Dr.Hassaan Ali 20142nd workshop of ED and

Penile Prostheses 1,2 Jan 2015

Aswan Egypt

Dr.Hassaan Ali 2014

ERECTILE DYSFUNCTION PRACTICAL VIEW

Definition of ED

Epidemiology

Anatomy and Physiology of erection

Causes ED

Examination of patient with ED

Investigations

Treatment

Dr.Hassaan Ali 2014

Synonym: Impotence

Persistent or recurrent inability to obtain or

maintain penile erection (or both)

sufficient for satisfactory sexual performance, for more than 3-months

duration(1).

Dr.Hassaan Ali 2014

NO!Sexual function is an important component of

quality of life and subjective well-being.

Sexual problems affect adversely mood, well-being, and interpersonal functioning.

Nearly every man can be successfully treated.

Dr.Hassaan Ali 2014

Incidence and prevalence is high

worldwide

Effects up to 52% of men (40-70yrs)

Complete impotence from 5% of 40yr olds

to 15% of 70yr olds

Only 10-20% solely psychogenic

Dr.Hassaan Ali 2014

Prevalence of ED by Age and Severity (%)

Severe

Moderate

Mild or

Mild/Moderate

100%

80%

60%

40%

20%

0%

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Dilatation arterioles&arteries

expanding of sinusoids

compression of subtunicalvenular plexuses

Emissary veins enclosed

increasing of intracavernouspressure to raise the penis

Dr.Hassaan Ali 2014

Transient intracorporeal pressure increase

[smooth muscle contraction]

Pressure decrease slowly

[slow reopening of the venous channels]

Pressure decrease fast

[venous outflow capacity is fully restored]

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Flaccid phase (1) Minimal arterial and venous flow; b

Latent (filling) phase (2) Increased flow in the internal pudendal

artery during both systolic and diastolic phases. Decreased pressure

in the internal pudendal artery; unchanged intracavernous pressure.

Some elongation of the penis.

Tumescent phase (3) Rising intracavernous pressure until full erection

is achieved. Penis shows more expansion and elongation with

pulsation. The arterial flow rate decreases as the pressure rises..

Full erection phase (4) Intracavernous pressure can rise to as much as

80–90% of the systolic pressure. Pressure in the internal pudendal

artery increases but remains slightly below systemic pressure. Arterial

flow is much less than in the initial filling phase but is still higher than

in the flaccid phase. approach those of arterial blood.

Skeletal or rigid erection phase (5) As a result of contraction of the

ischiocavernous muscle, the intracavernous pressure rises well

above the systolic pressure, resulting in rigid erection..

Detumescent phase (6) After ejaculation or cessation of erotic stimuli,

sympathetic tonic discharge resumes, resulting in contraction of the

smooth muscles around the sinusoids and arterioles. This effectively

diminishes the arterial flow to flaccid levels,.

Dr.Hassaan Ali 2014

Supraspinal pathways

[ hypothalamus, limbic system and cerebral cortex

Parasympathetic nerves S2-4 mediate erection

Sympathetic nerves T11-L2 control ejaculation and

detumescence

Smooth muscle relaxation

Nitric oxide diffuses into cavernosal smooth muscle cells, activates Guanylate cyclase converts guanosine

triphosphate to cGMP resulting in smooth muscle

relaxation.

Effect of cGMP stopped by Phosphodiesterase type 5 which

exists primarily in corpora cavernosa

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Sedentary lifestyle

Obesity

Smoking

Hypercholesterolemia

Diabetes mellitus

Dr.Hassaan Ali 2014

OrganicI. Vasculogenic : Arteriogenic Cavernosal Mixed

II. Neurogenic

III. Anatomic

IV. Endocrinology

PsychogenicI. Generalized

A. Generalized unresponsiveness

1. Primary lack of sexual arousability 2. Aging-related decline in sexual arousability

B. Generalized inhibition 1. Chronic disorder of sexual intimacy

II. Situational

A. Partner-related 1. Lack of arousability in specific relationship 2. Lack of arousability owing to sexual object preference 3. High central inhibition owing to partner conflict or threat

