Zafar Khan, M.D.

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Zafar Khan, M.D.
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Evaluation of the Impotent Male

• Medical and Psychosexual history
• Physical examination
• Nocturnal penile tumescence
• Neurologic testing
• Sacral Evoked response
• Genitocerebral Evoked response
• Hormonal Testing

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• Only 15 of the cases have
• any psychogenic cause

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Evaluation

• Nocturnal penile tumescence testing (NPT)
• To distinguish psycogenic from organic causes
• NPT occurs during REM sleep, 4 to 5 erectile
  episodes per night, lasting longer than 30 min
• Increase of circumference greater than 3cm
• Increase of rigidity 70 of maximal

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Rigi Scan
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Snap Gauge
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VascularCauses
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• Diabetese Mellitus
• Atherosclerosis
• Hyperlipidemia
• Smoking
• Radiation Vasculitis (Prostate - Rectum)

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Evaluation

• Vascular Evaluation
• Pulsed Doppler analysis
• Duplex-Ultrasonography
• Arteriography
• Cavernosometry / Cavernosography

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PhysiologyofErection
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VenousCauses
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Venous LeakLoss of erection soon after its
development

• Venous incompetence
• Shunt between corpora cavernosa and corpus
  spongiosum
• AV malformation

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Evaluation

• Cavernosometry
• Injection of 10?g PGE1
• Intracorporal pressure measurement (120mm Hg)
• Corporal infusion (maintainance 5ml/min)
• Pressure decay (lt 45mm/Hg in 30 sec)
• Cavernosography
• Infusion of contrast medium

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NeurogenicCauses
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• Spinal Cord Injury
• Multiple Sclerosis
• Pelvic Surgery (Prostate - Rectum)

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Evaluation

• Neurological testing
• Biothesiometry
• Sensory perception of vibratory stimulation
• Sacral evoked response (BC reflex latency)
• 30-40 mil/sec at 50 volts
• Genitocerebral evoked potential studies
• Cerebral response to dorsal penile nerve
  stimulation

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HormonalCauses
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• Andropause
• Elevated Prolactin Level
• Hypogonadism

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Hypogonadism

• 4 to 5 million men with Hypogonadism
• Declining Gonadal Function in Aging Men

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Testosterone Therapy Delivery Systems

• Oral tablets1
• Intramuscular injections
• Transdermal patches
• Applied to scrotum or nonscrotal areas
• Transdermal gel

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Signs and Symptoms of Low Testosterone
(Hypogonadism)

• Loss of libido
• Erectile dysfunction
• Depression
• Lethargy
• Osteoporosis
• Loss of muscle mass
• Regression of secondary sexual characteristics
• Oligospermia or azoospermia
• 1.Tenover JL. Endocrinol Metab Clin North Am.
  199827969-987.

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Androgen Deficiency in Aging Males (ADAM)
Questionnaire

• 1. Do you have a decrease in sex drive?
• 2. Do you have a lack of energy?
• 3. Do you have a decrease in strength
  and/or endurance?
• 4. Have you lost height?
• 5. Have you noticed a decreased enjoyment of
  life?
• 1. Adapted from John E. Morley, MB, BCh, St.
  Louis University School of Medicine.

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ADAM Questionnaire (contd)

• 6. Are you sad and/or grumpy?
• 7. Are your erections less strong?
• 8. Has it been more difficult to maintain your
  erection throughout sexual intercourse?
• 9. Are you falling asleep after dinner?
• 10. Has your work performance deteriorated
  recently?
• 1. Adapted from John E. Morley, MB, BCh, St.
  Louis University School of Medicine.

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ADAM Questionnaire Validation

• Study of 316 male Canadian physicians
• Results demonstrated
• High sensitivity (88)
• Low specificity (60)
• 1. Morley JE, et al. Endocrine Society. June
  1998. Abstract.

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Diagnostic Testosterone Testing

• Additional Tests
• LH and FSH
• To ascertain whether cause is primary or
  secondary
• Serum prolactin
• High prolactin levels may suggest presence of
  pituitary tumor
• 1. Tenover JL. Endocrinol Metab Clin North Am.
  199827969-987.

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Diagnostic Testosterone Testing

• Initial Tests
• Plasma total testosterone
• Measures free plus protein-bound fractions
• Morning sample recommended
• lt300 ng/dL (10 nmol/L) suggests hypogonadism
• Plasma free testosterone
• Measures non-proteinbound testosterone fractions
• Recommended in older patients
• lt50 pg/mL (173 pmol/L) suggests hypogonadism

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AndroGel Dosing

• Recommended starting dose 5 G/day to deliver 5
  mg testosterone
• Titratable from 5 G to 7.5 G and from 7.5 G to
  10 G per day
• 2.5-G packet available for titration
• Prescriptions written as
• AndroGel 5 G QD
• AndroGel 7.5 G QD
• AndroGel 10 G QD

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Contraindications of Testosterone Therapy

• Known or suspected prostate cancer
• Male breast cancer
• Women (patches, gel)

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Special Warnings and Risks of Testosterone
Therapy

• Hepatotoxicity (prolonged use of high doses of
  oral androgens, eg, methyltestosterone)
• Prostatic hyperplasia and prostate cancer in
  geriatric patients
• Patients with increased risk of prostate cancer
  with clinical or demographic characteristics

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Special Warnings and Risks of Testosterone
Therapy (contd)

• Edema in patients with preexisting cardiac,
  renal, or hepatic disease
• Gynecomastia
• Sleep apnea

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Mechanism of Action
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Mechanism of Action of PDE5 Inhibitors
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Mechanism of Action of PDE5 Inhibitors
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PDE5 Selectivity
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VIAGRA Concentration inHealthy Male Volunteers
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VIAGRA Safety Information
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Improvement in Mild to Moderate ED
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Improvement in All Patients
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Cardiovascular Safety
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VIAGRA in Men with CoronaryArtery Disease
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PDE5 Inhibitors Onset and Duration of Activity
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Tadalafil Most Common Treatment-Related Adverse
Events
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Metabolic Equivalents (METs) of Selected
Physical Activities
Resting
1 Walking 2 mph,
level 2 Walking 3 mph, level 3 "Sexual
activity" pre-orgasm 2-3 "Sexual activity"
during orgasm 3-4 Cycling 10 mph, level
6-7 Walking 4.2 mph, 16 13 (Bruce treadmill
stage 4)
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Tadalafil and Nitrate Interactions SBP Results
Day 1 (Part A)
Tadalafil
150
140
130
Standing SBP (mm Hg)
120
110
100
-0.5
0.0
0.5
1.0
2.0
2.5
3.0
3.5
4.0
5.0
6.0
Time After Administration (h)
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Muse - 500 mcg / 1000 mcg
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Intracorporal Injections

• Prostaglandin - PGE1 20mg (Caverject)
• Phentolamine - 5mg
• Papaverine - 30mg
• Trimix

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Caverject
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Reversal of Drug Induced Priapism

• Epinephrine - 0.001mg/mil
• Dopamine - 0.003mg/mil
• Neosynepherine - 1mil/10mil

Inject 1-3 mil in corpora cavernosa, may need
more to subside the erection.
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Vacuum Device
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AnatomicalCauses
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• Peyronies Disease
• Penile Fracture
• Microphallus

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SurgicalTreatment
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Penile Prosthesis
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Semi-Rigid Penile Prosthesis
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Phone [phone]eMail zafarkhanmd_at_urologyand
you.comURL www.urologyandyou.com
Zafar Khan, M.D.