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Erectile Dysfunction Treatment: Andrology, Medications, Surgical Options & More

Don't suffer in silence with erectile dysfunction. Learn about your treatment options, including medications, surgical treatments, and penile implants.

Erectile Dysfunction Treatment

Erectile dysfunction (ED), or impotence, is the inability to get or keep an erection firm enough to have sexual intercourse.

It can be caused by physical problems, psychological factors, or a combination of both.

ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for ED.

The first step is to find out what’s causing your problem. This may involve:

  • Talking with your doctor about your symptoms and medical history.
  • Your doctor will want to know about any medical conditions that may be causing your ED. He or she will also ask about your psychological state, relationship difficulties, and sexual history. This can help determine whether your ED is caused by physical or psychological factors.
  • Your doctor may do blood tests to check for diabetes, low testosterone, and other hormonal problems.
  • Your doctor may also ask for tests to check the blood flow to your penis and to rule out vascular problems that could be causing your ED.
  • Your doctor may ask you to keep a log of your erections and sexual activity.
  • You may need to track your erections over a period of several weeks to find out what’s causing your ED.
  • Your doctor may give you a physical exam, including a rectal exam.
  • This may be done to check for an enlarged prostate or signs of nerve damage in the pelvis or lower back.

Medications

Certain drugs can cause or worsen erectile dysfunction. If you suspect that a drug you’re taking might be causing ED, talk to your doctor about it. He or she may be able to change your dose or prescribe a different medication.

Vacuum devices

A vacuum device (also called a vacuum constriction device) is a safe, simple treatment for erectile dysfunction.

A penis pump is used to draw blood into the penis to create an erection. You then place a rubber ring around the base of the penis to maintain the erection.

Penile implants

If other treatments don’t work or aren’t suitable for you, penile implants may be an option.

Penile implants are usually not available on the NHS. You’ll need to pay for them privately.

Surgery

If you have severe erectile dysfunction, your doctor may recommend surgery.

The two types of surgery are:

  • Penile implants. This involves placing inflatable or flexible cylinders in the penis and is usually done in an outpatient setting.
  • Vascular surgery. This involves repairing blood vessels, usually in the legs, to improve the blood flow to your penis.

Lifestyle changes

Making lifestyle changes may also help. </p

Andrology; Evaluation of Erectile Dysfunction; Medications; Vacu therapy; Surgical treatment; Penile implants; Complications; Premature Ejaculation;

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Video transcription:

Good morning, everyone

thank you for all the students who have

joined in youtube for this andrology viva preparation

session we’ve got a trainee who is quite

magnanimous to join this cheating system

welcome, I’m dr shihab, I’m a urologist

I am happy to. I am happy to share this

with you youtube and I’m happy that teaching teaching

their class. Thank you very good. Thank you. That’s very kind of you. Today

We are going to discuss

the possible scenarios which can be discussed

or asked in the andrology exam table

let us start with a simple scenario: you have

a 25 year old gentleman, married for

past, 12 months quite anxiously. Presenting to your clinic

he complains that his erections are not enough. How are you going to evaluate him

uh? Thank you for this scenario. I’m concerned that this patient had

erectile dysfunction differential diagnosis or the

premature ejaculation or other

ejaculation disorders or algorithmic or

desired. I would, I would see the patient in a specialist

andrology or a sexual dysfunction clinic in the presence of bertner

if possible. Full sexual history should be taken

first onset of erectile dysfunction, sudden or

gradual duration of the

problem. If there is a presence of erection in the nocturnal or

early morning

ability to maintain erection- and I will ask about libido relationship

issues, then I will get a sexual function symptom

questionnaire

iie. If questionnaire- and I will take a

medical and surgical history if he has davis, diabetics or cardiovascular

disease

this is important, because it’s a screen for cardiovascular and men

representing, with erectile dysfunction, and if the patient had an

intermediate or high risk. Cardiovascular disease

this is a required specialist. Assessment

And management barrier, erectile dysfunction treatment. I would

ask about hypertension, dyslipidemia, peripheral, vascular, disease

in, the crime, disease benefit and benign surgery

or trauma, and I would ask about assessment of social stress

anxiety, the religion I would ask about drugs. This is important because erectile

