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
The physical pathways of a normal erection? After erotical stimulation And physical stimulation visual tactile genital
1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments
Pituitary & gonadic physiology - - Testostérone E(?) LH + GnRH + Hypothalamus Anterior pituitary FSH Testosterone behaviour prostate bones T E(?) + Testis
Anatomy UrologyHealth.org Anatomical Drawings
Anatomy UrologyHealth.org Anatomical Drawings
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)
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
Penile anatomy
Vascularisation
Anatomy of corpus cavernous Flaccidity Erection
Erectile physiology cgmp Ca ++ NO
NO - cgmp relaxation of the cavernous smooth muscle inducing erection
1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments
Incidence of erectile dysfunction in Europe 60 50 48,3 % (%) 40 30 26,7 % 20 10 0 Total 12,8 % 1,7 % 20-39 4,6 % 40-49 15,6 % 50-59 60-70 >70 S.I.M.G. Epidemiologic Study, 1997
1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments
Causes of erectile dysfunctions 18% psychogenic 43% physical 57% 82% 39% mix
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
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.
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
Hormones and aging Pituitary GH LH / FSH ACTH = IGF-1 Somatopause E 2 / T Menopause / Androclysis DHEA Adrenopause
Day-night testosterone level Testosterone level (ng/ml) 8 7 6 5 4 Age 25 y. Age 71 y. 4 8 12 16 20 24 time Bremner et al, J Clin Endocrinol Metab 1983; 56: 1278
1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments
Diagnostic tools Special investigations Duplex sonography with pharmacostimulation Intra cavernous injection test Lab. Blood and hormonal status Physical examination History
History Onset, nature, duration Rigidity, shape of the penis External factors (psych. or prof.. stress) Associated diseases Former therapies Expectations regarding the treatment.
Physical examination General condition Blood pressure, pulsations External genitals Inflammatory diseases (teeth) DRE Neurological evaluation
Lab tests Fasting glycaemia (HbA1c) Lipidic profile Blood formula Liver enzymes Hormones Testosterone (free) (PRL TSH T4) PSA % free PSA Urine
Specific tests Duplex sonography + intracavernosal prostaglandin Nocturnal penile tumescence test Vascular imaging Neurological testing
Duplex sonography PGE1 injection Art.flow>30cm/s Venous leakage
NPT REM sleep phases History
Vascular radiology arteriography cavernosography Anxiety / fibrosis
1. Anatomy and physiology of normal erection 2. Incidence of erectile dysfunctions 3. Causes of erectile dysfunctions 4. Diagnostic tools 5. Treatments
Hormonal treatment Testosterone injection Testosterone oral Testosterone transdermal testosterone undecanoate testosterone enanthate Testosterone gel
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
PDE5 inhib.. preferences 40% 43% 17% (34/86) (15/86) Levitra 20mg Viagra 100mg Cialis 20mg Sommer et al. (2003), ESSM, Istanbul
Yohimbini Tadalafil (Cialis) N H H H O CH3 N N O O O
MACA (lepidium Meyenii) Gonzales G. & al. 2002. Effect of Lepidium Meyenii (MACA) on sexual desire and its absent relationship with serum testosterone levels in adult healthy men. Andrology 34, 367-372.
PDE5 inhibitors, what dosage? Occasional treatment 1 tabl.. 30 to 60 min before planned intercourse Long term treatment Tadalafil (Cialis): 1-21 2 x 20 mg per week during 2-88 weeks Vardenafil (Levitra): 2-3x 2 5 or 10 mg per week during 2-82 8 weeks Sildenafil (Viagra): 2-3x 2 25 or 50 mg per week during 2-82 8 weeks
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.
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
Muse Alprostadil
MUSE Alprostatil
Caverject Alprostatil
Caverject Alprostatil Corpus cavernous Injection in the corpous cavernous
Semi rigid implant Acuform (Mentor)
Inflatable implant (AMS 700) réservoir de liquide Reservoir (full) pompe / soupape Reservoir (empty) cylindres
What s in a man s mind Dr Georges-A. de Boccard March 10 th, 2006