Erectile dysfunction (Impotence) Abdel-Hamid M. Abdel-Aziz Professor of Dermatology & Venereology, Al-Azhar University

“ Sex is the most fun you have without laughing” Woody Allen. But one can add : “sex is no laughing matter”.

Part I Erectile dysfunction ( impotence ) will be discussed under the following items: @ Sex in Ancient Egypt. @ Definition @ mechanism. @ Sexual response cycle @ Age & ED @ Causes @ Type of impotence. @ Evaluation of ED @ Diagnosis @ Treatment @ Retrograde ejaculation @ Peyronie’s disease

Sex, sexuality & love in ancient Egypt

Sex in ancient Egypt

Homosexuality in ancient Egypt It was regarded a sexual misconduct Homosexuality in ancient Egypt It was regarded a sexual misconduct. In the book of the dead ,people were confronted with their judges in the underworld for this conduct.

Masturbation in ancient Egypt

Even the gods had sex in ancient Egypt. Ra ( in the form of Atem) masturbated his children Shu & Tetnut into existence. They were twins

Phallus worship in Ancient Egypt Did the ancient Egyptians know the premature ejaculation? A: Yes. Magic is part of their medicine. The problems associated with ejaculation : premature, delayed, priapism,.. Could be attributed to a worship in the penis send his spells on the act of coitus.

Erectile dysfunction (ED) is also called impotence is defined as the inability of a man to achieve & maintain an erection firm enough for sex. Having erection trouble from time to time is not necessarily , a cause of concern. But if, it is an ongoing problem, it may cause stress, relationship problems &/or affect his self confidence. Premature ejaculation is a condition in which the entire sexual process of arousal, erection, ejaculation & climax occur more rapidly ,often in just a few minutes or even seconds , leaving the partner unsatisfied.

Mechanism of ejaculation penile erection is mediated by the parasympathetic nervous system. The sympathetic nervous system is responsible for maintaining the penis in flaccid state.

Mechanism of ejaculation 1.Emision phase 1. Emission phase: Deposition of seminal fluid from the ampullary deferens, seminal vesicles ,&prostatic gland into the posterior urethra.

2.Expulsion phase: It involves closure of bladder neck, followed by rhythmic contraction of urethra by pelvic-perineal & bulbospongiosus muscle & intermittent relaxation of external urethral sphincter

Mechanism of ejaculation pelvic floor muscles

Sexual response cycle

Sexual arousal in animals

Increase in ED with age

Causes of erectile dysfunction Erectile dysfunction is inability to develop or maintain an erection of penis during sexual performance. Causes: @ Psychological: - performance anxiety - Stress - Fatigue - depression, panic disorders, generalized anxiety - Negative feelings - Psychological problems @ Medical causes: diabetes, hypertension, heart & kidney diseases, liver diseases, high cholesterol - Neurogenic disorders: Parkinson's disease, Alzheimer disease, multiple sclerosis, stroke - Drugs: antidepressant, antihypertensive, diuretics - Life style: *Aging : It is four times higher in men in their 6Os than in men in their 4Os. *smoking :causes impotence because it promotes arterial narrowing. @ Penile disorders: peyronie’s disease, venous leakage @ Surgical causes: operations in pelvic area, radiation therapy

Causes of eractile dysfunction Several studies have been done on the percentage of the different factors causing ED.

Part II Erectile dysfunction ( impotence ) will be discussed under the following items: @ Sex in Ancient Egypt. @ Definition @ mechanism. @ Sexual response cycle @ Age & ED @ Causes @ Type of impotence. @ Evaluation of ED @ Diagnosis @ Treatment @ Retrograde ejaculation @ Peyronie’s disease

Causes of erectile dysfunction Erectile dysfunction is inability to develop or maintain an erection of penis during sexual performance. Causes: @ Psychological: - performance anxiety - Stress - Fatigue - depression, panic disorders, generalized anxiety - Negative feelings - Psychological problems @ Medical causes: diabetes, hypertension, heart & kidney diseases, liver diseases, high cholesterol - Neurogenic disorders: Parkinson's disease, Alzheimer disease, multiple sclerosis, stroke - Drugs: antidepressant, antihypertensive, diuretics - Life style: *Aging : It is four times higher in men in their 6Os than in men in their 4Os. *smoking :causes impotence because it promotes arterial narrowing. @ Penile disorders: peyronie’s disease, venous leakage @ Surgical causes: operations in pelvic area, radiation therapy

Causes of eractile dysfunction Several studies have been done on the percentage of the different factors causing ED.

