남성 성기능 장애

남성 성기능 장애

MALE SEXUAL DYSFUNCTION

“The penis does not obey the order of its master, who tries to erect or shrink it at will. Instead, the penis erects freely while its master is asleep. The penis must be said to have its own mind, by any stretch of the imagination.”

-Leonardo da Vinci -

학습목적 : 성기능에 대한 신경생리 , 혈역동 , 약물학을 이해하여 발기부전에 대한 원인과 치료원칙을 파악할 수 있게 한다 .

학습목표 ( 한국의과대학장협의회 ) - 음경발기의 기전을 설명한다 .

- 음경발기의 3 가지 형태를 설명한다 . - 남성 성기능장애의 원인을 분류한다 , - 남성 성기능장애의 진단법을 열거한다 학습목표 : ( 대한비뇨기과학회 )

  1.  남성의 성기능 생리를 설명한다 . 

2. 남성 성기능 장애의 원인을 열거한다 . 

3.   남성 성기능 장애의 진단방법과 치료방법을 열거한다 . 

4. 지속성 음경발기증 (priapism) 을 정의하고 원인을 열거한다 .  5. 지속성 음경발기증의 응급 치료법을 설명한다 . 

6. 혈정액 ( Hematospermia ) 의 원인 및 치료에 대해 설명한다 .  

▪ Corpora cavernosa Support corpus spongiosum and glans

▪ Tunica albuginea (of corpora

cavernosa) Contains and protects erectile tissue Promotes rigidity of the corpora cavernosa

Participates in veno-occlusive mechanism

▪ Smooth muscle Regulates blood flow into and out of the sinusoids

▪ Ischiocavernosus muscle Pumps blood distally to hasten erection Provides additional penile rigidity during rigid erection

phase

▪ Bulbocavernosus muscle Compresses the bulb to help expel semen

▪ Corpus spongiosum Pressurizes and constricts the urethra lumen to allow

forceful expulsion of semen

▪ Glans Acts as a cushion to lessen the impact of the penis on

female organs

Provides sensory input to facilitate erection and

enhance pleasure

Facilitates intromission because of its cone shape

Penile Components and their Function during

erection

Figure 21-1  Artist's cross-sectional drawing

of the penis, depicting the inner circular and

outer longitudinal layers of the tunica albuginea as well as the

intracavernous pillars. The

longitudinal layer is absent in the ventral groove housing the corpus spongiosum.  

Figure 21-2  Micrograph of the human tunica

albuginea, showing the interwoven elastic

fibers and the finer collagen fibers.

(Hart stain,=100.)

Figure 2-37  Male perineum, illustrating the internal pudendal artery and its branches on the left and the pudendal nerve and its branches on the right

I. Physiology of penile erection

1. Innervation of the Penis 1) Peripheral nerve

(1) sympathetic( T12-L2 ); detumescence, emission, ejaculation

sympathetic chain --- superior hypogastric plexus --- hypogastric n.--- pelvic plexus --- cavernous n.

  (2) parasympathetic( S2-4 ); tumescence

pelvic n. (nervi ergentes)---pelvic n.---pelvic plexus--- cavernous n.

  (3) Somatic

pudendal n.

2) Central mechanisms:

brain exert a modulatory influence over spinal reflex (1) Reflexogenic erectile mechanism

pudendal afferent --- sacral pelvic parasympathetic efferent

  (2) Psychogenic erectile mechanism

Figure 21-7  Penile neuroanatomy

.

lateral (green arrow) bundles of the cavernous nerve distal to the

prostate.

Table 21-3   -- Brain Centers Involved in Sexual Function 

Level Region Function

Forebrain Medial amygdala Control sexual motivation

Stria terminalis  

Pyriform cortex Inhibits sexual drive (hypersexuality when destroyed)

Hippocampus Involved in penile erection

Right insula and inferior frontal

cortex Increased activity during visually evoked sexual stimulation\ (sexual arousal)

Left anterior cingulate cortex  

Hypothalam

us Medial preoptic area (MPOA) Ability to recognize a sexual partner, integration of

hormonal and sensory cues

Paraventricular nucleus (PVN) Facilitates penile erection (through oxytocin neurons to

lumbosacral spinal autonomic and somatic efferents)

Brain stem Nucleus paragigantocellularis Inhibits penile erection (through serotonin neurons to

lumbosacral spinal neurons and interneurons) A5-catecholaminergic cell group Noradrenergic innervation of anterior horn motor

neurons

to perineal striated muscles

Locus ceruleus  

Midbrain Periaqueductal gray Relay center for sexually relevant stimuli

2. Anatomy and Hemodynamics of Penile Erection

1) Arterial supply

internal iliac a. internal pudendal a. dorsal a.

cavernous (deep) a.

bulbourethral a.

