Physiology ea Penile Erection le Pathophysiology ea Erectile Dysfunction (2006)

Urol Clin North Am. Sengoloa se ngotsoeng; e fumaneha ho PMC 2006 Januari 25.

E hatisitsoe ka mokhoa o qetelle o hlophisitsoeng e le:

Urol Clin North Am. 2005 November; 32(4): 379-v.

doi: 10.1016 / j.ucl.2005.08.007

PMCID: PMC1351051

NIHMSID: NIHMS6980

Robert C. Dean, MD^a 'me Tom F. Lue, MD^b

Boitsebiso ba Mongoli ► Boitsebiso ba Copyright le License ►

Moetso oa khatiso oa ho qetela oa mohatisi o fumaneha ho Urol Clinic North Am

Sheba lihlooho tse ling ho PMC hore Qotsa sehlooho se hatisitsoeng.

Kutloisiso ea limolek'hule le ea bongaka ea ts'ebetso ea erectile e ntse e tsoela pele ho theoha ka lebelo le phahameng haholo. Tsoelo-pele ho sibolotsoeng liphatsa tsa lefutso li thusitse haholo tsebong ea ho sebetsa ea mesifa e boreleli ea ho phomotsa / mesifa. Patlisiso e matla e hlahisitse tsoelo-pele e ngata. Kutloisiso ea tsela ea nitric oxide ha e a thusa feela kutloisisong ea limolek'hule empa hape e thusitse haholo kalafong ea ho hloka taolo ea erectile. Ha monna a tsofala kapa a etsoa opereishene, mekhoa ea ho thibela khatello ea kelello e se e qalile. Lits'oaetso tsohle tsa kliniki li simolohile ts'imolohong e phethahetseng ea tsebo, molek'hule, le tsebo e matla ea ts'ebetso ea erectile le dysfunction. Khaolong ena likarolo tsa ts'ebetso ea erectile li tla hlalosoa.

Hemodynamics le Mechanism ea Erection le Detumescence

Corpora Cavernosa

Letoto la penile erectile, haholo-holo lesapo le boreleli la cavernous le mesifa e boreleli ea marako a arteriolar le arterial, li bapala karolo ea bohlokoa ts'ebetsong ea erectile. Ha motho a le bohlasoa, mesifa ena e boreleli e kenella ka tumellano, e lumellang feela phallo e nyane ea methapo bakeng sa phepo. Khatello ea karolo ea mali ea oksijene (PO2) e batla e le 35mmHg. ¹ Bolao ba "flaccid" bo maemong a ho leka-lekana, joalo ka bopaki ba shrinkage hape nakong ea leholimo le batang le ka mora ente ea phenylephrine.

Ho tsosa takatso ea thobalano ho baka ho lokolloa ha li-neurotransmitters ho tsoa litsing tsa methapo ea methapo ea kutlo. Sena se fella ka ho khatholla mesifa ena e boreleli le liketsahalo tse latelang:

Phokotso ea li-arterioles le methapo ea methapo ea mali ka phallo e phallo ea mali maemong a diastoli le methating
Ho ts'oaroa ha mali a tlang ke lisosoids tse ntseng li eketseha
Khatello ea maikutlo a manyane a katamelano e pakeng tsa mofuta oa li-tunica albuginea le li-sinusoid tsa paripheral, e fokotsa ho phatloha ha venous
Ho otlolla tunica ho ea bophahamong ba eona, e kenyelletsang methapong e emeng pakeng tsa chitja e kahare le likarolo tse telele tsa kahare 'me e fokotsa leqhubu le letle haholo
Keketseho ea PO2 (ho isa ho 90 mmHg) le khatello ea methapo (e haufi le 100 mm Hg), e phahamisang botoneng ho tloha boemong bo its'epileng ho ea ho boemo bo otlolohileng (karolo e felletseng ea erection)
Keketseho e 'ngoe hape (ho ea ho limilimithara tse makholo a mangata tsa mercury) e nang le mesifa ea ischiocavernosus (karolo e thata)

Karolo ea penis e otlolohileng e khetholloa ka boholo ba eona le ho kenella ha eona ho "puboischial rami" (crura) le bokantle ba lesapo la mokokotlo (ligrents le methapo ea mokokotlo). Bakeng sa banna ba nang le penis e telele e boima kapa ligament e telele e emmeng, hangata angle e ke ke ea ba kholo ho feta li-degrees tsa 90, leha e na le boima bo felletseng.

Mehato e meraro ea bohlola e tlalehiloe thutong ea liphoofolo.² Ea pele e kenyelletsa keketseho ea nakoana ea khatello ea methapo, e bonts'ang qaleho ea ts'ebetso ea mesifa e boreleli khahlano le tsamaiso e koetsoeng ea venous. Karolo ea bobeli e bontša ho fokotseha ha khatello butle, ho fana ka maikutlo a ho buloa butle ha lits'oants'o tsa venous ka ho qala hape ha boemo ba basal ba phallo ea methapo. Karolo ea boraro e bonts'a ho fokotseha ha sekhahla ha lebelo le matla a tsoang venous outflow.

Ka hona, sebopeho se kenyelletsa boikhathollo ba boetsalibe, ho fokotseha kahare le khatello ea maikutlo.³ Bohlokoa ba ho phomola mesifa e boreleli bo bontšitsoe lithutong tsa liphoofolo le tsa batho.⁴^,⁵

Corpus Spongiosum le Glans penis

Li-hemodynamics tsa Corpus spongiosum le glans penis li batla li fapane le tsa cooraosavernvern. Nakong ea erection, phallo ea arterial e eketseha ka mokhoa o ts'oanang; leha ho le joalo, khatello e ka har'a Corpus spongiosum le glans ke karolo e le 'ngoe ho isa halofo e le' ngoe ho cosora cavernosa hobane sekoaelo se koahetsoeng (tšesaane holim'a Corpus spongiosum le hoo e batlang e le sieo holim 'a glans) se netefatsa pherekano e fokolang ea venous. Nakong ea karolelano ea bokhoni ba ho ikatisa, ho hatellana ho fokolang ha methapo e tebileng ea methapo le li-circflex pakeng tsa Buck's fascia le k'haraosa ea k'haravene e kentseng letsoho ho tlatselleng ho phatsimang ha moea le ha spongiosum le glans li hlile li sebetsa e le tšubuhlellano e kholo nakong ena. Karolong e thata-thata ea ho kopanya lintho, mesifa ea ischiocavernosus le bulbocavernosus li hatella ka matla masapo a spongiosum le a penile, a lebisang ho kenngoeng ho eketsehileng le khatello e eketsehileng lithetleng le spongiosum.

Neuroanatomy le Neurophysiology ea Penile Erection

Litsela tsa Peripheral

Ho bolokiloe hoa penis ke autonomic (kutloelo-bohloko le parasympathetic) le somatic (sensory and motor). Ho tsoa ho li-neurons tse ka har'a mokokotlo oa mokokotlo le mokokotlo oa mokokotlo, methapo ea kutloelo-bohloko e nang le kutloelo-bohloko e kopana ho theha methapo ea kutlo, e kenang kahare ho corpora cavernosa le corpus spongiosum ho ama liketsahalo tsa methapo nakong ea bokhoni ba ho senya le ho senyeha. Meroho ea somatic ke eona e ikarabellang bakeng sa ho hlasimolla le ho ruruha ha mesifa ea bulbocavernosus le mesifa ea ischiocavernosus.

