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Introduction & Imaging in Sexual Medicine

Sep 29 | 2:30 PM

Join us for the very first session of Instacon by Indian Multidsciplinary Society of Men's Health, Sexual Medicine & Healthy Aging, a one of it's kind sexual medicine club where some of the top doctors across the country talk about few basic concepts of sexual medicine and radiological and imaging part involved in andrology. Session Agenda- 8.00 PM: Introduction to Sexual Medicine 8.30 PM: Radiology & Imaging in Sexual Medicine

[Music] good evening and warm welcome to each one of you who have joined here to instacon a one of its kind club in the medifix mediflix platform to embark the scientific knowledge of sexual medicine the multi-disciplinary platform that will go into the details of diagnosis and management of sexual dysfunction sexual disorders this event is jointly organized by insta specialty hospitals coaching and indian multidisciplinary society of men's health sexual medicine and healthy aging a society that was formed five years ago with the intent to propagate scientific approach towards sexual medicine andrology men's health and healthy aging we will be having a series of sessions didactic lectures case-based scenarios and true life stories that has changed the practice of sexual medicine and has given significant relief to those patients from some of these sexual disorders or sexual dysfunctions today we will be having an introduction a great pleasure to invite him to give his talk on introduction to sexual medicine over to you can you sir thank you thank you dr richo good evening to everybody and welcome to this session in this talk i will be giving an introduction to sexual medicine and andrology and how over a period of time the sexual medicine and andrology has evolved sexuality is a complex interplay of multiple facets including anatomical physiological developmental cultural and relational factors in the human life all of these contributes to an individual's sexuality in varying degrees at various time as well as developing and changing throughout the life cycle so the sexual sexuality human sexuality is an interplay of multiple factors now let us come to sexuality in adults consists of seven major components one is the gender identity that everybody knows then orientation sexual orientation is very important in adult sexuality then sexual intention what is the intention of the individual in sexual behavior then comes the human sexual response cycle desire arousal orgasm and emotional satisfaction all these factors together contribute to the multiple points in human sexuality now what is sexual identity in sexual identity the one of the most important factor is gender identity so of late we have got a male behaving like female a female behaving like male so this gender identity is very important in now let us come to the sexual function there are few factors which contributes to the sexual function one is the the human sexual response cycle it is called the desire arousal and orgasm and after that there is one more factor called the resolution phase the interplay of the first six components which i narrated in the earlier slide this slide contributes to the emotional satisfaction of the individuals and the emotional experience which they derive from their sexual activity the expression of a person's sexuality is intimately related to his partners sexuality also partners sexuality is very very important in the sexual satisfaction and in the sexual function now let us think of the origin of sex male principle and pragardi is the female principle and in the concept of ardhan arishwara has evolved from this concept of purusha and pragardi and male and female principles in the same organism excess according to the hinduism that is why the ardhan arishwara concept has come so if you analyze a human being there are anatomically and physiologically male and female representation is there in each individual now the concept of sexuality in hinduism in hinduism in a hindu's life there are four stages in this life called they are called dharma artha kama and moksha dharma means duty and this is the student stage and this stage is called he has to observe the brahma's area and the chastity is to be practiced in this dharma period or and in both by men and women and the hindus expect that when a man and a woman gets married they should be virgin and that is that comes by the practice of celibacy during the dharma and then comes the artha after his education is over he is searching for a livelihood and this livelihood period he is searching for wealth as well as he is searching for the worldly plushes which includes the desire for worldly pleasure including sexual pressure and reproduction and that sexual pressure and reproduction period is called the karma kama means attraction to any object or any feelings and the last stage is the moksha that is spiritual life and salvation now the concept of sexuality in christianity during the pre-christ era that is the adam and eve and adam and you was created by the god for the propagation of the human life and they committed a sin and christian and sexuality in christianity is considered as the continuation of that sin now let us think of the concept of sexuality in christianity in the pre-christ era women were viewed primarily in the context of their ability to procreate hence they were sexualized they were sexualized and they were considered as sexual objects this has led men using women to satiate their desire and at that time uh what happens the sexuality was in a hayward stage and marriage was a legal contract a legal transaction at that time and usually young girls and ladies they got married older women or older men and these older men used to die at an ah after marriage because the wives were very young and re-marriages occurred and these videos were more more the widows were more and re-my ages were common during that period and this time also they were sexually exploited infidelity and divorce were common due to this early death of the husbands but during the christ era and later period the women enjoyed equal rights in every aspect of family social spiritual and sexual life and marriages became an unseparable institution in christian life actually the christian life and society starts from the christ only what i have told earlier is the pre-christian era now coming to the islam there are three factors which guides an islamic couple one is the islamic holy book quran and second is the hadith hadith are the sayings of prophet muhammad and the third is fatwas fatwas are rulings of religious leaders so these three factors controlled the life of an islamic islam life in islam and all admits all these three institutions in islam admits sexuality confined to heterosexual marriages between gender normative men and women not beyond that and polygamy was allowed and it was an accepted norm let us come to the origin of sex in a scientific way the evolutionary theory of origin of life and sex during the evolution the origin of life occurred from non-life what i mean is non-life is the chemicals the evolutionary scientists they have research and they have found that the earth is around 4.7 billion years ago the earth was formed and the first life occurred in the earth at 3.6 billion years back due to the combination of various chemicals a unicellular organism developed and this unicellular organism further changed and multiplied and now they became amphibious reptiles mammals and the final stage of the human beings and at this stage we don't know at what