Erectile Dysfunction

What is Erectile Dysfunction?

Erectile dysfunction (ED), which was once referred to as impotence, is when a man is unable to get or keep a firm erection that’s needed for satisfying sexual activity. Although there’s no specific timeframe that determines this condition, it’s generally agreed that it should be an ongoing problem for about six months. ED is fairly common in men who are above the age of 40, with the likelihood increasing with age and potentially other existing health issues.

ED can indicate a variety of underlying health problems and is a potentially overlooked risk factor for cardiovascular disease. ED could be brought on by any condition that impacts the blood vessels and nerves in the penis, hormone levels, various tissues, or other elements. It is often seen in connection with heart disease, diabetes, high cholesterol, high blood pressure, and other health conditions. Trouble with the endothelium, a type of lining in our blood vessels, is another common factor among people with ED.

Though physical health issues are typically at the root of most ED cases, it can also be primarily a psychological problem, especially in younger men. Even if the underlying cause is physical, ED often leads to psychological issues like trouble within romantic relationships, societal pressures and expectations, a blow to self-confidence, feelings of embarrassment, anxiety, and depression, among others. ED can greatly affect emotional well-being and quality of life for both the individual and their partner. The good news is that ED is usually treatable.

What Causes Erectile Dysfunction?

Erectile dysfunction (ED) usually has more than one cause. These causes can be psychological, such as depression or performance anxiety, or physical, related to other health conditions that affect the body’s functions. As men age, health conditions like heart disease, high blood pressure, and other chronic diseases, increasingly contribute to ED. Diabetes or metabolic syndrome can speed up the decline of erectile function as they affect multiple body systems and disrupt the molecular mechanisms that support erections.

ED can also result from neurological issues like multiple sclerosis, hormone changes (e.g., hypogonadism, thyroid issues), injuries (think pelvic fractures or spinal cord injuries), high cholesterol, stroke, sleeping disorders, chronic obstructive pulmonary disease (COPD), glaucoma, prostate enlargement with urinary symptoms, depression, as well as certain medications (like antidepressants, blood pressure medications, antipsychotics, opioids, and recreational drugs).

Heart disease is a prominent risk factor for ED. Half of men diagnosed with coronary artery disease also have significant ED. This is because the heart and the penis share similar-sized arteries, which are prone to the same atherosclerotic (or plaque buildup) issues. These problems can show up as ED years before heart disease becomes apparent, due to the smaller size of penile arteries. Men with ED often show signs of this plaque buildup up to 10 years before any obvious signs of ED appear, and their occurrence often precedes heart disease and strokes by up to 5 years. Particularly, young men with unexplained ED have up to 50 times the cardiovascular risk in their later life than their counterparts without ED. Clinicians should inform patients that ED can indicate underlying heart disease and should therefore lead to further tests for heart disease risks.

Cardiovascular risk equate to that of having ED has been observed in smokers or those with family history of heart attacks. A pooled analysis of 14 studies involving over 90,000 men with ED found higher rates of heart conditions, heart attacks, strokes, and death for these patients compared to those without ED.

ED also relates to other conditions like hypertension, high cholesterol, diabetes, low testosterone, obesity, smoking, alcoholism, prostate enlargement with lower urinary symptoms, depression, and premature ejaculation. Hypertension or high blood pressure is found in about 40% of men with ED, while high cholesterol is found in about 42% of men with ED. Undiagnosed diabetes is up to three times more likely in men with ED. Men over 50 with diabetes are also twice as likely to have ED. The longer and the more severe the diabetes, the greater the risk. Obesity increases the risk of ED by 50%. Smokers who quit see a 25% improvement in ED after one year. Heavy alcohol users also face a higher risk of ED. Depression is three times more common in men with ED, while men with depression are 40% more likely to develop ED. Additionally, physical changes to the prostate and urinary symptoms can cause ED in up to 72% of men with these conditions.

Prescribed medications cause about a quarter of all ED cases. Eight out of 12 commonly prescribed medication in the U.S. list ED as a possible side effect. These include most antidepressants, along with many blood pressure medications and diuretics. However, some blood pressure medications are less likely to cause ED.

Regarding prostate cancer treatments, up to 85% of patients may experience ED after surgery whereas only 25% may experience it after radiation therapy. Importantly, these statistics apply only to those who did not already have ED prior to prostate cancer treatment.

