Erectile Dysfunction (ED)

Erectile Dysfunction (ED) – Symptoms and Treatment

Definition of the Disease. Causes of the Condition
Erectile dysfunction is a prolonged (at least 6 months) inability of a man to achieve an erection sufficient for sexual intercourse. It’s a significant medical and social issue, leading to loss of self-esteem and family conflicts.

Internal Causes of Erectile Dysfunction

1. Cardiovascular Disorders: Various heart and vascular diseases contribute to intimate sphere issues (up to 65% of cases), including ischemic heart disease, arrhythmias, hypertension, and post-myocardial infarction conditions. Atherosclerosis significantly affects penile blood vessels, with some scientists considering potency dysfunction as a precursor to heart disease. High cholesterol and smoking also play a role, as do medications for hypertension and heart conditions, which can themselves cause significant erection problems.
2. Traumatic Factors: Traumatic events like pelvic bone fractures, urethral ruptures, head trauma, direct damage to the cavernous bodies, and conditions following prostate surgery for adenoma and cancer are major contributors to persistent potency disorders.
3. Nerve Conduction Disorders: Understanding the depth of the problem involves considering the nerve regulation scheme of erection by Dr. P.G. Schwarz.

External Causes of Erectile Dysfunction
Increased radiation exposure, working in high-frequency radiation conditions, and environmental factors cannot directly cause erectile dysfunction. However, erection issues may arise due to psychological trauma resulting from these factors.

Psychogenic Etiology
The most common cause of erectile dysfunction is fear of failure and lack of self-confidence, especially in young individuals. Relationship conflicts, or conversely, harmonious relationships leading to “routine” sexual activity, are also significant. Acute and chronic stress, professional fatigue leading to overall exhaustion, and underlying psychopathologies such as schizophrenia, paranoia, depressive states, as well as alcohol abuse, have a significant negative impact.

Symptoms of Erectile Dysfunction

Early Symptoms:

• Weak (or complete absence of) nocturnal and morning erections.
• Decreased libido (sexual desire).
• Increased time between foreplay and erection.
• Diminished intensity of orgasms, potentially leading to a complete loss of sensation.
• Premature ejaculation.
• Inability to engage in repeated sexual activity.
• Issues with performing a “routine” sexual act.
• Prolonged recovery time between erections.
• Decreased volume of ejaculate.

Late Symptoms:

• Inability to achieve sufficient penile rigidity.
• Inability to maintain penile erection.
• The extreme stage of erectile dysfunction – complete impotence.

Pathogenesis of Erectile Dysfunction

In the pathogenesis of erectile dysfunction, a leading role is attributed to pathologies of endothelial tissue, ultimately leading to impaired blood supply to the cavernous bodies of the penis. Atrophy of blood vessels plays a significant role, leading to sclerosis and replacement of healthy cells in the cavernous bodies with fibrous connective tissue. Therefore, the severity of erectile dysfunction depends on a combination of various causes and the degree of their impact on the cavernous bodies.

Classification and Stages of Erectile Dysfunction

Classification of erectile dysfunction (2017):

I. Psychogenic:

1. Common forms:

• General susceptibility disorder;
• Initial absence of libido;
• Age-related decrease in sexuality;
• General libido disorder;
• Chronic disorder.

1. Situational: a) Regarding the sexual partner:
   • Libido disorder towards a specific partner;
   • Absence of libido towards partner preferences;
   • Suppression of libido due to conflictual relationship with partner.
     b) Doubt in one’s abilities:
   • Dysfunctional disorders (premature ejaculation);
   • Anticipation of failure (doubt in achieving or maintaining an erection).
     c) Chronic stress:
   • Pathological mood (loss of spouse, relative, job loss).

II. Erectile Dysfunction Associated with Organic Lesions:

• Vascular;
• Neurogenic;
• Anatomical;
• Hormonal;
• Drug-induced.

III. Polyetiological Erectile Dysfunction.

Complications of Erectile Dysfunction:

• Complete inability to achieve any penile rigidity (impotence);
• Chronic stress;
• Decreased self-esteem;
• Disruption of social adaptation;
• Family problems;
• Infertility;
• Severe mental disorders, even leading to suicide.

Diagnosis of Erectile Dysfunction:

The diagnosis of erectile dysfunction in men should start with general anamnestic data. At the initial stage, attempts are made to identify possible etiological factors and determine individual characteristics of sexual life. Special attention should be paid to sexual behavior during the so-called “routine” sexual act. For this purpose, various questionnaires and scales are widely used, such as the International Index of Erectile Function (IIEF-5), the Loran-Segal scale, the Sexual Communication Profile (SCP), and others. A thorough examination allows for the identification of hair character, defects of the penis, and testicular size. Rectal examination is of great importance, allowing judgment on the size, consistency, and shape of the prostate.

