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Dúvidas denucci@ gdenucci Arquivo

Dúvidas denucci@ gdenucci .com Arquivo Drogas Utilizadas no Tratamento da Disfunção Sexual Masculino Site www. gdenucci.com. Definição. A disfunção erétil masculina é a incapacidade em obter ou manter uma ereção peniana rígida o suficiente para o intercurso sexual.

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Dúvidas denucci@ gdenucci Arquivo

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  1. Dúvidas denucci@gdenucci.com Arquivo Drogas Utilizadas no Tratamento da Disfunção Sexual Masculino Site www.gdenucci.com

  2. Definição A disfunção erétil masculina é a incapacidade em obter ou manter uma ereção peniana rígida o suficiente para o intercurso sexual.

  3. Estudo epidemiológico de DE em Massachusetts • Prevalência de DE em homens de 40–70 anos. N = 1290 Feldman HA et al. J Urol. 1994;151:54-61.

  4. Distribuição por Idade (MA) 1290 Homens 70 60 50 40 % 30 20 10 0 40 50 60 70 anos DE Leve DE Moderada DE Completa

  5. The incidence of concomitant hypertension and ED with advancing age Incidence of hypertension and ED, % Age, years 56-65 51.4 66-75 62.3 76-85 67.2 86 68,4 Beneficial effects of extendedreleasedoxazosin and doxazosinstandard on sexual health - BJUINTERNATIONAL |97, 559 – 566 1

  6. Arterial Supply Cavernous a. Dorsal a. C. cavernosum C. spongiosum Bulbar a. Internal pudendal a. Urethral a.

  7. Venous drainage Superficial dorsal v. Cavernous v. Deep dorsal v. C.cavernous v. Circumflex v.’s Prepostatic plexus Urethral v. Internal pudendal v. C. spongiosum Bulbar v.

  8. Flaccid State Tunica albuginea Emissary v.

  9. Erect state

  10. Penile Erection 1 2 3 4 3 5 6 7 25 Pud. A. (ml/min) 0 200 I.C. (cm H2O) 100 0 Cavernous nerve Pudendal nerve

  11. Normal sonogram of penis (c) Longitudinal color flow Dopplerultrasound of normal cavernosal bodies and flow through cavernosalartery (arrow) and the helicine branches (arrowheads). (d) Thecorresponding line drawing of the blood supply to the penis. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  12. Cavernosal artery peak systolic velocity (PSV). Peaksystolic velocity of the cavernosal artery decreases from base ofthe penis to the glans penis. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  13. Cavernosal artery peak systolic velocity (PSV). A higher PSV of the cavernosalartery (measured more proximally) as compared to distalmeasurement in the same patient Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  14. Penile Erection 1 2 3 4 3 5 6 7 25 Pud. A. (ml/min) 0 200 I.C. (cm H2O) 100 0 Cavernous nerve Pudendal nerve

  15. Phases of erection • Flaccid phase. Velocities are in therange of 5–15 cm/s. ICP around 20 mmHg. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  16. Penile Erection 1 2 3 4 3 5 6 7 25 Pud. A. (ml/min) 0 200 I.C. (cm H2O) 100 0 Cavernous nerve Pudendal nerve

  17. Phases of erection (b) Filling phase. Spectral Doppler waveform demonstrates increased systolic velocity and increased diastolic flow. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  18. Penile Erection 1 2 3 4 3 5 6 7 25 Pud. A. (ml/min) 0 200 I.C. (cm H2O) 100 0 Cavernous nerve Pudendal nerve

  19. Phases of erection (c) Tumescent phase. The systolic velocities stabilize, diastolic flow decreases or becomes reversed. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  20. Penile Erection 1 2 3 4 3 5 6 7 25 Pud. A. (ml/min) 0 200 I.C. (cm H2O) 100 0 Cavernous nerve Pudendal nerve

  21. Phases of erection (d) Rigid phase. Spectral Dopplerwaveform demonstrates very high resistance waveform with no diastolic flow and minimal systolic flow. The peak systolic velocitiesdecrease. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  22. Penile Erection 1 2 3 4 3 5 6 7 25 Pud. A. (ml/min) 0 200 I.C. (cm H2O) 100 0 Cavernous nerve Pudendal nerve

  23. APPENDIX Erectile Dysfunction -THE JOURNAL OF UROLOGY - Vol. 175, S25-S31, March 2006

  24. Causas de disfunção erétil • - Psicogênicas (20%) • Orgânicas :- vasculares - arteriais - hormonais - neurogênicas - penianas

  25. Phases of erection (c) Tumescent phase. The systolic velocities stabilize, diastolic flow decreases or becomes reversed. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  26. Arteriogenic erectile dysfunction. Sequential timed (at 5, 10, 15, 20, 25 and 30 min) recordings of spectral Dopplerwaveforms of the cavernosal artery after injection of prostaglandin E demonstrate persistent low peak systolic velocity of the cavernosalartery (<25 cm/s). a Doppler evaluation of erectile dysfunction – Part 2 - International Journal of Impotence Research (2006), 1–6

  27. Causas de disfunção erétil • - Psicogênicas (20%) • Orgânicas : • vasculares - venosas • Hormonais • neurogênicas • penianas

  28. Phases of erection (d) Rigid phase. Spectral Dopplerwaveform demonstrates very high resistance waveform with no diastolic flow and minimal systolic flow. The peak systolic velocitiesdecrease. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  29. Venous leak (veno-occlusive insufficiency). Bilateral(a and b) spectral Doppler waveforms of the cavernosal arteries at25 min post-injection of prostaglandin E demonstrate a high peaksystolic velocity (440 cm/s), which excludes arterial insufficiencyas a cause of erectile dysfunction in this patient. However,a persistent diastolic flow velocity of more than 5 cm/s issuggestive of venous leak. Doppler evaluation of erectile dysfunction – Part 2 - International Journal of Impotence Research (2006), 1–6