dysfunction or

I would ask about current medications. Its effect may be affected, erectile

dysfunction

such anti-hypertension. If there is a until they represent an euleritic

antipsychotic. If he had anti-androgens

and, I would ask about erectile dysfunction, treatment, that

already tried

and, their outcomes. Then I would ask about social

if. There is. If the patient is smoking all alcohol consumption

then, I will examine the patients

a full physical examination, including thyroid cardiovascular, abdominal, with

the

measuring of west and neurological. I would

I would asked about height weight body mass index

assessment of secondary sexual characteristics. I would examine external genitalia assessment. I would

the first by I will begin by venus if there is five moses or denial

deformities

or legions. If they this and b rune is disease

or. This I would examine the thesis. I would confirm the presence and size

consistency

irregularities. Then I will do a digital vector examination

especially if the patient more than 40 years

to assessment, the prostate

and. If the patient has neurological symptoms contract, the anal sphincter against the gloves

finger against gloves finger during

dre is the good general test for integrity of

is. Two three four then I would I would do

I would do some testis some tests, or

uh classically. I would do a

routine twist faster in the blood glucose

fasting lipid profile and total

testosterone, taking at the 8th to 11 a.m

if. There is any problem or a lower, lower or borderline. I would

I would request. If is arch, six hormone binding globulin

and. If there is in the history or or

any problem in the thyroid, I would ask thyroid

functioning test. I would request

dsa if there is abnormality in prostate and after appropriate

counseling counseling the patient especially

in the age of more than 50. bro latin. I would request a broad

latin if

lake lack of sexual interest and

and. If the patient has diabete diabetes mellitus, I would request hb1

hp a1c, okay, very good. That’s very cooperative

answer! Thank you for that

and. Regarding the medicines the I will just start from the first. So that

we will see how we can improve the

answers in few places regarding the medications which are

associated with ed

you can broadly debate them as something which you use

urology prostate cancer treatment. Like

For example anti-androgens and lh, antigonist or agarnist

you can say about phi alpha reductase inhibitors, which we use for the normal

bpe

and. There is a group of

anti-hypertensive tablets like beta blockers

thioside, diuretics, angiotensin

converting, enzyme, inhibitors and

spironolactone. There is again a set of psychiatric

drugs like

selective serotonin rehab, take inhibitors, tricyclic, antidepressants

benzodiazepines, antipsychotics and phenetoin

two. Other drugs are h2, blockers

and digoxin. So if you have a kind of a classification

it’s, quite easy to say most of the

points what you said, but with lot of confidence

and we’ll go one by one. What do you know

about? The physiology of erection do any stages in the

erection stage of elections is can

it’s, zero is a flaxseed, one is latent. Then tom sends a full election. Rigid erection than the

