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The diagram below on the basic mechanisms of erection and flaccidity of the penis also shows the blood supply and innervation of the penis. The mechanisms of erection and flaccidity are shown in the upper and lower inserts, respectively.
Penile erection is a complex physiologic process that occurs through a coordinated cascade of neurologic, vascular, and humoral events.
In the flaccid penis, a balance exists between blood flow in and out of the erectile bodies.
ErectionWith sexual arousal through imaginative, visual, auditory, tactile, olfactory, and other erotic stimuli, nitric oxide (NO) is released by nonadrenergic, noncholinergic (NANC) neurons. On arousal, parasympathetic activity triggers a series of events starting with the release of nitric oxide and ending with increased levels of the intracellular mediator cyclic guanosine monophosphate (cGMP).
Non-adrenergic, non-cholinergic nerves and vascular endothelium release nitric oxide in response to sexual arousal, which activates cytoplasmic guanylate cyclase, converting GTP into cGMP. Cyclic AMP (cAMP) and cyclic GMP (cGMP), the intracellular second messengers mediating smooth-muscle relaxation, 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.
It is well established that NO and cGMP are the most important transmitters for onset and maintenance of erection. Detumescence and return to the Flaccid stateDetumescence.After ejaculation or cessation of erotic stimuli, sympathetic tonic discharge resumes, resulting in contraction of the smooth muscles around sinusoids and arterioles.
During the return to the flaccid state, cyclic GMP is hydrolyzed to GMP by phosphodiesterase type 5. Molecular Mechanism of Penile Smooth-Muscle Contraction.Norepinephrine from sympathetic nerve endings, and endothelins and prostaglandin F2 from the endothelium, activate receptors on smooth-muscle cells to initiate the cascade of reactions that results in elevation of intracellular calcium concentrations and smooth-muscle contraction. Trabecular muscle tone is controlled and penile blood vessel smooth muscle tone may be influenced by three neuroeffector systems. Nonadrenergic-noncholinergic (NANC) nerves, which control blood vessel and corporal smooth muscle relaxation.
To sum upIn the flaccid state, the smooth muscle cells of the penile arteries and the corpora cavernosa are in a state of tone (contraction).
The mechanisms of erection and detumescence are much more complex than that described above with many other factors and secondary messengers playing a role. Erectile dysfunction (ED) is a condition wherein a man fails to keep an erection firm enough for sexual intercourse. Sexual arousal in men is a complex process that involves the hormones,A  brain, nerves, emotions, A blood vessels and muscles.
Another condition, metabolic syndrome, that involves increased blood pressure,A  body fat around the waist, high insulin levels and high cholesterol may cause erectile dysfunction. Erectile dysfunction often shares common risk factors associated with cardiovascular disease, that includes obesity, lack of exercise, A hypercholesterolaemia, smoking. Erectile dysfunction (or impotence) is one of the most prevailing complaints in male sexual medicine. See related patient information handout on erectile dysfunction, written by the author of this article. Erectile dysfunction is defined as the persistent inability to attain or maintain penile erection sufficient for sexual intercourse. Symptoms of poor blood circulation are usually seen in the lower limbs, where the blood has difficulty travelling back up to the heart. Most of the time, the symptoms of circulation problems are present in the lower extremities. Tip: To turn text into a link, highlight the text, then click on a page or file from the list above. Magnesium is important element that help human to lose weight and most of plants are green because of the magnesium element are there that’s how you will notices. During erection, relaxation of the trabecular smooth muscle and vasodilatation of the arterioles results in a severalfold increase in blood flow, which expands the sinusoidal spaces to lengthen and enlarge the penis. Originally termed endothelial-derived relaxing factor, NO is known to be the most important physiologically occurring vasoactive molecule in the entire cardiovascular system. The increased levels of cGMP alter transmembrane calcium ion flux, resulting in cavernosal smooth muscle relaxation, dilatation of cavernosal and helicine arteries and engorgement of lacunar spaces. Finally, cGMP is metabolized to GMP via phosphodiesterase, of which four isoforms (types 2, 3, 4, and 5) have been identified in human penile tissue. Other phosphodiesterases are also found in the corpus cavernosum, but they do not appear to have an important role in erection.
Protein kinase C is a regulatory component of the calcium-independent, sustained phase of agonist-induced contractile responses. Relaxation of the smooth muscle (arterial and cavernosal) causes increased inflow of blood into the lacunar spaces of the corpora cavernosa.
After ejaculation or cessation of the erotic stimuli, the smooth muscle surrounding the arteries and the lacunar spaces contracts.
A person with ED have a persistent inability to attain and maintain a sufficient erection so as to permit satisfactory sexual intercourse. This problem might impart significant impact on the quality of life (QoL) of the person concerned, his partners and families as well. The brain plays a major part in setting off the series of physical outcomes that makes an erection, which starts with the onset of sexual excitement.


