Erectile dysfunction (ED), formerly termed impotence, is defined as the failure to achieve or maintain a healthy penile erection suitable for satisfactory sexual intercourse. It is a common condition in men aged over 40 years, with the prevalence increasing steeply with age and other co-morbidities. At age 40, about 40% of men are affected while 70% will report having ED by age 70.Recent studies have demonstrated an increasing incidence of ED in men younger than 40 years, and this trend is likely underestimated because of low reporting by younger patients.
Despite this startling prevalence and the undisputed impact that erectile function has on a man’s self-esteem and quality of life, ED remained largely an under-diagnosed disorder. Erectile dysfunction can cause considerable emotional damage to the patient and their partner as well as have a significant impact on their quality of life. On the bright side, erectile dysfunction is almost always treatable.
Causes of ED
- Psychogenic ED: Psychogenic conditions are frequently related to misunderstandings within the couple as well as problems related to work activities that can frequently affect sexual desire. A psychogenic cause should be suspected if there is sudden onset of the erectile dysfunction especially if related to a new partner or a major life-changing event.
- Endocrinological causes: Among these hypogonadism is the most important which may be featured by small testicular size and low levels of testosterone in blood. Hyperprolactinemia also causes a decrease in sexual desire and, therefore, in sexual performance; finally, hypothyroidism can cause a decrease in desire, probably due to hyperprolactinemia resulting from hypothyroidism
- Cardiovascular disease: Cardiovascular disease (CVD) is a very significant risk factor for erectile dysfunction. Almost 50% of men with known coronary artery disease have significant erectile dysfunction. ED usually precedes CVD onset, and it might be considered an early marker of symptomatic CVD. About 40% of men with ED will have hypertension while 35% of all hypertensive men will also have ED. Also, hyperlipidaemia is found in about 42% of men with ED.
- Diabetes: Undiagnosed diabetes is up to three times as likely in men with erectile dysfunction (28%) compared to non-diabetic men with normal erections (10%). Also, the longer a patient has diabetes and the more severe, the greater the risk of ED.
- Obesity: Obesity and morbid obesity are significant risk factors for ED. Treatment of obesity with bariatric surgery has been shown to significantly improve sexual performance.
- Depression: Patients with depression are almost 40% more likely to have ED than normal men without depression. Conversely, the incidence of depression in men with ED is almost three times greater.
- Neurologic diseases: Neurogenic causes, such as multiple sclerosis, Parkinson’s disease and spinal cord injuries are mainly characterized by failure to initiate sexual intercourse. Furthermore, patients undergoing radiotherapy and radical pelvic surgery (i.e., radical prostatectomy) have a high risk of lesions of the cavernous nerves with consequent neurogenic ED.
- Smoking & Alcohol Intake: Both smokers and alcoholics also report an increased risk of ED compared to the general population.
- Drug induced: Certain drugs like antidepressants (especially SSRIs), cimetidine, ketoconazole, spironolactone, sympathetic blockers (methyldopa, clonidine, and guanethidine), thiazide diuretics, and other antihypertensives. Among antihypertensives, angiotensin Converting Enzyme (ACE) inhibitors and calcium channel blockers are the least likely to cause ED. Beta-blockers are only a minor contributor to ED, while alpha-blockers actually improve erectile function.
- Role of Cycling: The role of bicycle riding in ED is somewhat controversial. Traditional racing bicycle seats place considerable pressure directly on the perineal nerves as well as the pudendal and cavernosal arteries which suggests it could be a potential problem to serious cyclists.
Evaluating the patient
It is often difficult for many patients to verbally discuss about their sexual health. This is understandable based on the cultural norms, but it is impressed upon not to shy away from your doctor because he is the only person who can offer a workable solution. A thorough medical history, detailed sexual history, and physical examination are required before embarking upon any treatment or further investigations.
