Erectile Dysfunction (Impotence)

Definition of the Disease. Causes of the Condition

Erectile dysfunction is the prolonged (at least 6 months) inability of a man to achieve an erection sufficient for sexual intercourse.
Humans are the only biological species on our planet capable of maintaining an erection for a considerable amount of time. Disruption of this ability is 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 lead to disturbances in the intimate sphere (up to 65% of cases) – ischemic disease, arrhythmia, hypertension, conditions after myocardial infarctions. Vascular narrowing (atherosclerosis) is also largely inherent in the vessels of the penis. Some scientists consider potency dysfunction as a precursor to heart pathology and recommend starting cardiac examination as early as possible if problems arise in the intimate sphere. Elevated cholesterol and smoking, which lead to vessel wall damage, are also significant. In addition, medications for hypertension and heart problems themselves can also cause significant erectile dysfunction.
  2. Traumatic Factors – one of the main factors in the development of persistent potency disorders. These include fractures of the pelvic bones, urethral ruptures, head trauma, direct damage to the cavernous bodies, conditions after surgeries on the prostate gland for adenoma and cancer.
  3. Nervous Conductivity Disorders. To understand the depth of the problem, it is recommended to simply look at the erection regulatory scheme by Dr. P.G. Schwartz.
    According to this scheme, there are 14 structures regulating erection. Disruption at any level can lead to various disturbances in a man’s intimate sphere. These structures can be disrupted as a result of strokes, trauma, intervertebral disc herniation, tumors of various locations, multiple sclerosis, and other neurological diseases.
    In addition, there is a group of causes related to the malfunction of the endocrine organs (endocrine causes): diabetes mellitus, leading to damage to peripheral vessels and nerves, thyroid dysfunction, obesity. The decrease in testosterone levels, including age-related, due to fatigue, hormonal imbalance, is also significant.
    Inflammatory diseases of the genitourinary organs (prostatitis, vesiculitis, urethritis) can also cause erectile dysfunction.
    External Causes of Erectile Dysfunction
    Increased radiation background, working in conditions of high-frequency radiation, and environmental factors cannot be the cause of erectile dysfunction. However, erectile dysfunction can occur due to psychotraumatic effects as a result of these factors.

Psychogenic Etiology

The most common cause of erectile dysfunction is fear of failure, lack of self-confidence, especially at a young age. Conflicts with a partner are also significant, as are stable relationships leading to what is known as “routine” sexual activity. Acute and chronic stress, professional exhaustion leading to overall body depletion, are of great importance. In some cases, hidden psychopathology manifests itself – schizophrenia, paranoia, depressive states. Excessive alcohol consumption has a significant negative impact as well.

Symptoms of Erectile Dysfunction


Early Symptoms:

  • Weak (up to complete disappearance) nocturnal and morning erections.
  • Decreased sexual desire (libido).
  • Increased time between foreplay and erection.
  • Diminished intensity of orgasm, even to the point of losing sensation.
  • Premature ejaculation.
  • Inability to engage in repeat sexual activity.
  • Difficulties with performing the “usual” sexual act.
  • Increased recovery time between erections.
  • Decreased volume of ejaculate (amount of semen ejaculated during intercourse).

Late Symptoms:

  • Inability to achieve sufficient penile rigidity.
  • Inability to maintain penile erection.
  • Extreme erectile dysfunction – complete impotence.

Pathogenesis of Erectile Dysfunction

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

erectile disfunction

Classification and Stages of Erectile Dysfunction Development

Classification of Erectile Dysfunction (2017):
I. Psychogenic:

  1. Common form:
  • 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 the preferences of the object;
    • Suppression of libido due to conflictual relationship with the partner.
      b) Doubt in one’s abilities:
    • Dysfunctional disorders (rapid ejaculation);
    • Fear of failure (doubt in achieving or sustaining 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 level of penile erection (impotence);
  • Chronic stress;
  • Decreased self-esteem;
  • Impairment of social adaptation;
  • Family problems;
  • Infertility;
  • Serious mental disorders, even leading to suicide.

