Erectile Dysfunction (ED)

Definition and Causes:

Characterized by the inability to achieve and maintain an erection of sufficient rigidity of penis for enough duration to perform sexual intercourse.

Causes:

Sexual arousal is a very complex process involving nerves, blood vessels, muscles, hormones, brain signals, and emotions. Any problem within the process may affect directly or indirectly and cause erectile dysfunction.

Common causes include:

• Heart diseases
• Clogged blood vessels (atherosclerosis)
• High sugar or blood pressure (BP)
• Obesity
• Low male hormones (testosterone)
• Certain medications
• Tobacco use
• Alcoholism
• Enlarged prostate (male organ which forms sperms)
• Treatment for prostate cancer
• Injuries and surgeries which may affect lower abdomen/back (pelvic region) and spinal cord

Psychological causes of erectile dysfunction:

– Brain plays a major role in an initial (arousal), an event that causes erection and it starts from sexual excitement.

– There are multiple factors which may affect the arousal and includes:

• Depression, anxiety or mental health condition
• Stress
• Relationship problems with the partner/ inhibitions and limitations of the surroundings
• Poor communications

Symptoms:

The patients present with a complaint of:

• Trouble getting an erection
• Keeping an erection with sufficient rigidity to perform sexual intercourse
• Reduced sexual desire to start with

Investigations and Treatment:

Diagnosis with erectile dysfunction (ED) is considered if an individual cannot achieve or maintain an erection repeatedly for sexual performance for at least three months.

History:

• Detailed history is required to exclude other causes of dysfunction such as loss of libido or premature ejaculation. History should also include inquiry about a person’s mental health any form of stress or anxiety or if the dysfunction is due to physical or psychological factors

Physical examination includes:

• Assessment of BP, pulse, temp with local area examination of penis, testicles, and nerves by stimulating surrounding sensitive areas. The detailed examination helps to identify between the physical/structural factors or neurological (nerve) involvement

Labs:

• Blood samples are collected and sent to check for common causes of ED i.e. blood sugar, cholesterol, and male hormone (testosterone) levels

Ultrasound:

• To check the blood flow through the penis. A wand-like a device (transducer) held over the vessel supplying the penis, a video image is created to see if there is any problem in the blood flow

Overnight erection test:

• Most men have an erection during sleep without knowing it. A special tape is wrapped around your penis and if in the morning the tape is removed that means you had an erection unknowingly during your sleep, indicating the dysfunction is psychological and not physical

TREATMENT:

1) General principles:

• Improve capacity to acquire and sustain an erection
• Treatment varies according to the underlying condition.
• Treat suspected underlying cause (if possible)
• Avoid risk factors for ED
• Use of ED specific medications

2) Non-pharmacologic:

• Stress reduction, counseling, psychotherapy
• Lifestyle modification including avoidance of risk factors, e.g. encourage the reduction in the use of recreational drugs including alcohol and tobacco, lose weight

3) Pharmacological:

When treating the underlying cause:

• Use alternate medications for drugs that cause ED e.g. for high BP use calcium channel blockers (Norvasc) instead of beta-blockers (Tenormin)

ED specific medications can be divided into:

• Oral agents: Includes sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis); are all FDA approved agents

• Note: The above agents are not recommended to be used with some drugs used for angina/ heart disease such as nitroglycerine.

• Intrapenile self-Injections
  • Alprostadil (the prostaglandin PGE₁): Injected into the base of the penis, maybe painful not recommended for daily use. Inject 10-20 mins before sex; erection may last up to an hour
• Intraurethral insertion:
  • Alprostadil: Gel inserted with an applicator into a small opening at the tip of the penis (urethra)

Mechanical devices:

• Penile ring: Patient who can acquire but can’t sustain an erection can use metal or plastic or leather ring which snaps around the base of the penis placed immediately after attaining the erection, to prevent blood draining out of the penis too quickly

• Vacuum devices: Removes air from the vacuum chamber over the penis, creating a suction that draws blood into the penile region. Once the blood rushes into the penis an elastic tourniquet at the base holds blood so the erection can be sustained for sexual activity

Surgical implantation of penile prosthesis:

• Reserved for patients who fail the first and second line of treatment

Medications:

Medications which are used to treat erectile dysfunction are as follows:

Risk Factors and Prevention:

• Smoking
• Overweight/ obese
• Injuries
• Enlarged prostate
• Medications such as antidepressants, antihistamines, etc.
• Prostatic surgery and radiation therapy for cancers
• Psychological conditions such as stress, anxiety or depression
• Drug and alcohol misuse

Outcome:

• With the variety of treatments available for erectile dysfunction, leads to satisfactory outcomes
• The patient is unable to get the partner pregnant due to the dysfunction