erectile dysfunction presents
TRANSCRIPT
男性性功能障礙Huang Guan-lin M.D. / YC Shen M.D.
司馬奕 桓溫
Why erectile dysfunction matters
2007 taiwan EDCATN=990 male (40~89)The average ED rate would is 26% by IIEF5 score
However, the rate of ED is only 13% by self report
2007 Taiwan EDCAT ED prevalence
16.09
24.38
41.92
52.87
5.27
15.44
23.98 25.27
40-49 50-59 60-69 70+0
10
20
30
40
50
60
¦Ûz
¶qªí
%
age(yr)
The anatomy and physiology of ED
Ext. iliac artery
Helicine a.
Neuro control
MPOA, PVN, hippocampus, mygdala,PAG, ventral tegmentum
AUTONOMIC CONTROL CENTERT11-L2, S2-S4 Pelvic plexus → cavernous n. stimulation
SOMATIC CONTROL CENTERS2-S4Bulbocavernous m. /ischiocavernous m.
The use of PDE5 is to inactivate the following?
1. C-GMP 2. 5-GMP 3. Guanylyl cyclase 4. GTP
Hemodynamic physiology
1. Flaccid phase
2. Filling phase, P→ F↑
3. Tumescence phase, P↑
4. Full erection phase
5. Rigid erection phase
6. Detumescence phase
More than 30cm!!!
Classification of ED
33%33%
33%
PSYCHOGENICORGANICMIXED
1.Lack of arousability2.Partner problem3.Performance problem4.Mood problem
1.Neurogenic2.Hormonal3.Arterial4.cavernosal/ vein5.Drug6.Systemic Dz
Organic ED
• Neurogenic– Brain: AD, parkinsonism, trauma– Neuron: OP/RT, Alcohol/DM → cavernosal n.
• Hormone– Hypothalamus/pituitary gland– Hyper/hypothyroidism
• Artery – Trauma– HTN, hyperlipidemia, DM, smoking
Organic ED
• Vein– Veno-occlusive dz– Peyronie dz, albugenia injury, shunt
• Drug– SSRI– antipsychotics– Diuretics: thiazide/ spirolactone– B-blocker– Antiandrogen
• Systemic DZ– CKD, DM…
Risk factors
AgeDMSMOKINGCholesterolCKDHTNObesity/metabolic syndromeBicycling?
How to approach the ED pts?
Evaluate the ED severityErection hardness score: simple, easy to screen
分數
5-7 嚴重
8-11 中度
12-16 輕度到中度
17-21 輕度
DD psychogenic / organic表徵 器質性 ED 心因性 ED
發生時間 漸進性 突然發生
情境 全都一樣 某些情況出現
過程 無差別 有起伏變化
無關性交的勃起 差 有
性生理問題 續發性 出現一段時間
與性伴侶問題 續發性 開始就有
對性行為焦慮害怕 續發性 開始就有
HISTORY TAKING
• Underlying dz• OP history?• Medication?• Morning erection?
Lab and examination
• Sugar, cholesterol, TG, testosterone– Gonadal hormone if need
• Most patients do not need further examination Penis vascular Doppler Penis arterial angiography Cavernosography Nocturnal penile tumescence/rigid scan Psycho-evaluation Hormone (testosterone, LH, prolactin, SHBG, FSH)
angiography
Cavernosography
Rigid scan
Treatment
Oral medication
Injection
Operation
1
2
3
轉介泌尿科
Common side effect:1.Flush2.Headache3.Dyspepsia4.BLUE visual field
Common side effect:1.Flush2.Headache3.Dyspepsia4.BLUE visual field
PDE5 inhibitor Sildenafil Vardenafil Tadalafil
商品名 威而鋼 樂威壯 犀利士
上市劑型 (mg) 25,50,100 5,10,20 5,10,20
Tmax
達到血液最高濃度60min 40min 120min
半衰期 3-5hrs 4-5hrs 17.5hrs
有效作用期 4-8hrs 2-8hrs 24-36小時
食物影響 高脂食物 高脂食物 無
價格 NTD300(100mg) NTD300(20mg) NTD400-450(20mg)
如何選擇此三種藥物 ?
威而鋼 :
單次使用 ,市場舖貨最廣 ,臨床試驗最齊全樂威壯 :
單次使用 ,最強結合效力 ,適用於困難治療病人犀利士 :
周末狂歡 ,CP值高
注意事項• PDE5 inhibitor:治療勃起功能障礙,非春藥• 坊間及網路假藥甚多,請轉介醫師處方• 使用有機硝酸鹽類為絕對禁忌症– NTG, isosorbide mononitrate, isosorbide
dinitrate
Other oral medications
• Apomorphine(Uprima)– Central neuro-control D1,D2 receptor
• Yohimbine– ɑ2 adrenoceptors blocker
• Trazodone– SSRI with ɑ blocker effect– Psychogenic ED prefer
Injection/suppository ,PGE1
Caverjet
MUSE
Complications
• Priapism• Fibrosis• Hematoma• Infection
Operation
OP
REVASCULARIZATION ARTIFICIAL PENIS
INFLATBLEMALLEABLE
EASY USEEASY PLACEMENTCHEAPPHYSIOLOGY INFLATION↓
MECHNICAL FAILUREEXPENSIVELESS LONG TERM DURABILITY