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Diabetes & Erectile Dysfunction

Nov 24 | 2:00 PM

Erectile dysfunction (ED) is a common diabetic complication. Men with diabetes are more likely than men without diabetes to have developed ED 10–15 years earlier. After the age of 40, the prevalence of ED is estimated to be greater than 50.4% in Indian diabetic men. Join Col. Dr. K Ravindran Nair as he discusses the management of ED in Diabetes.

[Music] good evening everyone uh myself dr bush ali i would like to welcome you on behalf of team netflix for a session on diabetes and erectile dysfunction to introduce our speakers we have with us colonel k ravindranayan he is the director of center for andrology sexual medicine and infertility today we have a moderator with us as well it's dr anyan his director insta specialty hospitals and amma scans cochi good evening all and welcome to today's session on diabetes and erectile dysfunction we are very fortunate to have a don in the field dr carroll davinci to speak on the topic today and i'm sure that we are all of us are going to greatly benefit her from his immense knowledge and wide experience i wholeheartedly welcome dr cannell nyer for this session sir thank you very much and thank you all the listeners for attending this conference uh today's topic is uh erectile dysfunction and diabetes let us see what is erectile dysfunction erectile dysfunction is the inability to attain or maintain an erection of penis sufficient for pino vaginal intercourse the erectile dysfunction is very much prevalent in our society and this is not what slide i am showing is the prevalence of erectile dysfunction in the society and not in the diabetic patient so first let us see what is happening in the society and then we will see what is happening in the society 70 percent of men suffer an episode of ed at some time during their life in the life span and 30 percent of men experience erectile dysfunction at least once in a month 10 percent of the adult population suffers from erectile dysfunction and 5 to 60 percent is the prevalence of ed noted in the literature and an analysis of the data in from our institution has shown that the prevalence of erectile dysfunction is about 69 a very high percent of erectile dysfunction coming probably this is a center which is focusing on andrology and sexual medicine now ed patients are very lucky patients why because ed offers unique chance to undergo a detailed medical examination provided he understands the problem of that and one is able to detect the medical problems at an early stage as dr anya mentioned about the cardiac patients hence if you detect the if you have erectile dysfunction and undergo a thorough medical checkup you can explore and find out what are the problems with you and your sexual health and overall health will imp now let us come to the aging diabetic men above the age of 50 years 50 percent to 60 percent of men with diabetes have difficulty in getting an erection a very high percentage of diabetic population above the age of 60 years 95 percent of diabetic men have difficulty in getting an erection so erectile dysfunction is very much closely associated with diabetes mellitus diabetic man present with the eddy 10 years earlier than a non-diabetic man that is very important because at the age of 40 if a man develops erectile dysfunction he should submit to himself for a thorough medical checkup and probably he may be detected to have diabetes mellitus diabetic men are two to three times more likely to develop ed than non-diabetic men very important very high prevalence of erectile dysfunction in diabetic men in diabetic men ed is more severe and resistant to treatment than in the general non-diabetic population the reason for this i will come in the in the in the later part of my talk it is very difficult to treat a man with erectile dysfunction who has long term diabetes and it is as a doctor anyone said it is seriously associated with the cardiovascular disease hypertension low testosterone chronic kidney disease and hyperlipidemia all these things will aggravates the ed in diabetic population let us see what are the disk risk factors of ed in a diabetic man one is the advancing age if a diabetic man as he increases as he increases in his age the erectile dysfunction gets worsens and the duration of diabetes melissa is very important usually a diabetic man develops some sort of erectile dysfunction at the at after five years of onset of diabetes and microvascular retinopathy if a man if a man has got microvascular retinopathy he will surely go for erectile dysfunction then neuropathy nephropathy of diabetes macrovascular disease of diabetes that is cardiovascular disease of diabetes is always associated with erectile dysfunction and poor glycemic control with the high level of hba1c is also a risk factor for diabetes militias obesity insulin resistance metabolic syndrome lower urinary tract symptoms especially in bph then depression smoking alcohol sedentary habits lack of exercise several therapeutic drugs like anti-depressants anti-hypertensive recreational drugs marijuana and other drugs all are risk factors in diabetic patients for e then the role of statins most of the diabetic patients have hyperlipidemia and they may be taking statins there is the about the statins there is a big controversy whether static statins consumption can produce easy that people it is the literature