Anatomy of penis,

pathophysiology of
erection and impotence
Anatomy of the penis
and male urethra
 Gross Appearance
• The penis is composed of 2 corpora cavernosa and
the corpus spongiosum, which contains the urethra,
whose diameter is 8-9 mm.
• These corpora are capped distally by the glans.
• Each corpus is encolsed in a fascial sheath (tunica
albuginea) and all are surrounded by a thick fibrous
envelope known as Buck’s fascia (deep fascia).
• Beneath the skin of the penis (and scrotum) and
extending from the base of the glans to the urogenital
diaphragm is Colle’s fascia, which is continuous with
Scarpa’s fascia of the lower abdominal wall.
• The proximal ends of the corpora cavernosa are
attached to the pelvic bones just anterior to the ischial
tuberosities.
• Occupying a depression of their ventral surface in the
midline is corpus spongiosum, which is connected
proximally to the undersurface of the urogenital
diaphragm through which emerges the membranous
urethra.
• This portion of corpus spongiosum is surrounded by the
bulbospongiosus muscle. Its distal end expands to
form the glans penis.
• The suspensory ligament of the penis arises from the
linea alba and pubic symphysis and inserts into the
fascial covering of the corpora cavernosa.
 Histology
• A. Corpora and glans penis
-The corpora cavernosa, the corpus spongiosum, and the
glans penis are composed of septa of smooth muscle and
erectile tissue that enclose vascular cavities.

• B. Urethra
-The urethral mucosa that traverses the glans penis is
formed of squamous epithelium. Proximal to this, the
mucosa is transitional in type. Underneath the mucosa is
submucosa which contains connective and elastic tissue
and smooth muscle.
-In the submucosa are the numerous glands of Littre, whose
ducts connect with the urethral lumen.
-The urethra is surrounded by the vascular corpus
spongiosum and the glans penis.
 Blood Supply
• A. Arterial
-The penis and urethra are supplied by the internal
pudendal arteries (the terminal branch of the anterior
trunk of the internal iliac artery).
-Each artery divides into a deep artery of the penis
(which supplies the corpora cavernosa), a dorsal artery
of the penis, and the bulbourethral artery.
-These branches supply the corpus spongiosum, the
glans penis, and the urethra.

• B. Venous
-The superficial dorsal vein lies external to Buck’s fascia.
-The deep dorsal vein is placed beneath Buck’s fascia
and lies between the dorsal arteries.
-These veins connect with the pudendal plexus which
drains into the internal pudendal vein.
 Lymphatics
• Lymphatic drainage from the skin of the penis is to
the superficial inguinal and subinguinal lymph
nodes.
• The lymphatics from the glans penis pass to the
subinguinal and external iliac nodes.
• The lymphatics from the deep urethra drain into the
internal iliac (hypogastric) and common iliac lymph
nodes.
 Nerve Supply
• The penis is innervated by somatic and autonomic nerves.
• The somatic nerves supply the sensory fibers and the
perineal motor fibers.
• The penis is innervated by both the parasympathetic and
sympathetic nervous system. The parasympathetic
innervation results in the formation of the erection, while the
sympathetic innervation is involved in ejaculation.
• The maintenance of an erection and the tone of the
cavernosal smooth muscle are determined by an
integrated response to neural stimulation and paracrine or
autocrine systems.
• Sympathetic noradrenergic fibers and parasympathetic
cholinergic fibers innervate the cavernosal tissue. Both sets
have opposing effects. In addition to these there are the
non-adrenergic-non-cholinergic fibers (NANC).
The Physiology of an
Erection
• There are 3 types of erection:

A. Psychogenic erections:
These occur as a result of visual or auditory stimuli.

B. Reflexogenic erections:
occur as a result of tactile stimulation of the penis, and are
important in maintaining the erection during sexual activity.

C. Nocturnal erections:
occur during REM sleep. Although the exact mechanism is
unknown, it is thought that low androgens levels is one of the
components.
• The physiological mechanism by which an erection
occurs begins with an increase in blood flow to the
penis, filling the sinusoids of the corpora cavernosum.
• The cavernosal smooth muscle relaxes to allow the
expansion to facilitate the extra volume of blood.
• This expansion presses on the venous plexus, which
creates an outflow obstruction, thereby increasing the
pressure within the penis and aiding rigidity.
• The relaxation of the smooth muscle of the penis relies
on the parasympathetic nervous system.
• The sympathetic nervous system controls
ejaculation, and also causes contraction of smooth
muscle. This constricts the blood-containing lacunar
spaces of the penis and empties them of blood,
therefore aiding detumescence.

