Erectile Dysfunction (ED) Known as Impotence

Erectile dysfunction (ED), also commonly called impotence, is defined as the inability for a man to obtain or sustain an erection during sexual intercourse. Studies have shown this to be a fairly common condition, with studies showing that up to 30 million men in the United States likely suffer from this condition.1

In this article we will take a look at this condition in a bit more detail, concentrating on causes, clinical features, diagnostic modalities and treatment.

Causes of ED

There are a variety of causes that can cause ED. These are listed below

1. Vascular causes – This refers to problems relating to blood vessels and blood supply that can lead to ED. Causes include

  • Atherosclerosis
  • Hypertension
  • Treatments for prostate cancer
  • Beta blocker treatment
  • Myocardial infarction

2. Neurological causes – This relates to problems with the nerve supply to the erectile tissue in the penis. Causes include

  • Multiple Sclerosis
  • Guillain-Barre syndrome
  • Alzheimer’s disease
  • Cerebrovascular accident

3. Psychiatric causes – Depression is a common cause of ED.

4. Drug therapy

  • Beta blocker treatment
  • Anti-depressant medication
  • Finasteride

5. Systemic disease – ED can accompany or be a part of the spectrum of a number of clinical conditions, some of which include –

  • Kidney failure
  • Diabetes mellitus
  • Liver cirrhosis
  • Hypertension
  • Hemochromatosis
  • Certain cancers

6. Endocrine causes – This refers to problems relating to hormone production.

  • Hyper and hypothyroidism
  • Diabetes mellitus
  • Hypogonadism

As is evident, there are a number of causes of ED, and identifying each of these is important when considering how to help a patient with ED.

Clinical features

A detailed history is essential to make a diagnosis as it can indicate the underlying reason for the patient to develop ED.

Clinical examination should be aimed at determining the cause of ED. For example, in patients with hypertension as a cause, it is essential to check the blood pressure. In the recent past, this has become more important especially because untreated hypertension can have effects on the blood supply to the penis as it causes vascular disease. In addition, a strong relationship has now been established between ED and heart disease, with ED now considered a marker of developing heart attacks in the
future.

Diagnosis

There are no specific tests to assess ED, and most tests are aimed at identifying the underlying cause of ED. Here are some examples –

1. Blood tests – These may be done to assess blood sugar levels and HbA1c levels (diabetes) or prostate specific antigen (prostate cancer), just to name a couple. Thyroid function tests will allow for diagnosis of hyperthyroidism or hypothyroidism.

2. Prostaglandin E1 injection – This helps assess whether using this therapy can be a useful treatment modality for patients. Following injection, the penis should attain an erection, and this can be analysed by the treating physician.

3. Penile ultrasound – This test involves placing an ultrasound probe on the penis and assessing the blood flow through the arteries and the veins. As erection is directly related to arterial blood flow, a specific velocity of blood flow is looked for to assess whether it is sufficient or not to achieve an erection.

4. Penile angiography – This test is usually reserved for patients who have developed ED due to trauma to the penile blood vessels. It provides a good guide as to what can be done surgically the reconstruct the blood vessels and to restore normal penile blood flow.

5. Urine examination – This is useful in diagnosing any disorders in the urinary system that can result in ED.

Treatment

Again, treatment of ED depends on the cause, and measures should be aimed at resolving that. However, while that is taking place, there are certain other specialist treatments that are now available that can help patients achieve and sustain an erection.

1. Phosphodiesterase-5 inhibitors

These are the most commonly used drugs these days to treat ED. Viagra is the name everyone is familiar with, and it is now recommended as the first line treatment for patients with ED.

Viagra is the most commonly used PDE-5 inhibitor.

However, these drugs should not be taken by patients who are on nitrate therapy. PDE-5 inhibitors are now considered to be the best treatment for ED.

2. Prostaglandin E1 injections

This has been mentioned before as a diagnostic method, but can also be used for treatment. The only issue with this is the requirement of an injection into the penis prior to sexual intercourse, which may not be acceptable to many patients.

3. Hormone therapy

This is usually recommended for patients who have ED as a result of low testosterone production, as in the case of hypogonadism. However, it is unclear as to whether this is actually beneficial to all patients. Treatments are also not the most convenient – oral medications are generally not effective, and getting an injection time and time again can put many patients off receiving this treatment. Skin patches are available, but wearing these everyday can make treatment rather costly for the patient.

4. Constriction devices

Wearing a constriction device at the base of the penis can help maintain blood within the corpus cavernosum muscle and thus help patients maintain erections for longer.

Penile Constriction Device

5. Intracavernosal injection of Alprostadil

This is still a commonly adopted method. Patients will be taught how to perform the injections, and the outcomes with regards to degree of tumescence are very good.

6. Intraurethral Alprostadil Pellet

Here a pellet of Alprostadil is inserted into the penis using a specific device, but its efficacy has been questioned a number of times.

7. Surgical treatment

This includes correction of the blood flow to the penis through the arteries or reducing the leakage of blood out of the veins. Penile implants are also available these days that can be inserted into penile muscles.

Conclusion

Erectile dysfunction is a common and rather embarrassing problem that men can face. Etiology is multi-factorial and there are many treatment modalities available these days that can help patients achieve and sustain erections. There is no doubt that this enables them to regain their lost confidence, allowing them to lead a normal sex life.

References

1. Benet AE, Melman A. The epidemiology of erectile dysfunction. Urol Clin North Am. Nov 1995;22(4):699-709