says that 30 percent of patients taking statins especially in diabetic patients with hyperlipidemia can go for erectile dysfunction and that the number of medications administered to a diabetic patient is associated with the worsening of the ed let us consider the psychological pathology physiology of erectile dysfunction in diabetes now diabetes is closely related to depression when a patient comes to know that he is diabetic he goes into depression because he knows nowadays people knows that diabetes has got many complications then recent studies show that diabetes mellitus present a two-fold risk of depression and depression prevalence is very high in diabetic patients erectile dysfunction versus any pre-existing depressive symptoms that is also the pre erectile dysfunction for if a man has got a already depression and if he goes into erectile dysfunction the symptoms of depression will further worsen and the development of ed can also generate anxiety in him and which aggravates cd through the adrenergic mechanism a man who has got a depression and erectile dysfunction will generate the anxiety and this anxiety will further aggravate the erectile dysfunction through the adrenergic mechanism and in such a patients the support from the partner is very important and lack of support from the partner also aggravates the problem then poor self-esteem these patients develop a poor self-esteem and that amplifies the anxiety which again increases the erectile dysfunction chances and all these together contributes to worsening of the existing erectile dysfunction now let us see the structural pathology of erectile dysfunction in diabetic patients what are the structures we should consider one is vascular second is muscular that is smooth muscles of the penis then neurological the nervous system of the penis then the tunica albuginea the covering of the corpus cavernosum the hormonal now let us see the vascular problem in diabetes mellitus with erectile dysfunction the functional or structural impairment of vascular endothelium the endothelium is the important factor here the endothelial dysfunction that the nitric oxide is synthesized by the endothelium and nitrogen neurons from l-arginine utilizing endothelial and neuronal nitric oxide synthesis nitric oxide synthase converts the ela from the l-arginine the nitric oxide is produced the nitric oxide is mediates the relaxation of the corpus caverno cell smooth muscles and the vascular smooth muscles so the relaxation of the vascular smooth muscles and the cavernosa smooth muscles are initiated by the nitric oxide this results in increased blood flow and sinusoidal digestion resulting in penile erection through the formation of cyclic guanosine monophosphate cgmb one of the factor protein of cgmb is cgmb dependent protein kinase that is pkg1 which is significantly reduced in diabetes this is another reason why the patients go for worsening of the diabetic ed in diabetes mellitus there is higher concentration of endothelial in one endothelin one is a potent vasoconstrictor and pro-inflammatory peptide and is associated with endothelial dysfunction alternations in endothelin receptor sensitivity enhances vasoconstrictor process and endothelin one activates rho a rho kinase pathway resulting in suppression of endothelium derived in nitric oxide and decrease the production of nitric oxide increase the apoptotic apoptotic activity of the endothelial cells the cell death also is playing a role in the erectile dysfunction in diabetic patients now insulin has a vasodilatory effect through nitric oxide synthase upgradation insulin resistance leads to defective endothelial function and vasoconstriction hyperglycemia leads to the formation of advanced glycation products the advanced the glycation products they are end products from covalent bonds with vascular collagen they form covalent bonds with the vascular collagen and this collagen gets deposited in the vascular walls this results in vascular thickening decreased elasticity of the blood vessel walls endothelial dysfunction and atherosclerosis and the end result is reduction in vascular lumen and blood flow and this is if you see this is a histopathology slide which we have done the histopathology of the corpus cavernosum and in a diabetic patient you see the vascular lumen and the blue structure which you are seeing is the collagen the vascular lumen is very much reduced and the vascular wall is very much thickened and this is a collagen deposits and obstructing the muscular lumen this is the biopsy of the corpus cavernosum which we have taken during the penile processes implant surgery in diabetic patients and this is a mason's trichrome stain this is another histopathology slide which shows severe arteriosclerosis in a diabetic patients and he has got hypertension also let us consider the structural pathology of vascular and sinusoidal smooth muscles what is happening with the smooth muscles smooth muscles are replaced by collagen fibrous tissue altered smooth muscle collagen ratio this is all what we have found in the in our biopsy biopsy studies vascular rehabilitation is impaired action of vasodilator drugs are blended because the especially the pde5 drugs and other drugs like pg e1 and papaverin their actions are blundered because of the collagen deposits in the vascular wall and the wall does not get dilated ineffective compression of emissary veins the emissary veins which are