Erectile Dysfunction & Related Conditions: Symptoms, Diagnosing, ED Drug Therapy

In modern medical practice, erectile dysfunction (ED) is not considered a separate disease. This syndrome is normally based on a problem with a man’s health, which can be quite serious. Therefore, when a symptom of ED occurs, a complex examination of the male organism is of great importance, since it should help to find out the exact cause of the pathology.

What is impotence or erectile dysfunction?

The scientific definition of erectile dysfunction is “the inability to achieve / maintain the erection necessary to fully satisfy the sexual need.”

ED is a relatively new term. It was offered by American health professionals instead of the more common “impotence”. The fact is that the old term sounds too categorical, burdens the perception of pathology and is not associated with the possibility of a successful cure.

How common is Erectile Dysfunction?

Statistics of WHO are disappointing: about 10% of men over 20 have problems with erection. In addition, among the representatives of the older age category (over 60), one in three is not able to carry out a sexual intercourse. Moreover, there is a negative dynamics of this problem. Now, according to rough estimates, there are 150 million men in the world suffering from ED. Physicians predict that in a quarter of a century this number could double.

How do most men deal Erectile Dysfunction?

According to medical statistics, only one out of five men suffering from ED goes to see a specialist. And only 37% of them get the necessary treatment. Many mistakenly believe that ED is not a medical pathology, but simply a result of fatigue and nervous overexertion.

To sum up, the pathology is very common, but men do not rush to seek help from specialists. They prefer to ignore the problem or practice ineffective (and sometimes dangerous) self-medication. As a result, the disease progresses, and then it becomes even more difficult to normalize one’s sexual life.

It is important to understand that erectile dysfunction cannot be considered as a separate urological diagnosis. It is necessary to take into account the general condition of the male organism and to involve medical specialists of different profiles in solving the problem. This will provide qualified assistance to patients with erectile dysfunction and allow achieving positive long-lasting results.

Physiology and pathophysiology of erection

Erection is an increase in the elasticity of a penis with a simultaneous increase in its volume, which is due to the rapid filling and stretching of the cavernous bodies because of sexual arousal. This mechanism is rather complicated; it assumes a number of consecutive neurovascular changes leading ultimately to the relaxation of smooth muscle tissues of sinusoids, arterioles and arteries.

At the end of the 20th century, medical scientists discovered new information about the mechanism of erection and the causes of sexual dysfunction. It means that there are more ways to treat this problem adequately.

According to the latest studies, an erection occurs as follows. Sexual stimulation activates the parasympathetic nervous system. From the vascular tissue of the cavernous bodies, neurotransmitters (in this case nitric oxide) are released, which causes cyclic guanosine monophosphate to accumulate in the cavernous tissues, which reduces the concentration of intracellular calcium, which leads to relaxation of the walls of the vessels and cavernous bodies. Lacunas are filled with blood from the arteries, as a result, veins are blocked, and the outflow of blood from the penis is suspended. This phenomenon is called a vein-occlusive mechanism.

So, the erection should be considered as a multi-stage neurovascular process, proceeding according to this scheme: sexual stimulation – release of neurotransmitters – accumulation of guanosine monophosphates in cavernous tissues – relaxation and contraction of smooth muscle tissues.

What causes erectile dysfunction?

What causes erectile dysfunction

Depending on the factors that have lead to erectile dysfunction, there are three main types of ED:

  1. organic ED
  2. psychogenic ED
  3. mixed ED

Psychogenic causes

Organic causes

  • Depression
  • Stress
  • Fear
  • Anxiety
  • Vascular or vasculogenic
  • Neurogenic (nervous system and spine disorders)
  • Hormonal (diabetes, andropause or men’s’ “menopause”)
  • Penis disorders
  • Medicaments
  • Mixed

Men’s sexual problems were traditionally associated, first of all, with the mental factor. It was believed that stress and nervous tension directly affect the quality of sexual life. Today, another point of view has appeared. The doctors came to the conclusion that the vast majority of ED cases (up to 80%) are caused by organic causes. That is, ED is a complication of a physical illness. It was noted that problems with erection are associated with lifestyle. A great role here belongs to such factors as physical activity and bad habits.

Naturally, the age of a man has a certain effect on the quality of his sexual life. An elderly person has a lower testosterone level, his blood flow rate decreases, the nervous system is no longer so sensitive, and the vessels lose elasticity. Nevertheless, these natural age processes alone cannot underlie erectile dysfunction. The main cause of sexual dysfunction is a more serious somatic disease. If a man does not suffer from chronic ailments, he can maintain the ability to intercourse until very advanced years.