Litsela tsa Autonomic

Tsela e nang le kutloelo-bohloko e simoloha ho 11^th thoracic ho 2^nd likarolo tsa mokokotlo oa lumbar mme o feta ho rami e tšoeu e eang ho genital ea kutloelo-bohloko ea bohloko. Metsoako e meng e tsamaea ka methapo e lumbar splanchnic ho isa mesenteric le hypogastric plexuse e tlaase, e tsoang ho eona likhoele tse tsamaeang methapong ea hypogastric ho ea mothapelong oa pelvic. Ho batho, likarolo tsa T10 ho T12 hangata ke tšimoloho ea likhoele tse nang le kutloelo-bohloko, 'me lisele tsa ketane ea ganglia tse kenelletseng botoneng li fumaneha kahare le kahare la caudal.⁶

Tsela ea parasympathetic e hlaha ho li-neurons tse lipakeng tsa sele e pakeng tsa karolo ea bobeli, ea boraro le ea bone ea mokokotlo oa mokokotlo. Metsoako ea preganglionic e feta methapong ea pelvic ho ea ho pelvic plexus, moo e kopantsoeng ke methapo e nang le kutloelo-bohloko e tsoang ho "hypogastric plexus" e phahameng. Meroho e metala ke makala a mothapo oa "pelvic" o kenyang botoneng. Makala a mang a pelvic plexus a ka hare ho rectum, bladder, prostate le sphincters. Masapo a hlabang a senyeha habonolo nakong ea pherekano e ntle ea rectum, bladder le prostate. Kutloisiso e hlakileng ea nako ea methapo ena e bohlokoa ho thibelo ea iatrogenic ED.⁷ Human cadaveric dissection e senoletse makala a morusu le a morao-rao a methapo ea kutlo (ea pele e tsamaisana le urethra 'me e qetellang e phunya urogenital diaphragm 4 ho 7 mm lateral ho sphincter) le lipuisano tse ngata pakeng tsa puisano ea methapo le methapo ea methapo.⁸

Ho hlohlelletsoa ha "pelvic plexus" le "nervernous nerves" ho etsa hore motho a thelle, athe ho ts'oaroa ha kutu ea kutloelo-bohloko ho baka ho senyeha. Sena se bolela ka ho hlaka hore mokhoa oa ho kenya oa parasympathetic o ikarabellang bakeng sa tumescence mme tsela e nang le kutloelo-bohloko ea thoracolumbar e ikarabella bakeng sa detumescence. Litekong tsa likatse le likhoto, ho tlosoa hoa lesapo la mokokotlo ka tlase ho L4 kapa L5 ho tlalehiloe ho felisitse karabelo ea Reflex erectile empa ho beoa le mosali ka mocheso kapa ho tsosa ka motlakase sebakeng sa medial preoptic ho hlahisitse erection e tšoailoeng.⁹^,¹⁰ Paick le Lee ba boetse ba tlalehile hore erection ea apomorphine e susumetsoang e tšoana le erection ea psychogenic ho rat mme e ka ts'oaroa ka tsela ea kutloelo-bohloko ea thoracolumbar haeba ho ka etsahala likotsi tsa litsing tsa thapelo tsa teral parathempathetic.¹¹ Ho motho, bakuli ba bangata ba nang le kotsi ea lesapo la mokokotlo ba boloka bokhoni ba psychogenic erectile le hoja erection ea reflexogenic e felisitsoe. Li-erections tsena tsa mokokotlo tse fumanehang hangata li fumanoa khafetsa ho bakuli ba nang le liso tsa methapouron e tlase tlasa T12.¹² Ha ho na kelello ea psychogenic e etsahalang ho bakuli ba nang le liso ka holimo ho T9; tlhahiso e utloisang bohloko e hlahisoang e le maemong a T11 le T12.¹³ Hape ho tlalehiloe hore ho bakuli bana ba nang le li-erections tsa psychogenic, ho lelefatsa le ho ruruha ha botoneng ho a bonoa empa ho tsitsa ho sa lekana.

Ka hona, ho ka etsahala hore litšusumetso tsa "cerebral" ka tloaelo li tsamaee ka mokhoa oa kutloelo-bohloko (inhibiting norepinephrine release), parasympathetic (ho lokolla NO le acetylcholine), le somatic (ho lokolla acetylcholine) tseleng ho hlahisa erection e tloaelehileng. Ho bakuli ba nang le lesapo la mokokotlo la sacral, litšusumetso tsa "cerebral" li ntse li ka tsamaea ka tsela e nang le kutloelo-bohloko ea ho thibela ho lokolloa ha norepinephrine, mme NO le acetylcholine li ntse li ka lokolloa ka ho hokahana ka "mela" le postganglionic parasympathetic le somatic neurons. Hobane palo ea li-synapses pakeng tsa thoracolumbar outflow le postganglionic parasympathetic le somatic neurons li ka tlase ho tlhonolofatso ea sacral, erection e tlang ha e na ho ba matla.

Litsela tsa Somatic

Tsela ea somatosensory e simoloha sebakeng sa sensory receptors letlalong la penile, glans le urethra le kahare ho corpus cavernosum. Ka boteng ba glans ea motho ho na le liphetho tse ngata tse amanang le tsona: qetello ea methapo ea mahala le li-receptor tsa tšebetso ea motho ka kakaretso ea 10: 1. Li-nerve tsa pheletso tsa mahala li nkiloe ho myelinated A_δ le likhoele tsa C tse se nang moeli 'me ha li tšoane le sebaka se seng le se seng sa' mele.¹⁴ Likhoele tsa methapo tse tsoang ho li-receptor li fetoha libopeho tsa methapo ea mokokotlo ea botona, e kopanyang methapo e meng ho ba methapo ea kutlo. Ea morao-rao e kena mokokotlong ka metso ea S2-S4 ho emisa methapo ea mokokotlo le li-interneuron sebakeng se bohareng sa bohlooho sa karolo ea lumbosacral.¹⁵ Ts'ebetso ea li-neurons tsena tsa kutlo e romela melaetsa ea bohloko, mocheso, le ho ama ka tsela ea spinothalamic le spinoreticular ho thalamus le sensor cortex bakeng sa pono ea kutlo. Leqhubu la dorsal la penis le ne le sebelisoa e le letsoalo le ikhethileng; leha ho le joalo, methapo ea methapo e lekang nitric oxide synthase (NOS), e ikemetseng ka boeona, e bontšitsoe ho motho ka Burnett et al. le ka hara ratoa ke Carriers le basebetsi-mmoho le nna.¹⁶^,¹⁷ Giuliano le balekane ba hae le bona ba bonts'itse hore ho hlasimoloha ha ketane e nang le kutloelo-bohloko boemong ba L4-L5 ho etsa hore motho a ntšoe methapong ea mokokotlo oa botona le ho hlasimolla ha methapo ea kutlo ho tsosa ho tsoa ha mokokotlo oa likhoto.¹⁸ Liphumano tsena li bonts'a ka ho hlaka hore methapo ea methapo ke mokokotlo o kopaneng le likarolo tse ling tsa somatic le autonomic tse e nolofalletsang ho laola tšebetso ea erectile le ejaculatory.

Ntoa ea Onuf karolong ea bobeli ho ea ho ea bone ea lesapo la mokokotlo ke setsi sa bolulo ba sematomotor penile. Li-nerve tsena li tsamaea methapong ea kutlo ho isa mothapong oa pudendal ho kenella mesifa ea ischiocavernosus le bulbocavernosus. Konteraka ea mesifa ea ischiocavernosus e hlahisa karolo e thata ea ho emisa. Ho rarahana ha morethetho oa metso ea bulbocavernosus ho hlokahala bakeng sa kemiso. Lithutong tsa liphoofolo, ho fumanoe ka ho otloloha ka ho otloloha ha methapo ea kutlo ea lesapo la mokokotlo ke litsi tsa kutlo tsa bongo stem (A5-catecholaminergic cell group le locus coeruleus).¹⁹ Ho tsebahala ha adrenergic ea pudendal motoneurons ho kanna ha ameha litšebelisanong tsa morethetho oa mesifa ea mokokotlo nakong ea kemolo. Ntle le moo, ho bontšitsoe ka oxytocinergic le serotonergic innervation ea lumbosacral nuclei e laolang penile erection le mesifa ea perineal ho rat ea monna.²⁰

Ho ipapisitse le botebo le mofuta oa ts'usumetso ea setho sa botšehali, likhakanyo tse 'maloa tsa lesapo la mokokotlo li ka khothatsoa ke ts'usumetso ea setho sa botšehali. Tse tsejoang haholo ke bulbocavernosus Reflex, e leng motheo oa tlhahlobo ea methapo ea methapo le tlhahlobo ea electrophysiologic latency. Leha ho senyeha ha bulbocavernosus le mesifa ea ischiocavernosus ho ka fokolisa ho qaptjoa ha mohopolo, bohlokoa ba ho fumana tlhatlhobo ea bulbocavernosus ka kakaretso tlhahlobong ea thobalano e hanyetsana.

