Erectile Dysfunction

Erectile dysfunction is a sexual disorder characterized by the inability to initiate and maintain an erection of the penis during sexual activity.

Erection comes as a result of the hydraulic effect of blood entering and being held in the penile spongy bodies. This process begins as a result of sexual stimulation when signals are transmitted through neurons from the brain to the penis.

Erectile disorders can be a consequence of organic disorders such as cardiovascular system diseases, diabetes, neurological disorders e.g., trauma after surgical interventions on the prostate) hormone deficiencies (hypogonadism) or as a side effect of various medications as well as circulatory causes from changes in electrical conduction pathways.

Psychological impotence occurs when erection or penetration is not achieved as a result of psychological reasons (thoughts or feelings) rather than physical ones. This is rarer but possible to treat. Naturally, in the case of psychological impotence, there is a good response to placebo treatment. Erectile disorders can have major psychological consequences.

Besides treating causes such as in cases of potassium deficits or arsenic poisoning of water, the primary treatment consists in the use of PDE5 inhibitors (such as sildenafil or Viagra). In some cases, treatment includes prostaglandins in the ureter, injections into the penis, penile prosthesis, penile pump, or vascular reconstructive surgery. The Latin term impotentia coeundi represents the inability to insert the penis into the vagina.

Signs and symptoms

Erectile disorders are characterized by a regular or repeated inability to achieve or maintain an erection.

Causes

• Use of various medications (SSRI antidepressants and nicotine).
• Neurogenic disorders (spinal cord and brain injuries, nerve disorders such as Parkinson's Disease, Alzheimer's Disease, multiple sclerosis, cardiac injuries.
• Cavernosal disorders (Peyronie's disease)
• Psychological disorders: anxiety, stress mental disorders (depression schizophrenia, drug abuse, panic disorders, personality disorders.
• Surgical interventions (interventions on the colon, prostate, urinary bladder, which may damage the vascular and nerve network, radiotherapy.
• Age (is 4 times more in men aged 60 compared to 40 years old.
• Renal insufficiency
• Diseases such as diabetes and multiple sclerosis are thought to indirectly affect through changes in blood flow and the nervous system.
• Lifestyle: smoking causes impotence as it leads to narrowing of the arteries.
• In rare cases, they are iatrogenic (medically induced).

Surgical interventions such as complete or partial removal of the prostate or external source radiotherapy for its cancer treatment are common causes of impotence. There are no accurate data on the impact of circumcision on impotence. While a link has been observed with cycling, the duration of cycling or pressure on the penis from the saddle directly relate to erectile disorders.

An epidemiological link has been observed with chronic periodontitis as with coronary and cerebrovascular diseases.

A link is observed with the use of non-steroidal anti-inflammatory drugs 3 times a day for over 3 months in different ages, races, smokers, diabetes, hypertension, increased cholesterol, coronary disease, and other health problems.

There are two mechanisms to explain penile erection:

Firstly, it is reflexive from direct touch of the penile body (involves the peripheral system and the lower part of the spinal cord).

Secondly, psychogenic erection is achieved from erotic or emotional stimuli (uses the limbic system in the brain).

In both cases, an undamaged nervous system is needed to achieve and complete the erection. Penile stimulation from the nervous system leads to the release of nitric oxides which bring about relaxation of the smooth muscle of the cavernous bodies. Also, to have a healthy erectile system, normal values of testosterone (produced by the testes) and functioning pituitary glands are needed.

Looking at the normal mechanisms of erection, impotence can come as a result of hormonal deficits, disorders of the nervous system, damage to the blood supply, or psychological problems. Reduction in blood flow can come as a result of damage to endothelial function associated with coronary artery disease, but can be caused by prolonged exposure to light.

Diagnosis

There are no formal tests to diagnose erectile dysfunction.

Firstly, diseases such as hypogonadism, prolactinoma are excluded through blood examinations. Health conditions such as diabetes, poor diet, obesity, cardiovascular disease such as coronary artery disease, and peripheral vascular disease are sought.

The easiest way to distinguish between the physiological and psychological form is to determine if the patient has ever had an erection in life.

If he refers that he has never had one then the cause is physiological, if he has had at times it is of physiological and psychological nature.

Duplex Ultrasound is used to evaluate blood flow, venous leakage, signs of atherosclerosis, calcifications of the erectile tissues.

By injecting prostaglandin, vascular dilation is observed and penile blood pressure is measured.

Penile nerves function: tests of bulbocavernous reflex are used to determine the nerve sensitivity of the penis. The doctor presses the glans (head) of the penis, which gives an immediate contraction of the anus if the nerve function is normal. The doctor measures the delay between pressing and contraction by observing the anal sphincter or feeling it through a finger placed in the anus.

Nocturnal penile tumescence (NPT)

Normally a man may have 5 to 6 erections during sleep, especially during the REM (rapid eye movement) period. The absence of these nocturnal erections indicates problems in nerve function or in the blood supply to the penis. There are two methods to measure changes in penile rigidity and circumference during nocturnal erection.

Penile biothesiometry

Through electromagnetic vibrations, the sensitivity and nerve function of the glans and shaft of the penis are measured.

Dynamic infusion cavernosometry (DICC)

Liquid is pumped into the penis at a known pressure and amount to measure vascular pressure in the cavernous bodies during erection.

Corpus cavernosometry

Cavernosography : measures vascular pressure in the cavernous body. Through a catheter, liquid is injected under pressure into the cavernous bodies, and the amount of leakage necessary to maintain an erection determines the venous flow. The outflowing veins start to become visible as a physiological solution with a contrast agent is injected, making a cavernosogram.

Treatment (depends on the cause)

• Exercise, especially aerobic is an effective treatment in erectile dysfunction.
• When pharmacological treatment fails, a vacuum pump can be used to achieve an erection, with a constricting ring placed on the penis to hold it.
• A penis pump that does not have a constricting ring can also be used, used for temporary treatment to increase penile length or as a vibrator to aid in masturbation.
• Rigid or inflatable implants can be used.
• PDE 5 inhibitors in the form of sildenafil (Viagra) Verdanafil (levitra) or tadalafil (cialis) This group of medications block the action of phosphodiesterase leading to degradation of cGMP.