B. Performance-related 1. Associated with other sexual dysfunction/s (e.g., rapid ejaculation) 2. Situational performance anxiety (e.g., fear of failure)

C. Psychological distress- or adjustment-related 1. Associated with negative mood state (e.g., depression) or major life stress (e.g., death of partner)

Mixed

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Vascular

Diabetes

Medication

Pelvic Surgery,

Radiation

or TraumaNeurological Causes

Endocrine

ProblemsOther

Vascular

Diabetes

Medication

Dr.Hassaan Ali 2014

Hypertension

Smoking

Diabetes

Hyperlipidaemia

Peripheral vascular disease

Blunt perineal or pelvic trauma

Pelvic irradiation

Dr.Hassaan Ali 2014

Central:Lesions of medial preoptic nucleus, paraventicular nucleus, hippocampus

Spinal trauma

Myelodisplasia (spina bifida)

Pelvic surgery/radiotherapy

Multiple sclerosis

Intervertebral disc lesion

Peripheral neuropathies

Alcohol

Diabetes

HIV

Dr.Hassaan Ali 2014

Hypogonadism

Low testosterone

Raised SHBG

Raised Prolactin

Thyroid disease

Hypothyroidism

hyperthyroidism

Dr.Hassaan Ali 2014

Peyronie’s disease

Micropenis

Penile anomalies (hypospadias etc

Dr.Hassaan Ali 2014

AntihypertensivesThiazides

B blockers

Centrally acting drugs

AntidepressantsTricyclics

MAO inhibitors

SSRI

AnticholinergicsAtropine

AntipsychoticsPhenothiazines

AnxiolyticsBenzodiazepines

Psychotropic drugsAlcoholOpiatesAmphetaminesCocaine

Dr.Hassaan Ali 2014

I. Generalized

A. Generalized unresponsiveness

1. Primary lack of sexual arousability

2. Aging-related decline in sexual arousability

B. Generalized inhibition

1. Chronic disorder of sexual intimacy

Dr.Hassaan Ali 2014

II. Situational A. Partner-related

1. Lack of arousability in specific relationship

2. Lack of arousability owing to sexual object preference

3. High central inhibition owing to partner conflict or threat

B. Performance-related

1. Associated with other sexual dysfunction/s (e.g., rapid ejaculation)

2. Situational performance anxiety (e.g., fear of failure)

C. Psychological distress- or adjustment-related

1. Associated with negative mood state (e.g., depression) or major life stress (e.g., death of partner)

Dr.Hassaan Ali 2014

History taking (including drug intake).

physical examinations: testes, penis, signs of hypoandogenism.

Investigation

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Medical

Surgical

Psychiatric

Medication

Smoking

Alcohol

Recreational drug use

Dr.Hassaan Ali 2014

International Index of Erectile Function questionnaire (IIEF) most common questionnaire

addresses erectile function, orgasmic function, desire, intercourse satisfaction, overall satisfaction

Erectile function 1,2,3,4,5,15

Intercourse satisfaction 6,7,8

Orgasmic function 9,10

Sexual desire 11,12

Overall satisfaction 13,14

Dr.Hassaan Ali 2014

International Index of Erectile Function

5-item version for quick office evaluation

Score of 5-7 sever ED

Score of 8-11 moderate

Score of 12-16 mild to moderate

Score of 17-21mild

Score of 22- 25 no ED

Dr.Hassaan Ali 2014

Gradual onset

Normal ejaculation

Normal libido

Medical risk factor

Trauma/surgery/radiotherapy to pelvis

Current medication

Lifestyle

Dr.Hassaan Ali 2014

Sudden onset

Early collapse of erection

Self stimulated or waking erections

Premature ejaculation or inability to ejaculate

Problems/change in relationship

Major life event

Psychological problems

Dr.Hassaan Ali 2014

Genitourinary examination Testes size and consistency

Secondary sexual characteristics

Penis for Peyronie’s plaques,

Pulses (femoral), BP

Rectal examination

Dr.Hassaan Ali 2014

Laboratory Investigation

complete blood count,

urinalysis,

renal function,

lipid profile,

fasting blood sugar,

thyroid function.