Litsela tsa Supraspinal le Litsi

Boithuto ho liphoofolo bo khethollotse sebaka sa medial preoptic (MPOA) le "patventricular nucleus" (PVN) ea hypothalamus le hippocampus e le litsi tsa bohlokoa tsa kopanyo bakeng sa ts'ebetso ea thobalano le penile erection: electrostimulation ea sebaka sena induces erection, le lesions sebakeng sena sa ts'ireletso ea moeli.²¹^,²² Marson et al. ente vaerase ea pseudo-rabies ho "co Corpos cavernosum" ea "" "" "" "" "" "venal cavernosum, 'me e ngotsoe ke" neurons "ho tloha mantlha e kholo ea methapo ea kutlo ho ea ho methapo ka lesapo la mokokotlo, lesapo la mokokotlo le hypothalamus.²² Mallick le basebetsi-mmoho le bona ba bonts'itse hore ho ts'oaroa ha methapo ea methapo ea botoneng ho ratoa ho bile le tšusumetso ea ho thunya hoo e ka bang 80% ea li-neuron ho MPOA empa eseng libakeng tse ling tsa hypothalamus.²³ Lits'ebetso tse sebetsang tse tsoang ho MPOA li kena ka bongata ba methapo ea methapo le sebaka se haufi sa "midbrain" (haufi le substantia nigra). Lits'ebetso tsa pathologic libakeng tsena, joalo ka lefu la Parkinson kapa kotsi ea cerebrovascular, hangata li amahanngoa le ho se sebetse hantle ha erectile. Ho ts'oaroa ha axxx ho litšoene, likatse le likhoto ho bontšitse tatellano e tobileng ho tloha ho li-hypothalamic nuclei ho isa litsing tsa ho ikatisa tsa lumbosacral autonomic. Li-neuron tse ka har'a li-nucleot tsena tsa hypothalamic li na le li-peptidergic neurotransmitters, ho kenyelletsa oxytocin le vasopressin, tse ka 'nang tsa ameha ho etsoang ka penile.²¹ Litho tse 'maloa tsa boko le litsi tsa thupelo le tsona li kentse letsoho tšebetsong ea thobalano. Sehlopha sa lisele tsa catecholamine tsa A5 le cusuleus li bontšitsoe ho fana ka bolulo ba adrenergic ho hypothalamus, thalamus, neocortex le lesapo la mokokotlo. Merero e tsoang ho nucleus paragigantocellularis, e fanang ka inhibitory serotonergic innervation, le eona e bontšitsoe ho hypothalamus, tsamaiso ea limbic, neocortex le lesapo la mokokotlo.

Ts'ebetso ea Bohareng ea Neural nakong ea thobalano

Positron emission tomograle (PET) le MRI e sebetsang (fMRI) e lumelletse kutloisiso e kholo ea ts'ebetso ea ts'ebetso ea ts'ebetso ea bongo nakong ea takatso ea motho ea thobalano. Tekanyetso ea PET le fMRI ea ho lekola e eketseha ho tsoa ha mali a likhoerekhoere tsa tikoloho kapa liphetoho mesebetsing ea motsoako oa lehae ka nako e itseng ka nako. U sebelisa theknoloji ena, ho tsosa takatso ea botona kapa ea botšehali ho qhekella ho barutoana ba batona ba bong bo fapaneng ba nang le litšoantšo tse tsosang takatso ka thobalano. Litšoantšo tsa bongo tse hlophisitsoeng tse nkiloeng nakong ea takatso ea thobalano li bapisoa le litšoantšo tse nkiloeng ha barupeluoa ba banna ba bontšoa litšoantšo tsa thobalano (boikhathollo, lingoloa kapa likarolo tsa video tse qabolang). Ho ka bonts'oa libaka tsa ts'ebetso ea ts'ebetso ea boko hammoho le libaka tsa bosebeletsi. Le ha mokhoa o bobebe oa meralo ena ea ho ithuta o makhethe, ho na le mabaka a mangata a amehang molemong oa thobalano o khahlisang haholo-holo o khahlisang ke lintlha tse bonoang. Bangoli ba lithuto tsena ba behile maemo a mangata a hlokahalang molemong oa ho lekanya mekhoa le barupeluoa; leha ho le joalo, ho rarahana ha maikutlo a batho le karabelo ea thobalano ho thata haholo ho e laola.

Ho 1999, Stoleru et al. o ithutetse banna ba robeli ba phetseng hantle ba nang le bong bo fapaneng le PET nakong ea takatso e matla ea ho kopanela liphate.²⁴ Mehato ea ts'ebetso ea ts'ebetso ea boko e ne e hokahane le maemo a testosterone plasma le penile tumescence. Ts'ebetso ea bohlokoa nakong ea pono e tsosang takatso ea thobalano e ile ea bonoa cortex ea lefatše le kahare e tlase, ho kenella ka ho le letona, cortex e ka tlase e ka letsohong le letšehali, 'me ea siea bokantle ba cortex. Ho tsoa thutong ena e ikhethang, ho ile ha hlahisoa mohlala o ikhethang oa tšebetso ea bokong nakong ea takatso ea thobalano. Mohlala o fana ka maikutlo a hore ho na le likarolo tse tharo tsa pono e tsosang takatso ea ho kopanela liphate e amanang le likarolo tsa bona tsa neuroanatomical: 1) karolo e nang le kelello - e lekola sepheo sa ho shebella e le thobalano e etsoang kahare ho moea o fokolang oa "temport cortex", "2)" leseli le linaha tse susumetsang tse entsoeng ka har'a insula e nepahetseng, sebaka se ka letsohong le letona la cortex le ka ho le letšehali le cingex cortex (libaka tsa paralimbic), 3) karolo ea 'mele - e hokahanya mesebetsi ea endocrine le ea autonomic ka lehlakoreng le letšehali la cingrate cortex.

Patlisiso e 'ngoe e ile ea etsoa ho sebelisoa tšusumetso ea pono ea thobalano le ho hlahlojoa ha PET. Bocher et al. o bonts'itse ts'ebetso e kholo kahara "infort lateral occipital cortex" e kenang ka lehlakoreng le letšehali, ka lehlakoreng le letšehali la "cortex" ea morao-rao, setšehali se ka morao-bohareng sa "gary", "patarietal inferior" ea maleshoane, tse setseng tse phahameng tsa parietal lobules, poleiti ea pele (sebaka sa Brodmann 10), libaka tsa "cortex" tsa pele le pele.²⁵ Bocher o boetse o hlokometse ho fifala ha mori o ka pele ho meding le bokantle, ho fapana le tlaleho ea Stoleru. Hape, litsi tsa mekhatlo ea bonono li ile tsa bonoa hore li qalile, haholo-holo kamora nakoana ea nakoana le gyrus ea morao-rao. Ho khahlisang, ts'ebetso ea "midbrain activation" e amanang le sebaka sa li-dopaminergic neurons. Ts'ebetso ea sebaka sa "midbrain" ha ea ka ea bontšoa lithutong tse ling. Ts'ebetso ena e kanna ea amahanngoa le ts'ebetso ea nako e telele. Tsusumetso ea botona le botšehali e sebelisitsoeng thutong ena e ne e le sekotwana sa video sa 30 se tsoelang pele. Lithuto tse ling li sebelisa tšusumetso ea nakoana ea thobalano (2-10 metsotso).

Park et al. ba ithutile barupeluoa ba banna ba phetseng hantle ba 12 ba sebelisang fMRI.²⁶ Ho shebella lifilimi tse hlephisang boitšoaro ka tsa thobalano li ile tsa fetoloa ka likotoana tse seng phoso. Ts'ebetso ea boko ba tikoloho e ne e bonoa ka kakaretso sebakeng se ka tlase sa lobe, cingrate gyrus, insulin gus, corpus collosum, thalamus, caudate nucleus, globus pallidus le lobes tse tlase tsa nakoana. Likarolo tse ling tsa ts'ebetso li ne li tšoana le lithuto tse ling, haholo-holo li-lobes tse tlase tse tlase, li-lobes tsa nakoana tsa nakoana le li-gyrus tse sa keneng.

Phuputsong e hlophisitsoeng hantle e sebelisang fMRI le pono e tsosang takatso e kopantsoeng le penile turgidity, Arnow et al. e bonts'itse karolo ea bohlokoa ea ts'ebetso sebakeng se nepahetseng sa subinsular / insula ho kenyelletsa le claustrum. ²⁷ Ts'ebetso ea sebaka sena e bonahala ka mokhoa o ts'oanang lithutong tse fetileng tse sebelisitsoeng PET.²⁴^,²⁸ Sebaka sena se amana le ts'ebetso ea maikutlo. Ho kenya ts'ebetsong mohloli thutong ena ho ka emela ts'ebetso ea somatosensory le ho amohela ho ikhetholla. Likarolo tse ling tsa ts'ebetso tsa ts'ebetso nakong ea ts'usumetso ea likamano tsa botona le botšehali e ne e le: "gyrus" e bohareng bo nepahetseng, gyrus ea nakoana ea sethala, leqhetsoana le letšehali, "gyri" ea naha e le ngoe, likarolo tse ikhethileng tsa pele le libaka tsa pele ho koloi. Hape, ts'ebetso e nyane e ile ea bonoa ho hypothalamus e nepahetseng. Dopamine e hakanyetsoa ho hypothalamus mme bopaki ba hore dopamine e tsamaisa boitšoaro ba monna ba thobalano bo matla haholo. Hape, gyrus e nepahetseng ea bohareng ba hare e bonoa e sebetsa. Mohlomong e amana le ts'ebetso ea pono.

