Erectile dysfunction or impotence is the inability to achieve and maintain an erection that allows intimate relations with a partner. Occasional erectile dysfunction is commonly found in males of reproductive age and is favored by unhealthy lifestyle, mental overwork, fatigue or environmental factors.
Recurrent erectile dysfunction that affects the couple’s relationship and leads to personal impairment and long-term abstinence is a cause for concern and requires specialist medical assessment and guidance.
Why does erectile dysfunction (impotence) occur?
Why does erectile dysfunction (impotence) occur?
Erectile dysfunction can be caused by a combination of factors including the transmission of nerve impulses to the brain, emotional state, androgen synthesis and, not least, the ability of the penile muscles and vasculature to function.
Nitric oxide or nitric oxide is a substance with an important role in increasing the contractility capacity of various muscle groups involved in obtaining and maintaining erection, contributes to the dilation of blood vessels and regulates the interneuronal transmission of electrical impulses. In addition, nitric oxide contributes to the release of testosterone into the circulation and is involved in the processes of regulating blood pressure, actively participating in preventing the formation of fat deposits at the endothelial level.
In most situations, erectile dysfunction is caused by a combination of physical and psycho-emotional factors without involving an organic pathology, but there are also conditions whose evolution can affect male sexual performance, namely:
- Heart disease – heart failure, coronary artery disease
- Atherosclerosis (fatty deposits inside blood vessels)
- High blood pressure
- Diabetes mellitus
- Obesity
- Metabolic syndrome: association between hypertension, hyperinsulinaemia (elevated serum insulin levels), abdominal obesity leading to an abdominal circumference greater than 102 cm in men and hypercholesterolaemia
- Parkinson’s disease
- Multiple sclerosis
- Peyronie’s disease
- Obstructive sleep apnea syndrome
Metabolic syndrome accompanied by hypoandrogenism (low testosterone levels) is known as HAM syndrome and manifests as chronic fatigue, decreased muscle strength and mass, increased fat tissue with abdominal distention, mood swings and erectile dysfunction.
The pathological mechanism that causes testosterone deficiency and thus erectile dysfunction in men with metabolic syndrome is explained by the effect of leptin on the androgen-producing testicular tissue, represented by Leydig cells. Leptin is a hormone synthesized by adipose tissue that acts as an inhibitor of testosterone secretion after binding to specific receptors on the surface of Leydig cells.
Certain drugs used to treat adenoma or prostate cancer are a common cause of erectile dysfunction in patients undergoing these types of treatment. Chronic alcohol consumption, substance use and trauma or surgery to the sacral spine or pelvic floor muscles are risk factors for erectile dysfunction.
Psychological causes of impotence are depression, anxiety syndrome, prolonged intellectual stress and lack of communication with the partner.
Tests for impotence
Erectile dysfunction is a condition whose diagnosis is established mainly through the patient’s history and physical examination in consultation with the urologist. The investigations that may be recommended to patients with erectile dysfunction are mainly aimed at determining the causes of impotence and are represented by:
- Determination of serum concentrations of testosterone, blood glucose and cardiac enzymes/markers that may lead to a diagnosis of hormonal imbalance, diabetes mellitus or an evolving heart disease. Perform an extended lipid profile to assess risk factors contributing to atherosclerotic processes.
- Biochemical and microscopic examination of urine
- Imaging investigations such as Doppler ultrasound may signal the presence of circulatory obstruction or blood flow deficiency in the penis. This type of investigation may sometimes involve the prior local injection of substances to stimulate blood circulation with the appearance of an erection.
- A psychological examination to determine depression and other similar conditions that can cause erectile dysfunction.
Diagnosis
The diagnosis of erectile dysfunction is established by the urologist based on the information obtained from the patient’s history and clinical examination. In certain situations, however, the specialist may recommend additional investigations to determine the pathologies that may predispose to impotence.
Impotence treatment
The treatment of erectile dysfunction is etiological and addresses the causes that determine the appearance of this condition.
