Erectile dysfunction (ED), or impotence which is a misleading term because impotence describes a more general inability) can be defined as inability to obtain and maintain an erection sufficient to carry out intercourse. Another definition rather indicates that the erection should “enable a sexual activity for the individual”.
Background and epidemiology
Erection problems are common; Over half of all men between the ages of 40 and 70 are experiencing and to some form of erection problems and the inconvenience is increasing with increasing age. A total of 40-70 years of age indicates that about 20 percent have minor erection problems, 25 percent have moderate inconvenience and 10 percent have completely lost their ability to erect. The affected man usually experiences ED as very negative and feelings of mood, insufficiency, anxiety, anger and frustration are common. The male’s partner is also affected by his sexual problems.
Etiology, pathogenesis and clinical picture
Somatic causes, including cardiovascular disease and diabetes, are considered to cause about 80 percent of all ED, while the remaining 20 percent are conditioned by psychological disorders. Quite often, both somatic and psychogenic factors are of importance to the resulting failure erection.
For patients with advanced cardiovascular disease, more than 30 percent have total erectile dysfunction and more than 50 percent ED of varying degrees. Diabetics constitute a high risk group for erectile dysfunction, inter alia due to neuropathy, leading to impaired neuronal signaling between nerve cells and the smooth muscle cells of the penile swelling bodies. Even poor sugar settings in diabetics impair the erectile function. Smokers are also overrepresented among the applicants for erection problems. A deteriorated endothelial cell function of these three groups may be the common denominator.
It is well known that both the hypertension disease and its treatment can lead to erectile dysfunction. Even modern anti-depressant drugs (SSRIs) can interfere with sexual life, sometimes in the form of disturbed desire or orgasm experience, but ED may also occur. When erectile dysfunction has erectile dysfunction, the symptoms usually develop for a long time.
Major surgical procedures in the small pelvis, such as radical prostatectomy or cystectomy, rarely lead to erection problems in the aftermath. Somatically-induced ED is often associated with spontaneous and natural erections, at night and morning, disappearing or decreasing. The lust, however, is often unchanged and the man can get trials and orgasm without the erection work.
Psychically-induced erectile dysfunction often develops suddenly and nightly erections and so-called morning conditions persist. These patients can generally get erections through masturbation and during the foreplay, but immediately before or during a sexual intercourse, the erection ends. (See diagram for causes of erectile dysfunction.)
Factors such as touch, sight and hearing, sexual fantasies and unconscious thoughts induce normal erection requires physiological blood levels of the male hormone testosterone. Lack of testosterone can thus cause impaired sexual desire, but ED is also common when testosterone enhances the mechanisms that lead to physiological erection. The sexually stimulating factors affect the brain’s erection center in the hypothalamus, from which signals are sent via the spinal cord to the penile swelling bodies.
The smooth muscle cells of the swelling bodies are relaxed by releasing nitrogen oxide as the signal substance, penis blood-filled. The blood-filled swelling bodies compress the veins so that the blood can not flow out of the penis. The resulting erection usually occurs until the man reaches orgasm and trigger.
In erection, a conversion of the substance guanosine triphosphate (GTP) to cyclic guanosine monophosphate (cGMP), which is the intracellular messenger which produces muscle relaxation in the penis. High levels of cGMP thus exist in the penis and are one of the conditions for the erection of erection. Phosphodiesterase type 5 (PDE5) is the enzyme which then is responsible for the degradation of cGMP and thus is an enzyme whose activity counteracts erection.
Frequently, anonymity and a simple physical examination are sufficient in investigating men with erectile dysfunction. A history of focusing on the prevalence of diabetes mellitus, cardiovascular disease, neurological disorders, psychological disorders, obesity, previous surgery and any medications that may have side effects in terms of sexual function as well as the abuse of tobacco, alcohol and drugs, including anabolic steroids. In order to define the patient’s erectile dysfunction, a short sexual name is taken. Estimation schedules for ED can sometimes be helpful in diagnostics. An often-used estimation scale is the International Index of Erectile function (IIEF), which is also in a shortened version, IIEF-5.
The physical examination is focused on external genitalia, prostate and male sexual characteristics such as muscle, hole and body hair. Laboratory, it is often enough to check fast blood sugar. If at the same time there is a libido disorder and / or no nightly and spontaneous erections, a testosterone assay may sometimes be motivated.
If there are serious interpersonal problems with the partner or if you find other serious psychological or social disorders, it is advisable to involve a psychologist, sexual adviser or sexologist in therapy.
There are no actual differential diagnoses for ED. However, ED may be the first symptom of other diseases (see above).
Treat erectile dysfunction
Pharmacological treatment is now usually the first-hand option for the treatment of erectile dysfunction.
The group of drugs that dominate the oral treatment is phosphodiesterase type 5 inhibitors (PD5 inhibitors). In the Swedish market there are several preparations with this function; sildenafil, tadalafil, vardenafil and avanafil. It is contraindicated for all preparations of this type while co-medicating with nitroglycerin preparations. In the case of sexual stimulation, these drugs appear to relax the blood vessels in the penis due to reduced cGMP degradation (see above), which means that blood can fill the penile swelling bodies. This improves the erectile function. These drugs only work if intact penile swelling body inervation exists, so the effect is often worse at ED caused by, for example, radical prostatectomy.
For many patients, intravenous injection with prostaglandin E1 is an effective and proven treatment. The smooth muscle of the penile swelling bodies is relaxed by prostaglandin. In rare cases injection therapy may cause erectile pain and once a patient may have a persistent erection (priapism). If this happens, the patient should seek specialist help. Alprostadil, which is the active ingredient in intravenous treatment, can also be administered by means of an intrurethral staple (Bondil) or as a solution that is dropped into the urethra (Vitaros). Another injection is Invicorp, which may cause less pain when injected.
Treatment using a sexologically trained therapist is sometimes valuable because the patient is offered help to integrate sexuality into his or her life situation. This treatment can be done, for example, by so-called sensuality training aimed at reducing the patient’s / pair’s performance anxiety. In young men, “sex therapy” is often a better alternative than prescribing drugs, especially in men with disturbed body perception.
With the help of a pubic ring and vacuum-reaction pump, the patient can get an improved erection. The increased rigidity is achieved through a light venous penis of the penis by pulling an elastic rubber band (pubic ring) over the penis base. The pubic ring can be advantageously combined with vacuum reel pump or injection treatment. A vacuum pump consists of a plastic cylinder that is applied around the penis and where vacuum can be obtained with a pump. By suppressing blood-filled penis, and the blood can then be retained by means of the rod produced by the pubic ring.
Surgical treatment of erectile dysfunction is now very rare and reserved only to patients where all other methods failed. The treatment consists primarily of insertion of penis implants, which are available in two types: semirigida and hydraulic penis implants. Semirigidal implants are placed in the swelling bodies and the erection is continuous but can be positioned stably in different positions, for example bent downward or straight up. Hydraulic implants consist of two cylinders placed in each swelling body. These implants are connected to a fluid reservoir and a pump mechanism that allows the fluid to pass between cylinders (erection) and reservoir. In all implant surgery, the risk of infection is relatively high. Quite often infections cause the implant to be removed.
The prognosis is improved if the underlying cause of the patient’s erectile dysfunction can be discovered and treated optimally.
The disease as such gives no real complications except for the inability of erection and sexual intercourse as well as the psychogenic / psychiatric diagnoses that may arise as a result of the patient’s ED. Complications are rather secondary to treatment such as priapism, overdosage, drug-related side effects, complications for implants, injections, etc.