Ho 2003, Mouras et al. ithute banna ba 8 ba sebelisang fMRI; leha ho le joalo, likotlo tsa video ha lia ka tsa sebelisoa.²⁹ Ho fapana le moo lifoto tsa (tse sa nkeng lehlakore le tse tsosang takatso ea botona le botšehali) li ile tsa bonts'oa kapele ho barupeluoa. Ba sebelisa maikutlo a makhuts'oane a ho bonts'a thobalano, ba ne ba lumela hore likarabo tsa neural tsa pele li tla hlahisoa ho fapana le likarabo tsa neural ho pono ea boroko ba penile. Hape, ts'ebetso ea "gyri" e bohareng le e tlase e bonts'itsoe, hangata e amana le sepheo sa maikutlo ha se hore karolo ea thobalano. Ntle le litsing tse ngata tsa boko tse bonts'itseng ts'ebetso ea ts'usumetso ea thobalano e bonts'ang maikutlo (likamano tse peli tsa parietal lobules, leqhetsoana le tlohileng tlaase parietal lobule, tokelo ea postcentral gyrus, tokelo ea parietoccipital salmus, setsebi se phahameng sa occipital gyrus, bilateral precentral gyrus), cerebellum e bontšitse ts'ebetso ho lithuto tsa 3 le ho holisa lithutong tsa 4. Litlaleho tse ling tse ngata li bonts'itse ts'ebetso ea ts'ebetso ea cerebellum ho araba lifilimi tse tsosang takatso le ho shebella litšoantšo tsa balekane ba lerato. Ka hona, ho bonahala eka tšusumetso ea thobalano e bonoang e baka ts'ebetso libakeng tse kahare ho cerebellum.

Ka tsoelopele le fMRI, papiso e hlakileng ea ts'ebetso ea ts'ebetso ea ts'ebetso ea ts'ebetso ea ts'ebetso ea botšehali ho arabela ka ts'usumetso ea thobalano e bonahetseng e entse lihlopha tse fapaneng. Stoleru et al. o ithuta lithuto tsa banna tse phetseng hantle ha a bapisoa le banna ba nang le hypoactive takatso ea thobalano (HSDD).³⁰ Karolo e ka letsohong le letšehali la gyrus rectus, karolo ea medial orbitofrontal cortex e ile ea lula e sebelisoa ho banna ba nang le HSDD, e fapaneng le ho sebetsa ha eona ho banna ba phetseng hantle ka lebaka la takatso e bonoang ea thobalano. Sebaka sena ho lumeloa hore se tla laola ho laola boitšoaro ka tsela e susumetsang. Ts'ebetso e tsoelang pele ea sebaka sena e ka thusa ho hlalosa pathophysiology ea HSDD. Montorsi et al. bapisa banna ba nang le psychogenic erectile dysfunction (ED) le taolo e matla e latelang ho tsamaisoa ha apomorphine.³¹ Bakeng sa banna ba nang le psychogenic ED e atolositsoeng ea ts'ebetso ea "gingus" e kentsoeng, sefahleho sa masial le frontal basal se ile sa bonoa nakong ea ts'usumetso e bonoang ea thobalano. Ts'ebetso ena e atolositsoeng e kanna ea fana ka maikutlo a tlatselletso ea tlhaho ea tlhaho bakeng sa psychogenic ED. Ka tsamaiso ea apomorphine, setšoantšo sa fMRI ho bakuli ba psychogenic ED se ne se tšoana le taolo e matla. Apomorphine e bakile ts'ebetso e eketsehileng ea foci ho mokuli ea psychogenic ED (e bonoang ho li-nucleus accumbens, hypothalamus, mesencephalon). Hape hemisphere e nepahetseng e ile ea kenngwa tšebetsong haholo-holo ts'ebetso ea morao ea li-apomorphine. Ts'ebetso e nepahetseng ho feta ea letsoho le letšehali ke ntho e tloaelehileng e fumanoang lithutong tsa ts'ebetso ea thobalano.

Ho hlahloba bongo le PET le fMRI e fetohile sesebelisoa se matla thutong ea ts'ebetso e bohareng ea ts'ebetso ea thobalano. Likarolo tse ngata tsa boko tsa ts'ebetso li bontšitsoe litlalehong tsena. Litsi tse ling tsa ts'ebetso e tloaelehileng ea ts'ebetso li ka hlalosoa ka litlaleho tsena (Lethathamo 1). Psychogenic ED, ejaculation pele ho nako, ho kheloha ka thobalano, dysfunction ea orgasmic ke maemo a 'maloa feela a ka bang le liphetoho lipakeng tsa ts'ebetso e phahameng ea boko mme mohlomong hona joale ho ka ithutoa. Ha re qala ho utloisisa tšebetso ea boko kahara karabelo e tloaelehileng ea thobalano le ho tsosa, sesosa sa maemo a ho se sebetse ka thobalano se ka totobala.

Litsi tsa ts'ebetso ea boko le ts'ebetso e tsamaellanang

Ka kakaretso, meaho e kaholimo e ikarabella bakeng sa mefuta e meraro ea maiketsetso: psychogenic, reflexogenic le nocturnal. Psychogenic erection ke litholoana tsa bosholu ba maikutlo kapa litoro. Litšusumetso tse tsoang bokong li feto-fetola libaka tsa lesapo la mokokotlo (T₁₁-L₂ le S₂-S₄) ho kenya tšebetsong tšebetso ea erectile. Reflexogenic erection e hlahisoa ke takatso e susumetsang ho litho tsa botona. Litšusumetso li fihlella litsing tsa thapelo ea lesapo la mokokotlo; ba bang ba latela pampitšana e nyolohang, e hlahisang pono ea maikutlo, ha ba bang ba etsa hore matla a moea a romelle melaetsa ka methapo ea kutlo ho ea botoneng. Mofuta ona oa mofuta oa tlhaho o bolokoa ho bakuli ba nang le likotsi tsa mokokotlo oa mokokotlo. Ho fifala ha bosiu ho etsahala haholo nakong ea ha motho a robala ka leihlo le potlakileng (REM). Ho lekola ha PET ea batho boroko ba REM ho bonts'a ts'ebetso e eketsehileng sebakeng sa pontine, li-amygdalas le anterior cingulate gyrus empa li fokotse ts'ebetso ho cortex ea pele le ea parietal. Mochine o tsosang boroko ba REM o sebakeng sa pontine reticular form. Nakong ea boroko ba REM, li-neuron tsa cholinergic tse karolong e ka morao ea pontine li sebetsa ha li-adrenergic neurons tse sebakeng sa locus ceruleus le li-neuron tsa "serontonergic" tse bohareng ba mpa li le khutsitse. Ts'ebetso ena e nang le phapang e kanna ea ikarabella bakeng sa meketjana ea bosiu nakong ea boroko ba REM.

Mechine ea Limolek'hule ea Mokhatlo oa Kopano ea Motsoako oa Smooth le Phallo

Ho tsitsipana ha mesifa le ho phomola ho laoloa ke cytosolic (sarcoplasmic) mahala Ca²⁺. Norepinephrine ho tloha pheletsong ea methapo le endothelins le prostaglandin F2cy ho tsoa li-endothelium activate receptors liseleng tsa mesifa e boreleli ho eketsa inositol triphosphate le diacylglycerol e lebisang ho lokolloe ha calcium ho tsoa mabenkeleng a marang-rang a kang sarcoplasmic reticulum le / kapa ho buloa ha methapo ea khalsiamo ho lisele tse boreleli. tšusumetso ea khalsiamo e tsoang sebakeng sa extracellular. Sena se baka keketseho ea nakoana ho cytosolic mahala Ca2 + ho tloha boemong ba phomolo ba 120 ho 270 ho 500 ho 700 nM.³² Boemong bo phahameng, Ca2 + e tlama ho bataodulin mme e fetole tumellano ea morao-rao ho pepesa libaka tsa ho sebelisana le myosin light-chain kinase. Ts'ebetso e hlahisang e kenya letsoho phosphorylation ea liketane tse bobebe tsa myosin le ho baka ho potoloha ha li-myosin crossbridges (lihlooho) haufi le lifeshene tsa actin le kholo ea matla. Ntle le moo, phosphorylation ea ketane ea khanya e boetse e kenya tšebetsong myosin ATPase, eo hydrolyzes ATP e fanang ka matla bakeng sa ho fokola ha mesifa (Setšoantšo sa 1).

Setšoantšo sa 1

Setšoantšo sa 1

Mochine oa limolek'hule oa penile boreleli mesifa. Norepinephrine ho tsoa kutloelisong ea methapo ea kutlo le endothelin le PGF2a ho tsoa ho endothelium activate receptors liseleng tsa mesifa e boreleli ho qala ts'ebetso ea moferefere o qetellang ...