stage the sexual differentiation has occurred we let us consider how much scientific is the modern scientific view in sexual development it is said that the development of life occurred from non-life that is as i told you earlier from chemicals and then undirected naturalistic descent with modification occurred in this life and random genetic mutation within an organism occurred beneficial mutations are preserved for survival which is a process known as natural selection and beneficial mutations are passed on to the next generation for preservation of life over a period of time beneficial mutations accumulate and the result is an entirely different organism in this process we don't know at what stage the sexual differentiation occurred now the scientific view of origin of life and sexual differentiation remains an enigma sex is too complex for its origin to be explained by evolution and natural selection no scientist is able to explain at what stage of evolution the sexual differentiation has occurred evolutionary scientists cannot say when a fully furnished functional male and female developed and that what stage the sexual reproduction has started the about and origin the origin of sex is it an intellectual mischief and a confusion or an intelligent design we can say that sex is the product of an intelligent creator so the differentiation between male and female was done by an intelligent creator here we thank the creator the origin of sex the last word is by albert einstein who says that god does not play dice with the universe so this is where the intelligent creator comes the sexual differentiation was made by the intelligent creator those who believe in a unseen force we can say that or the unfor unseen force is we call god so at some point in the mutation stage the sexual differentiation was caused by the god that is what even albert einstein says now let us consider the evolution of sexology in the world now the first civilization in the world is the indus valley civilization which is called the rama empire and this civilization is from 10 000 to 2500 bc and the area involved from afghanistan to present myanmar this area was the area of indus valley civilization and this is the longest civilization a later period the egyptian civilization mesopotamian and sumerian civilization the chinese civilization greece and roman civilization the mayan civilization and the austrian civilization all these civilizations if you study in detail sexuality was there and sexual practices and sexual [Music] diseases all were explained i were in this civilization once you study the in detail about this in these civilizations now let us come to the the indian or the indus valley civilization or the so-called hindu culture now sexuality is defined in detail in atharva veda veda chapter 2 kanto prati mantras 1 to 5 details the to secure the love of a woman or the wife the the the mantra says the let the arrow of karma pierce your heart so this symbol of an arrow piercing the heart became the symbol of love and this is originated from the atharva veda and the atharva veda chapter 3 can 25 mantras 1 to 6 details how to arouse the passionate love of a woman that is his wife and this mantra says how to arouse the passionate love of the wife then chapter 4 four candle for mantra one to eight prayers searching medicines to rejuvenate organs of love and sex so even they were searching for medicines to rejuvenate their sexual life kando 8 9 and 11 mantras 1 to 3 prayers to fulfill the husband's wishes by wife to increase desire in wife towards husbands so this is all sexological practices in other words a particular segment is there where sexual sexology is described in detail so once you go through this uh ancient indian literature we see all these things then analysis of sexuality in rigveda and atharvaveda sexuality and gender identity are cultural constructs and not physiological attributes they are associated with the culture male sexuality was more priced than the female sexuality because the male sexuality is priced for reproductive ability so the reproductive ability was considered as the prime and this reproductive ability was attributed to male sexuality and female sexuality was priced only for reproductive value only but male was considered as a main reproductive agent as well as the protector of the family female sexuality is much more complex multiple dimensions the later vedic period the upanishad period [Music] explains foreplay and enticement of a woman and these supernaturals describes how to arouse a woman sexually and at the same time in the same period the targa and sushruta detailed the treatment for sexual disorders and sexual uh diseases five hundred eighty one seina described kama sutra and he wrote the kama sutra which is a treatise of sexology and along with this the ayurveda developed and in ayurveda there is a particular particular area called sastra and which deals with sexology and viralization now coming to the greek and roman civilizations hippocrates led to aristotle they were all pioneers and they were considered as fathers of sexology they have described sexual aspects of human life in detail then observational theories regarding sexual function re dysfunction reproduction contraception abortion sex legislation and sexual ethics were evolved during their time gallon and surroundings further advance the theories put forward by hippocrates plateau and aristotle hippocrates divided importance into natural and unnatural importance the natural importance is the organic importance and unnatural importance is the psychogenic importance sexology in medieval and arab medicine was also well developed al rashi a famous physician and writer wrote medical book called al harry containing many aspects of sexology then other people like abhishena and albu asis also explains various aspects of sexual medicine and treatment for sexual dysfunctions now in modern sexology has evolved from 16th to 20th century the sexual anatomy and sexual physiology was intensely studied during this period and private and public sexual education and sexual ethics were introduced during this period during the 19th century the biological medical historical and anthropological research by darwin mendel kraft having all these people has made the research into the modern sexology and research was bought brought into the modern sexology during the 20th century havelock ellis sigmund freud ivan blah legitimized investigations of sexual problems now let us consider the pioneers of sexology the german dermatologist evan blow he studied sex as an academic discipline and concept of psychology was introduced in medical education havelock ellick he is a psychologist and biologist he challenged the victorian view of homosexuality and sexual repression during the victorian era sex was repressed and homosexuality was condemned so he challenged this view the most important person in modern sexology was magnus hexfield and he has introduced the journal of sexology then the society for sexology institute for sexology conferences on sexology all this was done in berlin germany and during the nazi era his institute hashfield institute was destroyed by the nazis and his books and research papers and all other materials were burned down and he had to escape from germany and went to united states later period sigmund freud is an austrian a founder of psychoanalysis and psychotherapy in sexual medicine then alfred kinsway he has made a lot of research research in orgasm and he studied the orgasm seeking behavior of the couples then albert ellis cognitive behavior