2) Venous supply

superficial dorsal v. saphenous v.

deep dorsal v.

cavernous v. emissary v. periprostatic plexus internal pudendal v.

urethral v.

3) Sinusoidal system

Figure 21-3  A, Penile arterial supply. B, Scanning electron micrograph of a human penile cast showing helicine arteries opening directly into the

sinusoids without intervening capillaries

Figure 21-4  A, Photograph of

an emissary vein with subtunical

venous plexus of a human penile cast. The cast was made by

injecting blue material into the

corpus cavernosum and yellow

material into the deep dorsal vein. The skin and tunica albuginea

were then digested away with

KOH solution. B, and C, Penile

venous drainage.

Figure 21-6  Blood flow and intracavernous pressure changes during the seven phases of penile erection and  detumescence: 0, flaccid; 1, latent; 2, tumescence; 3, full erection; 4, rigid erection; 5, initial detumescence; 

6, slow detumescence; 7, fast detumescence. 

3. Mechanisms of Penile Erection

1) flaccid state

arteries & arterioles are tortuous & constricted sinusoidal compliance increase

2) erection state

arterial smooth muscle relax & resistance drop to minimum sinusoidal compliance decrease

compressed against non-compliant tunica albuginea

compressed emissary vein

Figure 21-5  The mechanism of penile erection. A, In the flaccid state, the arteries, arterioles, and

sinusoids are contracted. The intersinusoidal and subtunical venous plexuses are wide open, with free

flow to the emissary veins. B, In the erect state, the muscles of the sinusoidal wall and the arterioles

relax, allowing maximal flow to the compliant sinusoidal spaces. Most of the venules are compressed

between the expanding sinusoids. The larger venules are sandwiched and flattened between the distended

sinusoids and the tunica albuginea. This effectively reduces the venous capacity to a minimum.

C, and D, Scanning electron micrographs of casts of a canine subtunical venous plexus in the flaccid and erect states, respectively.  

4. Hormones & Sexual Function m ale sexual maturation

maintain sexual interest, seminal emission

5. Neurotransmitter & the Pharmacology of Erection

1) Adrenergic; intracavernous smooth muscle contraction, detumescence 2) Cholinergic; smooth muscle relaxation, erection

(1) inhibition of adrenergic nerve via inhibitory interneuron

(2) release of EDRF (endothelium-derived relaxing factor) from cholinergic nerve terminal

(3) nonadrenergic-noncholinergic (NANC) NO release

c-GMP accumulation

Figure 21-9  Molecular mechanism of penile smooth muscle contraction.

Norepinephrine from

sympathetic nerve endings and endothelins and prostaglandin F₂α from the endothelium activate receptors on smooth muscle cells to initiate the cascade of reactions that eventually result in

elevation of intracellular calcium concentrations and smooth muscle contraction. Protein kinase C is a regulatory component of the Ca₂+- independent, sustained phase of agonist-induced

contractile responses.  (From Lue TF: Erectile dysfunction. N Engl J Med 2000;342:1802-1813. Copyright © 2000 Massachusetts Medical Society.)

Figure 21-11  Molecular

mechanism of penile smooth muscle relaxation.

The intracellular second

messengers mediating smooth muscle relaxation, cyclic

adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP),

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. The resultant fall in intracellular calcium

leads to smooth muscle relaxation.

Sildenafil inhibits the action of phosphodiesterase 5 (PDE5) and

thus increases the intracellular

concentration of cGMP.

Papaverine is a nonspecific phosphodiesterase

inhibitor. eNOS, endothelial nitric

oxide synthase; GTP, guanosine

triphosphate.  (From Lue TF:

Erectile dysfunction. N Engl J Med 2000;342:1802-1813.

Copyright © 2000

Massachusetts Medical Society.)