Adjustment of these factors and in particular carrying out suitable weight loss exercise regime may help in reducing ED. Proper diagnosis of the underlying cause of the disease may be enough to treat and reverse erectile dysfunction. The majority of cases have an organic etiology, most commonly vascular disease that decreases blood flow into the penis. The corpora cavernosa are composed of a mesh-work of interconnected cavernosal spaces lined by vascular endothelium. Normal erectile function requires a complex set of dynamic neural and vascular interactions. Most causes of erectile dysfunction were once considered to be psychogenic, but current evidence suggests that up to 80 percent of cases have an organic cause.1 Organic causes are subdivided into vasculogenic, neurogenic and hormonal etiologies. Aging is an independent risk factor, and although the incidence of erectile dysfunction increases steadily with age, it is not an inevitable consequence of aging. Information from references 7 and 8.Excessive and long-term use of a number of substances may also cause erectile dysfunction. In all instances, medical conditions having an impact on erectile function should be corrected or their progression controlled. This is because the blood circulating in this area already has a challenging task to get back up to the heart. The expansion of the sinusoids compresses the subtunical venular plexus against the tunica albuginea. This also applies to corpus cavernosum function, where local smooth muscle relaxation, and in turn erection, is mediated predominantly by NO release.
The expanding lacunar spaces compress the subtunical venous plexus against the tunica albuginea, decreasing cavernosal venous outflow, increasing intracavernosal pressure, with resulting penile rigidity. Sildenafil inhibits the action of phosphodiesterase (PDE) type 5, thus increasing the intracellular concentration of cGMP.
Phosphodiesterase type 5 (PDE 5) is the predominant isoform in human corporal smooth muscle. Roughly 45 percent of the cavernosal body is made up of smooth muscle.The common mechanism of these agents may be via regulation of smooth muscle calcium.
The arterial pressure expands the relaxed trabecular walls, thus expanding the tunica albuginea with subsequent elongation and compression of the draining venules. The inflow of blood is reduced and the venous drainage of the corporeal spaces is opened, returning the penis to the flaccid state. Erection trouble at times is A necessarily not a major A cause of concern, however, if the dysfunction is continued for a longer period then it may cause relationship problem, stress or may affect self-confidence. Epidemiologic studies report that approximately 5a€“20% of men have moderate to severe erectile dysfunction. Any problem related to the above stated organs or conditions may result in erectile dysfunction. Regardless of the primary cause, erectile dysfunction can have a negative impact on self-esteem, quality of life and interpersonal relationships. An estimated 10 to 20 million American men have some degree of erectile dysfunction.1,2Increased understanding of the male erectile process and the development of several agents to improve erectile function have generated great public interest among men and their sexual partners. Penile erection can be elicited by at least two distinct mechanisms, central psychogenic and reflexogenic,3 which interact during normal sexual activity. Vasculogenic etiologies represent the largest group, with arterial or inflow disorders being the most common.
Several studies have indicated that patients and providers are reluctant to address sexual topics.
Problems with blood circulation are most often due to lack of exercise, which are quite common in today’s busy business world where a lot of time is spent sitting behind a desk.
Magnesium reacts only some metals or not at all with most of the acid like phenols, hydrocarbons, aldehides, alcohols, amines, and esters. In addition, stretching of the tunica compresses the emissary veins, thus reducing the outflow of blood to a minimum. Venous outflow drops as the expanding cavernosal spaces compress the venous plexus and the larger veins passing through the tunica albuginea.
The rapid filling of the cavernosal spaces compresses venules resulting in decreased venous outflow, a process often referred to as the corporeal veno-occlusive mechanism.
Erection of the penis is thus a haemodynamic event under the control of the autonomic nervous system. Variation in incidences reported is probably due to differences in the methodology and the socioeconomic status and age of the populations studied. The initial step in evaluation is a detailed medical and social history, including a review of medication use. These advances are expanding the treatment options available to primary care physicians in the management of erectile dysfunction. 3 Blood flow is provided primarily by the cavernosal branches of the internal pudendal artery. Psychogenic erections are initiated centrally in response to auditory, visual, olfactory or imaginary stimuli. Consideration should be given to discontinuation of any medication suspected of contributing to the erectile problem or, if required, switching to an alternative medication less likely to interfere with erectile function. In the flaccid state, inflow through the constricted and tortuous helicine arteries is minimal, and there is free outflow via the subtunical venular plexus.


Coordination of the neuronal activity from psychogenic stimuli occurs in the hypothalamus while reflexogenic erection involves a polysynaptic coordination in the sacral parasympathetic centres. As, for example, a minor physical trouble that might slow the sexual response makes a man A anxious about attaining and maintaining an erection. Each branch divides into numerous terminal branches that open directly into the cavernous spaces.
