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Erectile Dysfunction

ED

Erection problems in men, medically named as erectile dysfunction (ED), is undoubtedly the most important and stressful type of sexual dysfunction. By definition, erectile dysfunction is the inability to attain or maintain a penile erection to initiate or complete sexual intercourse (coitus). ED results from either psychogenic or organic factors, occurring in men of any age. Erection problems are not lethal health issues. However; it is a major health issue that disrupts the psychosocial life of the individual and the relationship between couples, eventually reducing the quality of life. Studies show that half of the men aged 40 to 70 years suffer from an erection problem. Also, severe erection problems are reported in 10% of men of the same age group. The incidence and severity of the erection problem increase significantly with age, especially after the age of 60.

Undoubtedly, the first issue to be addressed in men with erection dysfunction is to determine whether the problem is of organic or psychogenic origin. Organic sexual dysfunction means that the problem is caused by a physical (vascular, neural, or hormonal) disease. Organic causes of dysfunction are primarily addressed in men over 40 years of age presenting with the complaints of ED. On the other hand, psychogenic erectile dysfunction (PsED) does not occur due to a physical disorder but refers only to erectile dysfunction resulting from psychological distress and inadequate sexual skills. A significant part of erection problems occurring at a young age originates from the psychogenic infrastructure of the individual. We primarily think that the core problem may be psychogenic under the age of 40 and organic after the age of 40. Nevertheless, opposite situations are not rare. Therefore, cause and effect relationships should always be remembered. Sometimes, the cause of dysfunction is of organic nature; however, psychological factors (frustration or hopelessness) may add to the extent of the problem growing like a snowball in motion.

ERECTILE DYSFUNCTION OF ORGANIC NATURE

1-ED due to vascular pathologies (vasculogenic type)

a) arterial insufficiency (due to narrowed arteries)

b) cavernous insufficiency (due to venous leak)

c) mixed (a combination of the two)

2-ED due to nerve injuries (neurogenic type)

3-ED due to hormonal problems (endocrinologic type)

4-ED due to drug side effects

5-ED resulting from various surgeries or radiotherapy (iatrogenic type)

 

Organic ED always results from an underlying physical disease. The dysfunction often starts slowly, following a progressive course. In other words, it is not characterized by an abrupt onset most of the time when the cause is not acute trauma or surgery. It starts to manifest itself slowly at mild levels in six months, increasing its severity and causing dysfunction in the individual only after a certain period of time. If the patient reports that ED has started quite recently, we may argue that the problem is probably not organic but psychogenic.

Risk factors: Organic ED is often associated with predisposing risk factors, especially when it develops in middle adulthood. These factors cause us to experience the problem severely and at an earlier age. Even the alleviation of these risk factors or keeping them under control can be therapeutic alone. Moreover, studies have shown that the symptoms of ED had started for at least 2 years preceding major health issues like acute MI (heart attack) and stroke in most men. In other words, the erection problem emerging in the middle and advanced ages should be interpreted as a warning sign from the body. The major risk factors include;

·       Aging

·       Diabetes mellitus

·       Hypertension

·       Heart diseases

·       Smoking

·       High cholesterol levels

·       Obesity

·       Sleep apnea

·       Sedentary lifestyle

ED Due to Arterial Insufficiency: It is a reflection of the common problem of arterial stiffness, which is commonly called atherosclerosis. In other words, the problem results from the reduced diameter of the artery sending oxygenated blood to the penis (internal pudendal artery-dorsal penile artery), consequently leading to low blood pressure in the cavernous tissue of the penis. The artery supplying blood to the penis is extremely thin. It reaches the penis after directly originating from a large artery. Developing arterial stiffness will first affect the artery supplying blood to the penis. The diagnosis of ED developing due to arterial insufficiency is easily made by penile Doppler ultrasonography imaging. Treatment can be applied depending on the severity of the narrowing.

 

ED due to cavernosal insufficiency (Veno-occlusive): Normally, the veins located along the cavernosal tissue are constricted while oxygenated blood is filling in the penis. Consequently, the blood is trapped inside the cavernous bodies of the penis, maintaining an erection. If the mechanism constricting the veins is somehow impaired, the blood will flow backward from the cavernous bodies, resulting in erection problems. The usual symptom is the difficulty to attain a full erection or maintain it. Especially in positions where the woman is on top, the erection problem is felt more severely due to the effect of gravity. Cavernosal insufficiency, or venous leak, can occur in both young and old people. The occlusive mechanism is impaired mainly because of age-related degenerative changes, Peyronie's disease, diabetes, penile fractures due to trauma, and excessive and unnecessary use of penis pumps. The diagnosis is made by a penile Doppler ultrasound examination.

