Erectile dysfunction
What is erectile dysfunction?
Erectile dysfunction, also known as impotence, can be defined as the inability to achieve and/or maintain the erection sufficient to complete successful sexual intercourse.
Erectile dysfunction is a widespread problem, which affects millions of men in all age groups.
Impotence does not represent only a problem for the patient, as it can cause strain to the couple and family. This ultimately may lead to embarrassment, frustration and be responsible of patient’s low self-esteem.
There is a strong association between erectile dysfunction, Peyronie’s Disease and cardiovascular risk factors and impotence may represent the first sign of cardiovascular disease.
As erectile dysfunction can be the first warning sign of diffuse cardiovascular disease and a prompt intervention can treat erectile dysfunction and stop the progression of cardiovascular disease, it is important for the patient to seek medical attention.
A consultation with a Urologist who is experienced in the evaluation and treatment of erectile dysfunction represents therefore the best solution for the patient.
What are the causes of erectile dysfunction?
Erectile dysfunction can be subdivided in psychogenic and organic. Psychogenic erectile dysfunction cannot trace his origin to a physical problem or disease and is more common in younger men.
However, organic erectile dysfunction is much more common than psychogenic erectile dysfunction and in most cases the causes can be easily identified. Once identified, proper treatment can be recommended to help patients return to a satisfying sexual life.
Organic erectile dysfunction is usually caused by an injury (to the brain, spinal cord, peripheral nerves or arteries), by a disease (diabetes, high blood pressure or high cholesterol), by an operation (prostate gland removal, urinary bladder removal, surgery to the rectum) and by substance abuse (tobacco, drugs, alcohol and some medications).
What else is important to know of erectile dysfunction?
Approximately 40% of me at the age of 50 suffer from erectile dysfunction and this prevalence increases of around 10% each decade.
Although prevalence of erectile dysfunction increases with age, erectile dysfunction should not be seen ad an inevitable consequence of ageing
With adequate treatment, erectile dysfunction can be treated in almost all patients
How does a normal erection occur?
An erection is an involuntary reaction in response to sexual stimulation or erotic fantasy. Both sexual stimulation and erotic fantasy cause a chain reaction in which the brain, nerves, the heart, blood vessels and hormones work together to produce a rapid increase in the amount of blood flowing into the penis. The blood remains trapped inside the tunica albuginea of the penis and progressively engorges and distends the two spongy chambers in the shaft of the penis. As the two chambers rapidly fill with blood, they expand, and the penis becomes firm and elongated.
Which investigations are necessary in the patient with erectile dysfunction?
A thorough examination and history taking is necessary to distinguish between psychogenic and organic erectile dysfunction. Patients with psychogenic erectile dysfunction should be further investigated with a nocturnal penile tumescence test to confirm that the nocturnal erections are preserved. The confirmation of the presence of normal nocturnal erections rules out the presence of an organic cause of erectile dysfunction and the patients should be therefore reassured.
When organic erectile dysfunction is suspected and underlying cause is not obvious from the examination and history, efforts should be made towards the identification of the underlying condition, since erectile dysfunction may represent the first sign of diffuse cardiovascular disease. A prompt identification of possible cardiovascular risk factors such as diabetes, high blood pressure and high cholesterol levels is paramount to set up an adequate treatment plan and prevent further progression of the cardiovascular disease.
The Doppler Ultrasound scan of the penis is a relatively simple investigation, but it provides very important information on the blood supply to the penis.
Which are the treatment options for erectile dysfunction?
The management of the patient with erectile dysfunction is tailored to the underlying cause of erectile dysfunction and to patients’ preferences.
Various drugs are now available for the treatment of erectile dysfunction. Some medications are administered orally, some are injected directly into the penis while other are inserted into the urethra at the tip of the penis. When medical treatment is ineffective and contraindicated, the vacuum constriction device or penile prosthesis implantation guarantee the rigidity necessary for sexual intercourse.
Which oral medications are available in patients with erectile dysfunction?
The most common oral medications prescribed in patients with erectile dysfunction are Sildenafil, Tadalafil, Vardenafil and Avanafil. All these medications help to enhance erections and therefore do not trigger automatic erections as injections instead do. Therefore, sexual stimulation is necessary for these medications to work.
The most common side effects of these medications are headache, facial blushing, upset stomach and mild temporal visual effects (only for Sildenafil).