therapy was introduced into the sexology and for psychosexual dysfunction he described cognitive behavior therapy helen singer kaplan introduced the conceptual models for the human sexual response brought sexual desire problem to the force so he is the person who described the loss of sexual desire and he investigated this scientifically and later the sexology came as an academic discipline and the first academic discipline of sexology came in australia in curtin university later in europe european federation of sexology started and then in usa the kinsei institute institute for advanced study for human sex sexuality in winder university so later period sexological research sexual sexological advances has taken place in usa now coming to the uh interdisciplinary disciplinary references in sexual medicine sexual medicine is a combination of multiple medical disciplines now what are these medical disciplines and other disciplines involved in sexology the most important disciplines involved in sexology sexual medicine and andrology are neurology andrology gynecology radiology general medicine endocrinology psychiatry psychology psychotherapy sociology then cultural sciences jurisprudence ethnology ethology and psychosomatic medicine internal medicine etc so sexual medicine is a combination of so many specialities so a sexual medicine practitioner has to be acquainted with all these specialities to have a proper practice of sexual medicine now let us come to andrology what is andrology linguistically the word andros means deals with the mail andros deals with the mail the theme anthropology was introduced by a gynecologist in germany in 1951 and the name of the gynecologist was [Music] from the university of born and andrology was considered as a counterpart of gynecology this gynecologist coined the word andrology and she confirmed that it is a counterpart of gynecology and who defines andrology of a medical discipline engaged in all aspects of male reproductive health which includes sexual dysfunction reproductive function all aspects of male reproductive health andrology deals with a male sexual and reproductive health now coming to india sexology and sexual medicine in india where are we standing in our medical colleges there is no teaching of sexual medicine or andrology even during the mbbs career sexual medicine or there is no mention about this discipline then in in our country training sundays for anthropology and sexual medicines are very very few very limited one may be able to count on a finger then there are two main associations in india dealing with this problem one is our own association indian multi-disciplinary society of men's health and sexual medicine and healthy aging and the second is indian association of international association of sexual medicine modern medicine practitioners these two organizations are doing commendable job in the propagation of sexual medicine and andrology there are no committed practice practitioners in sexual medicine and whatever few practitioners are doing they are not full-time practitioners they are practitioners from other main disciplines like urology general medicine psychology psychotherapy psychiatry etc etc there is no authenticated journal or publication in india from for sexual medicine and andrology conferences on sexual medicine and andrology are very few especially during this uh this covered era there are no conferences but cscbi that is a council of sexuality education and parenthood international we are all members of that and they used to conduct annual consciousness but that organization is a conglomerate of unqualified things like ayurveda homeopaths etc we need sexuality adequation sexual media academic education sexual medicine public awareness has to be given and media has to be given media to expose the speciality of sexual medicine andrology and sexology and the most important thing is there are a lot of quacks practicing in this area and it is our duty the qualified doctors who are practicing sexual medicine and andrology to prevent these cracks or to expose these cracks in the general public and dissuade them in practicing this branch of medicine sexual medicine is a branch of modern medicine in conclusion i would like to say that sexology existed from the time of creation had a long journey through religion culture and science and still it is evolving it has not evolved fully still it is an evolving branch of medicine we have to take sexology and sexual medicine to the mainstream of medical practice and academics that is that should be our aim and there is no research in sexual medicine and their sexology the research is lacking very much thank you very much for giving an attention to my talk and i have covered a little bit the evolution of sexual medicine sexology and andrology and still we are evolving thank you very much thank you sir thank you dr kernel ravindra nair sir for the elaborate uh description of the evolution of sexual medicine from uh the time immemorial to the present days were sexual medicine practices one point that you highlighted here is sexual medicine as evolving and it is still not being accepted as a medical discipline academic discipline in the modern medicine so it is high time there has been attempts to make it as sincere it is a serious academic discipline and one among the modern medicine branches of modern medicine branch so that is a one interesting message and that is what this society of indian multidisciplinary society of men's health sexual medicine healthy aging intends to do with a series of lectures seminars and publications we are planning to come out with the scientific analysis scientific approach towards sexual medicine a very important branch in modern medicine many very important problems that people are facing the sexual problems sexual dysfunctions in male and female the number of people who are affected by these sexual dysfunction in both male and female are huge many of them do not know whom to approach many of them even amongst doctors there is no concerns they don't know what kind of treatment has to be given what kind of investigations has to be given so to uh go into the next session uh on the role of radiology and imaging so uh in sexual medicine after this introduction on sexual medicine by dr colonel ravindrana so thank you very much sir for that wonderful lecture so let us move on to the next topic uh i'm going to give the next talk on radiology role of radiology and imaging in sexual medicine so dr kennel nyer has given a the history of sexual medicine the evolution of sexual medicine and has ascertained again and again that's an important branch that has to be addressed with all the scient scientific approach and sincerity and has to be brought into the mainstream of modern medicine right now the priorities are not there in the medical curriculum and in the practice too that is why people with sexual dysfunctions do not know whom to approach and the doctors are not being trained scientifically in the investigations and management of sexual dysfunctions they are also at a loss to explain or go in a proper scientific methodology to understand the disease process and to cure them that is where we in coaching at the insta specialty hospitals at the center of sexual medicine andrology and healthy aging we formed a multidisciplinary team with a urologist anthropologist radiologist gynecologist and even a gastro surgeon and gastroenterologist as part of the team where we formed that particular multi-disciplinary team to address some of the sexual dysfunctions so this society was formed five