MALE SEXUAL DYSFUNCTION The penis does not obey
남성 성기능 장애 MALE SEXUAL DYSFUNCTION “The penis does not obey the order of its master, who tries to erect or shrink it at will. Instead, the penis erects freely while its master is asleep. The penis must be said to have its own mind, by any stretch of the imagination. ” -Leonardo da Vinci -
Penile Components and their Function during erection ▪ Corpora cavernosa ▪ Tunica albuginea (of corpora cavernosa) Support corpus spongiosum and glans Contains and protects erectile tissue Promotes rigidity of the corpora cavernosa Participates in veno-occlusive mechanism ▪ Smooth muscle Regulates blood flow into and out of the sinusoids ▪ Ischiocavernosus muscle Pumps blood distally to hasten erection ▪ Bulbocavernosus muscle Provides additional penile rigidity during rigid erection phase Compresses the bulb to help expel semen ▪ Corpus spongiosum ▪ Glans Pressurizes and constricts the urethra lumen to allow forceful expulsion of semen Acts as a cushion to lessen the impact of the penis on female organs Provides sensory input to facilitate erection and enhance pleasure Facilitates intromission because of its cone shape
Figure 21 -1 Artist's cross-sectional drawing of the penis, depicting the inner circular and outer longitudinal layers of the tunica albuginea as well as the intracavernous pillars. The longitudinal layer is absent in the ventral groove housing the corpus spongiosum. Figure 21 -2 Micrograph of the human tunica albuginea, showing the interwoven elastic fibers and the finer collagen fibers. (Hart stain, =100. )
Figure 2 -37 Male perineum, illustrating the internal pudendal artery and its branches on the left and the pudendal nerve and its branches on the right
I. Physiology of penile erection 1. Innervation of the Penis 1) Peripheral nerve (1) sympathetic( T 12 -L 2 ); detumescence, emission, ejaculation sympathetic chain --- superior hypogastric plexus --hypogastric n. --- pelvic plexus --- cavernous n. (2) parasympathetic( S 2 -4 ); tumescence pelvic n. (nervi ergentes)---pelvic n. ---pelvic plexus---cavernous n. (3) Somatic pudendal n. 2) Central mechanisms: brain exert a modulatory influence over spinal reflex (1) Reflexogenic erectile mechanism pudendal afferent --- sacral pelvic parasympathetic efferent (2) Psychogenic erectile mechanism
Figure 21 -7 Penile neuroanatomy. Figure 21 -8 Drawing from a human cadaveric dissection shows the medial (red arrow) and lateral (green arrow) bundles of the cavernous nerve distal to the prostate.
Table 21 -3 Level Forebrain Hypothalamus -- Brain Centers Involved in Sexual Function Region Medial amygdala Stria terminalis Pyriform cortex Hippocampus Right insula and inferior frontal cortex Left anterior cingulate cortex Medial preoptic area (MPOA) Paraventricular nucleus (PVN) Brain stem Midbrain Function Control sexual motivation Inhibits sexual drive (hypersexuality when destroyed) Involved in penile erection Increased activity during visually evoked sexual stimulation (sexual arousal) Ability to recognize a sexual partner, integration of hormonal and sensory cues Facilitates penile erection (through oxytocin neurons to lumbosacral spinal autonomic and somatic efferents) Nucleus paragigantocellularis Inhibits penile erection (through serotonin neurons to lumbosacral spinal neurons and interneurons) A 5 -catecholaminergic cell group Noradrenergic innervation of anterior horn motor neurons to perineal striated muscles Locus ceruleus Periaqueductal gray Relay center for sexually relevant stimuli
2. Anatomy and Hemodynamics of Penile Erection 1) Arterial supply internal iliac a. internal pudendal a. 2) Venous supply superficial dorsal v. deep dorsal v. cavernous v. urethral v. 3) Sinusoidal system dorsal a. cavernous (deep) a. bulbourethral a. saphenous v. emissary v. periprostatic plexus internal pudendal v.