II. Diagnosis

  Main Treatments Diagnostic Tests

Before 1970 Psychosexual therapy Psychosexual history 1970s Penile prosthesis

psychosexual therapy Medical

psychosexual history sleep lab

1980s Yohimbine

intracavernous transurethral therapy

vacuum device

History

physical examination testosterone,

duplex ultrasound

DICC (goal-directed approach) 1990s-

Present Oral phosphodiesterase-5

inhibitors Process-of-care model

1st ICUD algorithm

2nd ICUD algorithm (patient-centered approach)

Table 22-1   -- Evolution in the Diagnostic Workup for ED 

DICC, dynamic infusion cavernosometry and cavernosography.

ICUD, International Consultation on Urological Diseases.

 * Goal-directed approch

HISTORY & PHYSICAL EXAM

PSYCHOLOGICAL EVALUATION Tx OPTIONS DISCUSSED

serum testosterone NPT

Prolactin Visual sex

sti,ulation

Glycosylated Hgb

2nd Visit Partial or No Response

Full 30’ Erection Pharmacologic Intracavernosal (evenafter exercise) injection

Duplex Doppler of Penile Arteries

2' Intracavernosal Injection Psychological Rx

Intracavernosal Rx Regimen

R/O Neurogenic Impotence Arterial disease No arterial disease

Vacuum Device Therapy

Pudendal arteriography

Cavernosography

(only if surger is planned)

& Cavernosometry

if venous surgery planned

Penile Prosthesis

Figure 22-1  Diagnostic algorithm for ED recommended by the ICSM.

1. Arterial impotence

1) PBI (penile brachial index)

Penile Systolic Blood Pressure/brachial systolic pressure=PBI

normal >0.8, Impotent male <0.6

2) Intracavernous injection of vasoactive amine

  3) Duplex sonography and pulsed Doppler analysis peak systolic velocity (PSV) > 25 cm / sec

end diastolic velocity (EDV) < 5 cm / sec

resistive index = PSV-EDV/PSV

Figure 22-7  Artist's conception of the changes

in diameter and flow waveform in the cavernous arteries induced by

intracavernous injection of

prostaglandin E₁ in a potent young man as

demonstrated by duplex ultrasound.

Forceful

concentric pulsations are particularly noticeable during full erection.

F

intracavernous pressure changes during the seven phases of penile erection and detumescence: 0, flaccid; 1, latent; 2, tumescence; 3, full erection; 4, rigid

erection; 5, initial detumescence; 6, slow detumescence; 7, fast detumescence.

Figure 22-5  Collateral circulation connecting the right dorsal artery (RDA) to the right

cavernous artery (RCA) and the left cavernous artery (LCA) is shown by color duplex

ultrasound in a longitudinal view.

  4) Internal iliac or pudendal arteriography

2. Venous Impotence & Disease of Cavernous Smooth Muscle

Dynamic infusion cavernosometry and cavernosography (DICC)

  3. Neurologic Impotence 1) Somatic nervous system

2) Autonomic nervous system 3) Central nervous system

occur during a most REM sleep, also present during non- REM sleep

3-4 episode per night 90 min interval 20-25% to total sleep time ( 1.5 hour )

disrupted by sleep apnea, periodic leg movement,

nocturnal myoclonus

(1) mercury strain gauge (2) stamp

(3) Rigiscan

penile base > 3 cm, penile tip > 2 cm

rigidity 70% or greater, enable to intromission

Figure 21-13  A functional classification of impotence. Note that it is unlikely for an individual patient's impotence to derive solely from one source. Most cases have a psychogenic component of varying degree, and systemic

diseases and pharmacologic effects can be concomitant and causative.

 (Modified from Carrier S, Brock G, Kour NW, Lue TF: Pathophysiology of erectile dysfunction. Urology 1993;42:468-481, with permission of Exerpta Medica, Inc.)

Figure 22-2  Treatment algorithm for ED

recommended by the ICSM.

