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Pendahuluan
Masalah seksual komponen penting hidup manusia Disfungsi seksual frekuensi me dengan bertambahnya usia. Sepertiga lansia mengeluhkan masalah disfungsi seksual. Salah satu disfungsi ereksi.
Definisi
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
Neurotransmitter
Tumescence
Venous occlusion
Rigidity
Erection
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
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
Physical exam:
Focused neurovascular exam Size of testis DRE
Lab tests
UA Testosterone, CMP, Lipid panel PSA in men >50 years
SHIM IIEF 5
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
Nitric Oxide-cGMP Mechanism of Corpus Cavernosal Smooth Muscle Relaxation and Penile Erection
Endothelial cells NANC
NO
Guanylate cyclase
GTP GMP
cGMP PDE 5
RELAX
Penile erection
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
Contraindications
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
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
TERIMA KASIH
Diabetes
Obesity
Hypertension
Dyslipidemia