What is erectile dysfunction?

Erectile dysfunction, also known as impotence, is when a man is unable to reach or maintain penile erection enough for satisfactory sexual performance. It can be consistent or happen recurrently.  It can affect the ability to have an erection, ejaculate or experience orgasm. Even if in some cases, mostly among young men, it may be due to some underlying psychological issues, in other people it may be due to other medical conditions such as diabetes, high cholesterol or high blood pressure. Hence, erectile dysfunction may be the first remarkable symptom for other diseases that require treatment.

Erectile dysfunction can cause huge distress and have negative effects on the patient’s self-esteem and relationships. It is a condition that affects almost 50% of men aged older than 40 years. Penile erections occur following the integration of several processes in the man’s body and involves different organ systems at once. If one of these organ systems are affected, erectile dysfunction may ensue.

It is important to make the diagnosis of erectile dysfunction as this may be revealing some other serious diseases or cause various complications such as anxiety and depression. There are treatments available for erectile dysfunction varying from sexual counselling to oral or injected medications and surgery.

Causes and risk factors of erectile dysfunction

There are several factors that can cause erectile dysfunction. These include:

·         Vascular diseases: Problems with the vascular system accounts for around 50% of all the cases of erectile dysfunction. These problems may include obstruction of blood vessels with cholesterol plaques (atherosclerosis), obstruction of blood vessels supplying the heart (myocardial infarction) or high blood pressure. Damage to the blood vessels and nerves in the penis may happen after radiation therapy to the prostate and pelvis, which is a treatment for cancer. This can induce erectile dysfunction.

·         Trauma: Trauma to the pelvis can cause damage to the blood vessels and nerves in that area. An example may be due to long periods of bicycle riding.

·         Diabetes mellitus: Studies have shown that diabetes is an important risk factor for erectile dysfunction. This may be due to constant high blood sugar which causes damage to blood vessels and nerves found in the penis. Strict control of blood sugar levels can significantly decrease the risk.

·         Abnormal cholesterol levels: Studies have shown that having a low amount of high-density lipoprotein (good cholesterol) can increase your risk of having erectile dysfunction.

·         Sleep disorders: Men with obstructive sleep apnoea are more prone to have erectile dysfunction.

·         Endocrine disorders: In some cases, erectile dysfunction may be due to inadequate secretion of hormones (substances released in the body to carry out specific functions) responsible for proper erectile function. These include testosterone and thyroid hormones.

·         Penile problems: Some diseases may cause abnormalities in the penis such as scarring or curvature. If the tissue in the penis is scarred, blood can no longer flow properly in the organ to initiate normal erection.

·         Mental health disorders: Certain mental health problems can lead to erectile dysfunction. These include depression and post-traumatic stress disorder.

·         Prostate surgery: Erectile dysfunction may arise in some people undergoing prostate surgery. This may be due to damage to nerves during the surgical procedure.

·         Medications: Erectile dysfunction may also be a side effect of certain prescribed medications. Some examples include psychotropic drugs and antihypertensive agents.

·         Lifestyle: Lack of exercise, obesity and smoking can all cause erectile dysfunction. You are approximately 2 times more at risk of the condition if you smoke compared to non-smokers.

Sign and symptoms

Erectile dysfunction usually present with typical symptoms including:

·         Difficulty to have an erection

·         Having an erection not suitable for penetration

·         Inability to maintain erection until the partner has achieved orgasm

·         Premature or delayed ejaculation

·         Inability for you and your partner to experience sexual satisfaction

Your doctor will ask you a series of questions concerning your problem. These may include:

·         Are you able to get an erection which enables penetration even if it is for a short period of time?

·         Is your condition getting worse or is it stable?

·         How long has it been going?

·         Do you have a problem in maintaining an erection?

·         Are you able to achieve orgasm and ejaculation?

·         Do you have nocturnal or morning erections?

·         Do you feel any pain or discomfort when you ejaculate?

·         How often do you have sexual intercourse?

·         Have you tried any treatments for the problem?

·         Are you on any treatments for any other medical condition?

It is important for you to answer clearly and honestly to these questions as this guide your doctor to what is best for you.