trump sense

which is a three-stage, initial, slow and first phase

okay. If we can label it slightly differently. For example, erection can be

divided into four stages

placid stage filling stage full direction. Stage

And rigid direction stage d missions can

come later because we are discussing about the stages in erection

the determinants- may not come there. For

Example flaccid phase is the normal state of the penis

normally present in the men

and partial pressure of oxygen in the penis at the time

is 35 mm hg. Then there is filling phase where there is increased firmness. And

There is

increase of blood flow in the penis next comes. The full erection. Phase

This is the phase in which the finish

will become non-dependent and partial pressure. Of

Oxygen can go up to 90 millimeters of mercury. And

Intracavanosal

Pressure can go up to 80 millimeters of mercury penetration is

possible

in this phase, but for some men we need to go

we need they need to wait for rigid

erection. Phase

Fourth phase is the rigid direction phase. That is the phase with the maximal

detonations

there will be engorgement of the corpus spongios. Also previously in full

direction, only corpus, cavernos is

involved in rigid direction, phase corpus spongios also is engorged

and. Blood is forced into the corpus, with the help of contraction of pelvic

floor muscles

and systolic blood pressure can reach even

hundreds of millimeters of mercury I’m

glad that you mentioned correctly about the link between the cardiovascular

health. So it’s very important to make

sure that you

create, a kind of screening for the cardiovascular

health. There are lot of new evidence. To

Prove that

penile erectile dysfunction can serve as a

very nice screening tool to find

cardiovascular problems

much in early stage you said about smoking

about alcohol. Those are all very good

you can say a little bit more about the marital status. I told you that he’s

married for 12 months, so you can explain

about how good is marital relation with his wife is

there any problems, of

performance anxiety, he had any pre-marital

sexual intercourse with any woman. That

Can cause a kind of a bad feeling or kind of a guilt. Feeling

Which can cause

problems. Then the last one is what type of job is doing

which you haven’t covered

say, for example, if he’s a sedentary worker, a kind of physical activity

making, some movements that will be good. You mentioned about the base

circumference

in, the examination, the other one is the body mass index that’s

very important when you are measuring so

in a dedicated erectile dysfunction clinic even before the patient comes and

sees you

the nurse who is working. The patient

will measure, the patient’s weight and height, which will give you

body mass index, do anything

about

the neural control of erectile function, how it works

it’s controlled by sympathetic. It’s control between t11 and t l1- and this is

sympathetic and parasympathetic is between- is to the s4

and somatic sympathetic is

control ejaculation and the laws of erection and

parasympathetic is responsible of erection

and. There is sensation from the from the venus

to, the within the nerve to the on off

nucleus then return back to the

to. The other think that our good, so you can divide the neural

control into autonomic

which again divided into sympathetic and parasympathetic

sympathetic levels. As you said, it is through hypogastric plexus

parasympathetic

s234. It is through pelvic, plexus, and then the next group is somatic which

is by the parental nerve

it can serve both as sensory and motor and this neural supply supplies the

penis through the cavern nozzle nerves. Erection is primarily driven by the

parasympathetic

neurons, located in pelvic ganglion, which projects

into corpura cavernosa via the

cavernosal nerves, and I’m happy with your

explanation of the examination

it’s very important that we should examine the pineal shaft adequately

looking for any flakes

like, peyronie’s plaques and also the size of the

glands, and make sure that whether he is

circumcised or not, those examination findings should be nicely

documented

you mentioned about. The examination of the splinter

that can lead us to further do

kind reflects this like bulb cavernous reflex

so. Do anything about bulbour

cavernous, reflex

uh balboa covered noses if they’re. If we are

if during the dre, if we squeeze the glands, we feel

construction the the sphincter. This this

mean intact of s2345 is two three four

yeah, so this same bulbar cavernous reflex can be elicited even in a woman

by using stimulation of the clitoris. So what is the molecular control? Of

Erectile function, how it works, molecular

during stimulation. It’s release

no, nitro oxide, this nitric outside this. It’s a

release soluble soluble

tb to gmb securities. Jmb security is its

its second messenger which which which increase the calci inside the

cellular, and this make a dilatation of the

sinusitis and cause erection good. So for this question you can say

that

the molecular or neural control of erectile dysfunction

works by cyclic, gmp or cyclic amp pathway. If you see cyclic, gmp

nitric oxide stimulates the vinylate cyclase in the penis to turn cleaves the

governor signed

triphosphate gtp into cyclic gmp, with his cyclic governance

monophosphate

cyclic gmp promotes protein kinase g, which helps in smooth muscle relaxation