Patients with erectile dysfunction should undergo determination of hormonal levels (free and bound testosterone, prolactin, estradiol, gonadotropin), determination of blood sugar level, glycated hemoglobin, and lipid profile. The results of these analyzes will help identify a specific type of pathogenesis of dysfunction.

Pharmacological test: the reaction of penile tissues to the introduction of papaverine, prostaglandins, and other medicinal substances into the cavernous bodies is studied.

Examination of neurological reflexes of spinal cord roots also has certain diagnostic value.

Ultrasound Examination:

• Transrectal ultrasound of the prostate (TRUS) through the rectum allows for accurate determination of the size and structure of the prostate gland, diagnosis of prostatitis, benign and malignant prostate tumors. All these factors directly or indirectly affect erection.
• Doppler ultrasound of the penile vessels can assess blood flow, the degree of narrowing of the main arteries and veins during erection. It is a significant prognostic factor in erectile dysfunction.
• Thyroid ultrasound detects structural and size abnormalities of this important gland, which has a significant influence on the overall hormonal balance.

Assessment of the Cavernous Bodies:

• Nuclear magnetic resonance imaging of the penis helps determine decreased blood flow in fibrotic-sclerotic areas of the penis.
• Biopsy of cavernous tissue and its histological examination reveal the percentage ratio of altered elements of cavernous tissue.

Treatment of Erectile Dysfunction:

Which Doctor to Consult:

When experiencing erectile dysfunction, it is necessary to consult a urologist-andrologist. Self-treatment is not permissible as it can significantly worsen the condition.

Oral Phosphodiesterase Type 5 Inhibitors for Erectile Dysfunction Treatment:

Phosphodiesterase-5 inhibitors have revolutionized the therapy of potency disorders, affecting nitric oxide. This substance prevents venous tone reduction of the penis, thus improving erection. The name of the miraculous drug “Viagra” was coined long ago and waited for its time for several years. This concise and pleasant name translates as “the power of the mighty Niagara Falls.” The hour came in 1993 when the American company “Pfizer” accidentally discovered an outstanding side effect of a new drug for lowering blood pressure – sildenafil citrate. The drug was quickly introduced into wide clinical practice and became the first among many pharmacological agents for the therapy of erectile dysfunction. This was followed by new generations of PDE-5 inhibitors. These drugs increased clinical efficacy and minimized side effects. Primarily, these are “Levitra” (vardenafil) and “Cialis” (tadalafil). These drugs improve erection in many forms of erectile dysfunction, even with low testosterone levels in men’s blood.

Other Drugs for Erectile Dysfunction Treatment:

Now, a little about raising testosterone levels in the body. Research in this area has been ongoing for decades, but a real breakthrough has not yet occurred. Testosterone does not seem to want to accumulate in the male body, in addition to being expensive, drugs have many side effects. Among them, “Nebido” stands out – a drug for intramuscular injection, and “Androgel,” which needs to be applied daily to the skin. The active use of testosterone and anabolic steroids is complicated by their widespread use in bodybuilding and other power sports, making it impossible to fully control their use and distribution.

Psychotherapy:

For most forms of erectile dysfunction, psychosexual therapy plays a significant role, as well as lifestyle correction, elimination, or reduction of adverse life factors. To obtain consultation, it is necessary to contact a psychotherapist.

Mechanical Devices for Erectile Dysfunction Treatment:

Vacuum-constriction therapy (VCD therapy) plays a certain role in the therapy of erectile dysfunction. The main mechanism of this type of therapy consists of creating negative pressure (vacuum) on the cavernous bodies of the penis using special devices. Vacuum devices provide adequate erection in 60% of cases.

Surgical Treatment of Erectile Dysfunction:

Surgical treatment for erectile dysfunction is applied when conservative means are exhausted:

• Creation of an anastomosis between the suprapubic artery and the lateral artery of the penis is performed in case of narrowing of this artery;
• Operations on the veins of the penis are performed in case of veno-occlusive dysfunction;
• Phalloprosthesis (implantation of prostheses) is the final stage of erectile dysfunction treatment when other methods are ineffective. This method allows achieving results (full erection) in 70-80% of cases.

Shock Wave Therapy (SWT), Magnetic-Laser Therapy (MLT), Ozone Therapy, and Prostate Massage have no proven clinical efficacy in the treatment of erectile dysfunction, and the reasons for their use are purely commercial.

Diet and Physical Activity:

Balanced nutrition and physical activity play an important role in preventing and treating erectile dysfunction.
Physical exercises are aimed at improving blood circulation in the pelvic organs of a man (especially in individuals with a sedentary lifestyle), improving blood flow to the penis and testicles, where testosterone production necessary for a full erection occurs.
The exercises are very simple: walking – at least 6 thousand steps per day, squats (at least 50 times per day). The urological complex of respiratory gymnastics by Strelnikova has shown a good effect. Some exercises from yoga practice are also used: Janu Sirsasana, Paschimottanasana, Uttanasana, Baddha Konasana, Dhanurasana.