Erectile dysfunction
Is erectile dysfunction the same as impotence?
Yes, it is the same, but health professionals prefer the term Erectile Dysfunction because it more clearly defines the nature of the disorder than the term impotence used above, because the latter can be understood as weakness or can have a more negative connotation for many people.
What is erectile dysfunction?
Erectile Dysfunction is the persistent inability to achieve or maintain an erection sufficient to allow satisfactory sexual intercourse. Erectile Dysfunction does not refer to a lack of sexual appetite, nor to a lack of pleasure or orgasm in intercourse. Neither is Erectile Dysfunction synonymous with ejaculation that is too rapid or delayed, nor with curvatures in the penis when it is erect. It is only a disorder of penile rigidity. Erectile dysfunction is in no way due to excessive sexual activity or masturbation in the past, and there is no link to infertility.
Is erectile dysfunction a disease?
The World Health Organisation (WHO) defines erectile dysfunction as a class III disease, belonging to the same group as rheumatoid arthritis. It has the same range of severity and disability as radial fracture, infertility, rheumatoid arthritis or angina pectoris.
Is it a common disease?
Most men may experience erectile difficulties on an isolated occasion, but around 1.5 million men in Spain between the ages of 25 and 70 have a permanent or chronic erectile disorder. It is therefore a very common condition, affecting more than 100 million men worldwide and more than 1.5 million in Spain, although it is estimated that only 10% of affected men ever consult a doctor about their disorder.
Why is the percentage of consultations so low?
Various reasons can be found to explain it, such as the assumption that Erectile Dysfunction is an inevitable consequence of age, or that there is no effective and convenient treatment, together with the tendency not to accept it because of the lack of masculinity it seems to imply and the difficulty involved in discussing such intimate issues as sex life with a doctor.
Can erectile dysfunction affect a patient’s quality of life?
Yes, it can. Erectile dysfunction has a negative impact on the quality of life of all men who suffer from it. A study has shown that there is a correlation between the prevalence of this disease and the deterioration of different areas of the personal and family life of the men who suffer from it. Patients with erectile dysfunction see their self-esteem undermined, they feel insecure, anxious and are often rejected by their partners.
Is it possible to have erectile dysfunction with a certain partner and not with others?
Yes, sometimes erectile dysfunction can only occur with a specific partner. This is the case with psychogenic and situational erectile dysfunction. Generally, the patient is concerned about ‘looking good’ with a certain partner and this generates an anxious reaction at the moment of sexual intercourse. The erectile response is correct in other situations, but not when facing the relationship with that partner.
What are the causes of erectile dysfunction?
Basically, the causes that can produce erectile dysfunction are divided into organic and psychological: among the former, vascular, neurological, endocrinological and medication-related causes are the most frequent.
What influence do psychological factors have?
It is estimated that 30% of erectile dysfunctions have a psychological origin. The psychological factors that can affect erection are very varied. There are early situations that may facilitate its appearance in the medium or long term: a restrictive moral or religious upbringing, inadequate sexual information, traumatic sexual experiences or deteriorated relationships between parents, among others.
Other situations may condition its appearance in the short term: previous erectile dysfunction, problems in the couple’s relationship, sporadic erection failures, infidelity, depression, anxiety, stress, sterility problems, the change in sexual response as a consequence of age. Many of these factors end up becoming maintainers of Erectile Dysfunction, so that many organic Erectile Dysfunctions end up having a psychological component over time.
How can vascular diseases affect erection?
When the arteries that supply blood to the penis are diseased, insufficient blood reaches the penis and the erection achieves little rigidity. In everyday life there are a number of factors that we call vascular risk factors, as they promote the deterioration of the arteries.
The best known are high blood cholesterol, diabetes, smoking, high blood pressure and trauma to the pelvic region, which cause the arteries to become stiff and reduce in calibre, becoming arteriosclerotic.
