This document provides an overview of urology courses related to andrology and erectile dysfunction. It discusses the anatomy of the penis including blood supply and vascular physiology of erection. It describes erectile dysfunction and its causes including vascular, neurological, endocrine, trauma, and drugs. Methods of evaluation and treatment options are outlined including oral therapies, injections, prosthetics, and surgery. Male infertility is also summarized including definitions, evaluation involving history, exam and labs, and causes and treatment options.

1. Urology Department
Under-graduate courses
Andrology
By Moh.Hassan, MBBcH Revised by M.A.Wadood , MD, MRCS

2. Erectile Dysfunction
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3. Blood supply of penis
Arterial supply by the internal pudendal artery,
Venous drainage
1. Intracavernosal drainage
into subtunical venules.
2. Extracavernosal drainage.
(a) deep dorsal veins.
(b) cavernosal and crural veins.
(c) superficial dorsal vein.
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4. Vascular Physiology of Erection
1. Nitric oxide
• Following sexual stimulation, Nitric oxide
diffuses into the corporal smooth muscle and
induces smooth-muscle relaxation.
2. Venous outflow resistance
• Filling of the lacunar spaces stretches the
subtunical venules to create venous outflow
resistance and a further increase in
intracavernosal pressure.
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5. Vascular Physiology of Erection
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6. Erectile Dysfunction
• Erectile dysfunction is the persistent
inability to obtain and maintain an
erection sufficient for sexual
intercourse
• Infertility is the inability to produce
offspring, which is usually not caused
by impotence.
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7. Causes of ED
Vasculogenic impotence
1. Arterial disease: Atherosclerosis is a common
cause of organic impotence.
2. Venogenic impotence : an increase in corporal
smooth-muscle tone during stress or anxiety induce
a functional venous leak.
Diabetes mellitus in up to 75% of diabetic patients .
Renal failure 50% of dialysis-dependent uremic
patients.
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8. Causes of ED
Neurologic lesions affect erectile function at
many levels:
1. Intracerebral
2. Spinal cord
3. Peripheral nerves
Endocrine disorders less than 5%.
1. Hypogonadotropic hypogonadism
2. Hypergonadotropic hypogonadism
3. Hyperprolactinemia
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9. Causes of ED
Trauma
1. Pelvic.
2. Perineal trauma.
Postoperative or iatrogenic impotence.
1. Aortic or peripheral vascular surgery.
2. Renal transplantation
3. Pelvic suergery or irradiation.
4. Cavernosal-spongiosal shunts
5. Neurosurgical procedures.
Drugs.
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10. Evaluation of ED
Sexual history The onset, duration, and
circumstances of the erection problem.
• Psychogenic cause: sudden onset of impotence
or impotence under some circumstances.
• Organic cause: gradual deterioration of erectile
quality with preservation of libido
Medical history DM, hypertension, smoking, and
hyperlipidemia, liver, renal, vascular, neurologic,
psychiatric, or endocrine disease.
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11. Evaluation of ED
• Physical examination of body habitus and
secondary sexual characteristics (Gynecomastia, the
penile length, fibrotic region, or deformity of the corporal
bodies).
• Laboratory tests Hormonal status is adequately
assessed by serum serum testosterone, LH & prolactin.
• Specialized tests
Vascular testing
Duplex ultrasonography to assess cavernosal artery
diameter and flow velocity.
Cavernosography and cavernosometry.
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12. Treatment of ED
Sex therapy For Patients with psychogenic impotence .
Oral therapy
1. Oral phosphodiesterase inhibitors (sildenafil, Tadelafil,
Vardenafil)
increase intracellular concentration of cGMP causing
corporal smooth-muscle relaxation and erection.
Side effects headaches, dyspepsia & visual color changes
Contraindications: nitrate therapy, severe uncontrolled
hypertension, severe cardiac malfunction
2. Androgen replacement: for patients with androgen
deficiency
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13. PDE5 inhibition with sildenafil
Sexual
stimulation Corpus cavernosum
Erection
NANC
NO Smooth
GTP cGMP muscle
relaxation
of the
GMP cavernosal
PDE5 arteries &
the corpora
NO=nitric oxide; NANC=nonadrenergic-noncholinergic neurons;
PDE5=phosphodiesterase type 5