years ago and annual conferences were conducted on various topics some of the topics that we covered were erectile dysfunction a very very common problem they among one of the sexual dysfunction that is you come across in your practice another one was ejaculatory disorders another one was on hormones testosterone a hormone of weather and vigor that was a theme of one of the conferences another one was on men's health the entire theme on that year was a men's health because there is need to have a policy for the national policy for men's health in this country there are only three countries which has got an official policy for men's health one of them is canada so it india doesn't have a policy for men's health so that was the theme of that year so that is how this cause society has been propagating the ideas of andrology sexual medicine and healthy aging so the content of my talk here on the role of radiology and imaging will be an introduction to sexual dysfunctions in male and female and some of the radiological modalities and diagnostic features and sexual dysfunctions will be covered the multi-disciplinary multi-modality approach it's not just one modality there are multiple modalities of radiology can be used in the evaluation of sexual dysfunctions so a picture that i am showing here if you look at it in sex in mri and this was a experiment that was done 20 years ago to understand the sexual process of coitus the intercourse was in what happens during an intercourse it was imaged with the help of an mri in amsterdam and that 20 years have passed this is all for an understanding of furthering but not on a regular basis we need such kind of tests but there are much more interesting tests much more tests that can be used in our regular practice to come out to the proper diagnosis and help in the management of these conditions as dr kennel nyer has already explained the sexual dysfunction is a large and complex issue it can be laws of libido loss of the hormones it can be erectile dysfunctions problems that can cause marital issues there it's a very very complex issue that can cause issues in the society in the family and for the particular individual who is suffering but when you in our sexual medicine clinics the common four problems that we encounter are the majority of the problem is erectile dysfunction another is ejaculatory disorders the third one is part of infertility workup the some of the sexual problems related to male and female infertility workup and the fourth one is female sexual dysfunction so these are the four major categories of cases that comes to a sexual medicine practitioner and these are the cases that cas got a role for radiology and imaging to evaluate them and to help the andrologist or the sexual medicine specialist to solve the uh particular cases so as you all know radiology covers uh the most of the electromagnetic spectrum the x-rays are there ct scan is again x-ray the mri is radio wave and ultrasound is again a ultrasound is again the frequencies come in the microwave range but it's not exactly a part of the electromagnetic spectrum but what is not visible with the light radiology is using most of these energy spec in the spectra in the electromagnetic spectrum and trying to analyze the human body to come out with a proper image of the anatomical and functional image of the body that is what radiology is doing so this is a scientific approach towards and radiology is the i a modality that is ideally placed to explain the scientific uh explanations on the happenings of nature and in the body because most of the happenings in nature and the body are not in the not visible to the live in the visible light range it have it's happening in the electromagnetic spectrum range and unfortunately science has failed to explain the mathematical and physical principles involved in this electromagnetic spectrum to the common man or to the popular mind and that is one of the reasons why scientific explanations are still a distance away from the popular mind that is why they are more interested in narrated stories and not into the rational explanations that science wants to give with the help of electromagnetic spectrum but radiology is a truth radio radiology is a branch which uses this electromagnetic spectrum in a big way to explain the human body and in the structural anatomy as well as the function the sexual response cycle has already been explained by dr kennel nyer this is very important to understand the sexual response cycle the phase one is a desire you need to have a desire or libido or a mental stimulation and a physical reaction to have uh that's the first one there can be conditions where there can be laws of desire or loss of libido which can lead to loss of sexual responses the second phase is erosion or the excitement and increased lubrication heart rate and breathing are part of the rehearsal part which goes into the phase three that is the plateau and the phase four is orgasm where the climax and release of oxytocin and phase five will return to the baseline so it's very very essential to understand this sexual response cycle because many of the disorders are related to this particular cycle loss of desire is something that we evaluated in the last nine years those patients who have come to the clinic as part of erectile dysfunction when we evaluated we in 62 patients the loss of libido or loss of desire was part of was due to pituitary tumors so its radiology plays an important role mri was able to pick up the pituitary masses in these cases and in the eight nine years we saw 62 patients who presented to the clinic has electrical dysfunction having pituitary tumors so the loss of libido or loss of desire was the reason for that erectile dysfunction arousal is not sufficient enough and erectile dysfunction and the climax the ejaculatory disorders issues so these are areas that we need to go in and some of the research tools and where functional mri are being used to understand the which parts of the brain is getting activated so one of the technique signals that you sequences that is being used is blood oxygen level dependent bold signals you measure the small changes in brain blood brain blood flow and blood oxygenation now which which are coupled to underlying neuronal activity so this is still in research phases doing being done in centers where sexual medicine is taken in a very serious manner but this is still come into the popular practice it may take some time but these are promising tools with the help of functional mri studies coming back to practice on the ground level this what i am showing here is a paradise orchidometer being you used by urologists to measure the testicular sizes before the era of radiology and imaging this they compare the they hold the testes and compare this particular sizes and try to say that okay this might be 15 ml as if maybe 20 ml and that's it that's how they assess the testicular volumes this is called a spreaders or ketometer but a modality like a high resolution ultrasound has made the role of spreaders arched emitter negligent not very significant just with high resolution ultrasound it is possible to see the test is very clearly you can measure the volume uh and we did this analysis of comparison of a prada's orchidometer analysis assessment of testicular volumes with ultrasound and we realized that there is a difference of 5 ml between the paradise assessment and the testicular volume the simple reason being the prada takes into consideration the takes the volume of the skin and the subcutaneous tissue also but we are measuring