Erectile dysfunction (ED) consists of the impossibility of achieving an erection sufficient for penetration, or if it is achieved, it is not maintained with sufficient rigidity to achieve satisfactory sexual intercourse.
Usually, this disorder has a constant and progressive development, with a minimum duration of about 3 months. It affects up to 50% of patients between 40 and 70 years old (variable data according to different studies). Its frequency clearly increases with age, but there are cases and types that can be observed in younger people.
There are a series of risk factors for this pathology. Some of them are inherent to the patient, that is, they cannot be modified: advanced age, neurological diseases, alterations in the anatomy of the penis. Others, however, are modifiable, and therefore it is possible to act on them to prevent or delay the occurrence of ED: obesity, diabetes mellitus, high levels of cholesterol and triglycerides, sedentary lifestyle, tobacco use, metabolic syndrome.
These risk factors also predispose to the development of cardiovascular diseases related to generalised vascular disease (heart attack, stroke, large-vessel disease).
This relationship is due to the fact that, in the early stages of atherosclerosis, there is a loss of nitric oxide in the arteries of the whole body. Nitric oxide is necessary to obtain an erection. Research has been carried out in this field, and the results indicate that the appearance of erectile dysfunction can precede the appearance of cardiovascular events by an average of 2-3 years.
The causes of ED are very varied. Vascular, nervous and psychogenic mechanisms are involved In the erection development and maintenance. A malfunction in any of them can condition the appearance of this disease.
- Vascular alterations: atherosclerosis: arteriosclerosis (hypertension, high cholesterol, diabetes mellitus, tobacco use).
- Alterations of the nervous system (central or peripheral).
- Hormonal disorders: diabetes, decreased testosterone level, increased prolactin, thyroid and adrenal disorders.
- Secondary to surgery: radical prostatectomy, radical cystectomy, colon surgery.
- Other causes: medication, alcoholism, drug abuse, alterations of the anatomy of the penis, psychogenic.
» Clinical interview with a super-specialised andrologist.
Personal background factors possibly involved will be assessed, the course of the disease will be investigated and the possible cause established. It is also important to study the ejaculatory function and sexual desire.
» Internationally validated questionnaires.
They help to establish, as objectively as possible, the severity of the situation.
» Laboratory study.
Blood test including a lipid profile, basal blood sugar level, hormone profile, kidney and liver function, markers of prostate pathology. Besides differentiating different causes, they allow us to investigate the presence of other previously unknown pathologies (hypercholesterolaemia, diabetes, prostate cancer).
» Dynamic vascular study of the penis.
It is a technique which is increasingly used in the diagnosis and management of ED. It is essential that it is carried out by an experienced specialist, otherwise the information it provides is very limited..
First, an ultrasound of the penis according to protocol is carried out to observe the structure and rule out the presence of fibrous plaques or any other alterations that could lead to other suspected pathologies.
During the second part, a standardised amount of a drug that causes an erection is injected into the penis with a fine needle and, following the re-evaluation of the penile structure, the arterial and venous blood flows are measured after a certain period. This is extremely useful in order to differentiate vascular, neurological and psychogenic causes of ED, to determine the severity of the condition and to help decide on the most appropriate treatment.
During sleep completely natural erections occur, oxygenating the penis. Rigiscan® is a device that allows measuring the degree and frequency of the erections to evaluate if the vascular mechanism leading to erection is preserved. Its operation is simple, and consists of two tapes that are placed at the base and tip of the penis, attached to a recording device. The information provided allows differentiating, with great precision, whether the ED has a vascular origin or a psychogenic origin.
After the diagnostic study, and once the cause of the disease has been established, the most appropriate therapeutic alternative will be offered for each case. Generally, several treatment steps are defined as follows:
1 · The first step always consists in acting on the modifiable risk factors and make lifestyle changes (weight loss, healthy diet, exercise). This is essential for treating ED, to prevent it from worsening, and also to prevent the development of other cardiovascular diseases.
2 · Phosphodiesterase type 5 inhibitors. These drugs are administered orally. Sexual stimulation is necessary for them to be effective. The first on to appear was sildenafil, commercially known as Viagra®. Since then, many drugs from this family have been developed. They all present satisfactory results in more than 50% of the cases and the choice will depend on the characteristics and preferences of the patient. These drugs offer a good safety profile, although they are contraindicated in some cases, such as patients taking nitrates (nitroglycerine), because there is a risk of severe hypotension.
3 · Shock waves. In recent years, when the cause of the ED has a vascular origin, shock wave treatment has been established as the only curative alternative. This device delivers several electromagnetic impacts throughout the erectile structure of the penis, favouring, in the mid term, the appearance of new vascular tissue. It is completely administered on an outpatient basis, does not cause pain, and has no described side effects. Its effectiveness is not permanent while the risk factors that have caused the disease persist: hypercholesterolaemia, poor blood sugar monitoring, poorly controlled hypertension.
4 · The third step consists of intracavernous injections of prostaglandin E1 (alprostadil). This treatment has a different mechanism of action than oral drugs and ii is used when the latter have not been effective. It consists in puncturing the corpora cavernosa of the penis right before intercourse. Erection appears in a few minutes without the need for sexual stimulation. When prostaglandins alone are not effective, they are combined with other drugs to be administered in a single injection. There may be complications such as fibrosis, haematomas or priapism (sustained and painful erection), but they are rare and satisfaction with this treatment is generally good.
5 · In recent years, other methods to administer prostaglandins (alprostadil) have appeared in the market. They may be applied as a paste into the urethra with a swab, or as a gel to be applied on the glans. This guarantees greater patient comfort by avoiding injection, although its effectiveness may be lower depending on the case.
6 · Vacuum devices represent another treatment option that is offered when oral treatment has not been effective or cannot be administered. The device has the shape a tube where the penis is introduced to apply the vacuum. Its use is limited and there may be pain and small haematomas.
7 · Finally, when none of the aforementioned treatments have been effective, surgical implantation of a penile prosthesis is offered. For more information about penile prostheses check the corresponding section.