exit existing from the sinusoids are not properly compressed because of the lack of expansion of the sinusoids and which will lead to veno occlusive dysfunction there will be the patient will go into a stage in such advanced stage they go into a stage when there is no response with the sexual stimuli and the patient goes into importance not erectile function importance importance and erectile dysfunction are different terminologies now let us see the cellular causes of erectile dysfunction there are two types of cells are central to penile erection one is the endothelial cells lining blood vessels and trabecular space of the sinusoids they release the vaso active chemicals nitric oxide and the second cell are the smooth muscle cells they signal signal transduction through gap junctions and for relaxation of arterial and cavanosal smooth muscles which i will explain with the next slide a diabetes and many other diseases and aging impair the function of these two types of cells if you see this picture you see the endothelial cells and you see the smooth muscle cells and the gap junction between the cells there is a gap that is represented by that black dot that black dot represents the gap between the two cells here that here the signal trans transduction is by jumping of the electrical impulse from one cell to the other cell so when this gap junction is get filled with the fibrous tissue or the collagen tissue the signal conduction will be impaired as a result the smooth muscles will not get relaxed and these smooth muscles lining the sinusoids and the vascular wall will not relax because of this now let us see the structural pathology in neurological structures of the penis the reduction of parasympathetic tone it is the due to the involvement with the diabetes the symbol the parasympathetic tone of the parasympathetic nerves get impaired or reduced and there will be decreased the nitric oxide synthase activity as a result the nitric oxide production especially nerve relay and derived nitric oxide production is diminished reduction in nitric oxide released from endothelial cells and non-adrenal energy can known cholinergic neurons nnos and enos enos endothelial derived nitric oxide and nose are nerve divided in nitric oxide the first it is the endothelial derived nitric oxide is released which will further stimulate the release of nerve derived nitric oxide then increased oxidative stress leads to narrow hypoxia and the protein kinase seed production which will again interfere with the production of neuroderived nitric oxide that peripheral neuropathy of sensory and motor nerves disturbs the conduction of afferent and different impulses from and to the penis so the impulse of the sexual impulses coming from the brain as well as the sexual sexual stimuli going towards the brain from the penis are impaired because of the peripheral neuropathy affecting the dorsal penile nerves in some diabetic men dysfunction of the penile nerves precedes neuropathy in other peripheral nerves so if a man with a diabetes develops erectile dysfunction probably he may develop a neuropathy in a later period and in in a patient who already has diabetic neuropathy he will definitely have erectile dysfunction when he presents with neuropathy so at this stage the physician who is attending on him is mandatory to check or ask him about his erectile function now let us see the histopathological changes seen in corpus cavernosum in our study of men with diabetes erectile dysfunction this is a large series of study around around 82 patients we have done the histopathological study of the corpus cavernosum and what we see in the corpus cavernosum are one is decrease in smooth muscle condense second is interstitial fibrosis and hyalinization and atherosclerosis which i have already explained and that is seen in the histopathology helicopter sinusoid we know occlusive erectile dysfunction and there is marked reduction in arterial human now let us see the histopathological changes in and structural pathology of tunica albujunia in the diabetic individual first we should study the normal anatomy or structural anatomy of the tunica albudenia tunica albudunia is a bi-layered structure inner fibers are oriented directly circularly which supports the cavernous tissue radiating from this inner circular fibers are the inner cavernous pillars or struts it is called inner cavernous pillars or struts which supports the cavernous tissue especially during erection during erection these struts supports the cavernous tissue and in a diabetic patient when one death or in an advanced diabetic patient with advanced erectile dysfunction when we do the penile implant surgery it is very difficult to dilate the corpus cavernosum due to this tough fibrous struts and sometimes i may have to use scissors to introduce it into the corpus cavernosa to cut these struts outer layer is oriented longitudinally and elastic fibers are normally form and irregular irregularly that is the network on which collagen fiber is rest this is the normal histology of the tunica albuginea in our study of diabetic men with erectile dysfunction or the study of albugenia showed varying degree of hyalinization thickening and disorganization of the fibers the circular fibers and the longitudinal fibers are not oriented properly and sometimes we see that it is completely disrupted then in some cases we have seen subclinical fat deposits in the tuna after the