erectile dysfunction presents

40
男男男男男男男 Huang Guan-lin M.D. / YC Shen M.D.

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Page 1: Erectile dysfunction presents

男性性功能障礙Huang Guan-lin M.D. / YC Shen M.D.

Page 2: Erectile dysfunction presents

司馬奕 桓溫

Page 3: Erectile dysfunction presents
Page 4: Erectile dysfunction presents

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

Page 5: Erectile dysfunction presents
Page 6: Erectile dysfunction presents

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)

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The anatomy and physiology of ED

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Ext. iliac artery

Helicine a.

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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.

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The use of PDE5 is to inactivate the following?

1. C-GMP 2. 5-GMP 3. Guanylyl cyclase 4. GTP

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Page 12: Erectile dysfunction presents

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!!!

Page 13: Erectile dysfunction presents
Page 14: Erectile dysfunction presents

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

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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

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Organic ED

• Vein– Veno-occlusive dz– Peyronie dz, albugenia injury, shunt

• Drug– SSRI– antipsychotics– Diuretics: thiazide/ spirolactone– B-blocker– Antiandrogen

• Systemic DZ– CKD, DM…

Page 17: Erectile dysfunction presents

Risk factors

AgeDMSMOKINGCholesterolCKDHTNObesity/metabolic syndromeBicycling?

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How to approach the ED pts?

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Evaluate the ED severityErection hardness score: simple, easy to screen

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分數

5-7 嚴重

8-11 中度

12-16 輕度到中度

17-21 輕度

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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

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HISTORY TAKING

• Underlying dz• OP history?• Medication?• Morning erection?

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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)

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angiography

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Cavernosography

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Rigid scan

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Treatment

Oral medication

Injection

Operation

1

2

3

轉介泌尿科

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Common side effect:1.Flush2.Headache3.Dyspepsia4.BLUE visual field

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Common side effect:1.Flush2.Headache3.Dyspepsia4.BLUE visual field

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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)

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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

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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

Page 33: Erectile dysfunction presents
Page 34: Erectile dysfunction presents

Other oral medications

• Apomorphine(Uprima)– Central neuro-control D1,D2 receptor

• Yohimbine– ɑ2 adrenoceptors blocker

• Trazodone– SSRI with ɑ blocker effect– Psychogenic ED prefer

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Injection/suppository ,PGE1

Caverjet

MUSE

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Complications

• Priapism• Fibrosis• Hematoma• Infection

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Operation

OP

REVASCULARIZATION ARTIFICIAL PENIS

INFLATBLEMALLEABLE

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EASY USEEASY PLACEMENTCHEAPPHYSIOLOGY INFLATION↓

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MECHNICAL FAILUREEXPENSIVELESS LONG TERM DURABILITY