 

Neurogenic ED: Nerve injuries, both peripheral and central, can cause erection problems. Smooth muscles in the cavernosal tissue should be relaxed to attain an erection. Muscle relaxation occurs because of the effects of some molecules called neurotransmitters (mainly nitric oxide-NO), which are released from nerve endings. Neural injury precludes the release of these neurotransmitters and eventual muscle relaxation; consequently, the expansion of the cavernous bodies cannot occur even when the arteries supplying blood to the penis are patent. The most important disease that causes injury in the peripheral nerves is undoubtedly diabetes. Also; chronic alcoholism, chronic kidney failure, and nerve injuries after radical prostate surgery are other common causes of peripheral neurogenic ED. On the other hand, central neurogenic ED is caused by central nervous system disorders including multiple sclerosis (MS), Parkinson's disease, and spinal cord injuries (due to spinal fractures).

Hormonal ED: Low or high levels of hormones secreted from the hypothalamus, pituitary gland, and testes can diminish sexual desire and cause erection problems. The male hormone called testosterone acts like the fuel supplied to the entire system. Testosterone is produced regularly in testicles every day and secreted into the blood circulation at certain volumes especially in the morning hours. This hormone maintains the functioning of the system by acting on the respective receptors located all along from the brain to the skin. This way; masculine drives, sexual desire, and external male characteristics (male-type growth of facial and body hair, deep voice, and muscular look) are maintained. All kinds of diseases; which suppress (hypogonadism) or diminish testosterone hormone levels, cause problems in sexual desire and sexual behavior. In men, the role of the pituitary hormone secreted from the pituitary gland at the base of the brain is not known clearly. However, the overproduction of this hormone (hyperprolactinemia) suppresses testosterone hormone secretion. Also; the low levels of FSH-LH hormones (hypogonadotropic hypogonadism), which are secreted from the pituitary gland and responsible for stimulating the testicles, may diminish testosterone production. Furthermore, it has been shown that testosterone production in the testicles diminishes gradually every year (approximately by 1%) with aging. This occurs a little earlier and faster in some men, causing sexual problems due to inadequate levels of testosterone at an early age. This condition is called PADAM (partial androgen deficiency in aging man) in medicine or it is more commonly called andropause colloquially. The major symptoms of PADAM syndrome are listed below:

·       Diminished sexual desire and drive

·       Erection problems

·       Fatigue, exhaustion, lack of energy

·       High levels of irritability and edginess

·       Dry and thin skin

·       Reduced muscle strength and muscle mass

·       Less dense facial and body hair

·       Gynecomastia (increase in the size of male breast tissue)

·       Sleep disorders

 

These symptoms occurring in men over 40 years of age require testing male hormone levels to investigate the PADAM syndrome. Alterations in male hormone levels not only affect sexual life and mental health but can also end in more severe consequences, such as osteoporosis. The problem can be solved with hormone replacement and food supplements at adequate levels. The diagnosis of hormonal erection problems can be made readily by testing the levels of various hormones in fasting blood samples collected in the morning and sometimes by obtaining magnetic resonance (MR) images of the pituitary gland.

 

ED caused by drug side effects: Various drugs can cause erection problems. In fact, in almost 25% of patients presenting with ED complaints, the main cause of ED is the use of certain drugs. Some antipsychotics, antidepressants, antihypertensives (especially beta-blockers), and antiandrogenic medications are the most common drugs that can potentially cause ED. This problem can be solved by reviewing the existing diseases of the individual and side effects of medications to revise the treatment.

 

Iatrogenic and Traumatic ED: Nerve sparing is sometimes not possible in patients undergoing radical pelvic surgery for the treatment of prostate cancer, depending on the spread of cancer and the erectile capacity of the individual before the operation. If the nerve injury is extensive, ED may develop in these patients. Radiotherapy applied to this area (for example, for the treatment of prostate or rectum cancer) can cause nerve injury, too. Traumatic events like penile fractures or posterior urethral injury [rupture of the urethra (the muscular tube that allows for urination) at the bladder base] in traffic accidents cause nerve injury and ED. A penile prosthesis is usually the treatment for erectile dysfunction depending on the health status of the person.

MEDICAL EVALUATION OF MEN WITH ERECTION PROBLEMS:

 

Firstly, a detailed psychosexual anamnesis is obtained from the individual (when and how did it start?). Secondly; potential risk factors, drugs used by the patient, and any previous treatment are reviewed. The aim is to understand whether ED is situational (i.e. whether it is variable with different partners or situations) or whether it is chronic or progressive. After a physical examination of the penis, testicles, and the prostate; fasting blood samples should be collected in the morning to test the levels of hormones and of blood sugars and lipids. If necessary, penile Doppler ultrasonography and nocturnal penile tumescence tests are performed to determine whether ED is organic or psychogenic and how severe it is.

