الفهرس 
ANATOMY OF THE PENISOnly 14 pages are availabe for public view
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Abstract
E
D is very common among aging men, and it has a variety of possible etiologies, including combinations of factors.
When evaluating patients with ED, it is important to obtain a full history, which will usually reveal the etiology of ED and the potential cardiovascular risk associated with taking medications from the PDE-5 inhibitor class. Sudden-onset ED and the persistence of nocturnal erections should alert physicians to the possibility of psychogenic ED.
Physical examination should focus on the genitals and may include a neurological evaluation in addition to the routine overall exam. Evaluation of hormone status is the most important part of laboratory studies for ED, but blood glucose and cholesterol tests should also be performed to identify underlying conditions.
Most ED evaluations do not require invasive tests, but the clinician must be familiar with the indications and identify the need for further evaluations and investigations. An ICI pharmacotest is a first line option to evaluate penile vascular function. In the setting of an abnormal ICI test a penile blood flow study with CDDS should be the mainstay of ED testing. Additional testing with DICC or penile angiography is only rarely needed and should proceed only when surgery is being planned.
Modern treatment of ED been revolutionized by the worldwide availability of the three PDE5 inhibitors (sildenafil, tadalafil, vardenafil) for oral use, which are associated with high efficacy and safety rates, even in difficult-to-treat populations (e.g. diabetes mellitus, radical prostatectomy). Patients should be encouraged to try all three inhibitors and to develop their own opinions. They will choose the compound perceived by them to the best efficacy, as well as considering other features such as time of onset, duration of action, window of opportunity and their own individual experience with side-effects.
The current treatment algorithm for ED includes PDE5-I initially followed by intracavernosal injection (ICI), VCD, intraurethral suppositories and penile prosthesis implantation (in no particular order).
Technological advancements are applied to the treatment of ED, patients will ultimately have a plethora of new management options. For now, the external penile support devices with their unique innovative designs deserve future exploration.
The handheld penile vibrator may serve as a good option for penile rehabilitation because it increases the neurotransmitters from the cavernous nerve terminals that are involved in penile erection.
Low intensity extracorporeal shockwave appears to improve erectile function through recruitment of endogenous stem cells and it may give hope that ED may one day be curable.
Tissue engineering will make biological reconstruction of the phallus possible and nanotechnology will revolutionize local therapies for ED in the very near future, also the application of gene therapy for ED represents an exciting new field. Further improvement of endovascular technology, we may cure ED caused by focal vascular lesions.
VCD will continue to be a popular penile rehabilitation strategy as a recent animal study has clearly shown that VCD increases arterial flow and oxygen to the penis and improves early return of erectile function after radical prostatectomy.
Avanafil is a highly selective inhibitor of PDE5, possessing a unique diaminopyrimidine derived chemical structure.
Current penile implants will continue to provide the most satisfactory option for patients with severe ED. However, new implants may provide easier patient usage and easier implantation by surgeons. The future of technological advancements in the field of sexual medicine is bright, what technologies gain entrance into the medical field will depend upon their safety, efficacy and patient satisfaction.
New advances in the treatment of ED represents a viable future options for urologists in treating ED and will be used in the near future for patients with severe ED unresponsive to current first-line therapies.