Erectile Dysfunction

Patients present with an inability to achieve or sustain erection when performing sexual acts. Decreased pleasure, premature ejaculation or nocturnal erection may also be the presenting complaints.

The patient should be inquired about any history of diabetes mellitus, hypertension, cardiovascular diseases, prostate surgery or recent trauma. History of drugs, alcohol and caffeine intake should also be carefully taken. Psychological history regarding any worries, depression or recent significant event e.g. divorce should also be taken.

The physical examination should include the measurement of blood pressure, peripheral pulses and sensations. Examination of the genitalia should be performed to look for any lesions such as penile plaques, small testis, prostate carcinoma or infection. The size and texture of testes should also be inspected. It is also necessary to look for penile abnormalities such as priapism, Peyronie disease and epispadias.

Additional workup includes evaluation of the following:

• Hormonal levels:

1. Free testosterone levels should be checked at 8 am (peak level) if there is depression and decreased libido and secondary sex characteristics.
2. Luteinizing hormone should also be evaluated. If the levels of luteinizing hormone are high with low testosterone levels, Leydig cell failure might be present. On the other hand, if the levels of luteinizing hormone are low, there may be an underlying central nervous system defect.
3. Prolactin levels should be measured to detect hyperfunctioning of the pituitary gland.
4. The levels of thyroid stimulating hormone should be evaluated.

• HBA1c level: This test is helpful in detecting diabetes.
• PSA (Prostate specific antigen): Very high PSA levels indicate for prostatic carcinoma.
• Urinalysis: The presence of red or white blood cells, proteins or glucose indicate an underlying genitourinary or organic disorder.
• Injection of PGE1 into corpus cavernosa: If erection did not occur within 5 minutes of injection of PGE1 into the corpus cavernosa, an underlying abnormality is indicated.
• Biothesiometry: In this procedure, electromagnetic probe is attached on the left and right side of the glans and on the penis. The vibrational sense is then tested and compared with normal.
• Ultrasonography: It is used to measure the blood flow in corpus cavernosa after PGE1 is injected.
• Nocturnal penile tumescence test: In this test, bands are applied on penis for 2 or 3 nights and erection during sleep is evaluated with the help of a graph. It helps in differentiating between psychogenic and organic causes of erectile dysfunction. If erection is normal, the cause is most probably psychogenic.

The best solution for every patient should be identified and the partner should preferably be included in the discussion.

Pharmacological treatment:

These include:

• Phosphodiestrase-5 inhibitors such as sildenafil (Viagra) are very effective in inducing and maintaining erection. In the patients who are refractory to oral phosphodiesterase-5 inhibitors, they can be combined with prostaglandin E1 (PGE1) injections for better efficacy.
• Androgens are available in oral, injectable or gel form. They may have other side effects and should be used with caution.
• Intracavernosal injections of alprostradil are used in 40 ug dose to maintain adequate rigidity for 90 minutes
• Intraurethral PGE1 pallet is used in the patients suffering from diabetes, hypertension or myocardial infarction.
• Vascular Endothelial Growth Factor can also be used.

Devices:

Two types of devices are used for treating erectile dysfunction.

• Constriction devices: These are applied it at the base of the penis in case of venous leak.
• Vacuum devices: These devices create vacuum which draws the blood inside penis and sustains an erection of around 30 minutes. Side effects include hematoma, ecchymosis and perineal pain.

Surgery:

Surgical options include:

• Revascularization: This is performed in young patients with traumatic history by rotating the epigastric artery.
• Penile implant placement: Penile implants are used for organic erectile dysfunction when other treatments have failed. They are of two types; semi-rigid and inflatable. The inflatable type is better tolerated and can be used for 7 to 10 years.

Counselling:

Sexual counselling is an essential part of the treatment. The emotional aspect should be addressed with active involvement of the partner in order to reduce stress and improve the patient’s quality of life.

The all-cause mortality in patients suffering from erectile increases up to 25% with up to 44% higher risk of cerebrovascular events and 62% higher risk of myocardial infarction [10]. 
Associated morbidities include premature ejaculation, hypoactive sex desire, lack of pleasure, and depression.

Erectile dysfunction results from psychogenic causes or due to any organic disease.

Psychogenic causes

The psychogenic causes of erectile dysfunction include depression, performance anxiety and post-traumatic stress disorder

Organic causes

There are many organic abnormalities that may lead to erectile dysfunction.

• Vascular: Vascular disorders such as arterial insufficiency (as in atherosclerosis) and veno-occlusive dysfunction are the most frequent organic causes of erectile dysfunction. Erectile dysfunction may be one of the earliest manifestations of atherosclerosis in some patients [1]. Hypertension is also associated with erectile dysfunction [2].
• Neurologic: Erectile dysfunction may be seen in the patients suffering from epilepsy, multiple sclerosis and Guillain-Barré Syndrome.
• Endocrine: Erectile dysfunction is associated with diabetes mellitus with poor glycaemic control [3] [4]. Hypogonadism and hypothyroidism may also cause erectile dysfunction.
• Medication: Drugs such as antihypertensives, antidepressants, antipsychotics and cholesterol-lowering agents may also cause erectile dysfunction.
• Surgery: Erectile dysfunction may follow radical prostectomy that is performed to treat benign prostatic hyperplasia [5].
• Penile abnormalities: Erectile dysfunction may accompany penile abnormalities such as Peyronie disease, epispadias and priapism.

