Download Erectile Dysfunction

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ธนวัต จางคกูล
43076140
กนกพร ตั้งจิตติพร 43076173
เฉลิมพล ธวัชราภรณ์ 43076199
Erectile Dysfunction
Meaning :
“ The inability to achieve and maintain a penile
erection satisfactory for sexual intercourse”
(Does not include ejaculation disorders)
History
• The first description of erectile
dysfunction, about 2000 B.C., was
set down on Egyptian.
• Hippocrates concluded that too
much horseback riding was the
cause of disease.
• Aristotle, air influx into penis.
Anatomy of the penis
• Tunica Albuginea
• Corpora Cavernosa
-- Sinusoid
• Corpus Spongiosum
-- Sinusoid
• Glans Penis
• Artrial supply
• Venous drainage
• Nerve
Arterial Supply
• Internal iliac artery
• internal pudendal artery
[main]
– Dorsal artery
– Bulbourethral artery
– Cavenous artery
• External iliac, Obturator,
vesical and femoral
artery. [accessory]
Venous drainage
• Emissary veins,
transformed from
peripheral sinusoids
• Deep dorsal vein [main]
• Bulbourethral vein,
Cavernous vein
[ accessory]
Mechanism of erection :
Dilatation arterioles&arteries
expanding of sinusoids
compression of subtunical
venular plexuses
Emissary veins enclosed
increasing of intracavernous
pressure to raise the penis
Mechanism of Detumescence
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]
Neuroanatomy of penile erection
• Peripheral pathways
Sympa, - NE release
Parasym, + NO & Ach release
Somatic, +Ach release
– autonomic [ C. Cavenosa & C. Spongiosum]
– somatic [ Glans Penis & C. Spongiosum]
Neuroanatomy of penile erection
• Supraspinal pathways
[ hypothalamus, limbic system and cerebral cortex]
dopaminergic & adrenergic recepters
serotonin recepters
promotes sexual
drive
inhibits sexual
drive
Classification of Erectile
Dysfunction
•
•
•
•
•
•
•
Psycogenic
Neurogenic
Endocrinologic
Arteriogenic
Cavernosal (Venogenic)
Drug-induced
Erectile dysfunction associated with
aging, systemic disease & others
Cause of Erectile Dysfunction
Alcohol Abuse
Anxiety or Depression
Coronary Artery Disease
Diabetes
Hormonal Abnormalities
Hypertension
Peripheral Vascular Disease
Renal or Hepatic Failure
Anemia
Smoking
Surgery(Pelvic or Perineal)
Trauma to pelvic or spine
Medication : AntiHT, Antidepressant, Antiarrhythmic,Antipsychotics
Diuretics, Anticonvulsants, Antiandrogen, Narcotics
Treatments
of
Erectile Dysfunction
Treatments of Erectile Dysfunction
Drug Therapy :
Orally Administration
Intracarvernous Injection
MUSE or Intraurethral
Suppository
Vacuum Devices
Horrmone Replacement Therapy
Surgery
Others
Treatments of Erectile Dysfunction
•
Drug Therapy : Orally Administration
Yohimbine
Phentolamine
Apomorphine
Sildenafil
Treatments of Erectile Dysfunction
Drug Therapy : Orally Administration
Yohimbine
alpha 2 -antagonist
Side effect : anxiety, ปัสสาวะบ่ อย, tachycardia,
เพิม่ arterial pressure
Treatments of Erectile Dysfunction
Drug Therapy : Orally Administration
Phentolamine
vasoactive Drug
Side effect : orthostatic hypotension,
tachycardia
Treatments of Erectile Dysfunction
Drug Therapy : Orally Administration
Apomorphine (Sublingual)
Stimulate brain dopaminergic mechanism
Side effect : nausea, vomit, yawn
Treatments of Erectile Dysfunction
Drug Therapy : Orally Administration
Sildenafil
Phosphodiesterase Inhibitor
Side effect : headache, flushing, dyspepsia
visual disturbance
Contraindication : co-administration with nitrate
MI, CHF
Treatments of Erectile Dysfunction
Intracavernous Injection
ใช้ vasoactive agents ในการฉีดเข้ า corpora cavernosa
ทาให้ เส้ นเลือดขยายตัว เกิดการคัง่ ของเลือดที่ penis ทาให้ เกิด erection
Vasoactive Agent
Papaverine
Phentolamine
Alprostadil
Treatments of Erectile Dysfunction
Intracavernous Injection
Side effect : priapism, small nodule, subcutaneous
hemorrhage, pain, trauma, scar
*combination therapy จะให้ ผลการรักษาทีด่ กี ว่ า monotherapy
*การเพิม่ oral alpha-blocker (Doxazosin) จะเสริมฤทธิ์ในการ
ขยายหลอดเลือด
Treatments of Erectile Dysfunction
Intraurethral suppositories
“MUSE” (Medicated urethral system for erection)
มีหลอดบรรจุ alprostadil สาหรับสอดเข้ าทาง urethra โดยจะออก
ฤทธิ์ภายใน 8-10 นาที
อาการไม่ พงึ ประสงค์ : ปวด อาการบวมแดง
อาจมีเลือดออกในท่ อปัสสาวะ
Treatments of Erectile Dysfunction
Vacuum Devices
Pump จะดูดอากาศออกจาก cylinder ทาให้
เกิดสู ญญากาศเกิดแรงดึงเลือดเข้ า penis
และ elastic band จะป้องกันไม่ ให้ เลือดไหล
ย้ อนกลับ
Treatments of Erectile Dysfunction
Hormone Replacement Therapy :
Testosterone
เพิม่ sexual function
มีท้ งั ในรู ปแบบการฉี ด การรับประทาน และการทา
Treatments of Erectile Dysfunction
Surgery
- ผ่ าตัดใส่ Paired rod เข้ าใน
corpora cavernosa
- ผ่ าตัด repair arteries จะช่ วยได้ ใน
กรณี obstruction
Treatments of Erectile Dysfunction
Others
: Alprostadil gel
ทาที่ glans penis จะทาให้ เพิม่ penile rigidity
Comparision of Treatments
Use :
Oral
Intracarvenous
Medication
Injection
AUA guildline :
AUA guildline :
1st Line(Now)
1st Line(Old)
effective in
effective in
definable &
definable &
undefinable cause undefinable cause
MUSE
Vacuum
HRT
Surgery
Device
Injection
Oldest
alternatives
Treatment
Andropause Last choice
or Arterial
revascularize
and venous
ligament in
younger pt.