Diagnosis of Erectile Dysfunction:

Diagnosis of erectile dysfunction in men should begin with general anamnestic data. At the first stage, attempts are made to identify possible etiological factors and determine individual characteristics of sexual life. Sexual behavior during the so-called “usual” sexual act should be distinguished separately. For this purpose, various questionnaires and scales are widely used, such as the International Index of Erectile Function (IIEF-5), the Laurent-Segal scale, the Sexual Communication Profile (SCP), and others. Thorough examination allows to identify the nature of hairiness, defects of the penis, testicular size. Rectal examination is of great importance, allowing to assess the size, consistency, and shape of the prostate gland.

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

Pharmacological test: the response of penile tissues to the administration of papaverine, prostaglandins, and other medicinal agents into the cavernous bodies is studied.

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

Ultrasound Examination:

  • TRUS (transrectal ultrasound examination of the prostate) through the rectum allows for an accurate assessment of the size and structure of the prostate gland, diagnosing prostatitis, benign and malignant tumors of the prostate. 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 abnormalities and size of this important gland, which has a significant influence on the overall hormonal balance.

Evaluation of the Cavernous Bodies:

  • Nuclear magnetic resonance imaging of the penis helps to determine the decrease in blood flow in fibrotic-sclerotic areas of the penis.
  • Biopsy of cavernous tissue, along with its histological examination, reveals the percentage ratio of altered elements of cavernous tissue.

Treatment of Erectile Dysfunction

Which Specialist to Consult:
In case of erectile dysfunction, it is important to consult a urologist-andrologist. Self-treatment is not advisable as it can significantly worsen the condition.

Oral Phosphodiesterase Type 5 Inhibitors for Erectile Dysfunction Treatment:
The introduction of phosphodiesterase-5 inhibitors has revolutionized the treatment of potency disorders by affecting nitric oxide. This substance prevents a decrease in the tone of the penile veins, 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 huge Niagara waterfall.” The hour came in 1993 when the American company “Pfizer” accidentally discovered a remarkable side effect of a new drug for lowering blood pressure – sildenafil citrate. The drug was quickly introduced into wide clinical practice and gained the first place among many pharmacological agents for the therapy of erectile dysfunction. This was followed by new generations of PDE-5 inhibitors. These drugs showed an increasing clinical effect and minimized side effects. Primarily, these are “Levitra” (vardenafil) and “Cialis” (tadalafil). These drugs allow improving erection in many forms of erectile dysfunction, even with low testosterone levels in men.

Other Drugs for Erectile Dysfunction Treatment:
Now a little about raising testosterone levels in the body. Research in this area has been ongoing for many decades, yet a breakthrough has not occurred. Testosterone does not want to accumulate in the male body; moreover, the drugs are expensive and have many side effects. Among them, “Nebido” – a drug for intramuscular injection, and “Androgel,” which needs to be rubbed into the skin daily. The active use of testosterone and anabolic steroids is complicated by the wide use of drugs in bodybuilding and other power sports, making it impossible to fully control their use and distribution.

For most forms of erectile dysfunction, psychosexual therapy plays an important role, as well as lifestyle correction, eliminating or reducing unfavorable life factors. To receive counseling, it is advisable to contact a psychotherapist.

Mechanical Devices for Erectile Dysfunction Treatment:
Vacuum-constrictor therapy (VCD therapy) plays a certain role in the treatment of erectile dysfunction. The main mechanism of this therapy is the creation of 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 methods are exhausted:

  • Creation of an anastomosis between the superior vesical artery and the penile artery is performed in case of narrowing of this artery;
  • Operations on penile veins are performed in case of a veno-occlusive disorder;
  • Phalloprosthesis (prosthesis implantation) 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.

Extracorporeal Shock Wave Therapy (ESWT), Magnetic-Laser Therapy (MLT), Ozone Therapy, and Prostate Massage do not have proven clinical efficacy in the treatment of erectile dysfunction, and their use is 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 men (especially in individuals with a sedentary lifestyle), improving blood flow to the penis and testicles, where testosterone production occurs, necessary for a full erection. 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 the practice of yoga are also used: Janu Sirsasana, Paschimottanasana, Uttanasana, Baddha Konasana, Dhanurasana.

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