The impact of bike riding on ED is still debated. Traditional racing bike seats put a lot of pressure on the nerves and arteries in the pelvic region, which might increase the risk of ED in cyclists. Recent data suggested a significant increase in ED risk among cyclists compared to non-cyclists.

Risk Factors and Frequency for Erectile Dysfunction

Erectile dysfunction (ED) is often underreported because many people are reluctant to go to the doctor, or their doctors may not ask about their sexual health. This makes it hard to know the true number of people with ED. However, research suggests that over half of men in the US between the ages of 40 and 70 experience ED.

• Between 30 to 50 million men in the US, and over 150 million men worldwide, are estimated to have ED.
• This number might be much lower than the actual number of men with ED due to factors like cultural attitudes, doctors failing to ask about sexual health, and patient embarrassment.
• The chance of having ED increases with age and the presence of other health conditions like diabetes, lower levels of sex hormones, and heart disease.
• For example, 40% of men at age 40, and 70% of men at age 70, are believed to be affected by ED.
• It’s estimated that by 2025, ED will affect 322 million men globally.

Signs and Symptoms of Erectile Dysfunction

Before any treatment or tests can be carried out, it’s crucial for doctors to gather all necessary facts. This means taking a full medical history, including any sexual changes or issues, alongside a physical examination. Furthermore, it’s important to know all medications and supplements a patient might be taking, especially if they’re primarily for prostate issues, as some of these can act against male hormones.

One way that has proved effective in helping patients discuss the severity of their erectile difficulties is a scoring system. This ranges from 100% (the best, strongest erection they’ve ever had), 0% (no erection at all), to 50% (just enough for sexual penetration). This scale allows patients to better communicate the level of their erectile rigidity and monitor any changes after treatment. Additionally, questionnaires, such as the International Index of Erectile Function Questionnaire (IIEF), serve as a valuable tool. This can be filled out privately by the patient. This questionnaire has been broadly recognized as useful for monitoring the level of erectile dysfunction and the effectiveness of treatment.

• How strong is your erection now (with 50% being just enough for intercourse)?
• What is the best or strongest erection you can achieve at present?
• What’s the duration of your erection?
• Does your penis feel numb or unusual in any way?
• Does your penis lose firmness during foreplay?
• Does your penis only lose firmness when attempting vaginal penetration?
• Does your penis remain erect and hard until immediately after penetration? This could indicate anxiety or a venous leak.
• Do you still experience morning erections?
• If yes, are these morning erections better or do they last longer than the erections you achieve during intercourse?
• Do you have overnight erections? If so, how hard are they?

Other things that could be beneficial to discuss can be changes in erection quality from day to day or whether there’s been a recent improvement due to changes in sexual activity or partners. It’s also worth noting when the erectile problems started and if it was a sudden or gradual issue. If the problem is worsening, it’s crucial to identify whether it’s a problem with erection firmness or maintaining an erection. Questions about past traumas, methods of contraception, and previous treatments can also be pertinent. It’s equally important to address whether ejaculation and orgasm are normal, even when erections are not, and what the patient’s general interest in sex is. The patient’s partner’s perception can be beneficial in treatment and should be included whenever possible.

It’s also important to carry out a general cardiovascular examination, as problems with erections could be an early sign of heart disease or other circulatory problems. This would involve checking peripheral pulses and blood pressure. A careful inspection of the genitals can reveal issues including less than normal testicle size, infections, and the presence of fibrous tissue or plaques in the penis, and inability to retract the foreskin. A full cardiovascular evaluation should be considered for all patients without a clear cause of their erectile problems because impotence can often be the first sign of heart or blood vessel disease.

Testing for Erectile Dysfunction

Starting conversations about sexual health can be uncomfortable for doctors, largely due to cultural norms and potential embarrassment. But discussing it in a relaxed, casual manner can help. For instance, straightforward questions like “How is your sex life? Everything working OK for you?” can reveal if there are any problems. If a patient hesitates or indicates that things aren’t the same, the doctor should take it as a sign to do more detailed investigations.

It’s important to understand whether a person has erectile dysfunction due to psychological or physical reasons. Some signs that the issue might be psychological include sudden onset of problems, problems occurring only in specific situations, normal erections during masturbation or with a different partner, and variations in erection strength. If psychological issues are obvious, the patient can be referred to a mental health professional. Even if psychological problems aren’t evident, bringing in mental health experts can be helpful for dealing with related issues
such as performance anxiety or relationship stress.