• The maintenance of an erection and the tone of the

cavernosal smooth muscle is determined by an
integrated response to neural stimulation and
paracrine or autocrine systems.
The Neurophysiology
of an Erection
• When the NANC system is stimulated nitrogen oxide
(NO) is released within the smooth muscle cells of the
penis.
• The NO is converted from L-Arginine by nitrogen oxide
synthase, which in turn increases the production of
cyclic guanosine monophosphate (cGMP).
• cGMP decreases the intracellular concentration of the
calcium ions (Ca2+) that are essential for muscle
contraction. In this case, the Ca2+ is decreased and
smooth muscle relaxes, allowing blood flow to the
penis and expansion.
• cGMP is broken down by phosphodiesterase type 5
(PDE5).
• When this occurs the Ca2+ increases in concentration
in the cell, resulting in contraction of the smooth
muscle cells and detumescence.
• Sildenafil ('Viagra') is a PDE5 inhibitor, and allows for
erections to be maintained in response to stumuli. It
will not initiate an erection.
• When the sympathetic fibres are stimulated
noradrenaline (NA) is released from the nerve
terminal.
• This activates (α1) adrenergic receptors to produce
contraction of the smooth muscle of both the
vasculature and the corpora cavernosum. This causes
detumescence of the penis.
 Erectile
Dysfunction
• Erectile dysfunction, often referred to as impotence, is
the consistent inability to attain and/or maintain an
erection enough for penetration.
• While there may be no erection, the desire, sex drive,
the ability to achieve orgasm and the capacity to
ejaculate may still be present.
• Erectile dysfunction can strongly affect the quality of
life of those affected, and also that of their sexual
partners
• It often leads to depression and lack of self-esteem
and self-confidence. These psychological affects may
in turn perpetuate the disorder.
• Erectile dysfunction is a common problem among
men of all ages, ethnicities, and cultural backgrounds
• In 1995, it was estimated that more than 152 million
men worldwide experienced erectile dysfunction.
• Roughly, 2.3 million men in the U.K suffer from this
problem, with only about 10% actually receiving
treatment.
• The incidence of erectile dysfunction increases with
age.
 Causes of ED
• Age
It is estimated that between 30 and 40% of men of 40 years old
have suffered from some degree of erectile dysfunction.
• Vascular Disease
An alteration in vascular haemodynamics is thought to
be the leading cause of organic ED. It may affect those
suffering from:
-Myocardial infarction
-Coronary artery disease
-Stroke
-Peripheral vascular disease
-Hypertension
-Atherosclerosis/dyslipidaemia
• Diabetes
The prevalence of ED in diabetics has shown to be consistently
higher then the general population. It is also age related, with
an incidence risk of 15% at 34 years increasing to a risk of 55%
at 60 years.
• High density lipoprotein
The risk of suffering ED was inversely proportional to the level of
HDL-C.
• Smoking
Smoking in itself does not cause ED, but it is a risk factor for
those with heart disease and hypertension.
• Surgery or trauma
Surgery or trauma that affects the nerve supply or the blood
supply to the penis increases the risk of ED. Other suggested
causes include injuries from bicycles and fractures of the pelvis.
• Drugs
• It is thought that drug related ED is common, and may occur in
up to 25% of patients in a medical outpatient clinic.
• Such drugs include thiazide diuretics, the most common cause
of drug induced ED because of their common usage.
• Some antihypertensive agents may affect up to 40% of patients,
both by blocking calcium channels and by reducing the
systemic blood pressure necessary for penile rigidity.
• Anti-androgens such as oestrogens, luteinizing hormone-
releasing hormone agonists, H2 antagonists and spironolactone
may also cause ED.
• Antidepressants may also be a cause by affecting central
nervous system mechanisms.
• Digoxin inhibits the Na+-K+-ATPase pump, leading to an
increase in intracellular calcium that causes an increase in
tone of corporal smooth muscle.
• Hypogonadism
Men suffering from hypogonadism, whether it be
primary or secondary, characteristically suffer from
a lack of sexual desire and a decrease in both
frequency and intensity in response to sexual stimuli
• Psychological state
Erectile dysfunction has a positive correlation with
depression, anger, anxiety, stress, tiredness and familiarity or
dissatisfaction with a relationship. Dominant personality traits
have a negative correlation.
Any condition that leads to a diminished sexual interest can
cause erectile dysfunction.
• Erectile dysfunction also affects those who
have experienced any of the following:
- Prolactinoma
- Adult castration
- Alcoholism
- Acromegaly
- Chronic renal failure
 Approach Considerations
• The laboratory investigation for erectile dysfunction (ED)
depends on information gathered during the interview.
• Laboratory testing is necessary for most patients, though
not for all. On the basis of these study results, the physician
should be able to determine the medical status of the
patient, to identify and characterize the type of
dysfunction, and to determine the need for additional
testing (e.g. penile or pelvic blood flow studies, nocturnal
penile tumescence testing, or other blood tests).
• Imaging studies are rarely performed, except in situations
involving pelvic trauma or surgery.
• In making any decisions about further management or
referral, the patient’s needs, expectations, and priorities
should be discussed and taken into account.
• Laboratory Studies:
- Hormonal blood tests.
- Hemoglobin A1c.
- Serum chemistry panel (lipid, sugar, LFT, KFT…etc)
• Injection of Prostaglandin E1
- One of the most common tests used to evaluate
