Male Sexual Health

Erectile Dysfunction

How does the penile erection occur?

The normal penile erection in men is a complex phenomenon that involves relaxation of the soft spongy tissues in the three long cylinders in the penis. When this spongy tissue is engorged with blood under high pressure, the soft penis becomes rigid and erect. This is controlled by a highly complex system of control that involves brain, nerves and blood vessels. Under the onset of sexual stimulation, the blood vessels entering into the penis dilate and allow the smooth spongy muscle tissue in the penile cylinders to relax and this allows the spaces to fill with blood.

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Once these spaces are filled the outflow from these spaces through the veins is restricted by a complex array of factors for a period of time until the penile erection subsides following ejaculation. This is a normal course of events that happens during penile erection.

What is erectile dysfunction(Impotence)?

Erectile dysfunction is the inability to achieve and maintain adequate erection sufficient for having satisfactory penetrative sexual intercourse.

What are the risk factors for Erectile Dysfunction?

Problems with erections share the same risk factors for diseases affecting the heart. They are as follows:

  • Lack of exercise Obesity (overweight)
  • Smoking
  • High cholesterol level
  • A syndrome that includes high blood pressure, obesity and diabetes (metabolic syndrome)
  • Increasing age
  • Complex surgeries in the pelvis or abdomen including the prostate or the lower part of the bowel
How prevalent is erectile dysfunction?

Two major studies showed that the prevalence of erectile dysfunction is very common and it increases with age. A study called ‘Massachusetts Male Aging Study (MMAS)’ has shown the that the overall prevalence of erectile dysfunction is about 52% in men aged from 40 -70 years. If it was divided into three grades of severity, minimal erectile dysfunction was found in 17.2%, moderate dysfunction was found in 25% and complete erectile dysfunction was found in 9.6%. In another study done in Europe called ‘Cologne Study’, men aged 30 -80 years old showed a prevalence of 19.2% with a very steep age related increase from 2.3 – 53.4%. So these studies definitely show that erectile dysfunction increases with age as shared by the risk factors which also increase with age (mentioned above).

Is there any benefit in improving erectile dysfunction by changing my lifestyle?
Yes, the studies have shown improvement of erectile function by reducing body weight and increasing physical activity. Of course these changes that caused erectile dysfunction came slowly over period of years and one has to be patient to see the improvement after making lifestyle changes.
What is the importance of erectile dysfunction, if I am not particularly concerned about sexual function?

Even if you are not concerned about sexual function and you are not sexually active, the fact that you have erectile dysfunction shows that you are at increased risk of some other serious diseases like heart disease and heart attack. Therefore it is important for the erectile dysfunction to be assessed and treated at least by changes to lifestyle with improvement of exercise levels and reduction in body weight which will offer you the overall benefit of general health to other important organs.

What role does the male hormone (testosterone) plays in erectile function?

Good erectile function is governed by the blood vessels and filling of blood to the penis under high pressure. The presence of testosterone is necessary to maintain this function. Low testosterone levels can result in low sex drive which could have adverse influence on the sexual function and erectile function. Low testosterone is also associated with other significant diseases involving the heart, blood vessels and also could lead to poor control of diabetes.

What should I do if I am concerned about my reduction in erectile function?

You should seek help from your GP or primary care professional for further assessment of your problem. Your GP may do a clinical examination particularly concentrating on your penis and testicles and examine the size of your testicles. The size of testicles will give an indication whether your body is producing enough testosterone though it is not fully accurate way of assessing this.. He/she may also ask if you have other risk factors for heart disease, diabetes or high blood pressure.

What tests will I have?
Apart from the clinical examination, your doctor may check male hormone level (serum testosterone). They will also check your blood pressure, blood sugar and cholesterol and other lipids in your blood. These are particularly to address any underlying risk factors for erectile dysfunction so that these risk factors could be corrected which may in turn improve erectile function as well as prevent other significant diseases, like heart attack and stroke.
How will I be treated for erectile dysfunction?