Routine endocrinologic testing remains

controversial

Dr.Hassaan Ali 2014

1-Young patients who have always had

difficulty in obtaining and/or sustaining

an erection

2-Patients with a history of trauma

3-Where an abnormality of the testes or

penis is found on examination.

4-Patients unresponsive to medical

therapies that may desire surgical

treatment for ED.

Dr.Hassaan Ali 2014

1-Nocturnal penile tumescence and rigidity (NPTR)

2-vascular studies:Combined intracavernous injection & stimulation (CIS)

Duplex ultrasound

Dynamic infusion cavernosometry & cavernosography (DICC)

Selective penile angiography

3-neurological studies (e.g. bulbocavernosusreflex latency,nerve conduction studies);

4-endocrinological studies;

5-specialised psycho diagnostic evaluation.

Dr.Hassaan Ali 2014

3 B

.

4 B

4 B

GRLE Recommendations for the diagnostic work-up

B3Clinical use of a validated questionnaire related

to ED may help assess all sexual function

domains and the effect of a specific treatment

modality.

B3Physical examination is needed in the initial

assessment of ED to identify underlying medical

conditions associated with ED

B4Routine laboratory tests, including glucose-lipid

profile and total testosterone, are required to

identify and treat any reversible risk factors and

modifiable lifestyle factors.

B4 Specific diagnostic tests are indicated by only a

few conditions.

Dr.Hassaan Ali 2014

Total tumescence time 20% of night at puberty Adults – 27 minutes/nigh

RigiScan - 1985Monitors radial rigidity, tumescence, number, duration of erectile events

Portable – can use at home

Can record 3 different nights up to 10 hrs each

Results

Radial rigidity >70% = good erection

<40% = flaccid penis

Normal = 3-6 erections/night, 10-15 minutes per episode NEVA

deviceUses electrobioimpedance to assess volumetric changes in penis during nocturnal erections

Undetectable alternating current from glans to hip electrodes

Penile base electrode measures impedance & changes in penile length

Mean volume change in controls = 213% increase (14.4 mL)

Dr.Hassaan Ali 2014

Inject vasodilator, stimulate,

Bypasses neurologic & hormonal influences to evaluate vascular status

Use:

alprostodil 10-20ug

papaverine & phentolamine (Bimix 0.3 mL)

Trimix 0.3 mL

27 or 29g needle, compress for 5 min after injection

Normal results = normal venous occlusion

False negative up to 20% w/ borderline arterial flow

Dr.Hassaan Ali 2014

Penile blood flow study (CIS & blood flow measurement by US) is most reliable & least invasive evidence based assessment of EDRed = towards probe

Blue = away from probe

Can visualize dorsal & cavernous arteries in real time

Can diagnose high flow priapism

TechniqueMeasure flow velocities 5-10 min after injection

Rate erectile quality

Look at both cavernous arteries & diameters

Asymmetric cavernous arterial flow >10cm/s or reversal of flow across a collateral may mean atherosclerotic lesion

Dr.Hassaan Ali 2014

Peak Systolic Velocity (PSV)PSV < 25 correlates with abnormal pudendalarteriography

Severe unilateral arterial insufficiency >10 cm/s asymmetry

Severe vascular ED, diameter increase is <75%, diameter rarely exceeds 0.7 mmHigh systolic flow (>25 cm/s)

Persistent end-diastolic flow (EDV) (>5 cm/s)

Resistive Index (RI)RI = PSV – EDV/PSVMeasure 20 min after injection & stimulation

RI > 0.9 normal

RI < 0.75 venous leakage

Dr.Hassaan Ali 2014

Intracavernosal injection with color duplex Doppler ultrasound Most informative diagnostic test

Least invasive for vascular ED, high vs. low flow priapism, Peyronie’s plaque

Useful measurements

PSV, cavernous artery diameter, EDV, RI

PSV <25 = severe cavernous artery insufficiency

PSV >35 = normal inflow

Negative relationship between age & PSV

Dr.Hassaan Ali 2014

Cavernous arterial occlusion pressureBasically penile blood pressure measurement – 1989

TechniqueInject vasodilator

infuse saline into corpora to get pressure > systolic BP

apply Doppler to penile base

Pressure when cavernous arterial flow becomes detectable is cavernous artery systolic occlusion pressure (CASOP)