tunica vasculosa which is lining the inner part of the tunica albuginea we have seen fat deposits usually fat deposits are not seen in the corpus cavernosum then absence of elastic fibers in all such cases we have seen there are no elastic fibers in the tunica albuginea and this is a histopathology of the tunica albudina if you see the picture on the left side due due to the extreme weakness of the tunica albuginea herniation of the sinusoid has taken place taken into the tunica albudia permeating into the tunica this is a very classical slide which demonstrates the extreme disorganization of the tunica albugenia the the left one is the slide which shows a sinusoid which is herniates into the tunica albuginea the bluish colored structure seen in this slide is the tunica albuginea into which a sinusoid has herniated due to the extreme weakness of the inner circular fibers disruption of the inner circular fibers and on the right side you see increased collagen in the corpus cavern also in the same case i have presented the corpus cavernosum along with this because to show you how serious is the infiltration of collagen fibers in the corpus cavernosum or there is no smooth muscle in the corpus cavernosum it is all replaced by the collagen tissue this is all our study histopathology now the next we consider in a diabetic ed is the testosterone testosterone is closely associated with a diabetes mellitus the prevalence of hypogonadism in general population is 20 percent in men aged 60 to 69 years whereas in a diabetic population 44 percent of men with diabetes is reported to have hypogonadism so hypogonadism is very much prevalent in diabetic population and lower testosterone causes increase the insulin resistance poor glycemic control and worsening of ed this is the reason most most of the reason in by which the diabetic patients their ed get worsens due to the lower testosterone testosterone is very important in maintaining the structural integrity of the erectile tissue you see the the previous histopathology of the tunica albudenia this slide the left slide the integrity of the circular fibers have lost and this patient had very severe hypogonadism or hypo testosterone level and that also is a contributing factor for the weakness of the inner circular fibers of the tunica albugenia into which the sinusoidal has herniated what is the mechanism of hypogonadism in diabetes mellitus this is very important and the physicians who are treating the diabetes mellitus uh should see how a man with diabetes mellitus develops hypogonadism the low plasma concentration of sex hormone binding globulin which is the major carrier of testosterone in diabetic patients the sex hormone binding globulin as a low concentration the second is the increased aromatase activity in visceral adipose tissue and conversion of testosterone to estradiol because of the increase the aromatase activity the third third factor is diabetes mellitus associated leptin resistance causes reduced secretion of lh and testosterone the leptins are very much very much important in the release of lh and testosterone but there is a very high resistance leptin resistance which will prevent the secretion of lh and the testosterone then high insulin resistance leading to reduction in insulin action in the hypothalamus resulting in hypogonadotropic hypogonadism insulin resistance is also one of the mechanism which causes the lower level of testosterone because because of the insensitivity of the hypothalamus now let us see the radiological pathology in erectile dysfunction of a diabetic patients we have done more than 6 000 color duplex doppler ultrasound evaluation of erectile dysfunction patients including diabetic patients and other causes and what we have seen radiologically in diabetic patients are the pineal vascular study after pharmacological interaction we do they called the cddu or colored duplex doppler ultrasound of the penis one is the arterial dysfunction very common in diabetic patients and then second is the veno occlusive dysfunction earlier it is the veno occlusive dysfunction develops in a diabetic patients and later only the arterial dysfunction manifests other thing which we see is calcification in the penile arterial world now this is a arterial dysfunction in a diabetic patient you see the peak systolic velocity is very low it is less than 20 centimeter per second and this is a another case where you see the vino occlusive dysfunction very high end diastolic velocity you can observe in this now coming to the management of erectile dysfunction there are only two type of management in the medical management first what are the factors which predicts that your medical management will respond in a patient with ed having diabetes mellitus the first point i say is always a response to walciana's principles of sexual stimulation while sinus principle of sexual stimulation you all may be knowing that is a mononym that is mental auditory visual and tactile stimulation and if there is no response with any one of this or with all the four that means this patient will not respond to your medical treatments then second is baseline sexual function if the baseline sexual function is very poor and if his erection index is grade 1 or two he may not respond to medical management the poor response baseline response is poor he will not respond to medical treatment then patients are reporting some degree of npt nocturnal penile