The fist part of treatment for erectile dysfunction should be addressing lifestyle changes:

  • If you are smoking, you should consider stopping smoking and seek help for cessation of your smoking habit.
  • If you are overweight, increase your exercise levels gradually in a safe way. Before embarking on any regular exercise programs, consult your GP to ensure it is safe to do, taking into account other health problems you may have. Regular exercises like walking help to lose weight as well increase your energy levels and this should be increased gradually.
  • Weight reduction again can be addressed by appropriate dietary changes as well as an increase in physical activities.
  • Psychosexual counselling may be helpful if your erectile dysfunction is caused by any psychological stress or relationship issues.
  • If your testosterone levels are low, your doctor may recommend you to replace testosterone by means of various preparations of testosterone which are available as gel, patch or long acting injections or implants.
  • If you continue to have problems with having an adequate erection, tablets are available. These tablets include sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). These tablets are called PDE5 inhibitors. They act by prolonging the relaxed state of your smooth penile tissue (cavernosal tissue) thereby prolonging the erections. For these tablets to work, you need sufficient levels of testosterone. Therefore if your testosterone levels are low these tablets may not work as well as they should.
  • Caution about the Viagra like tablets: People who take a drug called nitrates for heart disease, previous heart attack or angina should not take the medications for erection mentioned above (PDE5 inhibitors). This is because of the risk of a severe fall in blood pressure and therefore these drugs (PDE5 inhibitors) are strictly contraindicated in patients who are taking nitrates regularly. Of course patients who are using nitrate spray can use these medications for erection very consciously if they use the medications for erections (PDE5 inhibitors) and if they develop heart pain (angina) they should not use the nitrate spray and they should call the emergency medical services and they should promptly inform the paramedics that they have used the PDE5 inhibitors and they should not use nitrate spray. The other side- effects due to these medications include headache and flushing of the face and also congestion of the nose. The tablets should be taken one half hour prior to the intended sexual intercourse and they should have normal stimulation for these medications to give and an erection. These tablets do not give erections involuntary if you not interested to have sex.
What are the options of treatment if I can not take PDE5 inhibitors?

If you are unable to take PDE5 inhibitors, the other options would be to inject a drug called Alprostadil directly into the penis, which will give an erection. This medication is also available as a pellet to be put inside the urethra which is called MUSE. This medication gives an erection involuntarily once you inject or put it inside the urethra. Of course the urethral administration causes a bit of irritation and using an injection can cause bruising and haematoma in the penis. One important risk of these medications, is prolonged erections called priapism.

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If you developed prolonged erections lasting for more than two hours, you should seek immediate medical attention as prolonged erections lasting for more than six hours can cause permanent damage to the penis. Therefore if you have an erection lasting for more than two hours, you should immediately go to the nearest hospital emergency department. This can be easily treated by aspirating some blood from the penis and to reduce or relieve the erection fully until your penis reaches the normal flaccid stated.

What other options of treatment are available if I do not want to use the injections or urethral pellets and if I am not allowed to take the tablets?

One other option that is available for managing the erection are vacuum devices. These devices are called VCD (vacuum constriction devices). They contain a cylinder which is applied over the penis and a vacuum can be created inside the cylinder by battery operated motor or a hand operated device.

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Once sufficient vacuum is developed inside the cylinder it is sucks blood into the penis and causes an erection. Once the adequate erection is achieved, a rubber band which is stored at the base of the cylinder can be deployed onto the root of the penis so the erection can be maintained. One should be very careful to remove the constriction rubber band after sexual intercourse. Using a vacuum constriction device does not involve the use of any medications though it may be perceived an unnatural way of inducing erection by patients and their partners. There is always a slight risk of causing bruises to the penis by the vacuum itself as well as by the rubber band.

What can I do if the above treatment options are not suitable for me?
If none of the above options are acceptable or suitable for you the final option would be to consider the insertion of an artificial penile implant. There are different types of implants available. Some implants are special metal rods which can be implanted into the penile cylinders. Modern implants contain inflatable cylinders which are inserted into the penile cavernosa (cylinders). These inflatable implants become filled with a special fluid which can be triggered by a device that is designed with a button implanted under the skin. These implants are not without problem. As time goes buy, there is a risk of infection and expulsion of the implants which may require further operations and sometimes result in permanent damage to the penile cylinders.
How can I prevent erectile dysfunction?
The best way is to prevent erectile dysfunction by taking steps from an early age, as early as 30 years old. Regular exercise and maintaining a healthy body weight and healthy diet may go a long way in preventing or delaying the onset of erectile dysfunction.