Recognizing the need for a mental health evaluation can be difficult, especially during a patient’s first visit. A few strategies to make this process smoother include explaining that mental health assessments are part of routine checks for everyone with erectile dysfunction, that it’s a one-time evaluation, and that it operates like a standard test – if everything is normal, the doctors proceed, but if anything is unusual, they take the necessary steps to deal with it.

Even though most patients with erectile dysfunction do not have an underlying psychological issue, the condition itself can lead to stress, reduced self-esteem, and relationship problems.

Doctors do not usually require specific tests to evaluate erectile dysfunction initially. However, they may order blood tests such as a complete blood count, electrolytes and renal function tests, liver function tests, HgbA1c to look for diabetes, a lipid profile, and a morning testosterone level. Other tests might be ordered if the patient appears to have other health issues, or in case the patient does not respond to the standard erectile dysfunction therapy.

A crucial aspect of treating erectile dysfunction is shared decision-making, where the doctor educates the patient on various appropriate treatment options and works with them to select the best course of action. This approach often overrides the need for extensive testing.

There are also a few additional optional tests that could be considered for specific patients. These include penile biothesiometry (a test for penile neuropathy), nocturnal tumescence testing (measuring night-time erections to identity psychological or physical causes), penile duplex Doppler ultrasound (measuring arterial vascular flow and checking for venous leak), dynamic infusion cavernosometry and cavernosography (specific tests for situations where a site-specific venous leak is suspected), and pudendal arteriography (visualizing the penile arterial vasculature, usually for young patients suffering from erectile dysfunction due to trauma).

Treatment Options for Erectile Dysfunction

Initial treatment for erectile dysfunction often includes changes to your lifestyle which not only improves erectile health but also reduces risk to your heart. Some recommended lifestyle changes include getting more exercise, changing to a Mediterranean diet or having nutritional counselling, stopping smoking, drugs, and alcohol, and managing diabetes, lipids, and cholesterol effectively.

A careful review of the patient’s medication history to remove or change harmful medications might be necessary. Some men might get benefit from psychosexual counselling especially if their erectile dysfunction is due to psychological factors. If the patient is willing, it may also be beneficial for their partner to be involved in counselling sessions.

L-arginine, an amino acid supplement, is used as a building block for nitric oxide synthase, the enzyme that produces nitric oxide in the body. By taking L-arginine supplements, nitric oxide synthase levels can be increased, which might improve erectile function. Various studies have shown this supplementation approach to be somewhat effective in treating mild to moderate erectile dysfunction.

Eroxon, a topical gel, is another commonly recommended treatment for erectile dysfunction. It is applied to the head of the penis and evaporates quickly providing a cooling effect on the glans, which induces tissue warming and stimulates the nerves. These actions eventually enhance blood flow and promote rigidity, aiding erections. Some 60% of men find success with using this gel, with the success rate increasing to 75% within 20 minutes of application. However, it should be noted that there are still limited studies on this gel and its interactions with common erectile dysfunction treatments like sildenafil and tadalafil are unclear. The availability of this product varies by country and its cost is roughly $8 per application in the UK.

A common first-line treatment for erectile dysfunction is the use of oral medications like sildenafil and tadalafil (also known as PDE-5 inhibitors). These work by increasing the relaxation of muscles and blood flow in the penis, aiding in erectile function. PDE-5 inhibitors are quite effective with success rates up to 76%. However, it’s important to note that sexual stimulation is still required for these drugs to work. Some potential side effects include headache, indigestion, nasal stuffiness, and mild visual changes, and there have been rare instances of permanent blindness or deafness associated with PDE-5 inhibitor use. It’s recommended these drugs are handled cautiously with antihypertensives, alpha-blockers, and nitrates due to potential profound hypotension risks.

For patients who fail to benefit from PDE-5 inhibitors, the recommendation is to try at least one other type of PDE-5 medication. It’s also recommended to check testosterone levels in these cases. Generally, it’s vital that patients understand how to take their medication correctly; for instance, sildenafil may not be effective if taken with food and may take several attempts before it begins to work successfully.

Another developing treatment includes a mix of daily L-arginine supplements combined with a PDE-5 inhibitor therapy.