only the testicular volume so ultrasound is more specific so we did a series of more than 500 cases to come back to a standardized value in comparison with pradas or kidometer assessment and 5 ml if prados is 20 it will be usually 15 ml in testicular ultrasound this is an imaging so one of the important tests that you need to do which is not being regular widely used the clinic because clinicians are not aware the radiologists have not propagated it properly it's an imaging panel essential for in male infertility workup and for ejaculatory disorders two tests one is high resolution ultrasound and color doppler of inguinoscrotal region which will give you beautiful images of testicular volume and echogenicity damage epidermal cysts obstructions infections assessment of varicose veils etc and one more test many many of the clinicians may ask you only one test but it it is essential to have these two tests as a combination of when you assess for male infertility ejaculatory disorders and most of the sexual dysfunctions in male the other important test is trans rectal ultrasound higher again a high resolution ultrasound probe that is introduced into the rectum which can give you beautiful images of seminal vesicle the vas reference the ejaculatory duct and the prostate the accessory sex glance of vessel of seminal vesicle as well as prostate and also the vas deferens and the ejaculatory duct can be beautifully an assessed for any infections inflammations or obstructions or cis with the help of trans-rectal ultrasound i would in this presentation i may not go into the details of each of these conditions i will quickly brush up and give you an overview of the role of radiology and imaging in sexual dysfunctions as i've already described we will be the four major categories of diseases that you come across in your sexual medicine practices erectile dysfunction ejaculatory disorders and male infertility workup and female sexual dysfunction may not go into the details of female deaf sexual dysfunction but there is a role for radiology imaging there with the help of 2d and 4d of pelvic floor and perennial ultrasounds and also the transvaginal ultrasound for the assessment of uterus adnexa and ovaries for cases of any pid endometriosis etcetera that leads to dyspareunia etcetera but the evaluation of male 4 infertility ejaculatory disorders and male erectile dysfunctions it is essential to do a high resolution ultrasound using high frequency probes the frequency ranges from 7 to 16 megahertz this is another important point that i wanted to share with all of you when you are asking for a radiology test you just don't write ultrasound of testis or you ask for high frequency ultrasound high resolution ultrasound specifically using 7 to 16 megahertz for probes that can give beautiful resolutions beautiful images of the test is what i am showing here is the test is and then the fluid around that's a hydrocele and then above the image on the left upper part is a septation inside that you can get it encyclopedia or in cases of hematocele and the image on the right you are you can see some color flow dilated tubular channels which increases on well silver or standing these are varico seals the dilated pamphlet from plexus so all these things can be evaluated satisfactorily with the help of a high frequency high resolution ultrasound not the routine ultrasound with 3.5 megahertz it has to be it's a different one it's high frequency high resolution ultrasound the probe is different and high frequency high resolution ultrasound who using high frequency probes can show you the testicular parenchyma as you see on both these sections but on the left side you can see some cystic tubular dilatations in the retina testes the mediastinum testis and also a cystic so this when you see some cystic tubular dilatations in the retina testes be sure that there is some kind of an epididymal duct obstruction and then that may be one of the reasons for the asus permeable asthenospheremia for this particular patient image on the right shows you tiny bright echoes within the testicular parenchyma that's a classic case of testicular microlithiasis which is a premalignant condition can be associated with the infertility too the other test i've already mentioned is trans rectal ultrasound trans rectal ultrasound as i told you the patient is in the left lateral decubitus position you are introducing a high frequency trans rectal probe into the anal canal and as you introduce you can see the prostate and as you go up you can see the seminal vesicle which has got a multi appearance the image on the left upper part is the seminal cycle and if you manipulate there you can see the ampoule of the vast difference very clearly you have to differentiate the seminal vesicle and the vast difference clearly then you can see the prostate in the transverse section and also in the sagittal view and also you will be able to evaluate the ejaculatory duct which is usually which is formed by the seminal vesicle duct and the vas defense duct so the seminal vesicles can be seen very clearly so for any hypoplasia or a genesis or aplasia of seminal vesicle or vaseline places which can be associated with asus permia or oligosphere or oligosphenosphemia you have to use the trans-rectal ultrasound which can give you vital clues for the management of that patient the image on the left shows you the trance rectal ultrasound appearance of seminal vesicles the bow tie appearance and the two small smaller cystic lesions more medial what you're seeing is the ampulla of the vas difference you should be able to differentiate the seminal vesicle and the vas different sampler vast difference is a structure that if you take a slightly oblique you can see it continues into the pelvic cavity because you can you may not be able to see the end of it whereas for the vast seminal basically you will be able to see the blind end of it and the image on the left lower side what you are seeing is an mri the magnetic resonance view image the coronal section of a seminal vesicle which shows you cystic tubular dilatation so tubular normal appearance of seminal vesicle and on the uh you can see the prostate as well as the ejaculatory duct the one very important advantage of mri is you will be able to see the wall of the seminal vesicle very clearly from the cystic part and which may not be differentiation of the wall from the cystic part may not be easy with the help of ultrasound so any infiltration or either due to a neoplasm or due to a granulomatous infection or an inflammation may be can be picked up with the mri very clearly but may not be easy to pick up unless the seminal cycle itself is enlarged and shows more diffuse equations when we say vast difference or seminal vesicle agencies we need to know the normal measurements which have already shown there the when it is less than 1.5 centimeter in ap diameter the seminal vesicles and when the vassal angle if it is less than 6 millimeter again we need to consider whether there is a component of eplasia or a hypoplasia and that now coming to imaging in erectile dysfunction erect this is erectile dysfunction is one of the commonest problem that you come across in the sexual medicine practice and there is definitely a role for radiology and imaging in that without radiology and imaging it is not possible i must say it is not possible to treat properly all cases of erectile dysfunction high resolution ultrasound of penis can show you the calcified plaques in the tunica albuginea in cases of peroneus disease of course mri also can give you beautiful images