Reflexogenic erections result from stimulation of sensory receptors on the penis which, through spinal interactions, cause somatic and parasympathetic efferent actions.3On arousal, parasympathetic activity triggers a series of events starting with the release of nitric oxide and ending with increased levels of the intracellular mediator cyclic guanosine monophosphate (cGMP). Regardless of the primary etiology, a psychologic component frequently coexists.5The severity of erectile dysfunction is often described as mild, moderate or complete, although these terms have not been precisely defined.
Increases in cGMP cause penile vascular and trabecular smooth muscle relaxation.3,4 Blood flow into the corpora cavernosa increases dramatically.
First, provide information about conditions that are commonly associated with sexual dysfunction, then follow with a question about the individual's concerns.
Laboratory tests are useful to screen for common etiologic factors and, when indicated, to identify hypogonadal syndromes.
The male sexual response cycle consists of four major phases: (1) desire, (2) arousal (erectile ability), (3) orgasm and (4) relaxation.
Before the initiation of testosterone therapy, the patient should be evaluated for the possibility of an occult prostate malignancy, which may be stimulated by supplemental testosterone.
Appropriate evaluation of erectile dysfunction leads to accurate advice, management and referral of patients with erectile dysfunction. This information may help assess the patient's sexual problems as well as identify high-risk behaviors and other concerns affecting the patient's overall health.Once a concern with the patient's sexual function is identified, the next step is to differentiate erectile dysfunction from other sexual problems, such as loss of libido or ejaculatory problems.
The physician should use appropriate vocabulary, avoiding slang or excessively technical terminology. Patients with suspected vasculogenic or neurogenic causes can be considered for a trial of therapy in the primary care setting. Having the patient define the terms in his own words will help the physician and patient communicate more effectively.13 The International Index of Erectile Function (IIEF)14 is a valuable tool for defining the area of sexual dysfunction (Figure 4). Patients with a suspected psychogenic etiology should be considered for sexual counseling or psychiatric referral as well.Patients requesting a more comprehensive evaluation or those not responding to initial therapy should be referred for further evaluation and treatment. The IIEF is designed to be a self-administered measure of erectile dysfunction, but it also assesses a patient's function in other phases of sexual function.
As such, it should be viewed as an adjunct to, rather than a detailed sexual history.Reprinted with permission from Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile dysfunction (IIEF): a multidimensional scale for assessment of erectile dysfunction. Because erectile dysfunction is frequently caused by medication, a review of the patient's drug therapy is essential and should include prescription and over-the-counter medications. Life stressors such as change in social status, divorce, death of spouse, loss of job, or family problems may have an effect on erectile function. Difficulty in erectile function affects the patient and his partner, so it is important to assess whether the erectile problem is troubling one partner more than the other, and if so, who and why.
Finally, the physician should determine the patient's and the partner's level of understanding of sexual anatomy and function, as well as what expectations each has with regard to treatment outcome. Men with erectile dysfunction and their partners often lack a full understanding of sexual processes or have unrealistic expectations regarding sexual performance and satisfaction.5PHYSICAL EXAMINATIONThe physical examination should assess the patient's overall health. Particular attention should be given to the cardiovascular, neurologic and genitourinary systems, as these systems are directly involved with erectile function. The cardiovascular examination should include assessment of vital signs (especially blood pressure and pulse) and signs of hypertensive or ischemic heart disease.
Abdominal or femoral artery bruits and asymmetric or absent lower extremity pulses are indicative of vascular disease. Skin and hair pattern evidence of vascular insufficiency should be noted.The patient's demeanor, dress, speech and overall appearance should be noted for signs suggestive of anxiety or depressive disorders. The superficial anal reflex, indicative of normal somatic function of sacral cord levels S2–4, is assessed by touching the perianal skin and noting contraction of the external anal sphincter muscles. It is performed by placing a finger in the rectum and noting contraction of the anal sphincter and bulbocavernosus muscle when the glans penis is squeezed. External anal sphincter tone can be assessed during this maneuver as well.The genital evaluation should assess for local abnormalities, such as hypospadias or phimosis, and evidence of hypogonadism. The penis should be palpated to determine the presence of local abnormalities such as fibrous plaques of the fascial covering (Peyronie's disease). The prostate gland should be assessed for size, consistency and symmetry.ADDITIONAL STUDIESIf not previously done, some basic studies should be considered to identify unrecognized systemic conditions that may predispose to erectile dysfunction. The specific testosterone assay to be obtained is debated.15,17 Testosterone is predominately protein-bound and is influenced by a variety of clinical conditions. An age-adjusted, first-morning, free testosterone level is probably the most accurate measure.17 If the initial testosterone level is low, follow-up studies should include luteinizing hormone and follicle-stimulating hormone levels to differentiate testicular from hypothalamic-pituitary dysfunction. These tests are not usually performed in the family physician's office and are not necessary before the initiation of therapy for most patients. Many of these tests are subject to significant variation in interpretations and are most appropriate for use in refractory cases.



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