Or prosthetic
penile
implantation
Comparision of Treatments
Agents :
Oral
Intracarvenous
Medication
Injection
Sildenafil
Alprostadil
Yohimbine
Papaverine
Phentolamine
Phentolamine
MUSE
Vacuum
HRT
Surgery
Device
Alprostadil
-
Testosterone
-
40-65%
90 % up
61 %
-
Apomorphine
Effective : Silden. 65-93% Monotherapy 70-74%
Others is lower Combined
90 %
Comparision of Treatments
Advantage
Oral
Intracarvenous
Medication
Injection
Comfortable,
High effective,
Less
Non invasive
no death evidence
Invasive
BMD
than inj.
Improve
and
sex fn.,mood
no death
evidence
& emotion
MUSE
Vacuum
HRT
Surgery
Device
High effective Maintain
Increase
muscle
strength
High effective
Comparision of Treatments
Dis
Advantage
Oral
Intracarvenous
Medication
Injection
Have Death
evidence data
50 % reject the
long term treatment
cause :
lower effective
in some case
as DM
MUSE
urethral
bleeding
problem of self inj.
Penile pain(11%)
priapism (0.5-5%)
More
expensive
than
injection
HRT
Surgery
Use only
Expensive,
in
uncomfort.
Device
Penile pain Patients and
decrease in response
less interest in sex
Vacuum
Partner’s
satisfation andropause
less than inj.
long term :
Anemia,
increase
bl. Viscosity
CI in
Prostate CA
Comparision of Drug Therapy
Agents
Sildenafil
Alprostadil
MUSE
Papaverine Phentolamine
Apo
morphine
Phosphodies- Alpha 1,2Stimulate
terase inhibitors
alpha-adrenagic
Alprostadil
adrenergic
Brain
: increase NO
: Inhibit smooth
blocking agent
receptor dopaminergic
: increase cGMP
muscle
:Carvenous smooth
blocking
mechanism
contraction
muscle relax
:Dilate arterial that effect
Mechanism Phosphodiesterase
inhibitors
Effective
Syn. PG. E
Like
:Arterioles smooth
vessel
muscle relax
:inh. Symp.
65-93%
Monotherapy 70-74%
avg. 75 %
Combined
90 %
40-65%
40-60 %
40-45 %
erection
65%
Comparision of Drug Therapy
Agents
Sildenafil
Alprostadil
MUSE
Papaverine Phentolamine
Apo
morphine
Admin.
oral
route
intracarvenous
injection
Intraurethral intracarvenous
suppository
injection
by
oral or
sublingual
Intracarvenous
injection
applicator
usual dose
25-100 mg
5-20 mcg
50-1000 mcg Single 10-60mg
Combine 3-5mg
(Papa+Phento
or
Papa+Alpro)
40-80 mg
-
Comparision of Drug Therapy
Agents
Sildenafil
Alprostadil
MUSE
Papaverine Phentolamine
Apo
morphine
Use in
Definable and
Definable and
case
undefinable
undefinable
injection
such as DM,
such as DM,
alternative
Olderly with HT
Olderly with HT
spinal cord injury
spinal cord injury
Contra
depression
- pt. Use nitrate,
indication
Heart Disease,
Renal&Hepatic
Impairments
Alprostadil like alprostadil
depression
Predisposition to
priapism eg
anemia,leukemia
Ab. Penile
Anatomy
Urethritis
Anatomical
deformation of penis
risk of
priapism
Heart Disease
like
Psychogenic
alprostadil
Type
NA.data
NA.data
Comparision of Drug Therapy
Agents
Sildenafil
Alprostadil
MUSE
Papaverine Phentolamine
Apo
morphine
ADR
16% Headache
35 % Penile Pain 30 % Penile
Papa + Phentolamine
Nausea
10% Flushing
2%
0.4 % Penile Pain
Vomit
8%
Yawn
7% Dyspepsia
3% Visual Disturb
Priasism or
Fibrosis
Pain
5% Urethral
bleeding
Priapism and
fibrosis
6% Drowsiness
sweating,Hypot.
Dis
Advantage
Have Death
only Alprostadil has approved in USA
evidences
Phentolamine has carcinogenic potential effect in rat
The End