1. Vascular surgery 1) Arterial origin

relieve of stenosis or occlusion of extrapenile artery         (internal iliac, internal pudendal, dorsal artery)

epigastric-corporeal anastomosis epigastric artery to deep dorsal vein 2) Venous origin

ligation superficial and deep dorsal vein

repair of fistula between glans & cavernous body

epigastric artery to deep dorsal vein

2. Penile prosthesis

   1) Semirigid, Malleable, Mechanical/Interdigitating    2) Inflatable

a. Single component

b. Two component

c. Threee component

3. Pharmacotherapy

1) Intracavernous injection of vasoactive agents papaverine, phentolamine, prostaglandin E1 Trimix

2) Phosphodiesterase type 5 (PDE5) inhibitor 3) other drugs

yohimbine testosterone  

4. Vaccum suction device

Male sexual dysfunction involving emission, ejaculation & orgasm

1. Physiology of Emission , Ejaculation, & Orgasm

pudendal nerve --- upper lumbar spinal sympathetic nuclei hypogastric nerve --- activate secretion and transport sperm

somatoefferent of pudendal nerve to contract bulbocavernous

muscle

emission ; semen into bulbous urethra

ejaculation ;

2. Disorders Affecting Emission, Ejaculation, &

Orgasm

1) Causes

bilateral sympathectomy at L2 level

high bilateral retroperitoneal lymphadenectomy retrograde ejaculation

2) Treatment

elimination of alpha blocking agent alpha sympathomimetics

electroejaculation  

3. Premature ejaculation desensitization

squeezing technique

application of local anesthetics or condom

PRIAPISM 1. Type

1) high flow 2) low flow 2. Causes

1. unknown(60%) : prolonged sexual stimulation

2. associated disease : Leukemia, sickle cell disease, pelvic tumor, pelvic infection

3. penile trauma

4. spinal cord trauma

5. use of medication

3. Pathogenesis & clinical findings

Erection Priapism

Involved portion corpora cavernosa orpora cavernosa corpus spongiosum

glans

Cause vasodilation of penile a. obstruction of venous outflow venoarterial disturbance

Sexual desire present absent

pain absent

present (ischemic)

duration minutes to hours hours to days

High-flow priapism Low-flow priapism

Characteristics painless, high PO2, bright red bloodpainful, low PO2, dark blood

not so rigid penisrigid penis, soft glans Mechanism pain, perineal trauma 로 인한 venous outflow가 차단되면서

Cavernosoarterial shunt blood stasis 로 인 한 hypoxia

Etiology trauma, idiopathic veno-occlusive disease Medical status not so emergency emergency

Treatment embolization disease specific

Figure 22-6  A, Color duplex ultrasonograph in a patient with high-flow

priapism shows turbulent flow within the corpus cavernosum resulting from rupture of a branch of the left cavernous artery. B, On selective penile

arteriography, a ruptured branch of the cavernous artery is seen filling the cavity.

4. Treatment : Urologic emergency

1) sedation followed by enema of ice-saline solution 2) Ketamine hydrochloride I.V. or I.M.

3) epidural or spinal anesthesia

4) sludged blood evacuation with large needle 5) shunting fistula 

6) management of primary disease

HEMOSPERMIA ( BLOODY EJACULATION )

not uncommon complaint of middle aged men usually the wife recognize the symptoms

1. Causes

1) hyperplasia of mucosa of seminal vesicle 2) adenomatous polyp

3) prostatic intraductal carcinoma 4) utricular cyst

1. Treatment

1) diethylstilbestero

2) electrocoagulation of granulation of posterior urethra 3) needle aspiration of utricular cyst

First

Author Year of

Report Number of

Subjects Age in Years

(range) Flaccid Length (cm)

Stretched (S) or Erect

(E) Length (cm) Country

Kinsey 1948 2770 20-59 9.7 15.5 (E) United

States

Bondil 1992 905 17-91 10.7 16.74 (S) France

Da Ros 1994 150 NA NA 14.5 (E) Brazil

Wessells 1996 80 21-82 8.85 12.45 (S), 12.89

(E) United States Ponchiett

i 2001 3300 17-19 9 12.5 (S) Italy

Ajmani 1985 320 17-23 8.16 NA Nigeria

Schneider 2001 111 18-19 8.6 14.48 (E) Germany

32 40-68 9.22 14.18 (E)

Awwad 2003 271 (N) 17-83 9.3 13.5 (S) Jordan

109 (ED) 22-68 7.7 11.6 (S)

E, erect length; ED, erectile dysfunction; N, normal; NA, not available; S, stretch length

.

Table 21-1   -- Penile Length in Adults

Modified from Awwad Z, Abu-Hijleh M, Basri S, et al: Penile measurements in normal adult Jord anians and in patients with erectile dysfunction. Int J Impot Res 2005;17:191-195.