and

calci is involved. Calci hemostasis is modulated

and. The smooth muscle relaxation results

in

pooling of blood inside the cavernosa sinuses

and expansion of the tunica results in

the blockage of the emissary veins, so there is less blood

loss from the cavernos and more pooling and as the pulling gradually

increases

as we discussed before the pressure inside increases

resulting in erection and the other set is cyclic. Amp adenosine monophosphate

we will discuss this when we discuss the drugs, because there are specific drugs

which acts through cyclic

amp pathway, it also derived from parasympathetic activation

of

adenylate cyclase. It also results in smooth muscle, relaxation

and erection, so there are two different

pathway. Apart from this. There are various other molecules like vasoactive

intestinal polypeptide, carbon monoxide, monoamines amino acids. Neuropeptides

Gaseous molecules are also linked, but those two

are, the most important pathway we need

to mention examination. You did very well the other

next stage

is to make sure that there is no related physical deformities

notable in a patient related to the hormone say, for example, is a male

pattern of hair growth

excessive pans, excessive fat and increased bmi can result in more

fat resources, which can result in more estrogen conversion that may

cause quite a big hormone disturbance. Let us assume our patient is a kind of a

sedentary. Worker

He is a smoker. He smokes for past seven years

at least five to six cigarettes per day

and. Otherwise he has no other medical co-morbidities

examination wise. He is thin bmi of 23 no physical problems. You said the

initial set of blood investigations. As you said, the breadth institutions were

normal

so. How are you going to treat him first? I would

. I would give him correct any reversable causes

such as altered lifestyle. He is sedentary, so I would advise him

uh to er to do exercise and his bmi 23

so. It’s good. I advise him to stop smoking

and optimize

. Just I he’s not diabetic. So

No need to control diabetes and then I would

I would psycho psycho sexual therapy

I would understand. I would understand, and address underlying

psychological

uh issues if there is any informations about it and treated it

yeah. I would give him sexual educations if there is

psychosocial psychosexual counseling and instruction and improving

partner relationship behavioral therapy programmed really

re-learning of kabul’s sexual relationship, okay

and investigation-wise, any investigations you need to do. Other

Than breakfast, I I till

investigation. I will do glucose and fasting glucose and

libido profile and total testosterone. Okay, what do about pineal

duplex, doppler ultrasound

I know. We are not using this frequently now but

uh before the days of pdf. Inhibitors

They are very, very popular. What do about them? It’s

If there is a suspicious vascular, vasculogenic cause of erectile

dysfunction

it’s required intra carbon nozzle injection

uh e1

uh. I use a tin microgram

to induce addiction, then a normal value. It’s a big systolic

velocity is more than 35 and in diastolic video city, less than

5 centimeters bill seconds. If a big system look velocity, lower

than 30, then it’s compatible with vasculogenic

erectile dysfunction. If the in diastolic more than

five, then it may indicated the avenue, occlusive dysfunction

very good, so the main values to remember is

peak, systolic velocity less than 30

considered as rtg arterial insufficiency, we can label the patient as arterogenic

ed

if n diastolic velocity is more than phi. It is consistent with venous leak and by

using

these. Two values psp and edv. You can calculate resistive index

resistive index is defined. As

Pick-Systolic velocity, plus in-diastolic velocity

divided by leak, systolic velocity

it, should be more than 0.8 for normal venue, occlusive function

those, who have any problems, especially venus league. They will have resistive

index

less than 0.8 very good, but we are not using the penile doppler

now unless, for some research purpose, or

some drug evaluation purpose. Let us assume this patient has no

major other endocrine problems or metabolic problems. How are you going

to treat him

uh if a patient not improved by changing the lifestyle? And

Psychosocial education, I would add bde5 inhibitor

which- is this medical treatment, it’s

enhanced carbon nozzle, smooth muscle relaxation and

erection by blocking the the breakdown of cyclic

cyclic guanine? First, I would cancel council division according to european guidelines, about european guidelines

I would see the patient needs and expectation, and I will share

him

decision making and if I would discuss with him

uh, what’s the type of bde5 available, we have

four type four indication: sildi nafil

uh viagra verdinevil. This its

success is different success. Almost around

in sildinefield around 84 and verdi

field about 80 and tedela feel about 80

when. I feel about 59 and I will in my practice I would

give him one long active trial by one

uh long, acting such as the de la field. If you want

uh spontaneous erection and if, under a short acting

such as sildenafil viagra, 50 milligram or 100 milligram

as as hour 25 as the

inc, as we see the effective of a treatment and if

he tolerate side effects and after

uh six weeks, I would see him and discuss what around good so the main trucks use

