Group 3 ธนวัต จางคกูล 43076140 กนกพร ตั้งจิตติพร 43076173 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 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 Sympa, - NE release Parasym, + NO & Ach release Somatic, +Ach release Peripheral pathways 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 promotes sexual drive serotonin recepters inhibits sexual

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, ปัสสาวะบ่อย, tachycardia, เพิ่ม 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 ในการฉีดเข้า corpora cavernosa ทำให้เส้นเลือดขยายตัว เกิดการคั่งของเลือดที่ penis ทำให้เกิด erection Vasoactive Agent Papaverine Phentolamine Alprostadil

Treatments of Erectile Dysfunction Intracavernous Injection Side effect : priapism, small nodule, subcutaneous hemorrhage, pain, trauma, scar *combination therapy จะให้ผลการรักษาที่ดีกว่า monotherapy *การเพิ่ม oral alpha-blocker (Doxazosin) จะเสริมฤทธิ์ในการ ขยายหลอดเลือด

Treatments of Erectile Dysfunction Intraurethral suppositories “MUSE” (Medicated urethral system for erection) มีหลอดบรรจุ alprostadil สำหรับสอดเข้าทาง urethra โดยจะออก ฤทธิ์ภายใน 8-10 นาที อาการไม่พึงประสงค์ : ปวด อาการบวมแดง อาจมีเลือดออกในท่อปัสสาวะ

Treatments of Erectile Dysfunction Vacuum Devices Pump จะดูดอากาศออกจาก cylinder ทำให้เกิดสูญญากาศเกิดแรงดึงเลือดเข้า penis และ elastic band จะป้องกันไม่ให้เลือดไหลย้อนกลับ

Treatments of Erectile Dysfunction Hormone Replacement Therapy : Testosterone เพิ่ม sexual function มีทั้งในรูปแบบการฉีด การรับประทาน และการทา

Treatments of Erectile Dysfunction Surgery - ผ่าตัดใส่ Paired rod เข้าใน corpora cavernosa - ผ่าตัด repair arteries จะช่วยได้ใน กรณี obstruction

Treatments of Erectile Dysfunction Others : Alprostadil gel ทาที่ glans penis จะทำให้เพิ่ม penile rigidity

Comparision of Treatments Oral Medication Intracarvenous Injection Vacuum Device HRT Surgery MUSE Use : AUA guildline : 1st Line(Now) effective in definable & undefinable cause AUA guildline : 1st Line(Old) effective in definable & undefinable cause Injection alternatives Oldest Treatment Andropause Last choice or Arterial revascularize and venous ligament in younger pt. Or prosthetic penile implantation

Comparision of Treatments Oral Medication Intracarvenous Injection Vacuum Device HRT Surgery MUSE Agents : Sildenafil Yohimbine Phentolamine Apomorphine Alprostadil Papaverine Phentolamine Alprostadil - Testosterone - Effective : Silden. 65-93% Others is lower Monotherapy 70-74% Combined 90 % 40-65% 90 % up 61 % -

Comparision of Treatments Oral Medication Intracarvenous Injection Vacuum Device HRT Surgery MUSE Advantage Comfortable, Non invasive High effective, no death evidence Less Invasive than inj. and no death evidence High effective Maintain BMD Improve sex fn.,mood & emotion Increase muscle strength High effective

Have Death evidence data Comparision of Treatments Oral Medication Intracarvenous Injection Vacuum Device HRT Surgery MUSE Dis Advantage Have Death evidence data lower effective in some case as DM 50 % reject the long term treatment cause : decrease in response less interest in sex problem of self inj. Penile pain(11%) priapism (0.5-5%) Penile pain urethral bleeding More expensive than injection Patients and Partner’s satisfation less than inj. Use only in andropause long term : Anemia, increase bl. Viscosity CI in Prostate CA Expensive, uncomfort.

Phosphodiesterase inhibitors Phosphodies- terase inhibitors Comparision of Drug Therapy Apo morphine Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine Mechanism Phosphodiesterase inhibitors : increase NO : increase cGMP Syn. PG. E alpha-adrenagic blocking agent :Carvenous smooth muscle relax :Arterioles smooth Like Alprostadil Phosphodies- terase inhibitors : Inhibit smooth muscle contraction Alpha 1,2- adrenergic receptor blocking :Dilate arterial vessel :inh. Symp. Stimulate Brain dopaminergic mechanism that effect erection Effective 65-93% avg. 75 % Monotherapy 70-74% Combined 90 % 40-65% 40-60 % 40-45 % 65%

Comparision of Drug Therapy Apo morphine Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine Admin. route oral intracarvenous injection Intraurethral suppository by applicator intracarvenous injection oral or Intracarvenous injection sublingual 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 Apo morphine Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine Use in case Definable and undefinable such as DM, Olderly with HT spinal cord injury depression Definable and undefinable such as DM, Olderly with HT spinal cord injury depression Alprostadil injection alternative like alprostadil like alprostadil Psychogenic Type Contra indication - pt. Use nitrate, Heart Disease, Renal&Hepatic Impairments Predisposition to priapism eg anemia,leukemia Anatomical deformation of penis Ab. Penile Anatomy Urethritis risk of priapism Heart Disease NA.data NA.data

Comparision of Drug Therapy Apo morphine Agents Sildenafil Alprostadil MUSE Papaverine Phentolamine ADR 16% Headache 10% Flushing 7% Dyspepsia 3% Visual Disturb 35 % Penile Pain 2% Priasism or Fibrosis 30 % Penile Pain 5% Urethral bleeding 6% Drowsiness sweating,Hypot. Papa + Phentolamine 0.4 % Penile Pain 8 % Priapism and fibrosis Nausea Vomit Yawn Have Death evidences only Alprostadil has approved in USA Phentolamine has carcinogenic potential effect in rat Dis Advantage

The End