil

45 Caverject Alprostatil

46 Caverject Alprostatil Corpus cavernous Injection in the corpous cavernous

47 Semi rigid implant Acuform (Mentor)

48 Inflatable implant (AMS 700) réservoir de liquide Reservoir (full) pompe / soupape Reservoir (empty) cylindres

49 What s in a man s mind Dr Georges-A. de Boccard March 10 th, 2006