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Disfungsi Ereksi

Divisi Geriatri Bagian Penyakit Dalam FK UNSRI 2012

Masalah seksual komponen penting hidup manusia Disfungsi seksual frekuensi me dengan bertambahnya usia. Sepertiga lansia mengeluhkan masalah disfungsi seksual. Salah satu disfungsi ereksi.

Disfungsi ereksi ketidakmampuan secara konsisten untuk mencapai dan/atau mempertahankan ereksi sedemikian sehingga mencapai aktivitas seksual yang memuaskan.

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

Sexual impulse

Normal pathway to erection

Release of NO & chemical substrates

Smooth muscle relaxation

Venous occlusion


Causes of erectile dysfunction

Aging Psychological Neurological Hormonal Vascular Medications Habits Other Depression, anxiety Cerebral, spinal, peripheral neuropathy, pudendal nerve Hypogonadism, prolactin, thyroid, Cushings, Atherosclerosis, venous incompetence Antihypertensives, antidepressants, estrogen, antiandrogens Cannabis, alcohol, narcotics, tobacco Diabetes, renal, hypertension, COPD

Kondisi yang berkaitan dengan disfungsi ereksi

Endocrine abnormalities Hypogonadism Hyperprolactinemia Hypothyroidism/hyperth yroidism Life style Cigarette smoking Chronic alcohol abuse

Aging Chronic disease Diabetes mellitus Heart disease Hypertension Lipid disorders Renal failure Liver disease Vascular disease

Neurogenic causes Spinal cord injury Multiple sclerosis Herniated disc Penile injury/disease Peyronie's disease Priapism Anatomic abnormalities

Medications Psychologic issues Depression Anxiety Social stressors Trauma/injury Pelvic trauma/ surgery Pelvic radiation

Obat-obatan yang berhubungan dengan disfungsi seksual

Thiazides Spironolactone Sympatholytics (methyldopa [Aldomet], clonidine [Catapres]) Peripheral agents (reserpine [Serpasil]) Alpha blockers Beta blockers (particularly nonselective agents) Erectile dysfunction, decreased libido Erectile dysfunction, decreased libido Erectile dysfunction, decreased libido Erectile dysfunction, ejaculatory dysfunction Erectile dysfunction, ejaculatory dysfunction Erectile dysfunction, decreased libido

Tricyclic antidepressants Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors Digoxin (Lanoxin) Histamine H2-receptor blockers

Decreased libido, erectile dysfunction Multiple phases of sexual function Ejaculatory dysfunction, erectile dysfunction Decreased libido, erectile dysfunction Decreased libido, erectile dysfunction

Alcohol (long-term heavy use) Ketoconazole (Nizoral) Niacin (Nicolar) Phenobarbital Phenytoin (Dilantin)

Decreased libido, erectile dysfunction Decreased libido, erectile dysfunction Decreased libido Decreased libido, erectile dysfunction Decreased libido, erectile dysfunction

A Practical Evaluation of Men with ED Basic evaluation

Medical History Cardiovascular history Endocrine history Sexual history/questionnaire

Physical exam:
Focused neurovascular exam Size of testis DRE

Lab tests
UA Testosterone, CMP, Lipid panel PSA in men >50 years


History of ED treatments
1960s sex therapy, counselling 1970s implants, vacuum devices 1980s penile injections 1990s oral medication - Viagra 2000s Cialis, Levitra 2010s gene & stem cell therapies

ED treatment algorithm
Ist line lifestyle changes, hormone issues

2nd line oral medication, counselling

3rd line penile injections, vacuum devices

4th line implants, vascular surgery

Counseling and/or Sex Therapy

Rule out depression Try oral medication in patient with psychogenic impotence Refer to sex therapist or psychiatrist for sever psychopathology

Nonpharmacologic Treatment Options

Lifestyle changes: Reduce fat and cholesterol in diet Decrease or limit alcohol consumption Eliminate tobacco use and substance abuse Weight loss if appropriate Regular exercise

Nitric Oxide-cGMP Mechanism of Corpus Cavernosal Smooth Muscle Relaxation and Penile Erection
Endothelial cells NANC

Guanylate cyclase



Penile erection

Site of PDE5 inhibition

NO = nitric oxide NANC = nonadrenergic-noncholinergic neurons PDE 5 = phosphodiesterase type 5

Mechanism of Action
Sildenafil, vardenafil and tadalafil are potent and selective inhibitors of cyclic GMP-specific phosphodiesterase type 5 (PDE5). Sildenafil, vardenafil and tadalafil are highly selective for PDE5, which is present in high concentrations in the smooth muscle of the penis

PDE5 inhibitors
Indications: Psychogenic ED Mild vasculogenic ED Neurogenic ED Side effects from medication(s) patient is already taking Side effects: Headache Flushing Dyspepsia Nasal congestion Visual disturbances Priapism

Nitrates and PDE5 inhibitors must not be used together Includes use of amyl nitrate Any treatment for ED is contraindicated in men for whom sexual intercourse is inadvisable due to cardiovascular risk factors

Compare the 3 PDE5

Sydney Mens Health

Penile Injection Therapy

Mechanism of action: smooth muscle vasodilator Administration: 10, 20, 40ug Inject directly into corporeal bodies of the penis Results: 70%-90% Dropout rates: 25%-60% Side effects: pain (36%), priapism (4%), fibrosis

Vacuum Constriction Device

Mechanism of Action: Penis placed in plastic tube Air evacuated from the tube Blood trapped in penis with constricting ring Erection limited to 30 minutes Results: 80%-90% Contraindications: bleeding disorders, sickle cell disease, anticoagulation Complications: coolness, petechiae, numbness, pain with ejaculation High drop out rate

Vacuum Devices
Was previously first-line treatment for ED Seldom used now that oral therapy is available Considered an alternative if patient fails oral therapy and does not want to proceed with surgery

Penile Prosthesis
Indications: Patients who have failed other therapies Peyronies disease Severe vasculogenic disease Advantages Good rigidity Freedom from medications Outpatient/24HR surgery Resume sexual activity 4-6 weeks No loss of ability to ejaculate or achieve orgasm

Malleable Prosthesis Easy for patient and partner to use Few mechanical parts Same-day surgery usually possible Least expensive type of prosthesis

Two-Piece Inflatable Prosthesis Small inflation pump provides comfort and ease Fast and easy one-step deflation procedure Better conceal ability when flaccid than with malleable or selfcontained devices

The Deadly Quartet (high risk ED) Metabolic Syndrome