Types of impotence 1. Venogenic impotence: The most common type. The veins leak the blood & penis fail to maintain an erection. 2.Diabetic impotence. 3. Psychogenic impotence: Due to depression , anxiety, stress… 4. Aeteriogenic impotence: in hypertensive patient where penis is unable to receive sufficient blood for erection. 5. Neurogenic impotence: any injury to the back particularly affecting spinal cord or vertebral column or surgery to urinary bladder, prostate or rectum. 6. Endocrinologic impotence : imbalance in testosterone or estrogen level in blood. Anabolic steroids cause imoptence Another classification of types of impotence: 1. Organic impotence: progressive course 2. Psycological impotence: starts sharp & associated with certain events of life.

Erectile dysfunction often early sign of heart disease

Anabolic steroids cause endocrinologist impotence

Diabetes & erectile dysfunction The most common cause of ED is impaired blood flow into the penis, which a common result of arteriosclerosis & diabetes

Hypertension & impotence

Psychogenic impotence

Evaluation of the erection quality EO: No tumescence ( no increase in volume). EI: Low tumescence, no rigidity. E2: Average tumescence, no rigidity. E3: Full tumescence, no rigidity. E4: Full tumescence, average rigidity. E5: Full tumescence, full rigidity. If low dose of intracavernous injection of prostaglandin E1 (Alpostradil)(5 -1Omg) at the base of corpus cavernosum leads to full erection (in patient with ED), neurogenic ,psychogenic or hormonal erection dysfunction is likely.

Diagnosis @ Duplex ultrasound @ Penile nerve function (bulbocavernous reflex) @ Nocturnal penile tumescence (NPT) @ Penile biothesiometry @ Dynamic infusion cavernosometry (DICC) @ Corpus cavernosometry @ Magnetic resonance angiography.

Vascular doppler recorder

Ultrasound velocity measurement The velocity can be calculated by the difference in transmit to receive time from the first pulse to the second (t2), as the scatter moves through the beam.

Effect of Doppler angle on the sonogram

Ultrasonography: PSV PSV: Peak Systolic Velocity: @ Above 35 cm/s: Normal @ Less than 25 cm/s: ED is arteriogenic in origin. @ Between 25 -35 cm/s Ed is due to stiffness of arterial wall. @ Asymmetric reading greater than 1O cm /s means a unilateral arterial insufficiency.

Doppler ultrasound of penis Ultrasound of the penis in the flaccid (soft) state: The flood flow in the cavernous artery is red in diagram is low & the velocity of blood flow (peaks in the lower part of the diagram) are also low.

Doppler ultrasound of penis Ultrasound of the penis in the erect (hard) state: Penile erection dilatation of arteries cause an increase in blood flow ( note the increase in one in the diagram) & higher velocity of blood flow (higher peaks in the lower part of the diagram) .

Cavernosal artery penile velocity (PSV) Peak systolic velocity of the cavernosal artery decreases from base of the penis (a). A high PSV of the cavernosal artery (measured more proximally) as compared to distal measurement in the same patient (b) Because of such variations: PSV consistently measured at the junction of proximal 1/3 & distal 2/3 of the penile shaft where the cavernosal artery bend.

Doppler waveforms Arteriogenic ED: Sequential timed 5, 1O, 2O, 25 &3O minute Recorded after Prostaglandin E Demonstrate persistent low PSV of the Cavernosal artery PSV ( 25 cm/s)

Ultrasonography : RI RI: Resistance index or rigid erection : which measure venous function @ O.9 –I : RI is normal @ Below O.75 : there is venous leakage- Oral treatment in ED will be inefficient. @ Pathological resistance index & end diastolic velocity point out veno-occlusive dysfunction @ Low PSV+ persistent diastolic flow: Occur in ED of mixed origin (arteriogenic & Venogenic)

Ultrasonography (Cont.) @Normal: PSV: > 35 cm /s & RI > O.9 @ Cavernous venous occlusive disease (CVOD): PSV >35 cm/s & RI < O.9 @ Mild arterial insufficiency (MAI): PSV between 25 & 35 cm/s @ Severe arterial insufficiency (SAI): for bilateral PSV < 25 cm/s

Arterial velocity sonogram (Waveform) @Resistance index (RI) ( Also called resistance index or Pourcelot’s index) @ Systolic/diastolic ratio, sometimes called A/B ratio @ Pulsatality index (PI). It needs to measure the mean height of the waveform.

