Erectile dysfunction

Good Erectile Function

Having good Erections => crucial for all men Because erections & the coitus they allow major pleasure brings self-confidence confirms his state of being a full worthy male

Comparison of 2 circumcised human penises, erect (on left) & flaccid (on right).

Consensus conference: all men 25 years old & older regardless of sexual dysfunction complaints => should be asked about Erectile Dysfunction RESULTS: Erectile dysfunction = common = early manifestation of atherosclerosis & a precursor to systemic vascular disease. Endothelial dysfn = etiologic factor linking ED & cardiovascular disease CCL: The recognition of ED as an early sign of systemic cardiovascular disease offers an opportunity for prevention, partc. in high-risk & underserved minority populations. The algorithm stipulates that All men 25 years old & older regardless of sexual dysfunction complaints should be asked about Erectiel Dysfunction The presence of ED => should prompt an aggressive assessment for cardiovascular risk & occult systemic vascular disease Billups KL, Bank AJ, Padma-Nathan H, Katz S, Williams R. Erectile dysfunction is a marker for cardiovascular disease: results of theminority health institute expert advisory panel. : J Sex Med. 2005 Jan;2(1):40-50; discussion 50-2. The Epicenter for Sexual Health & Medicine, University of Minnesota School ofmedicine, Minneapolis, USA. klbillups@earthlink.net

Normal erection Erectile dysfunction

Erectile dysfunction = the inability to achieve &/or maintain an erection sufficient to permit satisfactory sexual intercourse Most cases of erectile dysfunction have a vascular etiology &, in patients with known cardiovascular disease, the degree of erectile dysfunction correlates with severity of that disease. In addition, cardiovascular disease and erectile dysfunction share the same risk factors for atherosclerosis & have a common pathophysiology (endothelial dysfunction); thus, erectile dysfunction appears asan early and sentinel symptom in patients with occult vascular disease, of the coronary or carotid arteries Sekoranja L, Bianchi-Demicheli F, Gaspoz JM, Mach F. [Erectile dysfunction: a potential useful marker for cardiovascular disease] Rev Med Suisse. 2006 Mar 22;2(58):774-6, 778. Departement de psychiatrie, HUG, Geneve. lucka.sekoranja@hcuge.ch

Having no good Erections (Erectile dysfunction) => dramatic for all men A man who has no good erections anymore feels this as: major depersonalization major loss of malehood major loss of self-worth = beginning of a process that will cause a premature death

Aging & BMI => erectile dysfunction Erectile dysfunction Increased age (% of men) Increase in Erectile dysfn risk by 8.2% per year Increase in Erectile dysfn risk by 7.6% per kg/m² BMI. Higher BMI n = 675 workers (age range 45 to 60 yrs old) 5 45 y +3 50y +6 +9 55y +12 60y kg/m² kg/m² kg/m² kg/m² +15 kg/m² Figure: An increase in erectile dysfunction risk was observed by 8.2% per year and by 7.6% per kg/m BMI. Kratzik CW, Schatzl G, Lunglmayr G, Rucklinger E, Huber J. The impact of age, body mass index and testosterone on erectile dysfunction. J Urol. 2005 Jul;174(1):240-3 Department of Urology, Medical University of Vienna, Vienna

Statin Therapy => Erectile dysfunction Mean International Index of Erectile Function (IIEF) score (range 0-25) n = 93 men 25 20 15 10 5 0 Prior to statin therapy 21 After 6 months of statin therapy - 69 % Figure: Statin therapy reduced the IIEF score. Differences in dose, relative efficacy or relative lipophilicity of statin prescribed showed no correlation with change in IIEF score. Solomon H, Samarasinghe YP, Feher MD, Man J, Rivas-Toro H, Lumb PJ, Wierzbicki AS, Jackson G. Erectile dysfunction and statin treatment in high cardiovascular risk patients. Int J Clin Pract. 2006 Feb;60(2):141-5 St. Thomas' Hospital, London, UK 6.5 p < 0.001 22% experienced new onset erectile dysfunction Erectile dysfunction following statin therapy is more likely to occur in patients with severe endothelial dysfunction due toage, smoking and diabetes After 6 months of statin therapy, correlations were observed between lower IIEF scores (r = 0.62; p < 0.001) and age and diabetes and weakly with smoking.