penile function is the direct injection of prostaglandin
E1 (PGE1; alprostadil) into one of the corpora
cavernosa.
• Biothesiometry
- The sensitivity of the skin of the penis to detect
vibrational stimuli (ie, biothesiometry) can be
employed as a simple nerve function office screening
test, but it is infrequently indicated.
 Ultrasonography
• Vascular function within the penis can be evaluated by
means of duplex ultrasonography. In this procedure,
blood flow in the cavernosal arteries within the corpora
cavernosa is measured before and after the
intracavernosal injection of a test dose of a standard
vasodilator (e.g. 20 µg of PGE1).
• Criteria for evaluating the study results vary to some
degree. A peak systolic velocity lower than 25 cm/sec is
generally agreed to indicate arterial insufficiency. The
proposed value for the lower limit of normal ranges from
25-35 cm/sec, but a peak systolic velocity of 35 cm/sec
or higher clearly rules out arterial insufficiency. End-
diastolic velocity serves as a proxy for venous outflow; a
velocity of 5 cm/sec or lower when the penis is at full
rigidity indicates the absence of abnormal venous
leakage.
 Nocturnal Penile Tumescence Testing
• Nocturnal penile tumescence testing involves
placing several bands around the penis, connected
to a device such as the Rigiscan monitor, and
instructing the patient to wear the assembly for 2 or
3 successive nights. If an erection occurs, which is
expected during rapid eye movement sleep, its
force and duration are measured on a graph.
• Inadequate or absent nocturnal erections suggest
organic dysfunction, whereas a normal result
indicates a high likelihood of a psychogenic
etiology.
 Other Studies
• Angiography is useful if the patient is a potential
candidate for some type of vascular surgery. Young
men with traumatic vascular injuries resulting in ED
are candidates for this angiography because they
may qualify for a vascular reconstruction.
• In the vast majority of patients with ED, formal
neurologic testing is unnecessary. However, those
with a history of central nervous system (CNS)
problems, peripheral neuropathy, diabetes, or
penile sensory deficit may benefit from some level
of neurologic testing.
Treatment
 Sexual Therapy
• When there are psychological factors as a cause of
erectile dysfunction, a course of sex therapy may
be recommended. The therapy can be very useful
in helping couples re-establish their sexual
relationship. The therapy is often used in
combination with other therapies.
 Intracavernous injection therapy
• Prostaglandin E1 is now commonly used; one of its
benefits being a lower risk of experiencing priapism
• Mainly deals with initiation of an erection
• The dose required is dependant on the patient and
this is determined by measuring the response of the
patient to several dosages and then adjusting the
amount required for the desired effect.
• Many patients find this method for treating impotence
uncomfortable or inconvenient, and as a result there
is a high drop out rate of up to 50%
 Transurethral Therapy
• This form of therapy has the advantage of not using needles. A
small pellet is introduced into the urethra via an applicator. The
drug is absorbed and an erection forms in approximately five to
ten minutes.
• This form of therapy was developed in the United States and is
called - MUSE (medicated urethral system for erection).
• The active ingredient of the pellet is alprostadil. This drug relaxes
the muscles in the erectile tissue of the penis allowing increased
blood flow.
• MUSE should not be used in the following conditions:
- Allergy to alprostadil
- Abnormal penis anatomy
- Any patient who is at risk of priapism (e.g. multiple myeloma,
sickle cell disease)
- MUSE should not be used in pregnancy without a condom
 Vacuum devices
• The patient inserts his penis into the device, a
vacuum is created by withdrawing air and blood is
sucked into the penis to give an erection. A band is
placed around the base of the penis to decrease
blood flow from the penis, hence maintaining the
erection. There are no major complications of this
method, however some patients have complained
about bruising.
Oral Medications for erectile dysfunction
• Sildenafil
- Sildenafil ('viagra') is a selective PDE5 inhibitor. During
sexual stimulation, nerves in the penis release nitric oxide
(NO). This molecule in turn causes an increase in the
amounts of cGMP in the corpora cavernosa. It is this
elevation of cGMP that is responsible for the vasodilation
that produces erections. Sildenafil works by inhibiting the
enzyme that breaks the cGMP down.

- Sildenafil is supplied in 25, 50 and 100mg doses of

sildenafil citrate. The tablet is taken one hour before sexual
activity. It does not cause an erection unless the man is
sexually stimulated.
• The most common adverse side effects of this
treatment are:
- Headache
- Flushing
- Nasal stuffiness
- Visual disturbances

• There are other oral medications available such as:

- Phentolamine
- Yohimbine
- Delaquamine
- Trazodone
- Apomorphine
- L-arginine
 Hormone Replacement for
erectile dysfunction
• Only a small proportion of the cases of erectile
dysfunction are caused by a hormone deficiency
• In those cases, the most common cause is a
testosterone deficiency. This can be replaced in
hormone replacement therapy
• The most commonly used form of this therapy is the
depot formulation of the long-acting esters of
testosterone. The esters are converted to free
testosterone in the circulation
• Oral preparations have the problem of unpredictable
blood levels of testosterone, and the risk of liver
damage.
 Penile prosthesis

• The prosthesis may be rigid or inflatable. It is

inserted under general anesthetic and strict aseptic
conditions must be observed, otherwise an infection
may lead to the removal of the prosthesis.
Thank you