two emissions if there is no npt at all for some years or some months he will not respond to medical treatment then patients having a score of 7 to 17 in the erection domain of the lives of the iae of international index of erectile function scale below 6 if the if the score is below 6 is he will not respond to medical management then as i have already told you the color duplex dropper ultrasound responders with the borderline and above rpvl function psv 25 centimeter per second to 30 centimeter per second or in the diastolic velocity plus 6 to plus 10 centimeter per second that is mild vod they may sometimes respond but most of the time they may not respond then uncontrolled diabetes associated with the hypertension and hyperlipidemia will not respond to medical management then if a diabetic man is a current smoker and alcoholic and if he is a chronic smoker he will not respond to your medical treatment then symptomatic hypogonadism as i have explained earlier in symptomatic hypogonadism the threshold value is very important at certain threshold of testosterone level and above that threshold probably he may not respond every man has got a certain threshold and if if the threshold goes low then he will not respond to medical management this this is a very very very detailed subject the hypogonadism and erectile dysfunction and this is not i have i i have no place to talk on this subject at this moment now what are the medical management of erectile dysfunction in diabetics medicines one diabetes mellitus one is the pde5 inhibitors you all know it is uh the first one is sildenafil then comes the tadala film then then comes the eudanaphil and the latest which is available in in india is avaya fill and these medicines are available and if any responder is detected by your questionnaire and your investigation and if you feel that he will respond to these pde5 inhibitors you can try this and if it fails with the pg even into the interactive nozzle tissue pge1 papyrin phendrolamine and chloropromerson these are the drugs used or in combination cells next slides in capsule form can you please show the slides and the capsule gets dissolved and the pg e1 is absorbed which may induce an erection then testosterone can be given in combination with the any of this and usually change the selective equations testosterone level is very low so it is better to add testosterone in your prescription than the slight simple connecting device vacuum erection device can be used to induce an erection but in diabetic patients with to be no occlusive erectile dysfunction or the arterial dysfunction the ved vacuum erection device may not work but if you want you can combine any of this above therapy and apply vacuum erection device you can apply any of the permuta any of these drugs and methods uh permutation combination can be tried now coming to these excuses of erectile dysfunction in diabetes mellitus and once a diabetic patient goes into the end stage of erectile dysfunction that is no response to any of this stimuli or any of these drugs that is called the end stage erectile dysfunction and at that stage vinyl processes implant surgery is the only answer now [Music] uh penile processes implants there are various types of implants semi-rigid i am showing the in this picture the semi-rigid implants these are the semi-rigid implants you can choose according to the patient's preference as well as the convenience after explaining the pros and cons of each type of implants and this is the [Music] just showing the how i do the penile processes implants on the left side upper left side you see the transverse spinoscrotal incision and surface in slightly after the placing the implant you can see the surface light the implant is in position and the wound is closed and at the end and this is the on the up on the lower left side you can see a midline in australia the slide is not changed so we cannot see this on the right we cannot see the slide you can see we cannot see the slide incision on both sides so please change the slide the types of incision which i use but i prefer to use the transverse incision which i have shown on the left upper side so slide is not changed these are the incisions and this is our operating room setup on the right side you see the dilate dilators and on the the curved dilator with the handle is a dilator designed by me it has got lots of convenience and i generally use this dilator and not the haggard dilator and this is a various stages of the [Music] implants being done uh the after exposing the corpus cavernosum you dilate the corpus cavernosum distally and proximally and take the measurement of the corpus cavernosa cavity and choose the implant and put the implant into the corpus cavernosum which you have dilated and made a place a space for the implant to settle in and you have to use copious antibiotic irrigation while doing this procedure i will show you a short video this is a video showing the dilatation of the corpus cavernosum but in this uh i don't know how to this is the latest type of implant that is called a m spectra after implanting you can make the pennies flexible at any angle you wish and these are the inflatable penile processes there are two types of inflatable penile processes one is the three piece the top upper one is the three piece and the lower one is the two piece i have got many experiences the slide is for chainsaws and most of the patients they prefer