Figure 21 -3 A, Penile arterial supply. B, Scanning electron micrograph of a human penile cast showing helicine arteries opening directly into the sinusoids without intervening capillaries
Figure 21 -4 A, Photograph of an emissary vein with subtunical venous plexus of a human penile cast. The cast was made by injecting blue material into the corpus cavernosum and yellow material into the deep dorsal vein. The skin and tunica albuginea were then digested away with KOH solution. B, and C, Penile venous drainage.
Figure 21 -6 Blood flow and intracavernous pressure changes during the seven phases of penile erection and detumescence: 0, flaccid; 1, latent; 2, tumescence; 3, full erection; 4, rigid erection; 5, initial detumescence; 6, slow detumescence; 7, fast detumescence.
3. Mechanisms of Penile Erection 1) flaccid state arteries & arterioles are tortuous & constricted sinusoidal compliance increase 2) erection state arterial smooth muscle relax & resistance drop to minimum sinusoidal compliance decrease compressed against non-compliant tunica albuginea compressed emissary vein
Figure 21 -5 The mechanism of penile erection. A, In the flaccid state, the arteries, arterioles, and sinusoids are contracted. The intersinusoidal and subtunical venous plexuses are wide open, with free flow to the emissary veins. B, In the erect state, the muscles of the sinusoidal wall and the arterioles relax, allowing maximal flow to the compliant sinusoidal spaces. Most of the venules are compressed between the expanding sinusoids. The larger venules are sandwiched and flattened between the distended sinusoids and the tunica albuginea. This effectively reduces the venous capacity to a minimum. C, and D, Scanning electron micrographs of casts of a canine subtunical venous plexus in the flaccid
4. Hormones & Sexual Function male sexual maturation maintain sexual interest, seminal emission
5. Neurotransmitter & the Pharmacology of Erection 1) Adrenergic; intracavernous smooth muscle contraction, detumescence 2) Cholinergic; smooth muscle relaxation, erection (1) inhibition of adrenergic nerve via inhibitory interneuron (2) release of EDRF (endothelium-derived relaxing factor) from cholinergic nerve terminal (3) nonadrenergic-noncholinergic (NANC) NO release c-GMP accumulation
Figure 21 -9 Molecular mechanism of penile smooth muscle contraction. Norepinephrine from sympathetic nerve endings and endothelins and prostaglandin F 2α from the endothelium activate receptors on smooth muscle cells to initiate the cascade of reactions that eventually result in elevation of intracellular calcium concentrations and smooth muscle contraction. Protein kinase C is a regulatory component of the Ca 2+-independent, sustained phase of agonist-induced contractile responses. (From Lue TF: Erectile dysfunction. N Engl J Med 2000; 342: 1802 -1813. Copyright © 2000 Massachusetts Medical Society. )
Figure 21 -11 Molecular mechanism of penile smooth muscle relaxation. The intracellular second messengers mediating smooth muscle relaxation, cyclic adenosine monophosphate (c. AMP) and cyclic guanosine monophosphate (c. GMP), activate their specific protein kinases, which phosphorylate certain proteins to cause opening of potassium channels, closing of calcium channels, and sequestration of intracellular calcium by the endoplasmic reticulum. The resultant fall in intracellular calcium leads to smooth muscle relaxation. Sildenafil inhibits the action of phosphodiesterase 5 (PDE 5) and thus increases the intracellular concentration of c. GMP. Papaverine is a nonspecific phosphodiesterase inhibitor. e. NOS, endothelial nitric oxide synthase; GTP, guanosine triphosphate. (From Lue TF: Erectile dysfunction. N Engl J Med 2000; 342: 1802 -1813. Copyright © 2000 Massachusetts Medical Society. )
II. Diagnosis
Table 22 -1 -- Evolution in the Diagnostic Workup for ED Main Treatments Before 1970 Psychosexual therapy 1970 s 1980 s 1990 s. Present Diagnostic Tests Psychosexual history Penile prosthesis psychosexual therapy Medical psychosexual history sleep lab Yohimbine History intracavernous transurethral physical examination therapy testosterone, vacuum device duplex ultrasound DICC (goal-directed approach) Oral phosphodiesterase-5 inhibitors Process-of-care model 1 st ICUD algorithm 2 nd ICUD algorithm (patient-centered approach) DICC, dynamic infusion cavernosometry and cavernosography. ICUD, International Consultation on Urological Diseases.