Gradient between cavernous & brachial artery pressure <35 & equal pressure on L & R is normalPharmacologic ArteriographyTechniqueInject vasodilatorCannulate internal pudendal arteryInject contrastLook at anatomy of iliac, internal pudendal, penile arteriesAberrant anatomy in 50% of normal volunteersUseful for anatomy, not functionIndication:Young pt w/ ED due to traumatic arterial disruption or perineal compression injury. Essential for planning reconstruction

Dr.Hassaan Ali 2014

Pharmacologic Cavernosometry & CavernosographyCavernosometry

Saline infusion while monitoring intracavernouspressure

Assesses penile outflow

Cavernosography

Infusion of contrast into corpora after vasodilator induced erection

Good for young men who may be candidates for penile vascular operations

Dr.Hassaan Ali 2014

Penile Brachial Pressure Index

Inaccurate

Penile Plethysmography

Penile pulse volume recording

Infrared Spectrophotometry

Radioisotopic Penography

MRA

Cavernous Smooth Muscle Content

Dr.Hassaan Ali 2014

Only certain types of ED have the potential to be cured with specific treatments:General Measures

Smoking cessation

Reduce alcohol

Weight loss

Exercise

Hormonal: testosterone failure – give testosterone

contraindicated in men (prostate carcinoma or with symptoms of prostatism.)

Post-traumatic arteriogenic: surgical penile revascularization has a 60-70% long-term success

Psychogenic: underlying problem, sex therapy/counselling, phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil)

Dr.Hassaan Ali 2014

PDE-5 inhibitors potentiate NO’s effect

Do not increase NO levelsNeed sexual stimulation for PDE-5 inhibitors to work

Sildenafil (Viagra)

FDA approved 1998

Vardenafil (Levitra)

FDA approved 8/2003

Tadalafil (Cialis)

FDA approved

11/2003

Dr.Hassaan Ali 2014

TadalafilVardenafilSildenafil

15 min – 2 hr15 min – 1 hr15 min - 1

hrOnset of Action

17.5 hr4-5 hr3-5 hrHalf-life

Not tested15%40%Bioavailability

No effect↓↓ Absorption↓↓

AbsorptionFatty Food

YesYesYesHA, flushing, dyspepsia

YesRare RareBachache, Myalgia

RareRareYesBlurred/Blue vision

NoYesNoPrecaution w/

antiarrhythmics

YesYesYesContraindication w/

nitratesDr.Hassaan Ali 2014

Newer agents Avanafil

Post Radical Prostatectomy

Diabetes

Acts 15 min

No effect with food

Dr.Hassaan Ali 2014

25-50% placebo responseAcupuncture – psychogenic EDAndrostenedione – may benefit men w/ low testosterone, lowers HDL 10%Ginko biloba – may have blood-thinning effectKorean red ginseng – may benefitL-Arginine – precursor to Nitric Oxide, may lower BPYohimbine – most supplements contain little or none, can have serious side effectsZinc – good if low zinc, can be immunosuppressive

Dr.Hassaan Ali 2014

Plastic cylinder connected to vacuum

generating source place constriction ring

after engorgement

Remove ring within 30 min

Satisfaction rate 68-83%

Adverse effects:pain, petechiae,

bruising,

numbness

Dr.Hassaan Ali 2014

Papaverine

Phentolamine (alpha1 & alpha2-antagonist)

Alprostadil (Caverject & Edex 2-40mcg) -

Prostaglandin E1

CombinationsPapaverine + Phentolamine

Papaverine + Phentolamine + Alprostadil

Dr.Hassaan Ali 2014

Isolated from opium poppy

Inhibitory effect on PDE, increased cAMP & cGMP, blocks calcium channels

1-2 hr half-life

Good

Low cost

Stable at room temp

Bad

Priapism (up to 35%)