In some people, psychological problems may be the source of the erectile dysfunction. The following signs and symptoms may be present in that case:

·         Depressed mood

·         Loss of sexual interest

·         Problems and conflicts in the sexual relationship

·         Difficulty to fall asleep

·         Fatigue and weakness

·         Stress

Making a diagnosis

In order to make the diagnosis of erectile dysfunction, it is important for your doctor to take a thorough history from you. This will be followed by a physical examination which may comprise the following:

·         Blood pressure measurement

·         Taking the pulse in your legs

·         Assessing your sensation in lower limbs

·         Examination of your genitals and prostate

·         Examination of your testes and other associated structures

Other tests will be performed according to what has been obtained in the history and examination. These may include:

·         Blood tests: Samples of blood may be withdrawn to carry out certain tests such as hormone levels, serum chemistry panel, cholesterol levels and hemoglobin A1C (an average of the blood sugar levels for the last 3 months).

·         Urinalysis: Samples of urine may be taken to check for the presence of red blood cells, white blood cells, proteins or glucose. This may help in ruling out other problems that can arise in the genitourinary system.

·         Injection of prostaglandin E1: In this test, a substance called prostaglandin E1 is directly injected into the penis to evaluate for penile function. If an erection develops within minutes, this means that the blood vessels found in the penis are normal and are functioning properly. This will indicate that the problem may be at a different organ system.

·         Ultrasonography: In this procedure, a transducer emitting sound waves is used to visualise the penis and its blood vessels. This indicates whether blood flow is adequate to enable an erection.

·         Nocturnal Penile tumescence testing: In this procedure, several bands are placed around the penis before sleep. These bands are connected to a monitor that records any erections that may occur during night-time. The force and the duration of the erection are recorded. If the test is normal, this may highly indicate the presence of a psychologic cause of erectile dysfunction.

Treatment of erectile dysfunction

After having gathered all of the above information, your treatment will be tailored according to your condition. It is also important to involve your partner in the discussion on your treatment options.

These include:

·         Sexual counselling: If no medical or anatomical problem has been identified, sexual counselling may be the only therapy needed. It makes up the most important part in the treatment of people with sexual problems. The main goal is to increase self-confidence and self-esteem as well as to identify possible anxiety or thoughts that could be affecting one’s sexual desire and interest.

·         Discontinuation of causative medications: Whenever possible, drugs that may be triggering erectile dysfunction should be discontinued or replaced with another agent.

·         Medications: Several medications exist that can help in men with erectile dysfunction. The most commonly used are phosphodiesterase-5 inhibitors. They help in prolonging an erection. Some examples include sildenafil, vardenafil, tadalafil and avanafil. Men with erectile dysfunction and decreased sexual desire may benefit from hormonal replacements (testosterone) which are available in the form of oral medications, injections, gels or skin patches. It is important to clearly tell your doctor about any other treatments you are following for other medical conditions as the medications mentioned above may be dangerous if taken simultaneously.

·         Intracavernosal injection of vasodilators: This treatment modality include the direct injection of drugs into your penis to induce an erection. It will be important for you to learn how to properly inject the medications. However, this may cause certain side effects including painful, longstanding erections and scarring at the injection site.

·         Intraurethral suppository: Medications in the form of pellets or suppositories may be inserted into your urethra (opening through which urine flows out of the body). This will also induce an erection. Side effects may include painful erection and burning urethra.

·         Constriction devices: Men with vascular problems may benefit from a penile tourniquet which is a device that is placed at the base of the penis to maintain a rigid erection. This can be used in combination with medications for better results.

·         Vacuum devices: These are apparatuses that is placed on the penis to draw blood into it to induce an erection. After an erection is obtained, a constricting band can be placed at the base of the penis. About 50% of men who use vacuum devices achieve very good erections.

·         Surgery: Some selected people may undergo surgery. Surgical procedures may be done to revascularize the penis- meaning that the blood flow is restored. In other cases, penile implants may be placed into both sides of the penis as a last resort treatment option. However, these surgical procedures are accompanied by certain risks.

Complications

Erectile dysfunction has a huge impact on the individual affected. These may include:

·         Low self-esteem

·         Decreased self-confidence

·         Relationship problems

·         Depression

·         Anxiety

·         Lack of satisfaction in your sexual life

Prevention

Some preventive measures may include:

·         Strict blood sugar level control

·         Proper management of high blood pressure

·         Smoking cessation

·         Maintaining a healthy weight

·         Regular physical exercise

Prognosis

Some studies have shown that people with erectile dysfunction have a higher risk of having a cardiovascular accident later in life. Most erectile dysfunction may easily be managed with counselling and medications. 

Kim, E., 2020. Erectile dysfunction. 

Snyder, P., 2020. Overview of male sexual dysfunction.

Khera, M., 2020. Treatment of male sexual dysfunction.