Among the advantages of treating vascular impotence with shock waves are:
- The non-invasive nature of the therapy
- No pain for the patient
- No anesthesia
- No adverse effects and does not interfere with other pharmacological treatments
- ESWT sessions do not require prior preparation of the patient and are performed discreetly, in the urologist’s office
Other methods of treatment depending on the cause of impotence are:
- The nitric oxide deficiency of patients with erectile dysfunction is relieved by oral medication such as Sildenafil – Viagra, Tadafil – Adcirca, Cialis or Vardefil – Levitra, Staxyn, by the vasodilator effect they have on blood circulation.
- Improved blood supply to the penis helps to achieve an erection in response to sexual stimulation. It should be noted that this type of medication is not an aphrodisiac and does not replace the need for adequate sexual stimulation. The doses prescribed by the urologist may vary depending on the specifics of each case, but it should be mentioned that this type of medication is associated with certain side effects that may include nasal congestion, headaches, hot flushes, visual disturbances, back pain and stomach discomfort.
- Alprostadil in injectable form is administered at the base of the penis, one administration being sufficient to achieve and maintain an erection for approximately 60 minutes. The urologist instructs the patient on how to administer the active substance and explains the possible side effects of this type of treatment: priapism (painful prolonged erection) and, more rarely, the formation of fibrous scar tissue at the site of administration.
- Alprostadil in the form of urethral suppositories is another form of administration of the active substance. The small suppositories are inserted by the patient into the urethra using a special applicator. Erection usually occurs within 10 minutes after insertion of the urethral suppository and lasts between 30 and 60 minutes. Side effects of urethral suppositories may include minor bleeding from the urethra, a burning sensation in the penis and the formation of fibrous tissue.
- Testosterone substitutes are a therapeutic option for patients whose erectile dysfunction is due to insufficient synthesis of androgenic hormones. In these particular situations, testosterone analogue therapy can be used as a first-line therapy or as a secondary therapy in combination with other types of therapy.
If the medication is not effective and does not contribute to obtaining and maintaining a satisfactory erection, the urologist may recommend the use of a device in the form of a penile pump.
- The penis pump is a device in the form of an acrylic cylinder, equipped with an electric or manual mechanism, through which air is removed, with the appearance of a vacuum (provided the device is correctly applied to the penis). The vacuum created promotes the filling of the blood vessels in the penis and causes an erection that allows intimate relations with the partner.
- Penile implants or penile prostheses are mechanical devices to replace the erectile function reserved for patients with unfavorable therapeutic responses to conventional methods of impotence treatment. The procedure involves a surgical intervention on the penis through which the doctor will replace the erectile tissue that enters the penis with a mechanical implant. This procedure is irreversible, so the method is the last therapeutic option for patients in whom the usual treatments fail to restore the patient’s sexual function.
Regular exercise of increased or moderate intensity helps to improve blood circulation and prevents the development of diseases that cause erectile dysfunction such as heart disease, diabetes, insulin resistance of peripheral tissues and metabolic syndrome.
Psychotherapy, behavioral therapy and couples therapy are successful treatment methods for treating impotence in males with psycho-emotional erectile dysfunction. Appropriate treatment of associated diseases that cause erectile dysfunction are another recommended therapeutic option for treating impotence.
References:
- Erectile dysfunction, Rany Shamloul, Hussein Ghanem – https://www.sciencedirect.com/science/article/abs/pii/S0140673612605200
- Shockwave treatment of erectile dysfunction, Ilan Gruenwald, Boaz Appel, Noam D. Kitrey, Yoram Vardi – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607492/
- SOP: Physical Examination and Laboratory Testing for Men with Erectile Dysfunction, Hussein M. Ghanem, Andrea Salonia, Antonio Martin-Morales, The Journal of Sexual Medicine – https://academic.oup.com/jsm/article-abstract/10/1/108/6941143