  30. Causas de disfunção erétil • - Psicogênicas (20%) • Orgânicas :- vasculares - - hormonais - neurogênicas - penianas

  31. Normal sonogram of penis a (a) Transverse gray-scaleultrasound of the penis demonstrates the two corpora cavernosa(CC) surrounded by the tunica albuginea (arrowhead). The corpusspongiosum (CS) is seen inferior to the corpora cavernosa. All threecorpora are surrounded by the Buck’s fascia (arrow). (b) Thecorresponding line diagram. Doppler evaluation of erectile dysfunction – Part 1 - International Journal of Impotence Research (2006), 1–6

  32. Peyronie’s disease. Transverse gray-scale ultrasound images of the penis demonstrate a fibrousplaque (arrows) appearing as a hyperechoic band in the tunicaalbuginea. Doppler evaluation of erectile dysfunction – Part 2 - International Journal of Impotence Research (2006), 1–6

  33. Peyronie’s disease. Longitudinal gray-scale ultrasound images of the penis demonstrate a fibrousplaque (arrows) appearing as a hyperechoic band in the tunicaalbuginea. Doppler evaluation of erectile dysfunction – Part 2 - International Journal of Impotence Research (2006), 1–6

  34. High-flow priapism. The patient injured his penileshaft while riding a bull 15 days before admission. The patientpresented with painless persistent erection. (a) Color flowDoppler ultrasound of the penis with spectral tracing reveals anarea of color flow aliasing within the left corpus cavenosa near thetip of the penis with marked turbulence of blood flow, confirmingthe presence of an arterial-lacunar fistula. (b) The patient wastreated with arterial embolization. Pre-embolization arteriographyreveals early blush (arrow) corresponding to the site of the fistula.After embolization, the patient’s priapism subsided and normalerectile function returned (with permission from Bhatt et al. a b Doppler evaluation of erectile dysfunction – Part 2 - International Journal of Impotence Research (2006), 1–6

  35. Male (24 years old) with fracture of the penis.Following sexual activity, the patient presented with loss ofpenile rigidity, pain, hematoma of the penile shaft and hematuria.(a) Color Doppler sonogram of the penis demonstrates subcutaneoushematoma of variable echotexture in continuity with theright corpus cavernosa with an absence of color flow within thearea, suggesting a break in the continuity of the tunica albuginea(*). This appearance suggests penile fracture. The Foley catheteris within the urethra (arrow). (b) Retrograde urethrogram revealsassociated rupture of the bulbar urethra (arrow). The patientsubsequently underwent surgical exploration and repair (withpermission from reference Bhatt et al.10 a b Doppler evaluation of erectile dysfunction – Part 2 - International Journal of Impotence Research (2006), 1–6

  36. Percent distribution of organic causes of ED Erectile Dysfunction - THE JOURNAL OF UROLOGY

  37. Erectile Dysfunction -THE JOURNAL OF UROLOGY - Vol. 175, S25-S31, March 2006

  38. Beneficial effects of extendedreleasedoxazosin and doxazosinstandard on sexual health - BJUINTERNATIONAL |97, 559 – 566 1

  39. Regulação Periférica 1. Mediadores Contráteis • Noradrenalina (NA) • Rho A • Endotelina-1 (ET-1) • Prostaglandina F2a(PGF2a) • Tromboxano A2 (TXA2) • Angiotensina II

  40. The state of myosin light chain (MLC) phosphorylation in cavernosalsmooth muscle (SM) is regulated by MLC kinase and MLC phosphatase. RhoA-GDP RhoA-GTP Rho-Kinase MLC Phosphatase (Active) MLC Phosphatase~P (Inactive) Phosphatase phosphatase (?) Inhibition of TonicContraction—A NovelWay to ApproachErectile Dysfunction?- Journal of Andrology, Vol. 23, No. 5, MLC SM: Relaxed Penis: Erect MLC-P SM: Contracted Penis: Not Erect MLC kinase Calmodulin-Ca2+ [Ca2+]i

  41. Regulação Periférica 1. Mediadores Contráteis • Noradrenalina (NA) – até o momento, o único que aparentemente é clinicamente relevante, visto o uso terapêutico de bloqueadores adrenérgicos (fenoxibenzamina intra-cavernosa, fentolamina por via intra-cavernosa e via oral).

  42. Regulação Periférica 2. Mediadores Relaxantes • Óxido Nítrico (NO) • Acetilcolina (ACh) • Neuropeptídeos(VIP, CGRP) • Prostanóides (PGE1) • Histamina • ATP / adenosina

  43. Regulação Periférica 2. Mediadores Relaxantes Importantes • Óxido Nítrico (NO) • Prostanóides (PGE1) • Histamina

  44. Histamine-induced HCC relaxation MEPYRAMINE 1 mM HCC 4 min GTN mg 5 5 ACh 20 mg 20 HIST mg 100 10 30 100 British J. of Urology, 75, 1995

  45. Histamina • Causa ereção peniana quando administrada por via intra-cavernosa (30-100 microgramas por injeção). • Ereção fisiológica, curta duração, baixa incidência de priapismo. • Atua em receptores H2 e provavelmene H3. • Mastócitos penianos aumenta na puberdade.

  46. Prostaglandina E1 • Causa ereção peniana quando administrada por via intra-cavernosa e por via intra-uretral. • Mecanismo de ação desconhecido (aumento de AMP cíclico?)

  47. NO-cGMP Biochemistry L-NAME (-) GTP NOS SGC cGMP ARGININE NO PDE-5 GMP (-) Viagra

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