Hang ha cytosolic Ca²⁺ e khutlisetsa maemo a basal, litsela tse khahlisang calcium li nka sebaka. Mokhoa o mong o joalo ke ka ts'ebetso ea li-receptor tse nyakallisang tse kopantsoeng le liprotheine tsa G-tseo le tsona li ka bakang pherekano ka ho eketsa kutloisiso ea khalsiamo ntle le phetoho ea cytosolic Ca²⁺ Mmila ona o kenyelletsa RhoA, protheine e nyane, e monomeric G e sebetsang Rho-kinase. Li-phosphorylates tse sebetsitsoeng tsa Rho-kinase 'me ka hona li thibela kemiso e laoloang ea mesifa e boreleli ea myosin phosphatase thibela dephosphorylation ea myofilaments ka hona e boloka molumo oa contractile (Setšoantšo sa 2).³³

Setšoantšo sa 2

Setšoantšo sa 2

Tsela ea RhoA / Rho kinase: tsela ea methapo ea khalsiamo.

RhoA le Rho-kinase ba bontšitsoe hore ba hlahisoa ka penile boreleli ba mesifa.³⁴^,³⁵ Ho khahlisang, palo ea RhoA e hlahisitsoeng ka har'a mesifa e boreleli ea cavernosal ke 17 e phahame ho feta mesifa e boreleli ea vascular.³⁵ Sebaka se ikhethileng sa Rhokinase se bonts'itsoe ho etsa boikhathollo ba boikhathollo ba batho ba corpus cavernosum in vitro le ho etsa hore ho be bonolo ho etsa mehlala ea liphoofolo.³⁶ Lirata tse sa sebetsoang tse fetisoang le tse mpe tse mpe RhoA li bonts'itse ts'ebetso e phahameng ea erectile ha e bapisoa le liphoofolo tse laolang.³⁷ Tumellano e hlahang ke hore phasic contraction ea penile boreleli e laoloa ke keketseho ea cytosolic Ca²⁺ mme tumellano ea tonic e laoloa ke mekhoa ea calcium ea matla.³⁸

Ntle le karolo e bohareng ea phosphorylation ea myosin ho mesifa e boreleli ea mesifa, mekhoa e meng e ka feto-fetoha kapa ea sebetsa hantle mmusong oa contractile. Mohlala, caldesmon e kanna ea ameha seterekeng sa latch moo matla a contraction a bolokiloeng ka tekanyo e tlase ea phosphorylation ea myosin le litšenyehelo tse tlase tsa matla.

Ho phomola ha mesifa ho latela ho fokotseha ha mahala ha Ca²⁺ ho sarcoplasma. Calmodulin e ntan'o ikarola ho tloha ho myosin light-chain kinase ebe e e sefa. Myosin e sithabetsoa ke phososase ea myosin e bobebe ebe e tsoa mochesong oa mesifa, mesifa ea phutholoha.³² Ba bang ba fana ka maikutlo a hore tsela ea NO-cGMP inhibitory pathus ea corpus cavernosum mesifa ha se feela ho khutlisetsoa hoa mekhoa ea phetisetso ea lets'oao la thabo; mochini o sa tsejoeng o ka kenya letsoho boikhathollong ka ho theola sekhahla sa ho hira batho ba fetang sefubeng ka phosphorylation.

cAMP le cGMP ke man messengersosa a bobeli a amehang boikhathollong ba mesifa. Ba kenya ts'ebetso ea protheine ea cAMP- le cGMP e sebelisang protheine, eo ka nako e tšoanang ba etsang phosphorylate liprotheine tse ling le liteishene tsa ion, tse hlahisang (1) ho bula mecha ea potasiamo le hyperpolarization; (2) tatellano ea khalsiamo e kenellang ka hare ho endoplasmic reticulum; le (3) thibelo ea liteishene tsa khalsiamo tse itšetlehileng ka matla, li thibela bongata ba calcium. Seo se latela ke ho theoha ha "calcium" ea "cytosolic" le "mesifa" e hlasimollang.Setšoantšo sa 3).

Setšoantšo sa 3

Setšoantšo sa 3

Mochine oa limolek'hule oa penile boreleli ba mesifa. Man messengersosa a bobeli a makatsang a kopanyang mesifa e boreleli, cAMP le cGMP, a kenya protheine ea tsona ea liprotheine, e leng phosphorylate liprotheine tse ling ho baka ho bula ha potasiamo ...

Pathophysiology ea Erectile Dysfunction

tlhophiso

Ho hlophisitsoe likarolo tse ngata bakeng sa ED. Tse ling li ipapisitse le sesosa (lefu la tsoekere, iatrogenic, ho sithabela maikutlo) le tse ling ho ts'ebetso ea methapo ea tšebetso ea erectile (ho hloleha ho qala [neurogenic], ho sitoa ho tlatsa [arterial], le ho sitoa ho boloka [venous]. Mokhatlo oa Machaba oa Lipatlisiso tsa Bohlokoa o bonts'itsoe ho Lethathamo 2.³⁹

Tlhotlhomiso ya Dysfunction ea Male

Psychogenic

Pejana, ho hloka matla ha psychogenic ho ne ho lumeloa hore ke mofuta o atileng ka ho fetisisa, ka 90% ea banna ba se nang matla ba neng ba nahana hore ba na le bothata bona.⁴⁰ Tumelo ena e fane ka ts'ebeliso ea hore banna ba bangata ba nang le ED ba na le boemo bo tsoakaneng bo ka 'nang ba sebetsa hantle kapa bo boholo' meleng.

Boitšoaro ba botona le botšehali le penile erection e laoloa ke hypothalamus, tsamaiso ea limbic le cortex ea motsoako. Ka hona, melaetsa e susumetsang kapa e thibelang e ka fetisetsoa litsing tsa khefu ea lesapo la mokokotlo ho tsamaisa kapa ho thibela ho emisoa. Ho hlahisitsoe mekhoa e 'meli ea ho hlalosa thibelo ea ho senyeha ha methapo ea kelello: ho thibela mokokotlo oa setsi sa lesapo la mokokotlo ka bokong e le ho fetella ha tšireletso e tloaelehileng ea "suprasacral" le "kutloelo-bohloko" bo feteletseng kapa litekanyetso tse phahameng tsa "catecholamine" tse ka eketsang mesifa e boreleli ea penile. molumo oa lentsoe ho thibela boikhathollo bo hlokahalang bakeng sa tloaelo.⁴¹ Boithuto ba liphoofolo bo bontša hore ho tsosa ha methapo e nang le kutloelo-bohloko kapa tsamaiso e poteletseng ea epinephrine ho baka ho senyeha hoa botoneng bo otlolohileng.⁴²^,⁴³ Ka kliniki, maemo a phahameng a serum norepinephrine a tlalehiloe ho bakuli ba nang le psychogenic ED ho feta maemong a tloaelehileng a taolo kapa bakuli ba vasculogenic ED.⁴⁴

Bancroft le Janssen ba re karabelo ea botona le botšehali e itšetlehile ka tekano lipakeng tsa litšusumetso tse nyarosang le tse thibelang maikutlo kahare ho CNS.⁴⁵ Ba ntse ba leka lipotso tse thibelang likamano tsa botona le botšehali tse ka thusang ho tseba hore na mokuli o tla ba le sephetho se atlehileng haholoanyane ka kalafo ea kelello kapa ka kalafo ea pharmacologic.

Neurogenic

Ho hakanngoa hore 10 ho 19% ea ED e tsoa ho neurogenic.⁴⁶^,⁴⁷ Haeba e le 'ngoe e kenyelletsa lisosa tsa iatrogenic le ED e tsoakiloeng, ho ata ha neurogenic ED mohlomong ho phahame haholo. Le ha ho ba teng ha bothata ba neurologic kapa neuropathy ho sa qhele ka thoko mabaka a mang, ho tiisa hore ED ke neurogenic ea tšimolohong e ka ba phephetso. Hobane motsoako ke ketsahalo ea methapo ea methapo, lefu lefe kapa lefe kapa ho senyeha ho amang bokong, lesapo la mokokotlo, methapo ea kutlo le pudendal e ka etsa hore ho se sebetse hantle ho sebetse hantle.

MPOA, khubu ea "patventricular" le "hippocampus" li nkuoa e le litsi tsa bohlokoa tsa ho hokahanya thobalano le tlhoko ea penile.⁴⁸ Lits'ebetso tsa pathologic libakeng tsena, tse kang lefu la Parkinson, stroke, encephalitis, kapa lefu la sethoathoa sa nakoana, hangata li amahanngoa le ED. Matla a Parkinsonism a ka bakoa ke ho se leka-lekane ha litsela tsa dopaminergic.⁴⁹ Liso tse ling bokong tse boletsoeng hore li amahanngoa le ED ke maqeba, dementias, lefu la Alzheimer, lefu la Shy-Drager, le khatello ea maikutlo.

