Sexual function and dysfunction in men

Transcription

Georges A. de Boccard, M.D.
Consultant Urologist F.E.B.U.
Sexual function
and dysfunction in men
Training in Reproductive Health Research
Geneva Foundation for Medical Education and Research
Geneva March 15th, 2007.
The physical
Pathways of a
Normal erection?
After erotical stimulation
And physical stimulation
visual
tactile
genital
1. Anatomy and physiology of normal
erection
2. Incidence of erectile dysfunctions
3. Causes of erectile dysfunctions
4. Diagnostic tools
5. Treatments
Pituitary & gonadic physiology
GnRH
E(?)
+
-
Hypothalamus
Anterior pituitary
LH
Testostérone
+
T
Testosterone
behaviour
prostate
bones
E(?)
FSH
+
Testis
Anatomy
UrologyHealth.org Anatomical Drawings
Anatomy
UrologyHealth.org Anatomical Drawings
Neurophysiology
cavernous Nerves
– Parasympathetic nitrergic
– Sympathetic adrenergic
control of the blood flow (rigidity- flaccidity)
Pudendal Nerves
– Sensitive (positive feed-back)
– motors : contraction of perineal muscles
(ischio- and bulbocavernous)
Functional neuroanatomy of erection
Cortex
Thalamus
Hypothalamus
Limbic System
Medulla
Oblongata
Autonomic nuclei in
Reticular Formation
Systemic effects
Sympathetic
Chain Ganglia
T11-L2
Superior Hypogastric
Plexus
S2-S4
Pelvic Nerve
Hypogastric Nerve
Pelvic Plaxus
Pudendal Nerve
Cavernous Nerve
Dorsal Nerve of the Penis
P Hedlund
Penile anatomy
Vascularisation
Anatomy of corpus cavernous
Flaccidity
Erection
Erectile Physiology
cGMP
Ca++
NO
NO - cGMP
relaxation of the cavernous smooth
muscle inducing erection
erection
2. Incidence of erectile dysfunction
3. Causes of erectile dysfunction
4. Diagnostic tools
5. Treatments
Incidence of erectile dysfunction in Europe
60
48,3 %
50
(%)
40
30
20
26,7 %
15,6 %
12,8 %
10
1,7 %
4,6 %
0
l
a
t
To
9
3
20
9
4
40
9
5
50
0
7
60
0
>7
S.I.M.G. Epidemiologic Study, 1997
erection
4. Diagnostic tools
5. Treatments
Causes of erectile dysfunctions
18% psychogenic
43% physical
57%
82%
39% mix
Hormonal
disorders
6%
Medical treatment
8%
Vascular
diseases
33%
Drug addiction
7%
Neurological
affection
11%
Radical surgery
in the pelvis
10%
Diabetes
25%
Stief et. Al, Zeitgemäße Therapie der erektilen
Dysfunktion, Springer Verlag
Role of the vascular endothelium
Any condition that induces a lack of NO
production from the vascular endothelium
may be a cause of erectile dysfunction.
Since NO secretion is centrally modulated (brain),
any relational disturbance will negatively affect
the corpus cavernous, The same way
as a vascular or neurological disorder.
NO
GTP
5’GMP
Guanylate
cyclase
Ca2+
Ca2+
Ca2+
cGMP
PK
Ca2+
Ca2+
Ca2+ Ca2+
Muscle relaxation - erection
Inhibitors
PDE5
Hormones and aging
Pituitary
GH
IGF-1
Somatopause
LH / FSH
E2
/T
Menopause / Androclysis
ACTH =
DHEA
Adrenopause
Testosterone level (ng/ml)
Day-night testosterone level
8
7
Age 25 y.
6
5
Age 71 y.
4
4
8
12
16
20
24
time
Bremner et al, J Clin Endocrinol Metab 1983; 56: 1278
erection
4. Diagnostic tools
5. Treatments
Diagnostic tools
Special investigations
Duplex sonography
with pharmacostimulation
Intra cavernous injection test
Lab. Blood and hormonal status
Physical examination
History
History

Onset, nature, duration
Rigidity, shape of the penis
External factors (psych. or prof. stress)
Associated diseases
Former therapies
Expectations regarding the treatment.
Physical examination

General condition
Blood pressure, pulsations
External genitals
Inflammatory diseases (teeth)
DRE
Neurological evaluation
Lab tests
Fasting glycaemia
(HbA1c)
Lipidic profile
Blood formula
Liver enzymes
Hormones
– Testosterone (free)
– (PRL – TSH – T4)
PSA
– % free PSA
urine
Specific tests
Duplex
sonography
+intracavernosal
prostaglandin
Nocturnal Penile
tumescence test
Vascular imaging
Neurological testing
Duplex sonography
PGE1 injection
Art.flow>30cm/s
Venous leakage
NPT
REM sleep phases
History
Vascular radiology
arteriography
cavernosography
Anxiety / fibrosis
erection
4. Diagnostic tools
5. Treatments
Hormonal treatment
Testosterone injection
Testosterone oral
Testosterone transdermal
testosterone enanthate
Testosterone gel
testosterone undecanoate
PDE5 inhibitors
Sildenafil
Tadalafil
H
Vardenafil
O
CH 3
O
N
O
CH3
CH3
HN
N
N
N
N
N
H H
HCl
C H3
O
O
S O
N
N
O
H3 C
O
Viagra
Pfizer
®
Cialis
®
Lilly-Icos
®
Levitra
GSK-Bayer
yohimbini
Tadalafil (Cialis)
H
O
N
N
HH
N
O
O
O
CH3
PDE5 inhib. preferences
43%
40%
17%
(34/86)
(15/86)
Levitra 20mg
Viagra 100mg
Cialis 20mg
Sommer et al. (2003), ESSM, Istanbul
MACA (lepidium Meyenii)
Gonzales G. & al. 2002. Effect of Lepidium Meyenii (MACA) on sexual desire and its absent
relationship with serum testosterone levels in adult healthy men. Andrology 34, 367-372.
PDE5 inhibitors, what dosage?
Occasional treatment
– 1 tabl. 30 to 60 min before planned intercourse
Long term treatment
– Tadalafil (Cialis): 1-2 x 20 mg per week during
2-8 weeks
– Vardenafil (Levitra): 2-3x 5 or 10 mg per week
during 2-8 weeks
– Sildenafil (Viagra): 2-3x 25 or 50 mg per week
during 2-8 weeks
PDE5 inhibitors, tips
It is important to separate the intake of the
pill from the intercourse in order to avoid a
medically generated performance anxiety.
The medication shall not necessarily induce
a rigid erection
It should facilitate an erection following a
normal love process.
PDE5 inhibitors: warning
Simultaneous treatments with NO donors
(nitro-glycerine etc) that will induce a
possibly dangerous hypotension
Contra indication to sexual activity
Cardiovascular diseases like
– Recent myocardial infarction or angina
– Ictus
– Arrhythmia, uncontrolled hypertension
Muse
Alprostadil
MUSE
Alprostatil
Caverject
Alprostatil
Caverject
Alprostatil
Corpus cavernous
Injection in the corpous
cavernous
Semi rigid implant
Acuform (Mentor)
Inflatable implant
(AMS 700)
réservoir de
liquide
Reservoir
(full)
pompe /
soupape
Reservoir
(empty)
cylindres
What’s in a man’s mind
Dr Georges-A. de Boccard
March 10th, 2006