of the extent of the fibrous and calcified plaques in the tunica albuginea and this is an investigation that can give you beautiful images but the test that i want to highlight here is the penile doppler penile color doppler to a test an essential test to differentiate the types of causes of erectile dysfunction after injecting papaverin or prostaglandin e1 in the cavernosa so this is a test which will can differentiate arteriogenic causes of erectile dysfunction whether enough blood is coming into the caverno cell artery and into the uh helices and into the camera sinusoids or is the are there any causes of venous leak that is a defective veno occlusive mechanism so you need to understand the functional anatomy of penis there is a two corpora cavernosa and corpora spongiosa and corpura cavernosum has got the cavernosa artery coming in and giving blood through the helicine arteries into the vascular sinusoids and this cavernosa is covered by a tunica albuginea which has got circular and oblique fibers the arterial supply of cavernosa corpura cavernosa comes from the branches of internal pudendal arteries dorsal artery of penis and cavernosal arteries and once the sinusoids are filled with blood coming from the caverno cell artery into the helicine arteries and then once they are full filled the sinusoids are lined by the smooth muscles so the sinusoid anatomy also is very important to understand there is a smooth muscle involved the helicine branches and the cavernosal artery arteries are the the sinusoid smooth muscles are there and the tunica albigenia that covers the cavernosa corpora cavernous it's extremely important to understand these structures and because one in india any loss of integrity of these structures can lead to erectile dysfunction and this is a veno occlusive mechanism as i said once the blood comes through the caverno cell artery into the helices arteries and fills in the vascular sinusoids and if the smooth muscles are good once the tunic the emissary veins drain through the um tunica albuginea they are compressed by the tunica albuginea the circular and oblique fibers of tunica albuginea compresses them and that is how blood is being retained in the vascular sinusoids and you maintain the direction so this mechanism is called as we know occlusive mechanism if this mechanism is defective what happens is there will be venus leak whatever blood is coming in will will not get retained within the vascular sinusoids it will go off into the emissary veins into the circumflex veins and into the internal pudendal vein so this is one of the causes of erectile dysfunction the cause called as venous leak so the hemodynamics and mechanism of erection and knee tumor sense once there is a sexual stimulation there is a release of neurotransmitters relaxation of smooth muscles dilatation of arterioles and arteries wrapping of blood in the sinusoids compression of subchemical venules there is stretching of the tunica and compression of the emissary veins which increases the intracavernous pressure to more than hundred millimeters of mercury and then the contraction of the surfaces muscle also happens that's how the rigid erection phase is maintained ah so the penile color doppler the cddu the color doppler duplex ultrasonography of penis after injection of either papaverin or prostaglandin even can help you differentiate the arteriogenic erectile dysfunction and venous occlusive dysfunction and also the psychogenic erectile dysfunction this is an entity that we have our group has described and not much in the literature about the role of a pineal colon doppler to differentiate direct psychogenic erectile dysfunction i will go into the details of the some of the signs that we have described in the coming sessions on erectile dysfunction and penile doppler once you see in normal dopplers is we see the reversal of diastole and that shows the at different intervals of 5 10 15 and 20 and 25 and 30 minutes you do it for 30 minutes and if you see reversal of diastole being maintained that is a sign that the it is a normal erect uh normal function of erectile function is happening but if you see peak systolic velocity less than 25 centimeter per second that suggests arteriogenic rectal dysfunction if you see a higher diastolic component more than five centimeter per second continuously in a few at least in 10 minutes and 15 minutes and 20 minutes scans that is very suggestive of inoculative dysfunction but if you see innovation a normal waveform is reversal all of a sudden changing into a anti-grade flow forward flow industrially that is a very classical sign of psychogenic erectile dysfunction which our group has described dr kernel ravindrana and myself has described his finding and this is under uh this has been getting published now coming to the venus drainage venus drainage of the penis that from the cavernous side goes into the from the emissary veins into the circumflex veins goes into the cavernous vein and into the internal pudendal vein nowadays before the penile color doppler now the pineal condom is a modality that can help you diagnose venous leak with a high sensitivity and specificity previously what we used to do was a cavern osogram inject dye into the erect penis and see for the amount of dye that is getting into the internal potential vein and that is how the cavern knows nowadays we don't do a cavernosa gram pineal color doppler studies of after injecting pepper pepperine or prostaglandin even is enough to diagnose venous leak and arteriogenic dysfunction some of the tests using ct to evaluate the pudendal and the cavernous angiography not essential but it is possible to evaluate the city uh with the help of city and geography especially in cases of larisse syndrome where we expect occlusion at the bifurcation level uh we you may be able to do a ct angiography and show that but if another important test that is evolving in cases of erectile dysfunction is after in 2009 this group by piero mundorsi explained the triad of endothelial dysfunction cardiovascular disease and erectile dysfunction so that they say that endothelial erectile dysfunction cases has got a high correlation high risk for endothelial dysfunction and cardiovascular diseases and it is essential when you see an arteriogenic erectile dysfunction to evaluate these patients for cardiac cardiovascular disease for any impending ischemic heart disease so ct coronary angiography or cardiac ct can be widely used in these cases and that can help you show the stenosis as well as the vulnerable blocks it can show you not only the whole actually it can show you as a whole w-h-o-l-e that can the wall also can be evaluated the vulnerable plaque the fibro fatty plugs that on rupture causes ischemic heart disease or heart attacks so ct angiography also has plays an important role in the evaluation of erectile dysfunction in patients with especially with arterial genic importance arteriogenic erectile dysfunction it is essential to evaluate this investigate these patients for cardiac diseases because ed or erectile dysfunction is equal to endothelial dysfunction too now the last part of the session is on imaging and ejaculatory disorders ejaculatory disorders i already explained are another major category of patients coming to your clinic because and the common one is premature ejaculation in our clinic 21 of patients have come for in premature ejaculation after erectile dysfunction the commonest presenting complaints in a sexual medicine clinic will be premature ejaculation and what are the ejaculated disorders that you come across in your practice