Multiple medical studies confirm the direct relationship of ED with atherosclerosis, diabetes mellitus (DM) and arterial hypertension (AH). The presence of one of these pathologies increases the risk of ED occurrence by several times. Some medical scientists even believe that erectile dysfunction may indicate the presence of one of these chronic ailments in the initial latent form.

Erectile dysfunction and atherosclerosis

Vessels of a person suffering from atherosclerosis become less elastic, their lumen decreases. As a result of such changes, the male organ does not receive the necessary amount of oxygen. Significant risk factors for this are dyslipidemia, diabetes, nicotine addiction. About 60% of those suffering from ED are smokers with experience. Moreover, smokers experience hypercholesterolemia twice as often as people who do not have erectile dysfunction. Approximately 40% of men who have atherosclerotic changes in penile vessels have trouble in the genital area after 50. Various complications of atherosclerosis can develop in parallel. For example, erectile dysfunction is often diagnosed among patients with ischemic heart disease. The fact is the same pathologies are caused by the same risk factor – a disorder of the functioning of penile and coronary vessels. If ultrasound dopplerography recorded a significant reduction in blood flow, before the course of ED therapy it is necessary to make loading ECG samples.

Erectile dysfunction and hypertension

Many researchers note that erectile dysfunction often occurs among patients with high blood pressure. The combination of these two problems affects the quality of life of a man and significantly complicates treatment. Therefore, many hypertensive patients notice a decrease in sexual function when taking medications that lower blood pressure and refuse hypotensive drugs. Especially often, ED is associated with the use of OI-adrenoblockers and thiazide diuretics. However, we cannot claim that all types of drugs for hypertension lead to a high risk of erectile problems. On the contrary, some medications (in particular, angiotensin II antagonists) can enhance the erectile capabilities of men. The positive effect of AA II on the sexual function of men is most likely related to the blocking of angiotensin II receptors, which, as the researchers found, is able to stop spontaneous erections.

Erectile dysfunction and diabetes mellitus

ED statistics in diabetes is disappointing. Among men with diabetes, erectile disorders occur three times more often and begin on average 10-15 years earlier than among those who do not have this diagnosis. According to the latest data, erectile dysfunction affects more than half of men with diabetes. The risk of ED among diabetics is increasing with age and is associated with the duration of the underlying disease. In young men with diabetes (up to 30 years), the prevalence of ED is not higher than 15%. Men from 30 to 60 years are diagnosed with erectile disorders in about half of the cases. As for the older age category (70 years and more), here the vast majority – 95%, suffer from ED. Moreover, most often erectile dysfunction occurs in men with diabetes of the second type. The main cause of ED in diabetes is of an organic nature and is associated with polyneuropathy, micro- and macroangiopathy. In addition, researchers note that in men diagnosed with diabetes, erectile dysfunction correlates with the content of glycosylated hemoglobin, retinopathy, peripheral and autonomic neuropathy.

Erectile dysfunction and hormonal disorders

 A significant role in the occurrence of erectile disorders is played by hormonal disorders. Thus, it is noted that up to 35% of patients with ED have a testosterone deficiency. Many metabolic disorders are associated with this: overweight, hypogonadism, etc.

Erectile dysfunction and chronic renal failure

Chronic renal failure (CRF) is another pathology that is commonly associated with ED. More than half of these patients complain of problems in the genital area. In men with renal insufficiency, nocturnal erections were studied, and it turned out that after the dialysis procedure the sexual function improved somewhat, but did not completely return to normal. The most effective solution in this case is the kidney transplant.

Erectile dysfunction and bronchial dysfunction

Also, there is a connection between ED and obstructive pulmonary pathology. More than half of men with obstructive bronchitis and asthma have problems with erection. In addition, patients with duodenal ulcer (especially associated with Helicobacteriosis) are known to have this problem, as well as with urinary infections, steatohepatitis. However, there are still very few studies in these areas.

Erectile dysfunction and stress

The dependence of ED on the mental state of a man is a proven fact. So, the risk factor is depression. In men with moderate depression, the probability of problems with erection is 25%. In the case of severe depression, this figure increases up to 90%. A strong shock (for example, death of a loved one) can also cause ED. Nevertheless, the most common psychogenic factor is the man’s insecurity in his sexual abilities. This phenomenon is known as situational ED. In this case, a man is simply afraid to enter into an intimate relationship, believing that he can “disgrace himself” because of an unsuccessful sexual intercourse.