TREATMENT OF PATIENTS WITH ORGANIC ERECTION PROBLEMS:

 

Oral drug treatments: Today, the first-line therapy is orally taken medication for men with organic ED. These group of drugs, called phosphodiesterase type 5 inhibitors (PDE5i),  cause vasodilation in the artery supplying blood to the penis and leads to the relaxation of smooth muscles in the cavernous structures, increasing the quality of erection. In the absence of severe injury or vascular occlusions, these drugs are effective in 70-80% of men with ED. Today, sildenafil, tadalafil, and vardenafil are the most commonly used PDE5i drugs taken orally. Although PDE5i medications share a common mechanism of action, their duration of activity varies. These drugs should be taken at least one hour before intercourse. Long-term treatment with daily low-dose tadalafil (5 mg) has recently become popular. Physical dependence does not develop with the off-label use of these drugs when they are used just to increase sexual performance; however, it is known that they cause psychogenic erection problems in young people such as difficulties in attaining erection without the use of such medication. Therefore, it is the best practice not to use these drugs when they are not recommended by an expert urologist or psychiatrist. The use of these drugs is absolutely not safe in people taking nitrate group heart medications.

 

Hormone Treatments: If inadequate testosterone hormone levels are detected in the individual, he will benefit from receiving supplementary hormone treatment significantly. Although testosterone hormone supplements can be taken orally or by receiving depot injections, the most ideal and almost physiological way is to use gels or patches applied to the skin. If ED develops due to the overproduction of the prolactin hormone (hyperprolactinemia), drugs that lower the levels of this hormone (cabergoline and bromocriptine) help resolve the problem.

 

Vacuum Devices: They are beneficial especially when the problem is venous insufficiency. After applying negative pressure to draw blood into the penis; a ring is placed at the root of the penis, allowing the penis to stay erect. Its unnecessary use can injure the valves in the veins and cause erection problems to become permanent. Patient satisfaction is purely personal.

 

Self-Injected Medications: There are medications available that can be injected into the cavernous tissue of the penis or some medications in gel form can be instilled into the urethra. Alprostadil is a product that is licensed for this indication. It enables erection effectively by relaxing smooth muscles. Long-term use of alprostadil is associated with painful nodules inside the penis or can cause the penis to become bent significantly. Sometimes medical interventions may become necessary due to a condition called priapism, which is the prolonged and non-resolving erection of the penis.

EdSWT: Low-intensity shock waves therapy (EdSWT) is a current mode of treatment that has recently become increasingly used in clinical practice and reported in the scientific literature. It is applied to the penis at least for 6-12 sessions. Shock waves (SW) can increase the regeneration and erection capacity of tissues by triggering new vessel formation in the cavernosal tissue. It can be used especially in patients who cannot use (due to their side effects) or only partially benefit from PD5i drugs. No side effects have been reported in association with the use of EdSWT.

 

Venous Surgery: It can be considered as the first option treatment in ED patients with venous leakage as the primary causative problem. It is the process of ligating the deep vein of the penis (DDVL: deep dorsal penile vein ligation). The likelihood of permanent success with DDVL is low because the body will eventually form new collateral vessels, establishing the leak again. It has been demonstrated that the benefits attained by DDVL surgeries will be of short term and the long term results are discouraging. DDVL has already lost its former importance.

 

Arterial Surgery: It is a rarely performed type of surgery, especially in patients with isolated internal pudendal artery ruptures due to trauma (for example, due to traffic accidents). Similar to those applied to the heart, it is possible to perform bypass vascular surgery to restore the blood supply to the penis and its cavernous tissues. This type of delicate vascular microsurgery is called penile revascularization surgery and it requires experience to perform special techniques. They are performed rarely for limited areas of indication.

 

Penile prostheses: Penis prostheses or implants are the last and best option for patients, who have not benefited from any treatment. The aim is to attain erection artificially by placing an implant inside the penis. Multi-piece inflatable penile implants with a reservoir and a pump (inflatable pump implants) provide a significantly almost natural erection and they are hard to notice from outside. Patient and partner satisfaction is significantly high with this type of treatment. If the person is older and unable to use pump implants, the use of bendable one-piece penile prostheses will be a suitable option. Treatment with multi-piece prostheses is usually costly. Because it is a surgical intervention, it will naturally bear all types of potential risks pertaining to general surgery.

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ERECTILE DYSFUNCTION OF ORGANIC NATURE

1-ED due to vascular pathologies (vasculogenic type)

a) arterial insufficiency (due to narrowed arteries)

b) cavernous insufficiency (due to venous leak)

c) mixed (a combination of the two)

2-ED due to nerve injuries (neurogenic type)

3-ED due to hormonal problems (endocrinologic type)