premature ejaculation and ejaculation there is no ejaculation at all delayed ejaculation this ejaculation or painful ejaculation retrograde ejaculation the cement goes the sperms goes into the urinary bladder because the sphincter is not active then hematospermia blood in cement low volume ejaculate resource permeability asthenospermia as part of the male infertility workup and there is an orgasmia there is no gas and orgasmic ejaculation that is ejaculation is there but there is no orgasm at all so these are all the different types of conditions that you come across and definitely there is a role for radiology and imaging in this the some of the imaging modalities in ejaculatory disorders as i already mentioned about high-resolution inguinal scrotal ultrasound and color doppler then again the thrust the trans-rectal ultrasound of prostate seminal vesicles vas deferens ejaculatory duct this also can be used for trust guided procedures in cases of ejaculatory duct cysts or uteruses or any cysts that you come across that is causing obstruction mri is can be usefully can be used to evaluate prostate seminal vesicles wash difference ejaculatory that and perennial muscles in in a way we just got a uh in a better way but trans rectal ultrasound is more than enough in most of the situations in our practice cdd usa mentioned the penile cdu because 50 percent of patients with premature ejaculations we found has got erectile dysfunctions too so that also plays an important role sono urethrography and retrograde urethrography for evaluation of structures so sodium erythrography also is an essential investigation that can be used for me as for ejaculatory disorders so one of the pathologies you are looking for are infection of inflammation like chronic prostatitis chronic prostatic absence seminal vesiculitis epidemio architects phenicalitis and the obstructions caused by cis cysts utricle cysts or ejaculatory dust ducts or malarian cysts causing obstructions and especially in the reproductive age group and when it comes to the elderly age group it can be neoplasms that are causing obstruction agencies genesis in a place of a seminal vesicle and vessel a vast difference have already explained so these are some of the pathologies you are looking for what are the findings of chronic prostatitis in contrast heterogeneous appearance with dilated periprosthetic veins and the calcification of corcoramalacia increased vascularity and what one finding that we have come across in our studies is 80 percent of premature ejaculation patients came to our clinic had chronic prostatitis that needed treatment and half of them significantly improved or on the treatment for chronic prostatitis when that they when they were treated for chronic prostate diaries and premature ejaculation also significantly improve but there are different treatments and medicines for premature ejaculations too which about which we will come into our later episodes evaluation of hematosphermia blood in salmon many times this is a detailed flowchart required from the clinician side day after taking the history and physical examination to rule out the positive causes of hematospermia to make sure that it is a whether it is from the partner or by using a condom test for the partner as a source then there are can be systemic disorders like hypertension bleeding disorders cirrhosis of liver then associated symptoms and risk factors has to be evaluated but when the role of radiology and imaging is to look for a structural cause like infections inflammations of the accessory sex glands or there is any cystic lesions or there is any neoplasms causing obstructions so what is showed earlier with the help of transactional ultrasound and mri we will be able to evaluate them what we are basically looking for are the indra prosthetic and extra prosthetic cysts whether it's intra prosthetics is it can be the uterical cis or mullerian daxes or the ejaculatory daxes and depending on their location whether they are midline or paramedian or lateral lateral cysts are usually the retention cysts or the degenerative cysts of the benign prostatic hyperplasia but the mid lines is which are very common are the uterical cysts and paramedics are usually the ejaculatory ducts and this is a classical appearance of a prosthetic uteruses midline cyst within the prostate uh it it's not necessary that always the prosthetic cyst will be uniform with cystic it can get complicated with hemorrhage and proteinaceous materials inside that this is a 3d truss which can show you the cystic utricle cyst and the ejaculatory duct on either side of it once the mularian ducts are actually cysts that goes beyond the base of the prostate this is that goes above the prostate extra prosthetic cysts are the seminal vesicle cyst the cysts of the mass difference so it's possible to evaluate the cyst whether they are intraprosthetic or extra prosthetic and if they are inter prosthetic whether they are midline paramedian or lateral so that is how you evaluate the cysts and the contents of the cis with the help of transvector ultrasound and in some cases with mri which helps you to analyze the contents of the cyst with the help of different sequences which we can tell you calcification hemorrhage and especially with the still sequence and the t1 fat sad sequences will be able to evaluate the contents of the cyst but very importantly with trust guided aspirations you can evaluate and can reduce the you can understand the contents of the system can treat them too so in conclusion just i want to impress upon you that radiology and imaging plays a pivotal role in the diagnosis and management of sexual dysfunction those of you who are listening to us may wonder what radiologists can do in sexual medicine radiologists can do a lot radiologist forms a pivotal branch in the investigations of sexual medicine and that can lead to successful management of erectile dysfunction ejaculatory disorders female sexual dysfunctions and male infertility and female male and female infertility high resolution ultrasound again i'm stressing these two tests high resolution ultrasound with high frequency and probes of 7 to 16 megahertz and the truss a transactional ultrasound again using high frequency probe then mri and image guided procedures are essential in the practice of sexual medicine so again i want to emphasize a concept that we want to introduce your anthro radiology this was coined by our own kennel dr ravindra nayar and he always calls us we are all anthro radiologists and we are trying to practice this our practice of sexual medicine with a speciality of andro radiology and always be make sure that you are part of the clinical team talk to your patients understand the clinical the problem listen to the talk to your clinicians talk to your urologists or gynecologists or whoever is referring their patients understand the question clinical question very well that can give you a better perspective for the radiologist and help you to solve the problems always the team effort is more successful so with that message let me conclude my talk and thank you all for a patient listening what is how diabetes patients can manifest with erectile dysfun what is the correlation of diabetes with rectal dysfunction can you please explain that was the question see erectile dysfunction is very common in diabetic patients or diabetic patients standing diabetes more than five years erectile dysfunction is seen and say 10 to 15 percent standing diabetes around 60 to 70 percent develops erectile dysfunction and the pathophysiology of diabetes and erectile