Another risk factor is aggression. Researchers have found that in men prone to fits of anger, erectile dysfunction occurs quite often. In addition, one should not forget that a combination of organic factors with psychogenic causes is possible. In general, it can be argued that about 80% of all cases of ED have an organic origin and are a complication of a somatic disease (diabetes, AH, CRF, atherosclerosis, etc.). At the heart of ED, there are different mechanisms: vascular, neurogenic, associated with side effects of medical drugs. Also, we should not forget about the dependence of erectile problems on the level of education and lifestyle of a man.

What are the symptoms of erectile dysfunction?

Male impotence is manifested by such signs:

  • problems with achieving / maintaining an erection;
  • weak erection;
  • ability to maintain an erection only through conscious effort;
  • morning erection weakens and happens less often.

Such problems are usually attributed to the personal sphere and kept secret from others. That is why most men with ED are slow to share their problem with specialists and remain without treatment. In addition, many of them are sure that modern medicine cannot fix anything. However, this is not true, erectile dysfunction is successfully cured nowadays. According to statistics, treatment helps in nine out of ten cases. Earlier it was mentioned that ED is not an independent diagnosis, but a manifestation of another disease. Therefore, therapeutic courses are prescribed taking into account the underlying disease. The treatment can be both medicamental and psychological.

What are peculiarities of diagnosis of erectile disorders?

What are peculiarities of diagnosis of erectile disordersComplex diagnostics of erectile disorders involves examination of the patient, study of anamnesis, laboratory tests. For effective collection of necessary information, patients are given special questionnaires. The questionnaire has two important advantages: it saves the doctor’s time and helps the patient to avoid the awkwardness which is inevitable in a personal conversation.

Mandatory are the tests for the level of testosterone and glucose in the blood. The level of prolactin, lipids, and PSA can also be measured.

Further surveys are recommended for men with primary erectile dysfunction, in order to eliminate the organic nature of the disorder. They will also be necessary if there is an injury in the pelvic or perineal region.

The next method of diagnosis is monitoring of spontaneous nocturnal erections. It is a well-known fact that a healthy man has up to six erections in the fast sleep phase. Each episode of erection lasts 10-15 minutes. The total time of nocturnal erections reaches one and a half hours, which is 20% of the duration of a night’s sleep. In the case of ED, both the quality and the number of spontaneous erections at night decrease. This makes it possible to use monitoring for the purpose of differential diagnosis of mentally conditioned and organic forms of erectile disorders. If the erection lasted less than 10 minutes, and its stiffness was only 60%, we can talk about sexual dysfunction. Today the study of spontaneous nocturnal erections is considered to be the most reliable method of qualitative and quantitative evaluation of a male’s erectile capacity.

Another informative diagnostic method in this case is ultrasound dopplerography of male organ vessels. This procedure gives a good picture of blood microcirculation. And if implemented in the B-mode, it is possible to detect changes caused by Peyronie’s disease and cavernous fibrosis. However, the separate use of the two modes does not give exact results. Therefore, a duplex method of examination is used quite frequently. In addition, the effectiveness of the procedure largely depends on the technical level of medical equipment. Examination of the arteries of the penis is performed twice: at rest and during erection, which is achieved by visual stimulation (erotic video) or with a drug stimulating the erection. Then the results are compared.

The quantitative parameters of the study are the peak systolic velocity and the final diastolic velocity (PSV and EDV). Using standard formulas, relative values are calculated on the basis of absolute indices: the resistance index, the pulsation index (RI and PI).

For diagnostic purposes, the Viagra test can be combined with video stimulation, while monitoring erection and tracking hemodynamics in the penis with ultrasound. The main advantage of such a survey is that it is non-invasive and does not carry the threat of priapism. Nevertheless, the method has a significant disadvantage. The fact is that visual stimulation does not allow full standardization of the technique, because different patients require different stimuli to get excited.

Vasculogenic erectile disorders are detected using a special test, which involves intracavernous injection of vasoactive substances (most often alprostadil). If a full erection appears within ten minutes and lasts at least half an hour, it means that arterial and veno-occlusive hemodynamics are normal.

Several other studies are being conducted on a number of indications. These include cavernometry. The purpose of this method is to estimate the elasticity of a sinusoidal system and to determine its closing ability. For this, physiological saline is injected into the cavernous bodies, and its volumetric rate necessary for the appearance of an erection is established.

