How to Understand and Treat Erectile Dysfunction: Causes and Solutions

What is Erectile dysfunction?

The inability to attain and maintain an erection sufficient for satisfactory sexual performance. Persistent for 3 months and is benign

Synonym: Impotence

Significant impact on quality of life.

Epidemiology

Incidence and prevalence are high worldwide. Effects up to 52% of men (40-70yrs). Complete impotence from 5% of 40-year-olds to 15% of 70-year-olds. Only 10-20% solely psychogenic

Classification & Etiology

• Primary Organic (most common, 70%)
• Vascular
• Hormonal
• Neurological
• Medications
• Primary Psychogenic
• Mixed psychogenic and organic

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Vascular Factors

Vascular factors are CVD, atherosclerosis, hypertension, diabetes, Hyperlipidaemia, smoking, and trauma.

Central Causes

Parkinson's, Stroke, MS Tumours, Spinal Disease/Injury

Psychogenic Causes

General (disorders of intimacy, lack of arousability). Situational (partner, performance, stress)

Psychiatric illness (Anxiety states, depression, psychosis, alcoholism)

Hormonal causes

• Hypogonadism
• Hyperprolactinaemia
• Thyroid disease
• Cushing's disease

Anatomical causes

• Peyronie's disease
• Micropenis
• Penile anomalies (hypospadias, etc.)

Peripheral Causes

• Poly-/Peripheral Neuropathy
• Diabetes
• Alcoholism
• Uraemia
• Pelvic Surgery

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Clinical Evaluation for ED

• Hypertension
• DM
• Smoking
• Alcohol
• Medications
• Depression, anxiety
• Hypogonadism
• Thyroid dysfunction Uraemia
• Pelvic surgery/trauma
• Partner problems
• Libido
• Nocturnal erection

Diagnosis & Investigations

Taking a history

• Take an understanding approach
• Sexual history: International Index of Erectile Function Questionnaire (IIEF)
• Current and Past sexual partners
• Current emotional state
• Erectile symptoms (onset and duration)
• Previous problems, advice, and treatments
• Quality of erections (erotic and morning)
• Arousal, ejaculation, and orgasm difficulties
• General medical/past medical history and medications

• Examination
  • Genitourinary examination (anatomical abnormalities, size of testes)
  • Pulses (femoral), BP
  • Rectal examination (over 50 yrs)
• Bloods: fasting glucose, lipids, U & ES, LFTs, TSH, early morning serum testosterone (plus FSH and LH if testosterone is low). 
• Hemoglobinopathy screen (sickle cell) in afro-caribbean patients
• Dipstick urinalysis
• Vascular studies (duplex ultrasound cavernous arteries, arteriography, intracavernous vasoactive drug injection)
• Neurological studies
• Specialist psychodiagnostic evaluation

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Management & Treatment

Main goal: diagnose and treat the underlying cause

Modify reversible causes (lifestyle, drugs). Men who initiated physical exercise and weight loss have up to 70% improvement (note: cycling more than 3 hours per week may cause dysfunction). Hormonal (testosterone failure): give testosterone. Post-traumatic arteriogenic surgery. Psychogenic:

• Underlying problem
• Sex therapy/counselling,
• Phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil)

First-line treatment: Oral therapy

PDE-5 inhibitors improve the relaxation of smooth muscle. Contraindicated in patients receiving nitrates, recent stroke/MI, unstable angina. Sildenafil: well-tolerated, efficacy reduced after fatty

food, 50 mg starting dose. Tadalafil: longer half-life; start at 10 mg. Vardenafil: more potent (but not clinically more effective), useful in difficult-to-treat subgroups, effect reduced by fatty food.

Apomorphine hydrochloride: dopamine agonist, quick action, sublingual, not affected by foods

Vacuum devices

External cylinder, pumping air out around penis and causing engorgement

The clinical success rate of 90%

Work best: motivation, supportive partner

Adverse effects: pain, petechiae, bruising, numbness

Second-line treatment

Intraurethral alprostadil (prostaglandin E1): insert pellet urethral meatus; barrier contraception if partner is pregnant; less effective than intracavernous injections; may cause penile pain. Intracavernosal alprostadil: injected; may cause pain and priapism (refer urgently to hospital for blood to be drained)

Third-line treatment

Penile prosthesis: semi-rigid, malleable, or inflatable. Considered if impotence has an organic cause and fails to respond to medical management. Topical agents: some vasoactive drugs come in topical gel form and may suffer local reactions and side effects to partners if absorbed from the vagina.

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