A full general and cardiovascular examination should be undertaken, as erectile dysfunction could be the first symptom of underlying vascular disease. Peripheral pulses should be checked and blood pressure measured. The genitalia should be carefully inspected, looking at the testicular size (hypogonadism), signs of infection (such as redness and discharge in acute balanoposthitis), the presence of penile fibrosis or plaques (as in Peyronie disease), and phimosis (the inability to retract the foreskin). Hair distribution, breast size (gynecomastia), and a detailed neurological examination are helpful. The cremasteric reflex should be evaluated. (This is done by gently scratching or stroking the upper, inner thigh while observing the scrotum. A normal reflex would be retraction or elevation of the ipsilateral testicle. This reflex will be normal if the thoracolumbar erection center is intact.) Other helpful things to elicit in the patient history include vascular risk factors (e.g. hypertension and diabetes); lifestyle factors (such as smoking, activity level, alcohol intake, and the use of any recreational drugs), and general medication history.
- Blood tests: There are no specific tests absolutely required for the initial evaluation of ED, but certain tests that might be helpful include complete blood count (CBC), liver function test (LFT), kidney function test (KFT), thyroid function test (TSH), lipid profile, HbA1c to screen for diabetes mellitus, and a morning serum testosterone level.
- Penile Duplex Doppler Ultrasound measures arterial vascular flow and checks for cavernous veno-occlusive dysfunction (venous leak).It may also be useful after penile trauma, post-priapism, Peyronie disease, and ED patients who fail to respond to oral agents
- Nocturnal Tumescence Testing (NPT)is helpful in differentiating psychogenic from organic erectile dysfunction.
- Penile Biothesiometryis a simple office screening test for penile neuropathy using skin vibrational threshold sensitivity.
- Pudendal arteriographyclearly illustrates the arterial vasculature of the penis.It is typically reserved for young patients with erectile dysfunction secondary to trauma where revascularization surgery is being considered.
Initial treatment involves improving general health status through lifestyle modifications which may include increased physical activity, stopping smoking and alcohol, gaining good control of diabetes, lipids, and cholesterol. Men who have a psychological cause should be offered psychosexual counselling. Fortunately, the good news is that ‘almost every patient with ED can be successfully treated with currently available therapies.’
Nutraceuticals: L-arginine and L-citrulline have been proposed as nutritional supplements for ED. Oral phosphodiesterase-5 inhibitors (PDE-5 inhibitors), such as sildenafil and tadalafil, are usually the first-line treatment of erectile dysfunction. These are highly effective and have an overall success rate of up to 75%.It is important to instruct patients on how to correctly take their medication. For example, sildenafil is poorly absorbed and might be totally ineffective if taken with food.
Trazadone: It is a serotonin antagonist and reuptake inhibitor and has shown to improve erectile function in men with psychogenic ED, but has a marginal effect in men with organic ED. Testosterone supplementation appears to be more effective as a treatment for low libido than for ED. Testosterone supplementation is reasonable in men with proven hypogonadism and ED who have already failed PDE-5 inhibitor therapy or who also have low libido.
Intracavernosal Injections: Intracavernosal injections of papaverine, prostaglandin E1 (alprostadil), phentolamine, and atropine have been used to tackle ED. Out of these the single-agent used most frequently today is prostaglandin E1 as it has fewer systemic side effects and good efficacy while offering reduced priapism risk and less fibrosis compared to other agents.
External Vacuum Devices: External vacuum device therapy is safe, effective, and is also the most inexpensive long-term therapy for ED. It can also be used frequently if desired, but the use of the device initially requires practice for optimal performance.
Low-intensity shockwave therapy: Overall, low intensity shockwave therapy appears to be a reasonable, safe and moderately effective initial therapy for relatively healthy men with mild to moderate erectile dysfunction, with an overall success rate at 30 months of about 40%.
Complications of erectile dysfunction are predominantly emotional, both to the patient and his partner. It can cause a strain on relationships and negatively impact the quality of life of these patients. Of course, the cardiovascular pathologies and diabetic complications that may accompany this condition come with their own health issues.
One of the most important messages to the public would be erectile dysfunction is treatable and men should seek a proper consultation with a certified dermatologist in order to tackle it effectively and safely.
(The Author is a renowned Dermatologist; Sex Specialist & Hair transplant Surgeon and Director – DERMIS Skin & Hair Clinic Bemina, Srinagar. Feedback: email@example.com)