* Goal-directed approch HISTORY & PHYSICAL EXAM PSYCHOLOGICAL EVALUATION Tx OPTIONS DISCUSSED serum testosterone Prolactin Glycosylated Hgb NPT Visual sex sti, ulation nd Visit Full 30’ Erection (evenafter exercise) Partial or No Response Pharmacologic Intracavernosal injection Duplex Doppler of Penile Arteries 2' Intracavernosal Injection Psychological Rx Intracavernosal Rx Regimen R/O Neurogenic Impotence Vacuum Device Therapy Arterial disease Pudendal arteriography (only if surger is planned) Penile Prosthesis No arterial disease Cavernosography & Cavernosometry if venous surgery planned
Figure 22 -1 Diagnostic algorithm for ED recommended by the ICSM.
1. Arterial impotence 1) PBI (penile brachial index) Penile Systolic Blood Pressure/brachial systolic pressure=PBI normal >0. 8, Impotent male <0. 6 2) Intracavernous injection of vasoactive amine 3) Duplex sonography and pulsed Doppler analysis peak systolic velocity (PSV) > 25 cm / sec end diastolic velocity (EDV) < 5 cm / sec resistive index = PSV-EDV/PSV
Figure 21 -6 Blood flow and intracavernous pressure changes during the seven phases of penile erection and detumescence: 0, flaccid; 1, latent; 2, tumescence; 3, full erection; 4, rigid erection; 5, initial detumescence; 6, slow detumescence; 7, fast detumescence. Figure 22 -7 Artist's conception of the changes in diameter and flow waveform in the cavernous arteries induced by intracavernous injection of prostaglandin E 1 in a potent young man as demonstrated by duplex ultrasound. Forceful concentric pulsations are particularly noticeable during full erection.
Figure 22 -5 Collateral circulation connecting the right dorsal artery (RDA) to the right cavernous artery (RCA) and the left cavernous artery (LCA) is shown by color duplex ultrasound in a longitudinal view.
4) Internal iliac or pudendal arteriography
2. Venous Impotence & Disease of Cavernous Smooth Muscle Dynamic infusion cavernosometry and cavernosography (DICC) 3. Neurologic Impotence 1) Somatic nervous system 2) Autonomic nervous system 3) Central nervous system occur during a most REM sleep, also present during non- REM sleep 3 -4 episode per night 90 min interval 20 -25% to total sleep time ( 1. 5 hour ) disrupted by sleep apnea, periodic leg movement, nocturnal myoclonus (1) mercury strain gauge (2) stamp (3) Rigiscan penile base > 3 cm, penile tip > 2 cm rigidity 70% or greater, enable to intromission
Figure 21 -13 A functional classification of impotence. Note that it is unlikely for an individual patient's impotence to derive solely from one source. Most cases have a psychogenic component of varying degree, and systemic diseases and pharmacologic effects can be concomitant and causative. (Modified from Carrier S, Brock G, Kour NW, Lue TF: Pathophysiology of erectile dysfunction. Urology 1993; 42: 468 -481, with permission of Exerpta Medica, Inc. )
Figure 22 -2 Treatment algorithm for ED recommended by the ICSM.