Cavernography. The method consists of examining the vessels through which blood is discharged from the cavernous bodies.

Radioisotope phalloscintigraphy. This test gives a complete picture of hemodynamics in the cavernous bodies of the male organ.

Treatment methods for erectile dysfunction

Unfortunately, many patients with erectile dysfunction are pessimistic. They do not believe that modern medicine can help them return to a full sexual life. Moreover, some doctors believe that the extinction of sexual function with age is natural, and this is an irreversible process. Nevertheless, studies show that accurate diagnosis and adequate therapy help improve sexual function of 95% of patients.

Treatment scheme and impotence correction is determined by a specialists and should depend on the results of diagnosis and the available somatic diseases associated with ED. For example, men with a diagnosis of diabetes require safe hypoglycemic therapy.  Patience with hypertension should take antihypertensive drugs. In chronic obstructive pulmonary disease (COPD) adrenomimetics and theophylline are canceled, anti-inflammatory inhalation treatment is indicated. Patients with CRF need to strengthen dialysis and prescribe a course of anemia treatment. Patients with gastric ulcer H2-histamine blockers are substituted for proton pump inhibitors.

The most effective treatment for organic and psychogenic erectile dysfunction at this time are inhibitors of phosphodiesterase type 5 (PDE5). During sexual stimulation, the nervous system is activated and nitric oxide is released. This leads to the accumulation of cyclic guanosine monophosphate (cGMP) in the smooth muscle cells of the vessels. It has already been noted above that it initiates a chain of consecutive reactions leading to an erection. When the simulation stops, the cGMP level is reduced by phosphodiesterase-5. If, due to some factors, there is a shortage of cGMP, its destruction by phosphodiesterase 5 leads to erectile problems. The use of inhibitors does not have a direct relaxing effect on cavernous bodies. The mechanism is different: as a result of inhibition of PDE5, the level of cGMP increases and the relaxing effect of nitric oxide increases.

In the medical science there are a number of publications related to the use of Viagra (sildenafil citrate). Recently another inhibitor of PDE5 – tadalafil (Lilly / ICOS, Cialis) began to be used. It differs from sildenafil by several characteristics: chemical structure, selectivity, pharmacokinetic profile, clinical effect. According to the pharmacokinetic profile, the difference is significant: in tadalafil, the half-life is much higher than that of sildenafil. Every third patient who has taken tadalafil reached the clinical effect in 16 minutes and lasted for 36 hours. This allows the couple to freely choose the time for sexual intercourse. Suppose a man took the drug on Friday night. Full intimate intimacy is possible until Sunday morning, and a man can choose any suitable moment for him. Another advantage of this medicine is that its concentration does not decrease under the influence of alcohol and abundant fatty foods. Therefore, the patient can adhere to the usual life-style.

As for the possible side effects of tadalafil, most often are headaches and dyspepsia. In some cases, flushes of blood, nasal congestion and back pains. There were no visual impairments. It is extremely undesirable to take tadalafil (as well as sildenafil) simultaneously with nitrates. The combination of these drugs can lead to a sharp drop in blood pressure. If angina attacks occur while taking the PDE5 inhibitor, nitroglycerin is strictly prohibited. The use of any nitrate is allowed only two days after taking tadalafil. The tadalafil and sildenafil treatment should be taken cautiously if the patient has an anatomical deformation of the male organ or suffers from a disease that can lead to priapism (leukemia, sickle-cell anemia, etc.).

Most often, erectile dysfunction is associated with vascular pathologies. In many cases, surgical intervention is possible, which helps to increase the flow of blood to the penis and to complicate its outflow. The effectiveness of such operations varies between 20% and 80%.

The most radical method of eliminating problems with erection is the installation of prostheses in place of cavernous bodies. There are different types of such prostheses. The simplest prosthesis is a special semi-rigid rod. However, there are also more advanced devices – special cylinders, in which liquid can be pumped. Essential disadvantages of the method are the risk of complications and the irreversibility of the operation.

If erectile dysfunction is due to psychogenic factors, a therapist who specializes in sexual problems should define a course of treatment. This specialist is called a sex therapist. It is believed that discussing one’s thoughts and concern with a doctor plays an important role in the treatment and promotes the restoration of male power. Appeal for help to the sexual partner: there are negative moments, which can be corrected by sincere communication and good attitude.