Also the ageing of people, and therefore of tissues, contributes to the loss of elasticity of the arteries. Less frequently, the main failure of erection is the inability to store blood in the penis, as a consequence of a chronic failure of filling, which causes the penile tissue to be inadequately oxygenated and eventually deteriorate.
How can neurological diseases cause erectile dysfunction?
Sometimes the nervous system is affected by a neurological disease or trauma, causing the nerve impulse that triggers erection not to be transmitted, such as multiple sclerosis, spinal cord or head injury, and pelvic fracture.
Other times the nerves that have to conduct the nerve impulse generated in the brain malfunction, as can occur in diseases such as diabetes or alcoholism, or as a consequence of surgery in the pelvic area due to prostate, bladder or rectal cancer.
What hormonal alterations can cause erectile dysfunction?
Although the role of androgens, as the male sex hormones are generically called, in erection is not well determined, we know that individuals with a deficit in gonadal function (the hormone responsible for producing these hormones) tend to have erectile dysfunction.
This deficiency is called hypogonadism and may originate in the areas of the brain responsible for controlling the production of these hormones (hypothalamus and pituitary) or in the testicle, as this is where testosterone, the male hormone par excellence, is produced.
Another hormone involved in the production of erectile dysfunction is prolactin, a hormone produced in certain areas of the brain, an excess of which can cause erectile dysfunction. This excessive production may be due to multiple causes, including tumours affecting the pituitary gland (the area where it is produced under normal conditions), kidney failure or the inappropriate use of certain medications.
Hormones produced by the thyroid gland, either by excess production or not, can also be a cause of erectile dysfunction.
Is it true that diabetes can cause erectile dysfunction?
Yes. 30-50% of poorly controlled diabetic patients are affected by erectile dysfunction. The most important factor, together with the duration of the disease, is the lack of adequate control, since in these cases alterations appear in the blood vessels and nerves, which are the main driving elements of the erection mechanism.
Can drugs cause erectile dysfunction?
Yes, some drugs can cause erectile dysfunction as an adverse effect: drugs for the treatment of high blood pressure, hypercholesterolemia, diabetes, depression, stomach ulcers, insomnia, and some types of drugs used to treat cancer, as well as the use of addictive drugs.
Is there a link between alcohol or drug use and erectile dysfunction?
Alcohol abuse causes disturbances in erectile mechanisms, leading to transient erectile dysfunction in many cases. Certain drugs can affect the vascular mechanisms involved in erection. Many drugs affect not only erectile function, but also sexual desire.
Is there an association between smoking and erectile dysfunction?
Yes, an increase in the number of cases of erectile dysfunction has been observed in the smoking population. Nicotine causes a decrease in the size of blood vessels, which is why smoking is considered a vascular risk factor. It also acts by reinforcing other causes (arterial hypertension, arteriosclerosis, diabetes, etc.).
Diagnosis of erectile dysfunction
I have erection problems, what can I do?
The most important thing is to consult a doctor to diagnose the main cause of the problem.
Which doctor should I see?
The specialist who diagnoses this pathology is the andrologist. He or she will inform you and ask you to undergo the necessary tests in order to make a correct approach to the problem and will indicate the appropriate treatment in your case.
How does the doctor assess erectile dysfunction?
When you go for a consultation, the doctor will follow a diagnostic assessment process:
Medical history: the doctor will ask you several questions with the aim of discovering possible risk factors that could cause erectile dysfunction or contribute to its development.
Sexual history: the doctor will ask you several questions to find out since when and under what circumstances you have experienced signs of Erectile Dysfunction. This information is essential and should be expressed in a matter-of-fact manner. You should not try to use technical words whose exact meaning you may not know, but rather use simple language. The doctor will understand this perfectly well as he/she is used to hearing about similar problems.
Psychosocial assessment: to determine possible psychosocial factors related to Erectile Dysfunction that may require psychological consultation or treatment.