the two-piece implant and it is very simple to operate and it is very easy to conceal so please see the slide and in conclusion i will say that e d is equal to e d is equal to e d what is it erectile dysfunction is equal to endothelial dysfunction and equal to emotional dysfunction so e e d is equal to e d is equal to e d this is a dictum coined by me erectile dysfunction is equal to endothelial dysfunction is equal to emotional dysfunction thank you very much for appreciation listening and i hope you have got certain or at least some take-home messages in a diabetic patient having edi can i say it was a wonderful lecture it is a wonderful lecture drani drama given by colonel dr nyers explaining his experience and the kind of cases that we he does at insta specialty hospitals sir this is one question from dr sanil varghese oh which type of rejected dysfunction is common in diabetes in your practice this type of ejaculate ejaculatory dysfunction yeah the most common type of ejaculatory dysfunction in diabetes mellitus is retrograde ejaculation so another question is uh so what is principle of sexual stimulation please elaborate that that i have already explained oh the volcanoes principles classified the sexual stimulation into four groups the first group is called mananam that is this wall synapse principle is smuggled by the westerners and they have converted mananam into mental sexual activity and the second one is called sravanam srabanam is auditory auditory sexual stimulation that is the sex chat today's nowadays there is sex chat that is auditory and that was that was uh coined by walsall and walcyanin knew that the internet will come and this chat will happen so about 500 years after christ while saying i was born and that at that time itself he has explained the sramanam that is the auditory auditory sexual stimulation base today's sex chat and the third is darsanam that is viewing sexual films viewing viewing sexual parts various type of viewing that is called a darsanam you exhibit the sexual organs you see the sexual pictures and all these they come under the darsanam and the last one is called the sparsinam spersanum means tactile stimulation of the non-genital sexual area and the genital sexual area and this personam is the basic principle of sensate focus exercise therapy and in my methodology of sensate to focus exercise therapy i have included the ciana's classification of women the wall ciana's classification of men and the wall seen as principle of sexual stimulation hello good evening everybody my question my question is when a diabetic patient with ischemic heart disease is undergone a cabg using anti-ischemic agents like sorbet rate nitroglycerins or animal gene can have a um medical treatment of dysfunction sydney like that local like that we can use in those patients can i can i answer this yes sir yes yes definitely he can be treated medically and you are asked in the question you have asked the post to see cabg or pre cabg post cabg definitely post cabg is considered in our andrology and sexual medicine we are considering him as almost a normal man and he can be prescribed even if he is taking cardiac drugs he can be prescribed all rectal dysfunction drugs provided you you precaution to him for example if you are prescribing him viagra or any of the other proprietary products he has to stop the anti-hypertensive or all other cardiac drugs 24 hours prior to consuming the pd e5 inhibitors or any other drugs which will induce erectile dysfunction which will which is which will induce erection of the penis okay smaller to stop these drugs for 24 hours and after this 24 hours you can use it yeah even as arbitrate nitroglycerins okay yes if the cardiologist would suggest not to stop this drugs we must not the cardiologist should be aware the princeton classification of management of erectile dysfunction in cardiac patients we should go through that which one which one order classification of management of erectile dysfunction in cardiac patients thank you very much sir you are we have given a very nice lecture you are the senior most in this and i'm very happy i attend this today i consulted a patient who has got a cardiac problem and he has undergone a cardiac cabg two years back and he is still taking some cardiac drugs he came with erectile dysfunction he talked to me on telephone and i told him to come on friday so i will be consulting him thank you thank you very much thank you very much sir another question is sir another cost of implants yeah cost of implants cost of implant varies according to the type of implant you use and the experience of the surgeon who is doing the implant i think they are asking the basic cost of the implant processes cost time thing they are asking for not the full cost of the surgery cost they are asking for the cost of the processes different four types of processes oh the indian there there is an indian implant called the sharp penile processes which costs around 17 to 18 thousand rupees now to understand [Music] only the two-piece implants the semi-rigid is not available in india now yeah i don't i don't know whether the hospi medicare has uh supported the no no no they have got only the two two piece and the boston scientific has introduced another semi i mean flexible implant but that hasn't come to india which is not flexible in india now yeah that is not available spectra is withdrawn from the market and there is