Hormone Deficiencies That can cause Erectile Dysfunction

Testosterone & DHT Deficiencies can cause Erectile Dysfunction

DHEAs in men + aging male symptoms & sexual dysfn SUBJECTS: n = 348 patients The patients + total the Aging Male Symptoms (AMS) score of 29 => aging male symptoms the patients + an International Index of Erectile Function IIEF score < than 26 => sexual dysfunction. RESULTS: sign. serum DHEA-S & sign. E2 in the men + aging male symptoms sign. the DHEA-S & free testosterone in the men + sexual dysfunction Serum DHEA-S & free testosterone & age correlated sign. + the IIEF scores. The total AMS score correlated sign. only with age. serum total testosterone, FT, & DHEA-S levels correlated sign. with the andrologic symptoms of AMS the serum E2 correlated + psychological symptoms of AMS. CONCLUSIONS: DHEA-S & E2 might play someimportant roles in the symptoms of aging men. Basar MM, Aydin G, Mert HC, Keles I, Caglayan O, Orkun S, Batislam E. Relationship between serum sex steroids and Aging Male Symptoms score and International Index of Erectile Function. Urology. 2005 Sep;66(3):597-601 Department of Urology, University of Kirikkale, Kirikkale, Turkey.

Serum testo Quality of Erection Amplitude & duration Near full erections (in % sleep time spent within 80 % of maximal erection magnitude) (in % of sleep time during which max -erect-magnitude was = or more 1.5 cm) 40 Nocturnal Nl men Penile Erection % Kwan M. J Clin Endocrinol Metab. 1983, 57 : 557-562 30 20 10 0 34 Hypogonadal men - 62 % 13 Nl men 13 Hypogonadal men - 46 % Figure : Poor amplitude & duration of nocturnal erections in hypogonadal men. 7

Improving Erectile Function

Erections Stimuli => Hypothalamus => Pituitary gland secretes hormones Stimulation of parasympathic nerves Secretion of NO 2 in genital areas

Testosterone Improves Erectile Function

2 2.9 ng/ml Penile erection => testosterone level in penis & blood Testosterone level Healthy <men Men + erectile dysfn (ng/ml) Corpus Systemic blood Systemic Corpus Cavernosum (cubital vein) blood Cavernosum 6 Tumescence Tumescence + 30 % Detumescence Tumescence Flaccid Detumescence Tumescence 4 Flaccid 4.3 4.4 + 13 % Flaccid 4.1 4.1 Flaccid 3.5 2.6 3 3 3.2 0 Figure: In the healthy males, the penile erection was accompanied by an increase in the cavernous & peripheral testosterone concentration, in patients too although in a minimized way. n = 54 healthy males + normal erectile function & 46 patients + erectile fn Becker AJ, Uckert S, Stief CG, Scheller F, Knapp WH, Hartmann U, Jonas U. Cavernous and systemic testosterone lasma levels during different penile conditions in healthy males and patients with erectile dysfunction. Urology. 2001

Nocturnal Penile Erection % Testosterone Nocturnal Erections 40 30 20 10 Amplitude & duration (in % sleep time spent within 80 % of maximal erection magnitude) Nl men Hypogonadal men Prior Placebo Testo 200 mg + 131 % Near full erections (in % of sleep time during which max -erect-magnitude was = or more 1.5 cm Nl men Hypogonadal men Prior Placebo Testo 200 mg + 87 % 0 Figure : a 200 mg testosterone IM injection stimulates the amplitude & duration of erections in hypogonadal men. Kwan M.J Clin Endocrinol Metab, 1983, 57 : 557-562

Testosterone erections 100 Transdermal Improvement of Erectile function 75 50 25 Placebo oral + 53,2 % IM + 51,3 % 80,9 % 0 + 16 % Improvement of erectile function with different testosterone preparations in men w/ erectile dysfunction. Results of a meta-analysis of 16 studies selected out of 73 articles published between 1966-1998. Jain P, Rademaker AW, McVary KT. : Testosterone supplementation for erectile dysfunction: results of ameta-analysis. J Urol 2000 Aug;164(2):371-5 Departments of Urology and Preventive Medicine, Northwestern University Medical School, Chicago, Illinois, USA.

Testosterone => makes Viagra work better

Sex fn 8 6 4 2 0 Satisfactory erections + testo/viagra 70% Testo & Viagra=> erectile fn in Viagra non-responding males No response 30% International Index of Erectile Function (IIEF) scale Question (Q) 3 Prior 2 3.7 p < 0.05 Question (Q) 4 Prior Question (Q) 12 Figure: Andriol restored testosterone to normal levels In 84/120 (70%) Viagra non-responders, combined therapy Viagra with Andriol induced satisfactory erections & increased libido. n = 120 diabetic eretile dysfn men, aged 43-74 yrs, failing to respond at least 3x to 100 mg Viagra Kalinchenko SY, Kozlov GI, Gontcharov NP, Katsiya GV. Oral testosterone undecanoate reverses erectile dysfunction associated with 1.9 p < 0.05 3.4 Prior 1 p < 0.05 4.2 Sexual contacts per month Prior 0.5 p < 0.05 4