Corporal fibrosis (1-33%) due to acidity

<55% effective

Not FDA approved

Dr.Hassaan Ali 2014

alpha1 & alpha2-antagonist

Side effects

Hypotension

Reflex tachycardia

Nasal congestion

GI upset

30 min half-life

Increases corporal blood flow, but does not

cause significant increase in intracavernous

pressure

Dr.Hassaan Ali 2014

(Caverject & Edex 2-40mcg) - Prostaglandin E1

Exogenous form of a naturally occurring fatty acid

Causes smooth muscle relaxation, vasodilation, inhibition of platelet aggregation by elevating cAMP

Metabolized by prostaglandin-15-hydroxydehydrogenase in corpora cavernosa

96% locally metabolized after 60 min

Side effects

Pain at injection site or during erection

Hematoma

Priapism

Much lower incidence of fibrosis

Once reconstituted into liquid from powder, has shortened half-life if not refrigerated

Dr.Hassaan Ali 2014

Papaverine + Phentolamine

Papaverine + Phentolamine + Alprostadil

Lower incidence of painful erection

As effective as alprostadil alone

Good for failed therapy or painful erection w/ PGE1

Serious side effects

Priapism

Fibrosis

Contraindications

Sickle cell

Schizophrenia

Other severe psychiatric disorders

Severe systemic illness

Dr.Hassaan Ali 2014

Intraurethral suppositories

“MUSE” (Medicated urethral system for erectionAlprostadil (125mg,

250mg, 500mg,1g

Dr.Hassaan Ali 2014

TypesMalleable prosthesisADV: Low Mechanic Failure / Ease of useDISADV: Constant rigidity / ▲ Erosion Risk

Positional prosthesisSemiRigid – Articulating Segments

Better to maintain up/down positions

2 – piece inflatable prosthesisADV: Ease of implantationDISADV: ▲ Mechanical Failure Risk

Dr.Hassaan Ali 2014

3 – piece inflatable penis

Most closely resembles natural flaccidity

and erection

Provide penile girth expansion and rigidity

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Subcoronal – malleable or positional

Infrapubic - reservoir placement under direct

vision

Penoscrotal – better corporeal exposure, no

dorsal nerve injury, pump fixation possible

Dr.Hassaan Ali 2014

Dr.Hassaan Ali 2014

Foley removed next day

Antibiotic for 1 week

Oral narcotic used for 1 week

Restrict lifting activities if reservoir present

Have pts practice pumping 1 month after

sx

Dr.Hassaan Ali 2014

INFECTIONS – No significant illness, but to eradicate infection, removal of prosthesis is required.

To avoid it:

-Delay implanation if UTI or cutaneous inf

-Shave day of surgery

-Prevent by 10 minute skin prep

-Gent vancomycin

-Silicone has a sterile charge and should be irrigated

Dr.Hassaan Ali 2014

Infections occur either

1st few weeks - gram negative

After 6 months – gram positive Staph epi

Role of diabetes is controversial as related to

infection probability

EARLY INFECTIONS

Swelling, erythema, tenderness, drainage

Occasional fever

LATE INFECTIONS

Skin may be adherent to pump

Erosion is evidence of infection

REMOVE ALL COMPONENTS

Dr.Hassaan Ali 2014

Re-Implant?To minimize scarring of corporeal dilation, perform as soon as possible to PREVENT SCARRING AND PENILE SHORTENING

Rifampin/Minocycline coated prosthesis showed less infection rate than hydrophilic

coated devices.

IF mechanical failure, usually after 5 years

Dr.Hassaan Ali 2014

If dilator perforates proximal corpora, use a

larger dilator & allow perforation to heal

If dilator perforates urethra, ABANDON

PROCEDURE; place catheter 7-10 days

Can avoid by keeping tip of dilator under

dorsolateral surface of corpus cavernosum

If erosion of one cylinder:

REMOVE THAT CYLINDER. OK w/ one

Dr.Hassaan Ali 2014

“Concorde” type glans after placement b/c of

undersized, or inadequate dilation

SST DEFORMITY

Oversized cylinders cause pain and can erode

Dr.Hassaan Ali 2014

Peyronie’s disease

Scarring in tunic albuginea

Corporoplasty likely needed if length and girth

expanders used

If relaxing incision are done and gap is greater

than 1 cm, must cllose to prevent herniation

of cylinders

Dr.Hassaan Ali 2014

thanks

Dr.Hassaan Ali 2014