Ho banna ba nang le leqeba la lesapo la lesapo la mokokotlo, ts'ebetso ea bona ea erectile e itšetlehile haholo ka sebopeho, sebaka, le boholo ba lesion ea mokokotlo. Ntle le ED ba kanna ba ba le mathata a ho fifala le ho ruruha. Reflexogenic erection e bolokiloe ho 95% ea bakuli ba nang le marapo a khoele a kaholimo, athe ke hoo e ka bang 25% ea ba nang le marapo a khoele a tlase ba ka fihlelang erere.⁵⁰ Ho bonahala eka li-neuron tsa "parasympathetic neurons" li bohlokoa polokelong ea erection ea reflexogenic. Leha ho le joalo, tsela ea thoracolumbar e kanna ea lekana le tahlehelo ea lesapo la sacral ka likhokahano tsa synaptic.¹⁰ Ho banna bana, tšusumetso e fokolang ea tactile e ka baka tsoalo, nako e khuts'oane, e hlokang hore ba tsoelepele ho boloka mohopolo. Mathata a mang mokokotlong (ke mohlala, spina bifida, disc herniation, syringomyelia, tumor, myelitis e tsamaeang le, le sclerosis e ngata) li ka ama tsela eo ho kopanang le eona ka tsela e tšoanang.

Ka lebaka la kamano e haufi pakeng tsa methapo ea kutlo le litho tsa pelvic, ho buoa litho tsena ke sesosa sa ho hloka matla khafetsa. Tekanyo ea ho hloka matla ha iatrogenic ho tsoa lits'ebetsong tse fapaneng e tlalehiloe ka tsela e latelang: radical prostatectomy, 43% ho 100%; perineal prostatectomy ea lefu la benign, 29%; resection ea ka mpeng, 15% ho 100%; le sphincterotomy ea kantle ho maemo a 3- le 9-hora, 2% ho 49%.⁵¹^-⁵⁶

Kutloisiso e ntlafalitsoeng ea neuroanatomy ea methapo ea kutlo ea mokokotlo le ea mokokotlo e hlahisitse ts'ebetso e ntlafalitsoeng ea mofetše oa rectum, bladder le prostate, e hlahisang tlokotsi e tlase ea matla a iatrogenic.⁵³ Mohlala, kenyelletso ea ts'ebetso ea khatello ea methapo e fokolisang methapo ea mahlo e fokolitse menyetla ea ho hloka matla ho tloha ho 100% ho 30-50%.⁵⁷^,⁵⁸ Ho khutlisetsoa ts'ebetsong ea erectile ka mor'a ho buuoa ka matla pelvic ho ka nka 6 ho isa likhoeling tsa 24. Phekolo ea pele le alprostadil e intracavernous kapa sildenafil ea molomo e bontšitsoe ho ntlafatsa ho hlaphoheloa ha mosebetsi oa erectile.⁵⁹^,⁶⁰ Ho lumeloa hore li-erections tsa tlhaiso ea lithethefatsi li thibela liphetoho tsa methapo e amanang le infrequent kapa ha li na maqhubu nakong ea methapo ea methapo.

Maemong a ho senyeha ha pelvic, ED e ka ba sesosa sa ho lemala ha methapo ea methapo kapa ho haella ha methapo kapa ka bobeli. Liteko tsa liphoofolo liphoofolong tse butsoitseng, joala, khaello ea livithamini, kapa lefu la tsoekere li ka ama li-terminals tsa methapo ea methapo mme li ka baka khaello ea li-neurotransmitters. Ho diabetes, ho senyeha ha phomolo e itšetlehileng ka neurogenic le endothelium ho etsa hore ho be le tokollo e Nepahetseng ea NO.⁴ Hobane ha ho na mekhoa e tobileng ea ho leka ho hlahloba litaba tsa botona kapa botšehali, litho tsa bongaka li lokela ho ba hlokolosi ha li etsa tlhahlobo ea mafu a lefu la sethoathoa (ED). NADPH diaphorase stinge ea li-fibre tsa methapo ea methapo ea NANC ho li-assimens tsa penile biopsy e hlahisitsoe e le sesupo sa boemo ba neurogenic.⁶¹ Stief le metsoalle ba boetse ba etsa tlhahiso ea ho sekaseka mokhoa o le mong oa ts'ebetso ea motlakase oa cavernous bakeng sa tlhahlobo ea ts'ebetso ea methapo ea methapo.⁶² Ho hlokahala lithuto tse ling hape pele liteko tsena li ka sebelisoa khafetsa litloaelong tsa bongaka.

Bemelmans le basebetsi mmoho le bona ba entse somatosensory evokeential potentials le sacral Reflex lattures ho bakuli ba se nang matla ba se nang lefu le fetang la ramatiki mme ba fumane hore 47% e ne e na le bonyane tekanyo e le 'ngoe e sa tloaelehang ea neurophysiologic le hore tlolo e sa tloaelehang e fumaneha hangata ho bakuli ba tsofetseng.⁶³ Ho fokotseha ha maikutlo a penile tactile ka lilemo tse ntseng li eketseha ho boetse ho tlalehiloe ke Rowland le basebetsi-'moho le uena.⁶⁴ Kenyelletso ea senolo ho tsoa ho genitalia e bohlokoa ho fihlella le ho boloka erection ea reflexogenic, mme tlhahiso e ba ea bohlokoa le ho feta ha batho ba baholoanyane butle-butle ba lahleheloa ke kelello ea psychogenic. Ka hona, tlhahlobo ea maikutlo e lokela ho ba karolo ea bohlokoa ea tlhahlobo bakeng sa ED ho bakuli bohle ba nang le kapa ba se nang bothata ba neurology.

Endocrinologic

Hypogonadism ke ho se fumanehe ho sa lekanyetsoang ho baahi ba se nang matla. Androgens e susumetsa kholo le kholo ea mokhoa oa monna oa ho ikatisa le litsobotsi tse fapaneng tsa thobalano; litlamorao tsa bona ho libido le boitšoaro ba thobalano li thehiloe hantle. Tlhahlobo ea lingoloa tse phatlalalitsoeng ho tloha 1975 ho isa 1992, Mulligan le Schmitt ba phethile: (1) testosterone e ntlafatsa lithahasello tsa thobalano; (2) testosterone e eketsa khafetsa ea liketso tsa thobalano; le (3) testosterone e eketsa khafetsa ea li-erections tsa bosiu empa e na le phello e fokolang kapa e se nang tšusumetso ho li-erections tse susumetsoang kapa tse bonoang.⁶⁵ Phuputso e kopanyang li-erections tsa nocturnal le maemo a testosterone ho banna, e tlalehile hore monyako oa li-erections tse tloaelehileng tsa bosiu li mabapi le 200 ng / dl.⁶⁶ Banna ba nang le litekanyetso tse tlase tsa serum testosterone hangata ba na le litekanyetso tse sa tloaelehang tsa norecturnal erection ha li bapisoa le banna ba nang le maemo a tloaelehileng a testosterone. Leha ho le joalo, kalafo ea ka ntle ea testosterone ho banna ba se nang matla ba nang le litekanyetso tse tlase tsa testosterone ho tlalehoa e na le phello e nyane ho potency.⁶⁷

Bafuputsi ba 'maloa ba ithutile hore na androgen e sebetsa joang. Beyer le Gonzales-Mariscal ba tlalehile hore testosterone le dihydrotestosterone li na le boikarabello ba ho tepella maikutlong ka pelvic le estradiol kapa testosterone bakeng sa takatso e matla ea pelvic ea basali nakong ea papiso.⁶⁸ Litekong, ho tlalehiloe hore ho fokotseha phallo ea methapo, ho lutla hoa mouoane, le ho fokotsa halofo ea karabelo ea erectile ho tsitsipano ea methapo ea kutlo.⁶⁹^,⁷⁰ Phekolo ka Flutamide, estradiol, kapa gonadotropin-e lokollang antagonist ho kenyelletsa ho fallisoa ho mpefatsa karabelo ea erectile. Leha ts'ebetso ea penile NOS e fokotsehile liphoofolong tsena, lintho tse ka hare ho neuronal NOS (nNOS) le endothelial NOS (eNOS) ha li fokotsehe haholo ke kalafo. Ho fallisoa ho boetse ho eketsa ho ara-adrenergic ho arabela ha mesifa ea penile boreleli, ho eketsa apoptosis ka har'a corpus cavernosum ho litoeba, le ho fokotsa litaba tsa mesifa ea trabecular e boreleli.⁷¹^-⁷³ Ka karolelano, banna ba bangata ba kalafong ea nako e telele ea androgen ea mofets'e oa lefu la prostate ba tlalehile libido le ED hampe.