trusted in the field vertical telephile and avenophil

in many countries, some drugs may not be

available. For example, uk

commonly available drugs or cylinder fill and tetanolaphyl

so between these drugs say for example

you are selecting sildenafil. What is the dose? You will start the

patient. You set few doses, which is your

choice sildenafil my practice. I use 50 milligram

and. If the patient’s hubby, I will continue

if, not he want more. I would

increase to 100 if liz, if he

if, he has a side effects or less. We want less effective than 25

milligram. Okay, it’s correct that we need to

titrate, the dose based upon the

patient’s need, but you need to be cautious about the

what. The guideline says, for example, if

you take eau guidelines. It states it’s nice to start at 100

milligrams

uh, I mean not the eu guidelines. The initial guidelines said it’s better to

start at 100 milligrams

so that the patient will have a good

confidence and once the patient is confident and the drug is acting well

then based upon the side effects, we can

reduce to 50 milligrams. But if you take the latest ea guidelines

say 2020

it advises us to start at 50 milligrams and go for higher doses based upon the

side effects

in, which way the siltenophil and toddler fill

will differ with the tmax

and ser half-life ted de la field is more

uh more about more half a life is 17, hours still did nothing

about three four hours and sildenafil is affected by

by food, but te de la fil is not affected, okay

the t max, which is the maxim hours that is almost like one hour, for

children a field

and verdana field for tata laphil. It is two hours

if you take avanaval t-max is less it’s

only like 0.5 hours, so those are all the small differences

any specific side effects. Difference

Between cellular film sildenafil is has a

blue blue vision, blur blue bladed vision, field, is

he has myalgia and and back pain it’s a

due to at activated bde level. Yeah

So again, everything is because of the other

pde receptors. We want only to inhibit

the pde5

receptors, but because of pde 11 receptor blockade. Total field causes back pain

and, similarly

other pdf receptors. If we get blocked cylindrical can cause bluishness

sufficient

they are quite specific for them. Okay, let us assume you are starting this

patient on 50 milligrams

and. When are you going to see the

patient again after six weeks and okay

what? Will you do? I will? I will

I will assist the patient therapeutic outcome

patient, self-received treatment and treatment, associated

side effects and treatment. Satisfaction

Treatment associated satisfaction this according european guideline if

not adequate. I will. I will assist adequate use of treatment

option and provide new instruction, and

counselling ritual and if not

affected, then, I will consider alternative

combined therapies, okay, very good, so re-education is

very important because it is clearly

proven at least for fifty percent of people

with pdf initial failures. If they were

appropriately re-educated, we can salvage them and achieve good

results with pdefi

itself, when you will call that pdfi inhibitors failed for a patient

is there, any definition if the patients at least

eight times at the maxim dose and and

give him one hour before six, and if the patient get it in

empty stomach with sexual stimulation.

If all this available and the patient is not benefit then

it’s deemed a pharmacological failure. Most of the guidelines, says

full dose of pdf inhibitors, four doses. If it is not working in four doses, with