Physical examination: focusing especially on the penis to check for abnormalities such as nodules or fibrosis, as well as general assessment of health status, neurological function and secondary sexual characteristics.
Is there a test to assess erectile dysfunction?
Yes, there is a questionnaire, agreed by the international medical community, which is designed to help you identify the extent to which you do or do not have an ED problem. Your doctor may give it to you to be filled in at home and given to you at a future visit, but it should never replace a personal interview.
Will any diagnostic tests be necessary?
In some cases, questioning and physical examination may be sufficient to establish a diagnosis. But generally, it is advisable to do blood tests to determine hormone levels, cholesterol, glucose to detect the presence of diabetes and to check liver and kidney function. More invasive diagnostic tests are not usually necessary. In general, the tests to be performed are not painful or uncomfortable for the patient. However, in some cases, more complex tests may be necessary to determine the cause of erectile dysfunction.
Treatment for erectile dysfunction
Is there a treatment for erectile dysfunction?
Yes, regardless of the cause, most cases can be treated. At present, there are different treatment options available, which must be adapted to each patient.
Is erectile dysfunction curable?
The cure depends on the cause or causes. If it is due to psychological causes, such as stress or depression, treatment can help to solve it. When it is due to neurological causes or pathologies such as hypertension or diabetes, drugs can treat it effectively.
What treatments are currently available?
Depending on the cause of the Erectile Dysfunction, the recommended treatment will be psychological, medical or surgical.
In all cases, hygienic measures are applicable that can reduce the risk of suffering Erectile Dysfunction: giving up harmful habits such as smoking or drinking alcohol in excess, establishing nutritional diets to correct alterations in the metabolism, or changing a medication that is being taken.
In some pathologies these medications are essential, but generally, they can be replaced by others with fewer side effects on erection.
When is psychological treatment necessary?
Psychological factors should be addressed in all patients suffering from Erectile Dysfunction, as they can be both the cause of it and responsible for its maintenance, even if the underlying problem is organic. They can be addressed by a psychologist, a psychiatrist or a doctor from another speciality with knowledge of psychological therapeutic guidelines.
What does psychological treatment consist of?
Basically, it is based on modifying those attitudes that contribute to maintaining erectile dysfunction. By re-educating the sexual behaviour of the patient and his partner, we try to reduce the level of anxiety.
The aim is for erection and penetration to be just another element of the sexual relationship, and not the key aspect of success or failure in sexual intercourse. In many cases, anxiety in sexual intercourse is caused by an organic problem, which, if treated effectively, will make the anxiety disappear.
What does hormonal treatment consist of?
In those cases in which the cause of Erectile Dysfunction is a decrease in testosterone levels, the administration of this hormone by injection or patches restores adequate levels in the blood for proper sexual functioning.
My blood testosterone levels are normal, can I take testosterone?
No. When testosterone levels are not low, treatment with hormone supplements is not only not beneficial, but may even be harmful.
What other drugs are currently available for the treatment of erectile dysfunction?
Increased understanding of the mechanism of erection has led to the research and development of effective drugs for the treatment of erectile dysfunction. There are now drugs that can be administered orally, intraurethrally or intracavernously.
How do intracavernous drugs work?
Intracavernous drug administration consists of injecting a certain dose of the drug into the base of the penis with a small-gauge needle. The drug activates the normal processes that initiate and maintain a spontaneous erection.
Once the doctor has been able to determine the appropriate dose for each patient in the consultation room, he can train the patient in the injection technique so that he can administer the drug at home.
The patient is injected ten to fifteen minutes before intercourse and the dose is adjusted so that the erection lasts for about an hour.
The duration of the erection should never exceed four hours, and if this happens, the patient should see a doctor immediately.
Some patients experience pain in the penis during erection and there is a small risk of scarring inside the penis with prolonged use.
Papaverine was the first drug used for intracavernosal treatment and has also been used in combination with phentolamine and alprostadil.
