13-Oct-15 ERECTILE DYSFUNCTION. Urology Subdepartement dr. Mintohardjo Naval Hospital dr. Isdiyanto Septiadi, Sp.U

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1 ERECTILE DYSFUNCTION Urology Subdepartement dr. Mintohardjo Naval Hospital dr. Isdiyanto Septiadi, Sp.U 1

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4 So what is impotence or erectile dysfunction..? The persistent inability to achieve or maintain a penile erection sufficient for sexual intercourse. 13-Oct-15 4

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6 Primary ED (ie, the man has never been able to attain or sustain erections) is rare and is almost always due to psychologic factors (guilt, fear of intimacy, depression, severe anxiety) or clinically obvious anatomic abnormalities. Most often, ED is secondary (ie, a man who previously could attain and sustain erections no longer can). Over 80% = have an organic disease, ED leads to secondary psychologic difficulties. 6

7 WHAT IS THE AETIOLOGY OF ED..?? 7

8 HOW NORMAL ERECTION WORK..??? 8

9 PENILE ANATOMY 13-Oct-15 9

10 NORMAL ERECTILE FUNCTION Signal from the brain to penis via cavernosal nerves 10

11 11

12 Arterioles dilate (increased inflow) and venules are compressed (decreased outflow) Tunica albuginea is a non elastic fascial layer surronding the cavernosal bodies. 12

13 SO, FOR NATURAL ERECTIONS YOU NEED Intact nerves (somebody to start the air flow) Good blood flow to the penis (working compressor tubing) Intact/healthy cavernosal tissue ( a good tire sort of) The ability to block venous output from the penis (no leak in the tire) 13

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15 ERECTIONS Nerves to start Arteries to bring blood Tissue to hold the blood Ability to block veins 15

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18 CAUSES OF ED Heart Disease (vascular disease) Diabetes Smoking Peyronie s Disease Medications Prostate Cancer treatment 18

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21 HEART DISEASE AND ED Heart disease is actually vascular (i.e. blood vessel) disease Vascular disease that works on the heart usually is in all the blood vessels in tke body 21

22 HEART DISEASE AND ED Often we see the bood vessel disease first in the as ED Nerves to start Arteries to bring blood Tissue to hold the blood Ability to block veins % of men ED (aged 39-74) had coronary artery disease 22

23 DIABETES Diabetes slowly damages small blood vessels all over the body This decreases blood flow everywhere It really hurts nerves Nerves to start Arteries to bring blood Tissue to hold the blood Ability to block veins 23

24 SMOKING Smoking causes blood vessels to contract and also damages the lining of blood vessels Also directly acts on the nerves and decreases the ability of nerves to cause erections Nerves to start Arteries to bring blood Tissue to hold the blood Ability to block veins 24

25 25

26 PEYRONIE S DISEASE 26

27 PEYRONIE S DISEASE Scarring of the Tunica Albuginea Causes curvature Also can decrease the ability of the penis to block blood flow out of the penis Nerves to start Arteries to bring blood Tissue to hold the blood Ability to block veins 27

28 28

29 LOW TESTOSTERONE Low testosterone clearly associated with decreased sex drive and morning erections Thought to support cavernosal tissue Nerves to start Arteries to bring blood Tissue to hold the blood Ability to block veins 29

30 MEDICATION Blood Pressure medications Antidepressants Narcotics 30

31 PROSTATE CANCER TREATMENT Surgery (open or robotic) Radiation Cryotherapy Hormonal Therapy Watchful Waiting Active Surveillance 31

32 ED PREVELENCE WITH PROSTATE CANCER TREATMENT % after radical retropubic prostatectomy 13 70% after radiation therapy (brachytherapy or external beam radiation) 53 95% after cryotherapy 13-Oct % in patients undergoing hormonal androgen ablation 32

33 33

34 RADICAL PROSTATECTOMY The nerves run near the prostate, are microscopic, and can be injured during the case 34

35 ERECTILE DYSFUNCTION AFTER SURGERY Cavernosal nerves may be cut, cauterized or have excessive traction during surgery Inflammation and healing occur in the prostate bed immediately adjacent to the cavernosal nerves Both of these will cause permanent, or a period of neurapraxia (stunned nerves) (NOBODY TO PUMP AIR INTO THE TIRE) 35

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37 ED AND PENILE SHORTENING There is no difference in penile shortening from ED caused by prostatectomy, radiation to the prostate, and ED from other causes (except Peyronie s) 37

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40 TREATMENTS FOR ERECTILE DYSFUNCTION Tier 1 : Pills (Phosphodiesterase-5 Inhibitor) - Viagra (sildenafil), Levitra (Vardenafil), Cialis (tadalafil) Tier 2 : VED, Injections, MUSE Tier 3 : Implant 40

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46 PENILE IMPLANT Psychological barrier Very high satification rating (72-96%) Irreversible ED treatment perfomed when consevative treatments not effevtive/desired by patient 46

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48 QUESTIONS / DISCUSSION 48

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