appropriate

knowledge correct food intake and correct precaution about the timings and

everything

we can call it’s a pde five failure, so four doses with maxim dose, say: for

example, sealed in the filaments it will

be 100 milligrams. So what are all the contraindications

for pdf inhibitors

uh contraindications bda5? If the patient taking natarat

if there is recent myocardial, infarction or stroke. If there is a hypertension

more than 170

and over 100 or high potential more less than 90 over 50

if, there is any stable angina if there is severe or renal or hepatic

failure. Okay, so nitrates means it includes

everything

sublingual, nitroglycerine, isosorbate, mononitrate or dinitrate

all. Nitrates are contraindicated. Because

They can cause precipitous drop in the blood pressure if they are given

in combination, which could be sometimes

life threatening now say, for example, not our patient our

patient is quite young

in 20s. If you have a patient in, say 50s, who is already taking tamsulosin

for his bpe, what precautions he will take before

giving pde for inhibitors

if there is anything I will advise him to

uh to get time solution

uh in the in the evening and and the

morning and and the bde5 inhibitor in the

uh evening. I’m afraid

that maybe make a high severe hypertension

yes or it’s more like added hypotension

especially, orthostatic, hypotension is

the main reason. There is no role for priapism in this place

so. The patient should be already on

tonsillosing for quite long time, unstable alpha, blocker intake person

and. Then, as you said, maybe we can take alpha blocker to the morning

and pdf inhibitor for the evening sexual

intercourse

so that there won’t be any super added decrease in the blood pressure

and. There should be at least four hours

apart for both alpha blockers and pdf inhibitors

but taking morning and night is much

more advisable and easy to follow. There are some specific side effects: for

verdenafil we don’t use them. Regularly

But nfl is contraindicated in men’s with congenital

qt syndrome or people taking class

1a or class. Three anti-arithmetics, like amidarone sotalol or quinidine

so you’re. Seeing this patient after six weeks

patient had not much improvement, and

then you

re-educated him and you salvaged. He was fine for almost like six months

and. Then he feels the targets were not

working anymore. What is your choice

as, the patient? I will use a second line treatment if

I would use. There is a

intrauteral therapy erection, device

intrauterine syrupy, this albrostadil

uh brussang landin il1 is placed in the urethra

in via a special

applicator. It’s a medicated urethral system

immune

brushling prostaglandin e1. It’s increased

cyclic amb within the core, bore smooth muscle and

its

result in smooth muscle reaction, relaxation then

erection, but the success is just 30 to 60. Percent

Side effects is denial and urethral being

privacy and dizziness your throat bleeding

or. There is a

albert steele in in the form of

uh gel gel form formulation, vitaros, it’s 300, mcg and another option is

intra, interact, nozzle injection, it’s we can use farm such as alberto steady

it’s affected in success in more than 70.

babavirin. It’s bde, inhibitor and

and, combined with the fintulamine and

and blossom or minus with the alberosteal tree therapy. Is

Uh is reports. Success about 90 percent

another option is in the corp vaso active intestinal, peptide

plus fintolamine, effective more than 80 percent

and. It’s their benefit is it’s low

incidence of penile pain

and, priapism, contraindications

it’s, bleeding disorder, sickle cell disease

or. If the patient has

uh risk of peripheral adverse effects affection

adverse its pain, prolonged erection, prehibitism hematoma. If this not work

vacu erection device, it’s used when pharmacology

uh pharmacotherapy have failed and the it’s used useful in

veno occlusive dysfunction. It’s three pieces: vacu chamber

bomb construction band,

yeah, just one second, we’ll come to welcome device. Just in a minute

uh. Before we move to the vacu device

, you said about muse musc

know the expansions for all the abbreviations

quite confidently mu stands for

medicated

urethral system for erections, as you correctly said, it has

prostaglandin e1 and it works

in cyclic amp. So there is a big difference between the

pathway of cyclic amp, with pg e1x when compared to cyclic gmp for pde for

inhibitors

and. Other thing you have correctly mentioned about the bi mix

and try mix, and so by makes us

papavarine and pentolamine and dolamine is a alpha one adrenergic

receptor blocker

but try mix contain the presence of ultra stereo also

regarding ultra studio, the dose depends

upon, the way by which we are giving so intra carbon nozzle injections

we need to use thin needles, 29 or 31 gauge, and they are only like 10

micrograms or 20 micrograms. Intra urethral use can go up to 300 micrograms

as. You said especially the medications present. Just in the urethral

miatas. There is a new

drug available. It doses the maxim 300 micrograms

so when you are injecting the dose is

less when you are applying just

on the urethral metas. It is the maxim at 300 micrograms

as. You said there are some specific

urethral related side effects like irritation, burning sensation, ulceration

plaque formation etc

what is the major difference in the functionality wise because of the

difference in the pathway, cyclic, gmp and cyclic amp. How it is useful when you

are counseling, the patient

uh in cyclic gmb, the patient must be a

sexual stimulation.

But imb secretly has no need to stimulations

yes. So there is no nitric oxide role in cyclic amp, so there is no need

for the actual partner cooperation or sexual stimulation

why. If you are prescribing the pdf

inhibitors, we want a good relation between the

patient and the partner so that there is

adequate sexual stimulation resulting in nitric oxide and then the

pde phi

inhibitor will result in accumulation, and

calci, release, etc. While for ultrasound

if there is a conflict with the patient and the partner, if there is already some