Ts'oaetso efe kapa efe ea "hypothalamic-pituitary axis" e ka baka hypogonadism. Hypogonadotropic hypogonadism e ka tsoala kapa ea bakoa ke hlahala kapa ho tsoa likotsi; hypergonadotropic hypogonadism e ka hlaha ka lebaka la hlahala, ho lemala kapa ho buuoa ho testis, kapa mumps orchitis.

Hyperprolactinemia, ekaba e tsoa ho adnoma kapa lithethefatsi, e baka ho se sebetse hantle ha thobalano le thobalano. Matšoao a ka kenyelletsa tahlehelo ea libido, ED, galactorrhea, gynecomastia le ho hloka thari. Hyperprolactinemia e amahanngoa le litekanyetso tse fokolang tsa ho potoloha tsa testosterone, tse shebahalang e le tšebetso ea morao-rao ho thibelleng ha secretion ea gonadotropin-e lokollang secretion ke li-prolactin tse phahameng.⁷⁴

ED e ka boela ea amahanngoa le hyperthyroid le boemo ba hypothyroid. Hyperthyroidism hangata e amahanngoa le libido tse fokotsehileng, tse ka bakoang ke litekanyo tsa estrogen tse ntseng li potoloha, mme hangata le ED. Ho hypothyroidism, secretion ea testosterone e tlase le maemo a phahameng a prolactin a kenya letsoho ho ED.

Arteriogenic

Lefu la atherosclerotic kapa lefu le bohloko la masapo a hypogastric-cavernous-helicine a ka fokotsa khatello ea mali le phallo ea methapo e sa feleng libakeng tsa sinusoidal, ka hona, ea eketsa nako ea ho ba matla haholo le ho fokotsa ho tsitsipana hoa botoneng bo otlolohileng. Boholo ba bakuli ba nang le arteriogenic ED, mokokotlo oa penile perfusion ke karolo ea ts'ebetso e akaretsang ea atherosselotic. Michal le Ruzbarsky ba fumane hore liketsahalo le botsofaling ba ho qala ha lefu la ho ruruha le lefu la ED lia tšoana.⁷⁵ Lisosa tse tloaelehileng tsa kotsi tse amanang le ho haella ha arterial li kenyelletsa khatello ea mali, hyperlipidemia, ho tsuba koae, lefu la tsoekere, ho ferekana kelellong kapa lefu la pelvic, le ho hlonama ha pelvic.⁷⁶^-⁷⁸ Shabsigh le metsoalle ba tlaleha hore liphetho tse sa tloaelehang tsa penile vascular li eketsehile haholo ha palo ea maemo a kotsi ho ED e ntse e eketseha.⁷⁹ Ho arteriography, lefu le kopaneng la pudendal ea ka hare, penile e tloaelehileng, le methapo ea methapo ea methapo e fumanoe ho bakuli ba se nang matla ba atherosclerosis. Focal stenosis ea penile e tloaelehileng kapa lesapo la mokokotlo le lula le bonoa hangata ho bakuli ba banyenyane ba nang le lefu la sethoathoa kapa lefu la mokokotlo.⁷⁷ Ho palama baesekele e telele le hona ke ntho e ka bang kotsi bakeng sa vasculogenic le neurogenic ED.⁸⁰^,⁸¹

Tlalehong e 'ngoe, banna ba nang le lefu la tsoekere le banna ba baholo ba ne ba le leqeba le phahameng la ho ruruha ha methapo ea methapo ea methapo, le ho eketseha ho hoholo, calcization le lesapo la mokokotlo.⁷⁵ Nicotine e ka ama tšebetso ea erectile hampe, eseng feela ka ho theoha ho tsoa botoneng, empa le ka ho thibela ho phomola ha mesifa kahare, ka tsela eo, ka ho thibela ho nyekeloa hoa pelo.⁸²^,⁸³

Ho se sebetse hantle ha 'mele oa' mele (Erectile dysfunction) le lefu la pelo le tsona li arolelana mabaka a ts'oanang a kotsi joalo ka khatello ea mali, lefu la tsoekere, hypercholesterolemia le ho tsuba. ⁸⁴^,⁸⁵Makhopho a teng ka har'a methapo ea methapo ea methapo e atile haholo ho banna ba se nang matla ho feta ho batho ba lilemo tse tšoanang.⁸⁶ Ka hona, ho se sebetse hantle ha erectile e ka ba sesupo sa lefu le akaretsang kapa la kelello.⁸⁷

Mechanism ea Arteriogenic ED

1. Liphetoho tsa sebopeho

Ho ED ka lebaka la khaello ea methapo, ho na le phokotso ea khatello ea oksijene maling a Corpus cavernosum ha e bapisoa le e lekantsoeng ho bakuli ba nang le psychogenic ED.⁸⁸ Kaha PGE1 le PGE2 sebopeho se itšetleha ka oksijene, keketseho ea khatello ea oksijene e amahanngoa le ho phahama ha PGE2 le khatello ea TGF-β1-induced collagen synthesis ho rabi le human corpus cavernosum.⁸⁹^,⁹⁰ Ka lehlakoreng le leng, ho fokotseha ha khatello ea moea oa oksijene ho ka fokotsa tsitsipano ea mesifa ea cavernous trabecular mme ea etsa hore ho be le phokotso ea mofufutso o mongata.⁹¹^,⁹²

Lebota le nyenyefalitsoeng kapa lerako le ntseng le eketseha ho lekana le palo ea methapo methapong ea methapo ea methapo ea methapo e etsa hore khatello ea methapo e eketsehe.⁹³ Khanyetso e eketsehileng e boetse e fumanoe ho penile vasculature ea litoeba tse itjarileng ka nako e telele (SHR), 'me liphetoho tsena li ile tsa hlalosoa e le liphetoho tsa sebopeho sa lithaelese tsa mokokotlo le tse ling.⁹⁴^-⁹⁶ Keketseho ea keketseho ea matrix ea extracellular e ama likarolo tsa "interstitium" le "neural" tsa penis.

2. Vasoconstriction

Molumo o matlafalitsoeng oa basal le myogenic o 'nile oa bonoa methapong ea methapo e tsoang liphathing tse phahameng haholo. Ts'ebetso e ntlafalitsoeng ea kutloelo-bohloko ea kutlo e tsamaisanang le khatello ea mali le eona e tlalehiloe ho liphoofolo le khatello ea mali e matla.⁹⁷^,⁹⁸ Vasoconstriction e ntlafalitsoeng ea vasile ea penile ho SHR e susumetsoang ke infusion ea phenylephrine e hlahisitsoe ke hypertrophy ea lebota la vascular empa eseng phetoho ea li-neurotansmitters tse nang le kutloelo-bohloko.⁹⁴

3. Vasodilatation e holofetseng ea Endothelium

Ho bakuli ba nang le khatello ea mali ea bohlokoa, li-vasodilatation tse itšetlehileng ka endothelium li phahamisoa ke ho ts'oaroa ha li-agonists tse kang acetylcholine, bradykinin, kapa phallo, li fokotsehile.⁹⁹^-¹⁰¹ Bopaki ba morao-rao bo bonts'a hore ho se sebetse hantle ha endothelial ho potoloha ha mali ho ka bolela liketsahalo tse kholo tsa "coronary".¹⁰²^,¹⁰³ Endothelial dysfunction e lekantsoeng e le blorent acetylcholine-ikiwa vasoreationation e bonahala litsing tse nyane tse tsoang ho bakuli ba nang le khatello ea methapo ea kutlo.¹⁰⁴^,¹⁰⁵ Leha ho le joalo, ho na le ho haella ha thuto ea penile endothelial function ho banna ba nang le khatello ea maikutlo.

