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

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

3. 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

4. Sex, sexuality & love in ancient Egypt

5. Sex in ancient Egypt

6. 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.

7. Masturbation in ancient Egypt

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

9. 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.

10. 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.

11. 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.

12. 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.

13. 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

14. Mechanism of ejaculation pelvic floor muscles

15. Sexual response cycle

16. Sexual arousal in animals

17. Increase in ED with age

18. 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

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

20. 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

21. 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

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

24. 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.

25. Erectile dysfunction often early sign of heart disease

26. Anabolic steroids cause endocrinologist impotence

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

28. Hypertension & impotence

29. Psychogenic impotence

31. 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.

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

33. Vascular doppler recorder

34. 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.

35. Effect of Doppler angle on the sonogram

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

37. 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.

38. 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) .

39. 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.

40. 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)

41. 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)

42. 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

43. 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.

44. Flow velocity index

45. 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

46. 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.

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

48. Nocturnal penile tumescence
Rigiscan

49. Rigiscan
Snap gauge tape

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

51. 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

52. 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

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

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

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

56. Magnetic resonance
Angiography:
For Mondor’s disese

57. 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

58. 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

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

60. Vacuum pump

61. Herbal Therapy For ED

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

63. 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)

64. Intraurethral application of prostaglandin E1 “MUSE”

68. 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?

69. 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

70. Peyronie’s disease

71. Peyronie’s disease

73. 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

74. Verapamil

76. Penile strangulation by multiple metallic rings