ERECTILE

DYSFUNCTION

Urology Subdepartement dr. Mintohardjo Naval Hospital

dr. Isdiyanto Septiadi, Sp.U

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The persistent

inability to

achieve or

maintain a

penile erection

sufficient for

sexual

intercourse.

So what is impotence or erectile

dysfunction..?

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Most often, ED is secondary (ie, a man who

previously could attain and sustain erections no

longer can). Over 80% = have an organic disease,

ED leads to secondary psychologic difficulties.

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Primary ED (ie, the man has never been able to

attain or sustain erections) is rare and is almost

always due to psychologic factors (guilt, fear of

intimacy, depression, severe anxiety) or clinically

obvious anatomic abnormalities.

WHAT IS THE AETIOLOGY OF ED..??

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HOW NORMAL ERECTION WORK..???

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PENILE ANATOMY

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NORMAL ERECTILE FUNCTION

Signal from the brain to penis via

cavernosal nerves

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Arterioles dilate (increased inflow) and

venules are compressed (decreased outflow)

Tunica albuginea is a non elastic fascial layer

surronding the cavernosal bodies.

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SO, FOR NATURAL ERECTIONS YOU NEED…

Intact nerves (somebody to start the air flow)

Good blood flow to the penis (working

compressor tubing)

Intact/healthy cavernosal tissue ( a good tire –

sort of)

The ability to block venous output from the

penis (no leak in the tire)

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ERECTIONS

Nerves to start

Arteries to bring blood

Tissue to hold the blood

Ability to block veins

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CAUSES OF ED

Heart Disease (vascular disease)

Diabetes

Smoking

Peyronie’s Disease

Medications

Prostate Cancer treatment

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HEART DISEASE AND ED

Heart disease is actually vascular (i.e. blood

vessel) disease

Vascular disease that works on the heart

usually is in all the blood vessels in tke body

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HEART DISEASE AND ED

Often we see the bood vessel disease first in

the as ED

Nerves to start

Arteries to bring blood

Tissue to hold the blood

Ability to block veins

20 – 50 % of men ED (aged 39-74) had

coronary artery disease

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DIABETES

Diabetes slowly damages small blood vessels all over the body

This decreases blood flow everywhere

It really hurts nerves

Nerves to start

Arteries to bring blood

Tissue to hold the blood

Ability to block veins

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SMOKING

Smoking causes blood vessels to contract and

also damages the lining of blood vessels

Also directly acts on the nerves and decreases

the ability of nerves to cause erections

Nerves to start

Arteries to bring blood

Tissue to hold the blood

Ability to block veins

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PEYRONIE’S DISEASE

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PEYRONIE’S DISEASE

Scarring of the Tunica Albuginea

Causes curvature

Also can decrease the ability of the penis to block blood flow out of the penis

Nerves to start

Arteries to bring blood

Tissue to hold the blood

Ability to block veins

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LOW TESTOSTERONE

Low testosterone clearly associated with

decreased sex drive and morning erections

Thought to support cavernosal tissue

Nerves to start

Arteries to bring blood

Tissue to hold the blood

Ability to block veins

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MEDICATION

Blood Pressure medications

Antidepressants

Narcotics

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PROSTATE CANCER TREATMENT

Surgery (open or robotic)

Radiation

Cryotherapy

Hormonal Therapy

Watchful Waiting

Active Surveillance

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ED PREVELENCE WITH PROSTATE CANCER

TREATMENT

24 – 87 % after radical retropubic

prostatectomy

13 – 70% after radiation therapy

(brachytherapy or external beam radiation)

53 – 95% after cryotherapy

45 – 92% in patients undergoing hormonal

androgen ablation

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RADICAL PROSTATECTOMY

The nerves run near the prostate, are

microscopic, and can be injured during the

case

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ERECTILE DYSFUNCTION AFTER SURGERY

Cavernosal nerves may be cut, cauterized or have excessive traction during surgery

Inflammation and healing occur in the prostate bed immediately adjacent to the cavernosal nerves

Both of these will cause permanent, or a period of neurapraxia (stunned nerves)

(NOBODY TO PUMP AIR INTO THE TIRE)

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ED AND PENILE SHORTENING

There is no difference in penile shortening from

ED caused by prostatectomy, radiation to the

prostate, and ED from other causes (except

Peyronie’s)

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TREATMENTS FOR ERECTILE DYSFUNCTION

Tier 1 : Pills (Phosphodiesterase-5 Inhibitor)

- Viagra (sildenafil), Levitra (Vardenafil), Cialis

(tadalafil)

Tier 2 : VED, Injections, MUSE

Tier 3 : Implant

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PENILE IMPLANT

Psychological barrier

Very high satification rating (72-96%)

Irreversible ED treatment – perfomed when

consevative treatments not effevtive/desired by

patient

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QUESTIONS / DISCUSSION

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