Rochira V,.,Carani C. Sildenafil improves sleep-related erections in hypogonadal men: evidences from a randomized, placebocontrolled, crossover study of a synergiv role for both testosterone and sildenafil on penile erections. J Androl.Nov.2005 ModenaUni Viagra & testo Men + erectile dysfunction Number of valid erections 6 5 4 3 2 Placebo (no Testosterone) Sildenafil (no Testosterone) Testosterone + Placebo Testosterone + Sildenafil 1 0 Figure: Synergic action for both testosterone and sildenafil on penile erections n = hypogonadal men; randomised double-blind crossover trial

DHEA Improves Erectile Function

DHEA & Erectile Dysfunction Erectile function (of the International Index of Erectile Dysfunction- 15 item questionnaire w/ score 1 to 3 w/ 6 questions on erectile fn) (mean domain score; max. score = 30) 30 25 20 15 10 5 0 35 % 32 % DHEA 45 % 32 % 75 % 28 % 92 % Placebo 22 % 0 wk 8 wk 16 wk 24 wk weeks Figure : impressive improvement of erections after 24 weeks of intake of 50 mg/day of oral DHEA in 20 patients with erectile dysfunction (Reiter)

Hormones => Differences => Erectile fn Erectile function Before Main Hormone Sexual appetite Testosterone Melanotan II Sensitivity DHT/Testosterone, Melanotan II Erection Frequency Volume Hardness Persistence Testosterone Melanotan II, GH Melanotan II, GH Melanotan II, GH Orgasm Ejaculation DHT, Oxytocin

Inhibition of Prolactin Improves new Erections after orgasm

Orgasm => increases PRL (PRL remains still raised 30 after sexual arousal in men SUBJECTS: 10 healthy male volunteers => sexual arousal & orgasm => blood before, during and after masturbation-induced orgasm Orgasm => transient increases in heart rate, blood pressure & noradrenaline plasma levels. Prolactin plasma levels increased during orgasm remained elevated 30 min after orgasm. none of the other plasma conc. Of adrenaline, noradrenaline, cortisol, LH, FSH, ), FSH), GH, beta-endorphin andtestosterone. were sign. affected by sexual arousal and orgasm. Kruger T, Exton MS, Pawlak C, von zur Muhlen A, Hartmann U, Schedlowski M. Neuroendocrine and cardiovascular response to sexual arousal and orgasm in men. Psychoneuroendocrinology. 1998 May;23(4):401-11. Division of Clinical Psychiatry, Hannover Medical School, Federal Republic of Germany.

Inhibition of prolactin => sex drive & fn SUBJECTS: 10 healthy males participated => single-blind, placebocontrolled, balanced cross-over design => serum prolactin to high levels (protirelin, 50 µg i.v.) to low physiological levels (cabergoline, 0.5 mg p.o.). => Sexual arousal & orgasm induced by erotic film + masturbation TREATMENT: CABERGOLINE => serum prolactin => sign. all parameters of sexual drive (P<0.05), fn (P<0.01) & positive perception of the refractory period (P<0.01) protirelin => serum prolactin => small, but not sign. of sexual parameters The sexual effects observed from cabergoline were completely abrogated by coadministration of protirelin. CCL: acute changes in prolactin plasma levels may be one factor modulating sexual drive and function.. Krüger TH, Haake P, Haverkamp J, Krämer M, Exton MS, Saller B, Leygraf N, Hartmann U, Schedlowski M. Effects of acute prolactin manipulation on sexual drive and function in males. J Endocrinol. 2003 Dec;179(3):357-65.

Peyronie s disease

Fibrosis Lapeyronie s disease

Peyronie s disease

TREATMENTS for Peyronie s disease

Peyronie's disease = fibrosis of the penis may be reversed with multiple hormone replacement therapy (DHT, testosterone, GH and possibly hydrocortisone, vit. E depending on a man s deficiencies)

Lapeyronie s disease Cause: Fibrosis of the penis caused by a lack of androgens, testosterone and principally DHT Treatment: Testosterone enanthate inj. IM 250 mg every 7 to 10 days..two months, then after every 14 days DHT gel 2.5 % locally every day GH in sufficient doses (from 0,15 mg a day up; Hydrocortisone systemically may be helpful small physiological doses of (if deficiency diagnosed) Vit. E local & systemically (2.000 mg a day) DHEA (20 to 60 mg a day) Melanotan II?????

T. HertogheHormone Handbook 2010

Mail to office@hertoghe.eu www.hertoghemedicalschool.eu website