Erectile dysfunction is more common in the elderly with up to 25% prevalence in men in their 60’s and 89% in those in their 80’s, seriously affecting their quality of life [6] [7]. It is also more common in the lower socioeconomic classes.

Erection of the penis is controlled by a balance between contraction and relaxation of blood vessels, and the action of the ischiocavernous muscle. Contraction is mediated by noradrenaline and endothilin 1 whereas relaxation is mediated by nitric oxide, acetyl choline and adenosine triphosphate.

Erection of the penis requires a coordinated interaction of the peripheral nerves (S2 to S4), vascular events and events in corpora of the penis. Nitric oxide locally relaxes the vasculature of corposal smooth muscle with a half-life of about 5 seconds. Due to this relaxation, blood fills the corposa. Furthermore, there is occlusion of venules beneath tunica albuginea. This raises the intercarvosal pressure as high as 100mmHg. The ischiocavernous muscle then contracts and causes the pressure to rise up to 200 mmHg.

A normal level of testosterone is essential for the proper physiology of erection. Low levels of testosterone are associated with low libido, poor erection and ejaculatory dysfunction [8]. Erectile dysfunction occurs when this complex cycle of events is disrupted due to vascular, endocrine, psychogenic or other causes [9].

The following measures can be helpful in prevention of erectile dysfunction.

• Adequate daily exercise reduces the occurrence of erectile dysfunction and associated organic diseases.
• Weight loss: This reduces inflammation, increases testosterone level and improve the patient’s self-esteem.
• Cessation of smoking is essential.
• Precise glycaemic control in diabetics and pharmacologic treatment of hypertension is necessary to prevent erectile dysfunction.

Erectile dysfunction refers to an inability to achieve or maintain erection for intercourse. An underdiagnosed disorder, it occur either due to sensory abnormalities or decreased blood flow to the penis. The causes of erectile dysfunction may be vascular, neurogenic, psychogenic, endocrine or drug-related.

Phosphodiestrase 5 inhibitors such as sildenafil (Viagra) offer good short term treatment. Penile implants may be considered as long term treatment. If untreated, erectile dysfunction may increase the mortality by increasing vascular accidents such as myocardial infarction and cerebrovascular accidents.

Erectile dysfunction is associated with sexual deprivation which causes anxiety and depression. Exercise, weight reduction and cessation of smoking play huge role in prevention of this disease.

Erectile dysfunction means an inability to achieve or sustain normal erection of the penis. In the younger age, the cause is usually psychogenic. In older individuals, an underlying disease may be present. Diabetes and high blood pressure often cause erectile dysfunction. Erectile dysfunction can be treated by the use of drugs or implants.

1. Nehra A, Jackson G, Miner M, et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clinic proceedings. Aug 2012;87(8):766-778.
2. Burchardt M, Burchardt T, Baer L, et al. Hypertension is associated with severe erectile dysfunction. The Journal of urology. Oct 2000;164(4):1188-1191.
3. Romeo JH, Seftel AD, Madhun ZT, Aron DC. Sexual function in men with diabetes type 2: association with glycemic control. The Journal of urology. Mar 2000;163(3):788-791.
4. De Berardis G, Pellegrini F, Franciosi M, et al. Identifying patients with type 2 diabetes with a higher likelihood of erectile dysfunction: the role of the interaction between clinical and psychological factors. The Journal of urology. Apr 2003;169(4):1422-1428.
5. Larson TR. Current treatment options for benign prostatic hyperplasia and their impact on sexual function. Urology. Apr 2003;61(4):692-698.
6. Lopushnyan NA, Chitaley K. Genetics of erectile dysfunction. The Journal of urology. Nov 2012;188(5):1676-1683.
7. Latini DM, Penson DF, Lubeck DP, Wallace KL, Henning JM, Lue TF. Longitudinal differences in disease specific quality of life in men with erectile dysfunction: results from the Exploratory Comprehensive Evaluation of Erectile Dysfunction study. The Journal of urology. Apr 2003;169(4):1437-1442.
8. Guay AT. Testosterone and erectile physiology. The aging male : the official journal of the International Society for the Study of the Aging Male. Dec 2006;9(4):201-206.
9. Andersson KE. Erectile physiological and pathophysiological pathways involved in erectile dysfunction. The Journal of urology. Aug 2003;170(2 Pt 2):S6-13; discussion S13-14.
10. Miner M, Seftel AD, Nehra A, et al. Prognostic utility of erectile dysfunction for cardiovascular disease in younger men and those with diabetes. American heart journal. Jul 2012;164(1):21-28.

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