a new new flexible uh has been produced by boston scientific that's american company but that is still not available in india yes in india we have two we have two pieces are available now the two piece may cost around seven lakhs yes 5.5 5.5 yeah three pieces 7.5 and the three piece is around eight or nine seven point five to eight that range but the flexibility is not available in india now okay sir one question is what are the what are your success rates in doing implants in your system in india now so another question yeah what are the success rates in doing implant surgeries in your center is it uh does it have any complications or is it a hundred percent good but in our center or successor is 100 okay so often there is no complication at all there is no erosion reporter software is 100 success in our center okay dr vishnu singh yes enhanced sir i want to know about the iif skill i i ef skill oh sorry international index of sexual function scale international index of spectral scale rectal function it is a print that format is available you can download it from internet so how can we take readings it's a printed format dilatation of pupils or anything yes dilatation of pupils may not occur but it produces some congestion of the conjunctiva due to the extreme vasodilation i hope sarah has explained it pupillar dilatation is not a part of the vasodilatory mechanism it is uh increased vascularity that can lead to a little bit of conjunctival congestion that can happen uh we have so pupillary dilatation may not be a feature of uh using vasodilator plants i think vishnu we have answered your question thank you sir here's one more question i think how can we dilate a diet of corporate carbonation for a sufficient length and then you dilate the corporate also between the you have to go below the uh tunica vasculosa if you go through the tunica when you dilate there may be some more amount of bleeding but in advance the case of [Music] erectile dysfunction or the in this stage erectile dysfunction probably there may not be any bleeding from the corpus cavernosum because most of the vessels are all calcified or occluded so another question is what is the safest drug for cardiac patient and elderly how which is the safest drag for cardiac patient and elderly elderly patients cardiac patient no safer drug unless he goes for a cardiac evaluation and finds out what is the cardiac problem how serious is the cardiac problem whether he has got a one vessel disease two vessel disease or all the vessels are occluded don't prescribe any form of pd5 inhibitors for a eddy patients unless he is investigated for the cause of ed that is very important don't prescribe once a patient comes and tells that i have a directive dysfunction please don't prescribe pde five inhibitors unless you find out what is the cause or what are the comorbidities with him uh the listeners to this uh particular session has got lots practitioners from different streams different branches and the point that kenelser is trying to make here is please do not prescribe pde pha inhibitors without properly investigating properly understanding the causes of the erectile dysfunction in diabetic patients that you are investigating sometimes if the severity of cardiac disease is more and more prescription of pde5 inhibitors can be a little more troublesome for the patient so unless and until you investigate it thoroughly evaluate the cardiac condition evaluate the erectile cause of erectile dysfunction with the help of a penile colonoplus duplex ultrasound study which is currently one of the best studies that can help you differentiate arterial causes we know occlusive dysfunction etc and can give you a very good understanding about the disease process at which the patient right he is so this is a point that every listener to this session to take it especially in cardiac patients please do not prescribe uh pdf inhibitors without a proper assessment of the case sir can i ask one more question is that can we do penile processes in plant surgery in any age or patient in any age group yeah not in children the question is can you do penile implants yeah see what did you say any age group children are also included [Music] yes sir my question if i ask question like that's included you you ask the friend you ask the specific thing i think what what whether a young is with uh erectile dysfunction can we will be doing uh implant surgery so uh i think kennel sir is the right person to answer but i will give a brief answer from my side because it has to be evaluated if it is a cause of we know occlusive dysfunction a severe we know occlusive dysfunction which will not get will will not have any this any relief from medical management then the only option option left behind is a penile implant surgery irrespective of the age can i serve your explanation please now see penile prosthesis implantation surgery is for end stage erectile dysfunction when an erectile dysfunction leads comes to an end stage nd stage means nothing is working that patient is indicated that patient has to undergo penile processes implants that is one second indication is we know occlusive erectile dysfunction with a antidiastolic velocity above 15 centimeter or more in the diastolic velocity below 15 centimeter or less one may be able to manage with the bed combined with the intracorporeal injection therapy or pd5 inhibitors or if vad is not available you can use