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A spontaneous and simple-appearing sexual act, in fact, is a series of meticulously synchronized processes. The preceding activities of the nerve endings cause dilatation of arterioles by relaxing their smooth muscle coat, which in turn causes filling of the spaces of corpora cavernosa resulting in its expansion. After the penis is inserted in the vagina, an act of sexual intercourse or copulation takes place, and continues until the time of orgasm and subsequent ejaculation. Friction between the glans penis and vaginal mucosa, reinforced by several other afferent stimuli and psychogenic factors, causes a reflex discharge along the sympathetic to the seminal pathway, the muscle coats of the epididymis, ductus deferens, the seminal vesicles, and the prostate gland.
After ejaculation and cessation of exotic stimuli, sympathetic tonic discharge resumes; this results in the contraction of smooth muscles around sinusoidal spaces and arterioles. Aging has the strongest association with erectile dysfunction, and may be a common denominator in many patients.
Psychogenic causes include, among others, states of anxiety, depression, a troubled relationship, and fear of performance. Diabetes[16,17] and alcoholic neuropathy,[20,21] spinal cord injury, nerve damage, multiple sclerosis, and cerebrovascular accidents are significant contributory factors for organic impotence.
Erectile dysfunction has also been reported in patients on psychotherapeutic drugs, which produce central nervous system depression. Sleep laboratories monitor patients for rapid eye movement (REM) sleep, when an erection is seen.
Some physicians advocate intracavernosal injection of a small amount (10 mg of prostaglandin E1) of alprostadil.
A test of questionable value, duplex Doppler ultrasonography, has been used to evaluate arterial and venous blood flow of the penis. Vacuum constriction devices, were once a popular noninvasive method of treating impotence.[5,11] The vacuum, created in the cylinder of the vacuum constriction device, causes the flow of blood in the corpora cavernosa of the penis.
The team at Advanced Urology Specialists specializes in the latest technology in treating urological diseases such as ED, BPH and prostate cancer. Recommended PostsProfessionalism and Personalized Care in a Doctor-Patient RelationshipAdvancements in Genetics by Dr. We offer innovative, personal and high-quality urologic care for patients in Citrus, Lake, Marion and Sumter counties. Unfortunately, this harmony may be jeopardized by the occurrence of erectile disorders, and often lead to separation. Its precise erudition may add to the comprehension of the physiological phenomenon, comprising libido, erection, copulation, orgasm, and the ejaculation. Libido is the conscious feeling of the sexual urge, which originates in the brain center through the impulses received by various sense organs. Accordingly, strong pressure is exerted on the veins that normally drain blood from the penis. The sperm, along with the secretion of the accessory glands, are discharged into the posterior urethra, between the internal and external sphincter of the bladder.
Arterial flow is diminished to flaccid levels, much of the blood from sinusoidal spaces is expelled, and the venous channels are restored (Figure 2).