Alprostadil (Caverject®) is the only drug marketed in our country for intracavernous administration, being the most widely used throughout the world due to its effectiveness and safety.
What does transurethral therapy consist of?
The MUSE® system (Medicated Urethral System for Erection) has been designed for the local application of alprostadil to the penis through the urethra.
This treatment consists of inserting a small plastic cylinder into the urethra (urinary tract), through which the medication is administered.
It is important to urinate before inserting the cylinder, as the urine acts as a lubricant and facilitates the absorption of the medication to produce an erection.
Erection takes ten to fifteen minutes to occur and the drug is effective in 43% of patients. Application is often accompanied by stinging in the urethra.
Minor bleeding in the urinary tract has also been reported in 5 per cent of men. The use of condoms is recommended when the woman is pregnant or there is a possibility of pregnancy.
Is there any oral treatment?
In recent years, a number of orally administered drugs have been developed.
The first of these was Sildenafil (Viagra®), which belongs to a group of drugs called phosphodiesterase type 5 inhibitors. Subsequently, Tadalafil (Cialis®) and Vardenafil (Levitra®) also belonged to this group of drugs.
These drugs act at the peripheral level by promoting the accumulation of a substance that causes relaxation of the muscle fibres and arteries that carry blood to the penis.
The result is an increase in blood flow, which improves and maintains the erection.
The onset of effect varies, depending on the drug, between 20 and 60 minutes. The duration of effect, also depending on the drug, can be between 4 and 24 hours. These drugs are contraindicated especially in cardiac patients taking nitrite or nitrate therapy. Another drug is Apomorphine (Uprima®).
Apomorphine is administered sublingually, 20 minutes before sexual intercourse. The substance acts on the central nervous system. A possible advantage is that it can be safely taken by patients with stable angina pectoris who are being treated with nitrates.
All of these drugs can have side effects and have contraindications and must be prescribed by a doctor. In the event that you need to be treated with oral drugs, your specialist will indicate the most appropriate one for you.
What other treatments are there?
Suction or vacuum devices are another treatment alternative. It consists of a plastic cylinder into which the penis is inserted and attached to the body with a lubricating substance to create an airtight space.
After activating a mechanism (manual or electric), a vacuum is created which produces a suction effect on the penis, causing it to fill with blood.
Once the penis is rigid, an elastic constriction ring is placed at the base of the penis, which will prevent the blood from escaping, and the cylinder is removed.
It is a safe method as long as the ring is not left in place for more than 30 minutes and guarantees an erection until it is removed. In cases where other treatments do not work and surgery is not an option, these devices may be a good alternative.
What surgical treatments are used for erectile dysfunction?
Surgery can be an effective solution in some cases, but it should be the last treatment option, once non-invasive treatments have failed. Basically we can talk about arterial surgery, venous surgery and penile prosthesis implantation.
When is arterial surgery indicated?
It is recommended for young patients who have suffered an accident that has affected the normal blood supply. The aim of the surgery is to increase blood flow and pressure within the penis. The technique involves joining a normal artery (usually from the abdomen) to an artery in the penis and thus creating a ‘by-pass’ or alternative pathway for blood to enter the penis, bypassing the arterial blockage.
When is venous surgery indicated?
This type of surgery, which was very popular in the past, is not considered very effective nowadays, except in very selected patients. It consists of ligating or removing veins from the penis in a similar way to the technique used in the treatment of varicose veins.
What does penile prosthesis consist of?
The most common surgical treatment is the implantation of a prosthesis. In this procedure, two cylinders of synthetic material are inserted into the corpora cavernosa of the penis to provide rigidity to the penis.
There are several types of prostheses, but the ones that provide an erection most similar to the physiological one are the so-called hydraulic ones, which have a mechanism to inflate and deflate them, and which provide a state of flaccidity and a quite natural erection.
Although implants carry the risk of infection (especially in diabetic patients or patients with low defences), mechanical failures are minimal and complications are increasingly rare.