14. Treatment of ED
Nonsurgical therapy
Intracavernous pharmacotherapy Alprostadil alone or in
combination with papaverine and/or phentolamine mesylate
may be injected intracavernosally.
Transurethral alprostadil
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15. Treatment of ED
Surgical therapy
Inflatable prostheses: consist of a pair of inflatable
cylinders, a reservoir, a pump, and tubing to connect these
components.
Noninflatable prostheses: a pair of silicone rods
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16. Male Infertility
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17. Normal Hypothalamic Pituitary
Gonadal Axis
• Hypothalamus site of production of GnRH, which reaches
the anterior pituitary via the portal system.
• Pituitary: anterior pituitary secretes 2 hormones (gonadotropins)
 Luteinizing hormone (LH) released into systemic
circulation in a pulsatile fashion. LH is the major stimulus
to testosterone production by Leydig's cells. testosterone
exerts a -ve feedback on pituitary LH release.
 Follicle-stimulating hormone (FSH) is responsible for
initiation and maintenance of spermatogenesis (Sertoli's
cells
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18. Normal Hypothalamic Pituitary
Gonadal Axis
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19. Male Infertility
• Definition : the inability to achieve a
pregnancy resulting in live birth after 1 year of
unprotected intercourse (primary infertility).
• Incidence : male factor can be identified in
nearly 50% of these couples
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20. Evaluation of the Infertile male
History
• The duration of the marriage and attempts to conceive
• if either partner has been previously married.
• History of undescended testicles, hypospadias, gynecomastia, mumps,
herniorrhaphy or scrotal surgery.
• Retrograde or absent ejaculation is most often caused by diabetic
autonomic neuropathy, sympatholytic drugs, or retroperitoneal surgery.
Physical examination
1. Testes. The size and consistency.
2. Spermatic cord. Any asymmetry, the presence of varicoceles,
gynecomastia or galactorrhea.
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21. Evaluation of the Infertile male -
Laboratory evaluation
Semen analysis is the single most important.
• collected after 3 days of abstinence from ejaculation.
• On at least two occasions.
Parameter Normal range
Ejaculate volume 1.5-5.0 mL
Sperm denisty > 20 million/mL
Motility > 60%
Forward progression > 2 (scale 0-4)
Morphology > 60% normal
Agglutination No
Pyospermia No
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22. Evaluation of the Infertile male
Hormonal assays (In severely oligospermic or azoospermic)
• FSH, LH, testosterone and prolactin
Genetic assessment (karyotyping) for Azoospermia
chromosome number (e.g, Klinefelter's syndrome, 47XXY).
chromosome structure (e.g., abnormal Y translocations).
Radiologic evaluation
Transrectal ultrasonography (TRUS) is now the initial
diagnostic modality for documenting ejaculatory duct
obstruction and seminal vesicle/vasal absence or aplasia
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23. Male Reproductive Abnormalities
• Low-volume azoospermia
1. Ejaculatory duct obstruction (acquired or
congenital).
2. Congenital bilateral absence of the vas
deferens (CBAVD)
• Normal-volume azoospermia
1. Vasal or epididymal occlusion may be
congenital or acquired.
2. Spermatogenic failure Clinical clues to this
diagnosis include small testes
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24. Male Reproductive Abnormalities
• Hypergonadotropic hypogonadism
1. Klinefelter's syndrome: karyotype (47,XXY). Testes are
small and firm. Gynecomastia. Hormonal evaluation shows
elevated LH and FSH, testosterone may be low.
2. XX male syndrome is seen in 1 in 10,000
3. Bilateral mumps or viral orchitis, radiation,
chemotherapy, and other toxic/inflammatory insults
suppress spermatogenesis.
• Oligoasthenospermia Low sperm density and poor
sperm motility often coexist. Due to varicocele, toxins or idiopathic.
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25. Varicocele
• the most common cause of oligospermia.
• unilateral (on the left) in 80% of patients.
• bilateral in 18% of patients.
• Varicocele have been reported in about 15% of the fertile
male population.
• varicocele is seen in 40% of infertile
males.
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26. Treatment of ED
Low-semen-volume azoospermia (<1.0 mL)
1. Ejaculatory duct obstruction is diagnosed with TRUS.
• Transurethral resection if TRUS has defined a midline cystic
structure.
2. Vasal aplasia sperm retrival and ICSI.
Normal-semen-volume azoospermia cause is
Primary spermatogenic failure (FSH levels are elevated).
• Testicular sperm extraction (TESE) may retrieve sperms
and ICSI is done.
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27. Treatment of ED
Ejaculatory dysfunction
• Treated by either:
 Penile vibratory stimulation or
 Rectal probe electroejaculation
Retrograde ejaculation
• use post-ejaculate urine specimen and sperm
retrieval and ICSI.
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28. Treatment of ED
• Oligoasthenoteratospermia
1. Elimination of spermatotoxin.
2. Medical therapy. Clomiphene citrate, hCG, tamoxifen
citrate, oral kallikrein, pentoxifylline, and folinic acid.
3. Surgical therapy. (varicocelectomy)
improves SA in 40 - 70% of patients.
• Pregnancy occurs in 40% of couples within
1 year of treatment.
4. Assisted reproductive techniques (ARTs)
a. Intrauterine insemination (IUI).
b. Intracytoplasmic sperm injection (ICSI)
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29. Thank You