Erectile Dysfunction

Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his sexual needs or the needs of his partner. Most men experience this at some point in their lives and are not psychologically affected by it.

Condition – Erectile Dysfunction

 

Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his sexual needs or the needs of his partner. Most men experience this at some point in their lives and are not psychologically affected by it.

Some men, however, experience chronic, complete erectile dysfunction, and others, partial or brief erections. Frequent erectile dysfunction can cause emotional and relationship problems, and often leads to diminished self-esteem. Erectile dysfunction has many causes, most of which are treatable, and is not an inevitable consequence of aging.

It is important to distinguish ED from other forms of sexual problems. Conditions such as a low libido (sex drive), premature ejaculation, or the inability to achieve an orgasm, can also occur and may require medical attention.

Incidence and Prevalence

Erectile dysfunction is quite common and becomes even more common in older men. Surveys done both in Australia and other countries show that at least a third of men over the age of 50 have erectile dysfunction and about a fifth of those have complete absence of erections. With each decade of age, the rate of erectile dysfunction increases.

Anatomy and Physiology of the Penis

The internal structure of the penis consists of two cylinder-shaped vascular tissue bodies (corpora cavernosa) that run throughout the penis; the urethra (the tube for expelling urine and ejaculate); erectile tissue surrounding the urethra; arteries, veins and nerves. The longest part of the penis is the shaft, at the end of which is the head, or glans penis. The opening at the tip of the glans, which allows for urination and ejaculation, is the urethral meatus.

The physiological process of erection begins in the brain and involves the nervous and vascular systems. Neurotransmitters in the brain are released in response to physical or psychological stimulation. Nerves then send messages to the vascular system resulting in increased blood flow in the arteries to the penis. The corpora cavernosa and other erectile tissue expand as a result of increased blood flow and pressure.

Because blood must stay in the penis to maintain rigidity, the outflow blood vessels (veins) are closed during an erection. When stimulation ends, or following ejaculation, pressure in the penis decreases, blood is released, and the penis resumes its normal shape.

Causes

There are many underlying physical and psychological causes of erectile dysfunction. Often there may be several factors present at the same time. Some of the common causes are listed below.

• Vascular disease, including atherosclerosis or hardening of the arteries;
• Diabetes, which can damage blood vessels and nerves to the penis;
• Chronic medical conditions, including kidney disease and high blood pressure;
• Neurological diseases, including strokes, Parkinson’s Disease and spinal injuries;
• Drugs, including smoking, alcohol and many common prescription medications (such as those used to treat high blood pressure);
• Pelvic trauma, surgery or radiation therapy;
• Hormone disorders;
• Psychological causes, including depression, relationship issues, stress and performance anxiety; and
• Peyronie’s disease

Diagnosis

A medical examination may reveal evidence of neurological, vascular or hormonal diseases. Your doctor may also perform specialised investigations to determine the cause of the ED.

• Full blood count and kidney function tests;
• Blood sugar (serum glucose);
• Thyroid function tests;
• Hormone studies, including testosterone and prolactin;
• Prostate specific antigen (PSA), depending on the age of the patient; and
• Lipid and cholesterol studies.

Occasionally it may be necessary to undertake more detailed investigations, including studying the blood flow within the penis.

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Treatment – Erectile Dysfunction

Sometimes it is quite simple to treat ED. It may be possible to cease or change a medication which caused the ED in the first place. Correcting a low testosterone, or resolving a stressful situation, may lead to the return of normal erectile function.

More commonly it is not possible to correct the underlying problem or problems, and instead your doctor will devise a treatment plan which will overcome the medical or psychological factors which are causing the ED. This is called goal directed therapy, meaning the treatment is aimed at achieving useful erections, rather than correcting the underlying problem.

Types of treatment for ED include

• Injection Therapy
• Non-invasive Treatment
• Penile Implants
• Sex Therapy
• Vacuum Devices
• Vascular Reconstructive Surgery

Injection Therapy

Self-Injection involves using a short needle to inject medication through the side of the penis directly into the corpus cavernosum, which produces an erection that lasts from 30 minutes to several hours. They cause vascular dilation and a relaxation of smooth muscle, resulting in increased blood flow to the penis.