They are abridged by mixed erectile dysfunction, which is composed of a variable mixture of psychogenic and organic factors (Figure 1). This is usually due to physical causes such as endocrinopathies, nervous system disorders, or maldevelopment of the penis and its incompetent veins. With aging, there may occur atheroma of internal iliac arteries and their pudendal branches. Psychogenic erectile dysfunction usually has an acute onset, often related to specific events. The former include atherosclerosis due to smoking, diabetes, low levels of high-density lipoprotein cholesterol, high levels of low-density lipoprotein, and total cholesterol, as well as hypertension.
Damage or degeneration of peripheral nerves supplying the corpora may also cause impotence; cauda equina, and the lesions due to prolapsed intervertebral disc and iatrogenic neural injury during abdominoperineal resection of the rectum[20,21,24,28] are some examples. Further, testosterone secreted from Leydig's cell of the testes under the influence of luteinizing hormone affects men's sexuality.[16,17] Thus, the medications such as luteinizing hormone, releasing hormone agonist or stilbestrol, which lower circulating testosterone also cause erectile dysfunction. It is variously considered to be due to an elevation of serum prolactin concentration, sedative effect, anticholinergic effect, decreased dopamine activity, or central effects on the limbic system.[4,7,10] More and more drugs are being added to the list of those which induce erectile dysfunction (Table II).
Hypogonadism due to dysfunction of Leydig's cells, hyperprolactinemia, hyperparathyroidism, anemia, protein malnutrition, zinc deficiency, hypertension, and use of antihypertensive drugs[33] are a few implicated propositions. In order to achieve success in the aforementioned objectives, the patient and his partner need to provide a detailed confidential history.
The latest breakthrough (sildenafil) seems to occupy a place of pride among the current drugs for the purpose.
Yohimbine hydrochloride is an a-adrenoceptor antagonist, which acts both peripherally and centrally; however, it is not highly effective in established organic impotence. They have also been used in erectile dysfunction, as the presence of dopaminergic pathways in the paraventricular nucleus is important in engendering erectile response. A central dopamine stimulant has been given with success in patients with functional erectile dysfunction; however, many patients observe nausea and vomiting after its use.
This relatively acceptable, noninvasive route of drug delivery has proved to induce similar hemodynamic changes in the corpora cavernosa as have been achieved by intracavernosal injections.
Phentolamine (a-adrenoceptor blocker) and papaverine (non-specific phosphodiesterase inhibitor) have been used in the form of intracorporeal injections. They can be simple rods, malleable rods, self-contained hydraulic, multicomponent hydraulic, or articulated prostheses. Karavadia completed his residency with University of Texas Southwestern Medical Center in Dallas, where he served as chief resident.
It is imperative to comprehend the intricate mechanism of erection in order to individualize the approach to management. The proper functioning of the sexual apparatus is dependent not only on its nervous and muscular integrity, but also on the endocrinal and psychic factors. In the event of aroused libido, the brain center sends impulses to the spinal center, which in turn passes them expeditiously to the peripheral nerves of the penis. After orgasm is reached, the rhythmic contractions of the bulbocavernous and ischiocavernous muscles ejaculate the semen through the penis into the vagina.

With advanced techniques of diagnosis of the erectile functions it has been found that more than 75% of patients have organic causes.
Further, there is degeneration of the extra-corporeal smooth muscles resulting in venous leakage in the penis. Adrenal androgens, metabolite dehydroepiandrosterone sulfate, show a strong correlation with impotence. To restore confidence, the patient is taught all the consecutive intricacies of the disorder until full rectification of the erectile dysfunction is achieved. The previously used phentolamine, which is an a1-adrenoceptor antagonist, is another safe and effective treatment.
Nonorganic impotence responds positively with transbuccal apomorphine, but its use is limited by side effects such as orthostatic hypertension, nausea, vomiting, and persistent yawning. Sildenafil is a selective inhibitor of phosphodiesterase type 5, which results in the increased duration of action of intracorporeal cyclic guanosine monophosphate, that in turn results in the enhancement of normal erectile response (Figure 2). Topical nitroglycerin paste, prostaglandin-E1,[48] and papavarine[49] have been used with variable success (Table III). MUSE (medicated urethral system for erection), a popularly known procedure, consists of insertion of a prostaglandin E1 pellet in the urethra through an applicator.[49] Urethral pain, bleeding, and priapism may be unwanted side effects.
Other systems of the body are complementary and their disorders may ultimately affect this phenomenon, causing erectile dysfunctions.
Sympathetic nerves, which act as a motor to the seminal tract, simultaneously close the internal vesicle sphincter, and thus prevent a reflex of semen into the bladder. Priapism or risk of ischemic injury to the intracavernous smooth muscles[5,7,11] are unwarranted side effects. Thus, erection is a complex, involuntary, neuropsychological, hormone mediated vascular event that happens when blood flows rapidly into the penis and becomes trapped in its spongy chamber.
An erector muscle of the penis (ischiocavernosus) draws the penis forward and makes it well adapted for penetration of the vagina.
Further, the contraction of detrusor vesicae and the associated inhibition of constrictor vesicae prevent a simultaneous discharge of urine.
The psychogenic stimuli to the sacral cord may inhibit reflexogenic erection and subsequently activation of the parasympathetic dilator nerves to the penis. An increasing use of drugs, a legacy of civilization, has considerably compounded the problem. Later, the cavernous smooth muscles become less sensitive to the neurotransmitters because of the excessive sympathetic outflow and elevated catecholamine levels.
Therapy for erectile dysfunction, apart from psychosexual counseling, includes medical treatment by alpha adrenoceptor antagonists, dopamine agonists, phosphodiesterase type 5 inhibitors, sublingual apomorphine hydrochloride, or hormone therapy. Transdermal or transurethral corporeal drug delivery are other possible treatment modalities.

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