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Failure to achieve tumescence with adequate stimulation is termed erectile dysfunction. The mechanism of erection is complex: failure in any of the previously mentioned components can lead to erectile dysfunction. The commonest causes include psychogenic disturbance with failure to relax cavernous smooth muscle; arterial insufficiency as a result of atheromatous disease; and damage to the parasympathetic nervous system secondary to diabetes or following pelvic surgery such as radical prostatectomy, radical cystectomy or bowel resection. Oral pharmacotherapy is directed at achieving cavernosal smooth muscle relaxation by enhancing the effects of cyclic GMP.

Some men are prone to develop an erection which fails to subside after ejaculation and is termed a priapism. This can be either high flow or low flow, the latter condition being more common. Low flow priapism can occur spontaneously but is also seen in conditions such as sickle cell disease or leukaemia, or as a result of injection of drugs, such as intracavernosal prostaglandin E1, directly into the penis in men with erectile dysfunction. It leads to ischaemia of the corporal smooth muscle, which causes pain within the penis and will result in erectile dysfunction if left untreated. High flow priapism, where too much blood enters the penis, is usually secondary to an abnormal connection or fistula between the cavernosal arteries and sinusoidal spaces.

Peyronie’s disease may result in a bend in the erect penis that most commonly presents as a dorsal curvature that results from a localized thickening or plaque within the corpora cavernosa which prevents expansion of a segment during erection. Penile cancer is a rare malignancy of the penis and usually presents with a mass or ulceration of the penis. MRI scanning may be used in preoperative planning of Peyronie’s disease and local staging of penile cancer (see Fig. 76.19).

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