Lecture 18

1-2. Physical Exam


3. Descrie the pathophysiology of erectile dysfunction that is due to vascular, endocrinological, psychological, and idiopathic etiologies.


Erectile Dysfunction-the consistent inability to acheive and/or maintain an erection sufficient for sexual activity.


Mechanism of Erection
-Corpora Cavernosa are surrounded by tunica albugiea, and contain a lattice of blood sinusoids surrounded by trabeculae of smooth muscle
-Blood in the sinusoids exit through the tunica albuginea as emissary veins to form the deep dorsal vein.
-Parasympathetic nerves from S2-s4(S2,3,4 keep the dick off the floor) are for erection
-Sympathetic nerves from T11-L2 are for ejaculation and detumescence.
-Neuroendocrine messages from the brain due to audiovisual stimuli or fanasy(with or without tactile stimulation) activates the erectile response
-When flaccid the arterioles and sinusoids are contracted and the venous blood exits freely through emissary veins
-During erection the muscles of the sinsoid wallas and arterioles relax which increases blood inflow. This causes the sinusoids to expand and compress the venules, while the emissary veins are compressed under the tunica albuginea. The compression prevents venous outflow and erection occurs.
-Increased sympathetic vasoconstictor activity and break down of cGMP by PDE5 causes detumescence. This is mediated through alpha 1 adrenergic receptors
-The most improtant neuro transmitter is Nitric Oxide. NO activates GTP conversion to cGMP. cGMP causes smooth muscle relaxation and erection. VIP and PGE1 also support erection.


Psychogenic Anxiety; loss of attraction; stress; relationsship problems
Psychiatric Depression
Neurogenic Trauma; myelodysplasia; MS; diabetes; EtOH, pelvis surgery
Endocrine Primary or secondary hypogonadism; hyperprolactinemia
Arteriogenic Hypertension;smoking;diabetes;hypercholesterolemia; peripheral vascular dz
Venous Impariment of veno-occlusive mechanisms(venous leak)
Drug Induced Antihypertensives; antidepressants;hormones

4. Given the clinical presentation of any patient with eD, be abkle to:
a.) Recognize when a questionnaire, physiologic testing, and further lab tests are indicated
b.)when the most likely etiology is vascular, neurological, endocrinologica,psychological, or idiopathic
Using the history in diagnosis
-Psychogenic ED is characterized by sudden onest, situational, relationship issues, and normal nocturanl erections
-Organic ED is usually gradual in onset, progressive, absent nocturnal and morning erections.
- A quantitative structured questionnaire may be helpful to obtain a benchmark of the severity.
-Talk about current medications that could cause ED

Lab Tests
-used on an individual basis and based on goal oriented treatment plan
-Serum Glucose for diabetes
-Serum testosterone
-Serum prolaction
-thyroid hormone panel
-lipid profile
-serum PSA
-Nocturnal penile tumescence testing can help to evaluate psychogenic ED
-Selected cases can have cavernosography, cavernosometry, arteriography to check for normal anatomy, blood flow, and pressure response to erectile stimuli

psychogenic ED should be treated in cooperation with psychologist or psychiatrist and a physician .