Caverject is a prescription medicine available from most chemists. Some pharmacists will create mixtures of other injectable agents (sometimes know as trimix solutions) according to prescriptions by your doctor.

These drugs have been shown to produce erections in 80% of men who inject them. Some men claim that they produce erections that feel natural and improve sex. The injections are relatively painless and create an erection that begins about 5 to 15 minutes after the injection. It is recommended that self-injection be performed no more than once every 4 to 7 days. Side effects include infection, bleeding, and bruising at the injection site, dizziness, heart palpitations, and flushing. There is a small risk of priapism (an erection that lasts for more than 6 hours and requires medical relief). Repeated injection may cause scarring of erectile tissue, which can further impair erection.

 

Non-invasive Treatment

When determining which treatment is most appropriate for a patient, most doctors will commence with the least invasive option and move to more complex treatments if the response is not satisfactory.

Oral Medications include Viagra, Levitra and Cialis. These drugs belong to a class of medications called phosphodiesterase inhibitors, or PDE5 inhibitors. Their action is to increase the blood flow to the penis during sexual stimulation.

Viagra and Levitra are typically taken 1 hour prior to sexual activity, though this may vary from 30 minutes to 2 hours. Cialis is a longer acting drug, and the effect may persist for up to 36 hours in some men.

These drugs are quite safe for most men. They cannot be taken with some medications used to treat ischaemic heart disease (nitrates) and use with alpha-blockers (for high blood pressure or prostatic enlargement) should be carefully supervised by your doctor.

Common side effects of PDE5 inhibitors include headache, flushing of the face and neck, indigestion, and nasal congestion. Priapism, or a prolonged erection, is rare. Cialis may cause muscle aches and back pain.

Ease of administration makes oral medication attractive. These drugs, however, are not suitable for all men with ED, and may be less effective than other treatments.

 

Penile Implants

Penile implants involve the surgical insertion of malleable or inflatable tubes into the penis. A semi-rigid prosthesis is a silicon-covered flexible metal rod. Once inserted, it provides the rigidity necessary for intercourse and can be curved slightly for concealment.

An inflatable penile prosthesis consists of two soft silicone tubes inserted in the penis, a small reservoir implanted in the abdomen, and a small pump implanted in the scrotum.

To produce an erection, a man pumps sterile liquid from the reservoir into the tubes by squeezing the pump in the scrotum. The tubes act as erectile tissue and expand to form an erection. When the erection is no longer desired, a valve allows the fluid to return to the reservoir. Inflatable prostheses are the most natural feeling of the penile implants and they allow for control of rigidity and size.

 

Sex Therapy

A significant number of men develop impotence from psychological causes that can be overcome. Sex therapists work with couples to reduce tension, improve sexual communication, and create realistic expectations for sex, all of which can improve erectile function. Psychological therapy may also be effective in conjunction with medical or surgical treatment.

 

Vacuum Devices

Vacuum Devices work by manually creating an erection. The penis is inserted into a plastic tube, which is pressed against the body to form a seal. A hand pump attached to the tube is used to create a vacuum that draws blood into the penis, causing the penis to become engorged. The penis is removed from the tube and a soft rubber O-ring is placed around the base of the penis to trap blood and maintain the erection until removed. The ring can be left in place for 25 to 30 minutes.

Vacuum devices work best in men who are able to achieve partial erections on their own. They are easy to use at home, require no other procedure, and typically improve erections regardless of the cause of impotence. Some men experience a numbing feeling after placing the O-ring. Since the penis is flaccid between the ring and the body, the erection may be somewhat floppy.

 

Vascular Reconstructive Surgery

A small percentage of men undergo vascular reconstructive surgery to improve blood flow to the penis. Young men with a localised arterial blockage are the best candidates for this procedure.

Venous ligation is performed to prevent venous leak. Problematic veins are ligated or removed, which allows an adequate amount of blood to remain in the penis. It may improve function in a small number of patients with a venous leak, but some men may experience recurrent problems over the long term.