dysfunction in diabetes is very complex and i think it is very very [Music] very much interesting in starting a session on diabetes and erectile dysfunction yes sir yes sir we will have this asymptote uh there are many reasons and since we have done the research in cavernous cell biopsy which we have done around the 70 cases in diabetes we have found that [Music] the changes in the tunica albuginea as well as in the corpus cavernosum in diabetic patients it is very very it is very very interesting i don't know anybody has done biopsy of tunica albuginea and corpus cavernosum in diabetic patients coming with erectile dysfunction which i think in india we are the only people we have who have done yes and studied the diabetic penis i will say i will say diabetic penis right so what dr kennel nyer was it's a unique study that was being done is being done in our center because we do a lot of implant penile implant surgeries so that cavanaugh's biopsy is possible and the cavanosal biopsy histopathology in 70 cases of diabetic patients have given us a lot of insights into the happenings within the smooth muscle within the elastin within the collagen and also in the tunica virginia those are interesting findings we will which we will be describing them in the sessions that that will be coming up in this platform in instacon so i would recommend our request each one of you who have joined here to be there in this sessions because we will be coming out with some of the interesting findings that we have come across which will give you a rare insights into the newer insights into erectile dysfunction ejaculatory disorders female sexual dysfunction and male infertility male infertility so it's essential that we need to understand these concepts in our practice practitioners from all over the country who are registered for this talk i can see internal medicine i can see radiologists who have registered for it can see [Music] urologists can see surgeons and physicians a lot of physicians and endocrinologists have registered so all these practitioners we have got lots and lots of findings that from our own studies our own research is here at cochin which one of the research that dr kendall nair has elaborated here is on the cavernously and the tunica albuginea biopsies which i think ours is the largest series 70 cases we did the biopsies from the tunica albuginea and the cavernous tissue and studied the histopathology compared it with the penile colour doppler findings in cases of venous leak arteriogenic importance and the correlation of these studies has given us very valuable insights into concepts of arterioles atherosclerosis that's happening there and also the smooth muscle dysfunction the changes happening in the smooth muscle ratios and the elastin and collagen ratios of the tunica albuginea and the cavernous tissue so this is what dr kendall nyer was explaining so would you like to explain anything more on this subject or shall we wind it up today because there are no more questions and we will come again in this platform with a more interesting session case-based scenarios uh something that i would like to tell all of you is ken elsar takes very detailed history two pages three pages history itself for life stories on sexual medicine cases so the cases uh that is one once you go through the those two to three pages history on different aspect how right from their childhood all the sexual disorders that has happened the evolution of that and the investigations both the blood investigation hormonal investigation radiology investigations and when you come into a diagnosis and the treatment there are lots and lots we have to share with you and maybe we will have more lectures case-based scenarios and panel discussions on this instacon and i would recommend request all of you to come back for our next session uh which will be announced soon uh can you sir would you give i would like to give a conclusion message how the practice of sexual medicine has to evolve i know to conclude yeah a few points i will uh explain in conclusion one is a sexual medicine is an evolving speciality it is it it has not even evolved halfway through it is still 25 percent only evolved another 75 percent is remaining for you for evolution and then sexual medicine is intensely related to andrology so one should have a a basic study of andrology to understand sexual medicine and sexual medicine lots of quacks are doing sexual medicine without any scientific background anybody coming with erectile dysfunction or the so called importance which somebody was telling the first day they prescribe without going into detail without taking a proper history firstly they prescribe sildenafil or tadalafil without knowing the pharmacology of the drug i have seen so many prescriptions coming they don't know the pharmacology of the drug they say you take this medicine sildenafil 15 minute to 20 minutes before sexual intercourse it will not work then the patient will come and say the medicine has not worked why because the prescribing doctor does not know the pharmacology of the drug same is the reason with the uh tadalafil so all these things i think there are lots of ignorance remaining in sexual medicine practice even by the the amongst is not at all used for inducing erection because it has got lot lots of drawbacks so currently the drug of choice for intra penile injection is prostaglandin even so these are all studies to be understood so there are lots of things in sexual medicine people think that or such a eudena phil etc is the end of sexual medicine no end of sexual medicine we have not reached we have only reached 25 percent of sexual medicine us our research the tunica albuginea biopsy the corpus cavernosaur biopsy all has revealed lots of things what is happening in the pennies similarly nobody studies the prostate in in ejaculatory dysfunction prostate has to be studied in detail in platelet dysfunction as we have seen in so-called premature inoculation it is not the gut which is to be done of course dragon has got a a water role but prostrate has got the biggest role in in ejaculatory dysfunction the prostate has to be studied by high resolution ultrasound then we can see the intricacies what is happening in such case if a man comes with the premature ejaculation and if somebody does a transfected ultrasound with a high resolution ultrasound other radiologists or sexual medicine practitioners may laugh at us but we have seen the results by doing the test and giving appropriate treatment sexual medicine is very very interesting and it is scientifically thank you thank you sir that's all i have to say thank you sir for that that's all i have to say at this year thank you sir with that wonderful message the sexual medicine is an evolving branch it is multi-disciplinary and the scientific approach to sexual medicine with andrology radiology gynecologist and neurology everything involved the multiple specialities involved into that is is being practiced in some centers in at least in this country and we would like the such practices to uh to be emulated in other parts of the country were the same this kind of a scientific approach can give a solution to the sexual problems of male and female with that message let me wind up today's session i will once again thank each one of you have joined

BEING ATTENDED BY

Dr. Darius Justus & 256 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. 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. Rijo Mathew

Dr. Rijo Mathew

Consultant Radiologist | Kochi

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