Testosterone supplementation can be an effective treatment for low libido more than for erectile dysfunction. For men with both erectile dysfunction and hypogonadism, starting with an oral PDE-5 inhibitor as the initial therapy is recommended. Testosterone supplementation might be reasonable for those with confirmed hypogonadism and erectile dysfunction who have failed PDE-5 inhibitor therapy or who also have a low sex drive.

An alternative to medications are external vacuum devices, which are safe and effective non-surgical options for many patients with erectile dysfunction. These devices work by placing a cylinder over the penis and creating a vacuum around the penis. This increases blood flow to the penis, creating an artificial erection. The erection is then maintained with an elastic band for up to 30 minutes.

For erectile dysfunction unresponsive to medication or other treatments, more invasive procedures like penile prosthesis implantation might be recommended. There are two main types available: malleable and inflatable implants.

Penile revascularization surgery, a treatment that addresses the blood flow to the penis, arterial balloon angioplasty, and venous ligation surgery are further options but only applicable for very specific patient populations and often with marginal long-term results.

A promising but experimental treatment is low-intensity shockwave therapy which is believed to enhance natural agents in the body that promote erections.

Intracavernosal stem cells and platelet-rich plasma therapy are innovative therapies that are still in the investigative phase.

Lastly, various studies are evaluating penile rehabilitation therapy after radical prostatectomy surgery. While there’s no consensus on the optimal treatment method, duration, or timing, a combination of PDE-5 inhibitors and external vacuum device therapy seem to yield the best results.

Despite the lack of supporting data, it might be beneficial to use the penile rehabilitation techniques for prostate cancer patients who choose definitive radiation therapy. Given the affordability of sildenafil and tadalafil, there is little harm in prescribing them after prostate cancer treatment.

What else can Erectile Dysfunction be?

When a doctor is trying to diagnose erectile dysfunction (ED), they will consider a few other conditions that might be causing the symptoms. These include:

• Low hormone levels (hypogonadism)
• Loss of sexual desire (libido)
• Depression or related mood disorders
• Other mental health issues

It’s also possible that erectile dysfunction might be an early sign of other health conditions like diabetes or heart disease. Therefore, it’s important to distinguish true erectile dysfunction from other issues like premature ejaculation. Doctors usually do this by having a detailed discussion about the person’s sexual history.

What to expect with Erectile Dysfunction

The outcome of erectile dysfunction (ED) depends on what’s causing it. If psychological or sexual issues are the cause, counselling tends to work well. Most other causes of ED also respond well to oral drugs known as PDE-5 inhibitors. If these aren’t effective, there are a lot of other treatment options.

These include using an external vacuum device, inserting a drug pellet into the urethra, injections into the penis, and combining different therapies. It’s rare for patients to not respond to any of these non-surgical methods. If that’s the case, there’s also the option of surgery to implant a penile prosthesis. This surgery has a high success rate.

Basically, there’s a successful treatment available for almost everyone with ED with the therapies that are currently available.

Possible Complications When Diagnosed with Erectile Dysfunction

Erectile dysfunction (ED) can have negative effects on relationships and overall quality of life. It is often accompanied by heart-related and diabetes-related complications, which can lead to further health problems.

Priapism, which is a prolonged erection often caused by medications, is relatively rare despite the widespread use of drugs like PDE-5 inhibitors. It’s usually seen in only about 3% of all priapism cases. Here are certain medications and their associated risks:

• Penile injection therapy: Involved in 8.8% of priapism cases
• Trazodone: Associated with roughly 6% of cases
• Second-generation antipsychotic drugs: Responsible for 33.8% of cases

Treating drug-induced priapism usually involves injecting a solution of diluted phenylephrine, at doses of 200 μg, every 5 to 10 minutes. This continues until the erection subsides or until a maximum dose of 1mg of phenylephrine is used. If this treatment doesn’t work, a surgical procedure may be necessary. Quick treatment is crucial, as delayed therapy could lead to permanent tissue damage in the penis.

Preventing Erectile Dysfunction

An important point to note for everyone is that erectile dysfunction, a condition many men experience, is treatable. Therefore, if men are dealing with this issue, they should not hesitate to get help. To help prevent this condition, it’s equally key to follow a healthy lifestyle. This includes avoiding smoking, eating a balanced diet, and getting regular exercise. It’s also critical to effectively manage any pre-existing health issues like diabetes, obesity, or high blood pressure.