marital

disagreement ultrasound, is much better because the patient is not dependent on

the

partner for appropriate sexual

stimulation sometime in patient counseling, this will

help

us in a very big manner. What are the contraindications for intra-cavanosal

injections? It’s bleeding disorder and sickle cell

disease and if there is risk of periapism, this is what

yeah. So some men may be quite not tolerable to the injections so you

need to make sure that they are quite

happy to tolerate the injection or partner should be able to help in

injection as you said

triabism can develop in patients with sickle cell anemia

leukemia or multiple myeloma. If there is

fast history of trial person, we should be

very careful and keep the patient under

supervision

in the initial few days. Patients with pyrolysis disease, you need to be careful

because. The penile scarring can make the

injections quite difficult patients with buried, peonies, large

panels

obese permission, poor manual taxes t they may have quite difficulty the other

is

the people who are taking monoamine, oxidase, indicate

in, inhibitors, monoamine, oxidase

inhibitors, maoi medications, because alpha androgenic

medications

like, phenylephrine and epheneprine. They can’t be prescribed

along with monoamine oxidase inhibitors

and. We have to be very cautious in that patients using

anticoagulants can

bruise during the injection. Sometimes the breeze is so significant and cause

severe hematoma. So we need to be careful

with that okay now explain about the vacu device

let us assume that patient is not happy

with the needles and the patients part are also not happy in

trying needles and injections. How would

you explain vacu device to the patient. Welcome is

if. The pharmacology therapy is failed, then and

it’s useful in veno, occlusive, dysfunction

it’s, three chamber, three

components vacu chamber and bomb and construction

band. It’s

the patient, put the vacu chamber, then

make a negative pressure by bump and then after that

after erection, engorging and erection, the construction band put it in the base

of the

venus. The contraindication is anticoagulation therapy

and the patient may have side effects such denial, coldness, bruising

vein or obstructed ejaculations good, and also you need to advise. That

The patient should not use the band

longer

than 30 minutes because it can sometimes cause ischemia

and other problems. Again, you explain the

patient

and. Maybe he is happy and he’s gone home with the vacu device and he tried it

and. You are reviewing him in three

months time he’s not quite happy and just for the

sake of discussion. Let us assume that

you are going to discuss the pineal implant, surgical, treatments

for him

how. Are you going to explain it? Benign implant, this is

, it’s a

refractory to medical therapy or or in ischemic plaques and

peroneus disease. It’s I would

there is three types: it’s malleable simulated and inflatable it’s

not return back to previous

so. I will explain the patient that

bronze and tones. If of every every type

if, the most common type is three pieces. It’s three pieces

I will put a reservoir and retroperitoneum

and bomb in the scrot and the cylinder and the venus and this

uh the bronze. It’s it’s a bitter grief,

require, better manual dixitity highest to mechanical failure, better

rigid rigidity

flexibility, but in the cones he has almost a

complication of insertion. Technique need for

uh manual dextrity there is. There is

mechanical failure, higher mechanical failure

uh semirigids, it’s it’s! This required

requirement for manual district, district

low, mechanical failure on the symbol, insertion and

it’s, but it’s the cons, is a constant election

state

uh, lower rigidity, higher illusion rate, and I will explain

the side effects. It’s it’s

in fiction and s shape venus and glance and and the corporate

uh complication it’s as a very operative

uh. It’s a damage to other organs, corporal

rupture and early complication. Maybe hematoma and fiction being

wrong size, late, complication, auto inflation erosion. Mechanical

Failure like this okay! Good! That’s quite a nice

detailed discussion. Very very important is the infection

related complications

because. The pineal implant scenario can be

asked in the infection table. The

Scenario will start like you have a

patient, who is in the data list for penile 3

please

implant? How are you going to start the procedure so? What kind of sterility you

will maintain? What antibiotic

prophylactically you will give? How will you prepare the implants? Say

For example: ams

has got like a impregnated rifampicin, which gives it a characteristic

yellowish color, while choloplast 1

doesn’t have any color, so we need to immerse into the

antibiotic preparations. So if you read this quite in detail that will become a

complete full scenario, possibly in the

infection table and other commonest question is what

will. You do in case if there is

a infection post, three piece implant placement say, for example, six weeks post

operatively, patient presence with fever pain, erythema fixation of the scrotal

pump to the scrotal skin

and, maybe like a pus drainage. So what will you do in those conditions

if? If not specific? I will give him antibiotics for long

for a long time and observe the revisions. If not

if, not, I would make remove the implant and after

I would discuss the patient. During that I can use

a salvage technique. I use a

salvage technique by giving during the removing the

implant I would wash by antibiotics and hydroxy

alcohol hydro, heterosexual, right and then

then return back seven steps and trial to

insert another implant in the same situation

because. If the. If, if you remove

implant, then the penis will fibrosis- and this is then