Flow velocity index

Venous leak (Veno-occlusive insufficiency) Assessment: 1. End diastolic volume (should be less than 5 cm/s) 2.Resistance index (RI): Positive leak if RI <O.75 . However, it is normal if RI > O,9 3. Cavernosography. (Invasive method) 4. Cavernosometry. (Invasive method) Normal deep vein velocity is <3cm/s. Moderately increased vein leak if velocity is 1O -2O cm/s & marked increased leak if high than 2O cm/s

Venous leak (Vulvo-occlusive insufficiency Persistent PSV > 4O cm/s: Exclude arterial insufficiency as a cause of erectile dysfunction. However, persistent diastolic flow velocity of more than 5 cm is suggestive of venous leak. It indicates a low intracavernous pressure, inadequate, to obtain & maintain a rigidity sufficient for normal intercourse.

Nocturnal penile tumuscence monitor to record voltmetric changes within the penis nocturnally

Nocturnal penile tumescence Rigiscan

Rigiscan Snap gauge tape

Biothesiometry For measurement of normal skin sensation adequate to produce an erection

Normal cavernosography demonstrating corral attachment to ischiopubic ramus (horizontal arrow) 7 needle placement in the right corpus ( vertical arrow). Note that all radio-opaque (white) is confined within the corporal bodies International J. of impotence research. 16: 146, 2OO4

Abnormal cavernosography demonstrating cavernosal (oblique arrow) & crural (horizontal arrow) venous leak . Note the irregularity of the contrast outline (black) within the corporal bodies suggestive of corporal fibrosis. Int. J. of impotence research 16: 146, 2OO4

For cavernosometry infusion For cavernosometry infusion. Administration set with drip chamber, pump tube & patient infusion tube. ***************************** For cavernosometry /cavernosography infusion. Administration set with dual vented drip chambers, pump tube& detachment patent infusion tube

Used for infusion & pressure measurement in dynamic infusion cavernosometry /cavernosography. ***************************** All purpose tubes For infusion & pressure transmission in urodynamics & cavernosometry

Mondor’s disease: Thrombophlebitis of penile superficial Dorsal vein.

Magnetic resonance Angiography: For Mondor’s disese

Part III Erectile dysfunction ( impotence ) will be discussed under the following items: @ Sex in Ancient Egypt. @ Definition @ mechanism. @ Sexual response cycle @ Age & ED @ Causes @ Type of impotence. @ Evaluation of ED @ Diagnosis @ Treatment @ Retrograde ejaculation @ Peyronie’s disease

Treatment @ Exercise @ Vacuum Pump @Herbal therapy @ Injection therapy by papaverine, phentolamine & prostaglandin E1 @ MUSE: Alporostadiol as a urethral suppository @ Phospodiestrase type 5 inhibitors (Viagra) E: Alporostadiol @ Gene therapy @ Surgical : penile prosthesis

Exercise (Details of different exercises can be read in lecture on premature ejaculation)

Vacuum pump

Herbal Therapy For ED

Jes extender Traction technique to increase the size of penis by 3O % by just wearing it in your free time

Prostaglandin E1 (PGE1) known pharmaceutically as alprostadiol Prostaglandin E1 can be used as: @ A suppository (MUSE) to be inserted in urethra, 1O minutes before sexual intercourse. MUSE: Medicated Urethral Suppository for Erection. @ Bimix & trimix: This include papaverine (3O mg) + phentolamine (2mg) + prostaglandin E1 (2Omcg)

Intraurethral application of prostaglandin E1 “MUSE”

Gene & stem cells therapy for ED Int. J Gene & stem cells therapy for ED Int.J. of impotence research 17: 557, 2OO5 The genes are injected inside a herpes virus that has been modified. Could genes be the future choice for treating ED? Stem cell can they also help ED?

Part IV Erectile dysfunction ( impotence ) will be discussed under the following items: @ Sex in Ancient Egypt. @ Definition @ mechanism. @ Sexual response cycle @ Age & ED @ Causes @ Type of impotence. @ Evaluation of ED @ Diagnosis @ Treatment @ Retrograde ejaculation @ Peyronie’s disease

Peyronie’s disease

Peyronie’s disease

Verapamil 15% gel ,twice daily can treat peyronie’s disease Verapamil 15% gel ,twice daily can treat peyronie’s disease . It is a calcium channel blocker

Verapamil

Penile strangulation by multiple metallic rings