banding technique combined with pde5 inhibitors and hormone therapy hormone therapy has to be done in you know occlusive dysfunction if you are managing medically but the ideal treatment for a vod or we know occlusive dysfunction is the penile prosthesis implant surgery arterial dysfunction definitely ah penile implant is the only answer for arteriogenic erectile dysfunction no drug will function in that so the indications for pineal processes implant is very much streamlined and the second point i want to clarify he asked any age group or of course he may be meaning say 80 or 90. he i have done penile processes implant for a 85 year old man who got who went into a second marriage at that age with a 35 year old lady he was in any stage erectile dysfunction due to diabetes hypertension and age-related changes in the penis he underwent a penile process implant i think that we have covered all the questions and i think we can wind up this session yeah there's one question for cyan do these drugs cause hypotension hypo tension hypotension hypotension ah they are vasodilators it it may bring down the blood pressure to a 10 millimeter mercury and sometimes little more or less yes they can you they can cause hypotension especially a patient who is taking antihypertensive drugs if he takes pde pha inhibitors he may go into further hypotension so the advice as per for instance uh classification of management of erectile dysfunction in cardiovascular disease any patient who has to be treat any eye patient who has to be treated with the pde5 inhibitors they have to stop the antihypertensive drug at least 24 hours prior to consuming pde5 inhibitors so we had a lot from a person who has done more than 500 prevent process implant surgeries and many msv's microsoft various carselectomy and transgender surgeries i think everybody is really benefited from his talk so i think dr joe anything to add no know this was an excellent session can also expertise and experience i think we will have to share with more case-based scenarios with lots of questions being taken up from the attendees in the future sessions and i think we should plan more sessions with kennel sir and i've been fortunate enough to work with him as his radiologist doing a large series of cases of penile color doppler ultrasound which is give us given us really really very good insights into the whole process of the or the pathophysiology of erectile dysfunction there's a smooth arterial dysfunction the inoclusive dysfunction the smooth muscle dysfunction so it's a large spectrum erectile dysfunction when we see with a in a patient we need to understand at what stage of the erectile dysfunction he is whether there is an arteriogenic cause or whether there is a we know occlusive dysfunction whether it is mild severe mild moderate or severe and if it is an end stage end-stage disease then of course the choices are very much for denial implant surgery for which kernel dr ravinder narcer is an expert in this field and another thing i felt is i think this would be the area where the textbooks are very less in medical science yeah but here we have a living textbook before us now because his experience has fast and we have been asking him to write some books on this because i think they as doctor used to tell me the classic textbooks on this cd and on the basis of only 500 scams they have written the textbook here dr regio and uh dr dekalin together has crossed 6 000 cdd use so definitely we have to expert at expo from both of them i feel i think i think we should do it [Music] if you ask me one investigation to be done in a penile erectile dysfunction the most important investigation is cddu yeah the most conclusive and that has to be done uh with the people who knows how to do a cddu and visual stimulation has to be visual sexual stimulation has to be incorporated while doing the color duplex doppler ultrasound and that will differentiate the color duplex doppler ultrasound can differentiate between arterial or organic eddy and psychogenic eddy that we have proved there is no need of sending a eddy patient to a psychiatrist or a psychologist you just do a color doppler and you can differentiate between uh organic ed and psychogenic eddy yeah yes thanks a lot thank you very much yes i would like to thank on behalf of team netflix i would like to thank dr connor nair sir dr andy and sir dr reducer and all the attendees that were present today it was an excellent session and a very interactive one i'm sure our audience must have enjoyed it thank you so much

BEING ATTENDED BY

Dr. Darius Justus & 344 others

SPEAKERS

dr. Ravindran Nair

Dr. Ravindran Nair

Consultant Urologist & andrologist | Director - Centre for Andrology, Sexual Medicine & Infertility | Insta Specialty Hospital, Kochi

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dr. Aniyan KS

Dr. Aniyan KS

Director, Insta Speciality Hospitals and Amma Scans, Kochi

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dr. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

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dr. Ravindran Nair

Dr. Ravindran Nair

Consultant Urologist & andrologist | Director...

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dr. Aniyan KS

Dr. Aniyan KS

Director, Insta Speciality Hospitals and Amma...

+ Details
dr. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

+ Details

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