difficult to it’s difficult to insert and plant another time

okay. So in this scenario, say, for example, in exam we are

going very quick and you are answering

all the questions and there is some one

minute left in the last 10 minutes of the vaibhava

they can

ask. Some questions like do you aware of any plant preparations

which can help in erectile dysfunction like we have

sal palmito for bpe. Do you aware of any

plant preparations for erectile dysfunction

uh? Sorry, I don’t get your yeah. So there are some drugs available

from plant which is not like. Chemical

Based drugs, like sal palmito for benign prostatic

enlargement

we have drugs like yohimbine. Those few drugs were used, for

erectile dysfunction. The problem is

there is no strong studies to support it and the evidence is so cooler. Okay so

know about some plant preparations, and let us assume that your patient has

got now good erections

but. He feels that his ejaculation happens

quickly. So what is happening

and? How are you going to treat him

so indirectly premature ejaculation? How can you define premature, ejaculation

uh, premature ejaculation? I will it’s

ejaculation within it’s different different

uh identification, but it’s less than one minute

or less than three minutes or it’s

uh. It’s it’s within. I I e. If I

ee questionnaire and and this

is the treatment

if, the treatment is

education, then, if not benefit, I would use seratonin

serotonin reuptake inhibitor, selective, serotonin, inhibitor

diaboxetine or borrow baroxetine

baroque 18 is the most important and and

it’s a elongate the election time, but it it is not licensed and

baroque 18 on demand. It’s it’s licensed

between one, two one two three hours before erection

uh another. We can use local anesthesia

and another go ahead, yeah, okay, so regarding premature ejaculation

the, main thing is

, we can divide it as lifelong, premature, ejaculation or acquired

premature ejaculation

lifelong. Premature ejaculation is the one where patient

is having ejaculation within one minute

of regional penetration from the first sexual

intercourse or experience, but the

acquired premature ejaculation is the one where patient, got

significant and bothersome reduction

in the latency time after initial good period

and. Usually the time is like three

minutes or less than three minutes

and. The second definition is something like inability to delay. Ejaculation

In most of the vaginal penetrations and third group are the people with negative

personal consequences

distress, and it really avoid results in avoiding the sexual intimacy

you are correct. With the drugs there are

various drugs available, the main medical treatment, is

selective serotonin reuptake, inhibitor

and, topical treatments. There are some secondary treatments like addressing the

underlying conditions

and psychotherapy, making sure that patients are having enough counseling

tricyclic antidepressants

you, said dipoxitin local anesthesia tramadol. There are some evidences for

tramadol. There are some good evidences for combination, of

pharmacotherapy

and, psychotherapy combination, so psychology

and. What is happening from the

psychological background is a

very important thing to cover. So in essence the simple erectile

dysfunction

scenario can happen in many ways. Sometimes you will have a scenario with

a patient, presenting with rectal

dysfunction

and. The examiner can take you into the relation between erectile dysfunction

and cardiovascular screening and they can discuss what is the

relation between that. The second

scenario is

the examination findings, making sure you are covering all the physical

examination findings. Obesity

Risk factors like smoking, sedentary life etc

and. How are you examining the patient

third scenario? The examiner can take more into the medical management

and. You can just divide differing into various types of medicines and why

cylinder. Fill has some specific type of side. Effects

What is the reason for the catalytic is

back pain, which is due to pd file. Pd 11, inhibition so

we can understand few things that the another scenario is

getting into the vacu therapy or the intracavernosa injections, the last

part

is, the implants. The implants can be like a malleable

semi-malleable and two-part implants

without reservoir and three plant implants

in three-part implants. There are some

small differences, between

the, boston, scientific and choloplast and few things because of the antibiotic

impergination, especially the ams, has got the

antibiotic refurbising imperginated by

chole pastures no

antibiotic. These things are quite in depth, but sometimes

if. The same scenario is asked in the

infection. Table

You may be asked quite in detail about the steps and sometimes salvage etc

and. Once you finish, the three part processes. The next stop is the premature

ejaculation

definition various medications possible and also the main importance in

psychotherapy

and, improving the marital relation with the patient

once. You complete the whole things the

andrology

as such is fully complete, but apart from this as the other scenarios

possible in andrology, table

or, pineal, fracture pyronies disease and few other things which we’ll cover

in the future subjects

do, you have any questions for me before. We complete very good in detail, preparation, very

nice

calm answer, but I need to say by presenting more, you will present this

with lot of confidence because there is

a lot of knowledge, but we need to make sure that it is

flows very

smooth for the trainees who have joined us in the youtube

in the screen. Now you can see one of the very commonly discussed, andrology video

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