Ho SHR, phello ea boikhathollo ea acetylcholine e phuthohile ka har'a methapo e meholo le e nyane, mme ho hloka taolo ea endothelial ho bonahala ho hlaha ka ponahalo ea khatello ea mali.¹⁰⁶ Phomolo e itšetlehileng ka Endothelium e ts'oeroang ke acetylcholine e boetse e haelloa ka mekhahlelo ea likhoebo e tsoang ho SHR mme boikhathollo bona bo khutlisoa boteng ba indomethacin.¹⁰⁷ Ho senyeha ha phomolo e itšetlehileng ka endothelium ho ka hlahisoa ho angiotensin II thromboxane le superoxide methapong ea methapo e tsoang ho SHR kapa khatello e phahameng ea mali ka se.¹⁰⁸^-¹¹²

Cavernosal (Venogenic)

Ho sitoa ha mokhoa o lekaneng oa venous occlusion ho hlahisitsoe e le sesosa se tloaelehileng sa ho hloka matla oa vasculogenic.¹¹³ Ho se sebetse hantle ha Veno-occlusive ho ka hlaha lits'ebetsong tse latelang tsa pathophysiologic:

Ho ba teng kapa nts'etsopele ea liteishene tse kholo tsa venous tse hulang kahare ho corpora cavernosa.
Liphetoho tse fetolang (lefu la Peyronie, botsofali le lefu la tsoekere) kapa ho tsoa likotsi tse mpe ho tunica albuginea (penile fracture) e bakang khatello e sa lekaneng ea methapo ea subtunical le emissary. Ka lefu la Peyronie, "inelastic tunica albuginea" e ka thibela methapo ea emishene ho koala.¹¹⁴ Iacono le basebetsi-'moho ba phatlalalitse hore ho fokotseha ha likhoele tse potelletseng ka har'a mofuta oa tunica albuginea le phetoho ea merero e menyenyane e ka tlatsetsa ho feng matla ho banna ba bang.¹¹⁵^,¹¹⁶ Liphetoho karolong e ka tlasana ea sepakapaka li ka sitisa mokhoa oa veno-occlusive, joalo ka linako tse ling o bonoa ho bakuli kamora ho buoa lefu la Peyronie.¹¹⁷
Liphetoho tsa sebopeho likarolo tsa "microelastic" tsa trabeculae, mesifa e boreleli ea cavernous le endothelium li ka baka ho lutla hoa pelo.
Ho phomola ha mesifa ka mokhoa o sa lekaneng oa trabecular, ho baka ho eketseha ho sa lekanang ha sebe le khatello e sa lekaneng ea methapo e meng e ka tlase, ho ka hlaha ho motho ea tšoenyehileng ka molumo o feteletseng oa adrenergic kapa ho mokuli ea sa lokolloeng ka nepo ea neurotransmitter. Ho bontšitsoe hore phetoho ea adrenoceptor ea α kapa ho fokotseha ha NO ho lokolloa ho ka phahamisa molumo o boreleli oa mesifa le ho sitisa phomolo ho arabela boiketlo ba mesifa ea morao.¹¹⁸
Ho koaloa ha venous venous - sephetho sa ts'ebetso ea ts'ebetso ea ho lokisa maikutlo - ho ka baka ho phehella ha glans / cavernosum kapa cavernosum / spongiosum shunting.

Karolo ea Fibroelastic

Ho lahleheloa ke ho latela li-penile sinusoids tse amanang le ho eketseha ha li-collagen le ho fokotseha ha mesifa ea elastic ho ka bonoa ho lefu la tsoekere, hypercholesterolemia, lefu la methapo, likotsi tsa penile, kapa botsofe.¹¹⁹^,¹²⁰ Basebetsi ba Sattar le ba sebetsang le bona ba tlalehile phapang e kholo ea liperesente tse kholo tsa li-elastic fibre ka botoneng: 9% ho banna ba tloaelehileng, 5.1% ho bakuli ba nang le venous leakage, le 4.3% ho bakuli ba nang le lefu la arterial.¹²¹ Mohlaleng oa phoofolo oa vasculogenic ED, Nehra le metsoalle ba bontšitse hore ts'ebetso ea cavernosal extlates e na le mesifa e boreleli 'me e ka sebelisoa ho bolela esale pele trabecular histology.⁹² Moreland le basebetsi-'moho ba bontšitse hore prostaglandin E₁ e hatella syntla ea collagen ka ho fetola kholo ea factor-β1 mesifa e boreleli ea cavernous, e bolelang hore ente e kenang ea prostaglandin E1 e ka ba molemo ho thibela intracavernous fibrosis.⁸⁹

Mokokotlo oa Smooth

Hobane ts'ebetso ea mesifa ea borena e laola ketsahalo ea vascular e lebisang horere, ho ka lebelloa phetoho ea litaba tsa mesifa e boreleli le sebopeho sa phofo ea "erectile". Phuputsong ea lithane tsa penile ea motho, Sattar le metsoalle ba bontšitse phapang e kholo liperesente tse fapaneng tsa karolo ea mesifa e boreleli ea cavernous ho banna ba tloaelehileng ba nang le matla, ba nang le li-antidesmin (38.5%) kapa antiactin (45.2%), le hore sehlopheng sa venous (antidesmin , 27.4%; antiactin, 34.2% kapa sehlopha sa arteriogenic (antidesmin, 23.7%, antiactin, 28.9%).¹²¹ Phuputso e entsoeng ka in vitro biochemical e bontšitse khathatso e amanang le neurogenic le endothelium e amanang le mesifa ea penile boreleli ho banna ba sa foleng ba lefu la tsoekere.⁴ Ho vasculogenic le neurogenic ED, mesifa e boreleli e senyehileng e ka ba sesosa sa mantlha, ho mpefatsa sesosa sa mantlha.¹²² Opard le basebetsi-mmoho le bona ba bonts'itse ho senyeha ha boitšisinyo bo ntšelitsoeng ke methapo le α-adrenergic-e tsosang takatso ea mesifa e hlasimollang le ts'ebetso ea mesifa e fokotseng ho banna ba nang le matla a amanang le venous kapa arterial.¹²³

Liteishene tsa Ion li kenella ka botebo liketsahalong tsa biochemical tsa ts'ebetso ea mesifa, mme phetoho ea liteishene tsa ion e ka ba le tšusumetso e kholo ts'ebetsong ea mesifa. Fan le metsoalle ba tlaleha phetoho ea maxi-K⁺ mocha o liseleng tse tsoang ho bakuli ba se nang matla 'me o khothalelitse hore ho senyeha ha ts'ebetso kapa tsamaiso ea methapo ea potasiamo ho ka kenyelletsa matla a fokotsehileng a hyperpolarizing, liphetoho tsa calcium homeostasis, le ho phomola ha mesifa e boreleli ho bakuli ba sa sebetseng.¹²⁴ Lithutong tsa liphoofolo, Junemann le balekane ba hae ba bontšitse ho fokola haholo ha mesifa ka ho lahleheloa ke ho kopana ha sele le sele ho mebutlanyana ho fepa li-cholesterol tse phahameng bakeng sa likhoeli tsa 3.⁸² Ka setšoantšo sa mmutla oa ho hloka matla oa vasculogenic, Azadzoi le metsoalle ba bontšitse hore ho se sebetse hantle ka mokhoa o mong oa semmuso ho ka susumetsoa ke thipa ea koae.¹²⁵

Gap Junction

Mecha ena ea puisano ea li-interellular e ikarabella bakeng sa karabelo e kopaneng ea erectile, leha ho le joalo tšusumetso ea bona ea pathophysiologic e ntse e sa hlakisoe.¹²⁶^,¹²⁷ Ka lefu le matla la arterial, ho lahleheloa kapa ho fokotsa ho kopana ha membrane ho bonoa ka lebaka la ho ba teng ha likhoele tsa collagen lipakeng tsa membrane ea methapo.¹²⁸ Liphumano tsena li fana ka maikutlo a hore ho se sebetse hantle kapa ho lahleheloa ke likarolo tse ka fetolang tšebetso ea mesifa e hlophisitsoeng hantle.

Endothelium

Ka ho lokolloa ha li-vasoactive agents, endothelium ea corpus cavernosum e ka ntlafatsa molumo oa mesifa e haufi le eona mme ea ama nts'etsopele kapa thibelo ea mohopolo. HAPE, prostaglandin le polypeptide endothelin li se li hlahisitsoe seleng ea endothelial.⁵^,⁹¹ Ts'ebetso ea li-receptor tsa cholinergic seleng ea endothelial ka acetylcholine kapa ho otloloha ha lisele tsa endothelial ka lebaka la phallo e phahameng ea mali ho ka etsa hore mesifa ea boikhathollo e thethehe ka ho lokolloa ha NO. Lefu la tsoekere le hypercholesterolemia li bontšitsoe ho fetola ts'ebetso ea boikhathollo bo kopanetsoeng ba endothelium le ho senyeha ha mesifa.¹²⁹

Ka bokhutšoanyane, liketsahalo tse kholo li ka baka tšebeliso erectile. Ntle le moo, ha ho na lebaka le le leng le ka amehang ka bolokolohi Khatello ea litaba (ho kenyeletsoa maikutlong le kelellong) e ka lebisa boemong ba ho hloka matla. Kutloisiso e tsoelang pele ea lisosa tsa ho senyeha ha erectile e tla lumella ngaka ho fumana mekhoa ea phekolo le ho fa mokuli tiisetso.

References

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