In most cases the side effects are minor and tend to reduce with time. Therefore, only very few patients decide to discontinue the treatment due to side effects.
Who is the best candidate for injections, and intraurethral medications?
Injections are indicated in these patients who do not respond to oral medications or when oral medications are contraindicated.
Injection therapy induces an erection even without the need of sexual stimulation.
The main advantage of injections is that it can be easily self-administered while the main risk is to induce a prolonged erection and may occur if an excessive dose of the medication has been injected.
The main reasons why patients quit injections are inadequate response, fear of needles, desire for a permanent treatment alternative and concerns over side effects.
Who is a good candidate for the vacuum pump?
The vacuum pump is a tube, which is sealed around the flaccid penis. With the creation of a negative pressure, blood is rushed into the chambers of the penis. Once the desired rigidity is achieved, a constricting ring is applied to the base of the penis to prevent the blood from rushing out of the penis and the vacuum pump is then removed. The vacuum pump can be a viable solution for patients who do not respond or are not suitable for oral and injectable medications and are not keen on penile prosthesis implantation.
What are penile prostheses?
A penile prosthesis is an artificial stiffener, which is inserted under general anaesthetic into the chambers of the penis to guarantee the rigidity necessary for sexual intercourse. Penile prosthesis reproduces a normal erection and preserves all the normal feeling and sensation. The quality of the erections obtained with a penile prosthesis is excellent with almost all patients and partners fully satisfied with the outcome of surgery.
The procedure usually lasts less than one hour and the patients are usually discharged the day after. The penile prosthesis is usually inserted through a 3 cm long incision on the scrotal sac. Sexual activity is usually recommenced six weeks after.
Penile prostheses are available in a semirigid and an inflatable version. Semirigid or malleable penile prosthesis are made of two semirigid cylinders, which are inserted into the chambers of the penis. They produce a constant erection and the penis is usually bent laterally to be concealed in the underpants.
The inflatable penile prosthesis is instead made of two cylinders, which sit in the chambers of the penis, a scrotal pump and an intra-abdominal reservoir. All the system is filled with sterile water. When the patient wishes to obtain an erection, he has to squeeze the pump to transfer the fluid from the reservoir to the cylinders. This produces a very good level of rigidity and a natural looking erection. When the sexual intercourse is completed, the patient needs to press the deactivation button of the pump to transfer the fluid back into the reservoir and to render the penis flaccid.
Inflatable penile prosthesis by far produces the best results in terms of rigidity and concealing of the penis in flaccidity. Malleable penile prosthesis therefore is indicated only in selected groups of patients.
What is rehabilitation of the corpora cavernosa?
Some patients will experience a temporary loss of their erections following surgery or trauma, which has compromised the nerves and vessels feeding the penis. The lack of spontaneous erections induces progressive damage to the corpora of the penis with deposition of scar tissue as no fresh blood is rushed into the chambers of the penis on a regular basis. Scar tissue formation is an irreversible process that produces penile shortening and weak erections.
Therefore, while the vessels and nerves feeding the penis regenerate, it is paramount to trigger erections on a regular basis in these patients in order to bring fresh blood full of nourishment into the chambers of the penis and therefore minimize the formation of scar tissue.
How rehabilitation of the corpora cavernosa is performed?
Rehabilitation of the penis can be performed with oral medication, with injections or with the use of the vacuum pump. Rehabilitation can be usually started with oral medications while injections and the vacuum pump are indicated in patients who have not responded to oral medications.
How long should rehabilitation continue?
Rehabilitation should continue until natural erections have been fully restored. If there is no recovery of natural erections, a long-term solution such as oral medications, injections, vacuum pump or penile prosthesis implantation should be considered.
What is low intensity shockwave therapy?
Extracorporeal shockwave treatment (ESWT) can be offered to selected patients suffering from erectile dysfunction to regenerate the tissue inside the corpora of the penis to improve the quality of the erections.
The waves, which are produced by a handpiece that is placed on the body and can be transmitted to the corpora of the penis without involving nearby tissues.
Although the biological mechanism of action is not yet well understood, it has been suggested that ESWT promotes the release of angiogenic factors, which can help to generate new blood vessels, thus improving the blood supply to the corpora of the penis and ultimately the quality of the erections.