1. Vascular surgery 1) Arterial origin relieve of stenosis or occlusion of extrapenile artery (internal iliac, internal pudendal, dorsal artery) epigastric-corporeal anastomosis epigastric artery to deep dorsal vein 2) Venous origin ligation superficial and deep dorsal vein repair of fistula between glans & cavernous body epigastric artery to deep dorsal vein
2. Penile prosthesis 1) Semirigid, Malleable, Mechanical/Interdigitating 2) Inflatable a. Single component b. Two component c. Threee component
3. Pharmacotherapy 1) Intracavernous injection of vasoactive agents papaverine, phentolamine, prostaglandin E 1 Trimix 2) Phosphodiesterase type 5 (PDE 5) inhibitor 3) other drugs yohimbine testosterone 4. Vaccum suction device
Male sexual dysfunction involving emission, ejaculation & orgasm 1. Physiology of Emission , Ejaculation, & Orgasm pudendal nerve --- upper lumbar spinal sympathetic nuclei hypogastric nerve --- activate secretion and transport sperm somatoefferent of pudendal nerve to contract bulbocavernous muscle emission ; semen into bulbous urethra ejaculation ;
2. Disorders Affecting Emission, Ejaculation, & Orgasm 1) Causes bilateral sympathectomy at L 2 level high bilateral retroperitoneal lymphadenectomy retrograde ejaculation 2) Treatment elimination of alpha blocking agent alpha sympathomimetics electroejaculation 3. Premature ejaculation desensitization squeezing technique application of local anesthetics or condom
PRIAPISM 1. Type 1) high flow 2) low flow 2. Causes 1. unknown(60%) : prolonged sexual stimulation 2. associated disease : Leukemia, sickle cell disease, pelvic tumor, pelvic infection 3. penile trauma 4. spinal cord trauma 5. use of medication
3. Pathogenesis & clinical findings Erection Priapism Involved portion corpora cavernosa corpus spongiosum orpora cavernosa glans vasodilation of penile a. obstruction of venous outflow venoarterial disturbance Sexual desire present absent pain absent present (ischemic) minutes to hours to days Cause duration
High-flow priapism Characteristics Low-flow priapism painless, high PO 2, bright red blood not so rigid penis Mechanism painful, low PO 2, dark blood rigid penis, soft glans pain, perineal trauma로 인한 Cavernosoarterial shunt venous outflow가 차단되면서 blood stasis로 인한 hypoxia Etiology trauma, idiopathic veno-occlusive disease Medical status not so emergency embolization disease specific Treatment
Figure 22 -6 A, Color duplex ultrasonograph in a patient with high-flow priapism shows turbulent flow within the corpus cavernosum resulting from rupture of a branch of the left cavernous artery. B, On selective penile arteriography, a ruptured branch of the cavernous artery is seen filling the cavity.
4. Treatment : Urologic emergency 1) sedation followed by enema of ice-saline solution 2) Ketamine hydrochloride I. V. or I. M. 3) epidural or spinal anesthesia 4) sludged blood evacuation with large needle 5) shunting fistula 6) management of primary disease
HEMOSPERMIA ( BLOODY EJACULATION ) not uncommon complaint of middle aged men usually the wife recognize the symptoms 1. Causes 1) hyperplasia of mucosa of seminal vesicle 2) adenomatous polyp 3) prostatic intraductal carcinoma 4) utricular cyst 1. Treatment 1) diethylstilbestero 2) electrocoagulation of granulation of posterior urethra 3) needle aspiration of utricular cyst
Table 21 -1 First Author Kinsey -- Penile Length in Adults Stretched (S) or Erect (E) Length (cm) Country 15. 5 (E) United States 16. 74 (S) France Year of Report 1948 Number of Subjects 2770 Age in Years (range) 20 -59 Flaccid Length (cm) 9. 7 Bondil 1992 905 17 -91 10. 7 Da Ros 1994 150 NA NA Wessells 1996 80 21 -82 8. 85 Ponchietti 2001 3300 17 -19 9 Ajmani 1985 320 17 -23 8. 16 NA Schneider 2001 111 18 -19 8. 6 14. 48 (E) 32 40 -68 9. 22 14. 18 (E) 271 (N) 17 -83 9. 3 13. 5 (S) 109 (ED) 22 -68 7. 7 11. 6 (S) Awwad 2003 14. 5 (E) Brazil 12. 45 (S), 12. 89 (E) United States 12. 5 (S) Italy E, erect length; ED, erectile dysfunction; N, normal; NA, not available; S, stretch length. Modified from Awwad Z, Abu-Hijleh M, Basri S, et al: Penile measurements in normal adult Jordanians and in patients with erectile dysfunction. Int J Impot Res 2005; 17: 191 -195. Nigeria Germany Jordan
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