Overcoming Erectile Dysfunction: Strategies and Solutions

Erectile dysfunction is a persistent inability to achieve or maintain an erection sufficient for sex, lasting for more than three months.

Erectile dysfunction is more common in older people, but age itself is not a risk factor. Problems with erections are not part of normal aging. There are no natural reasons that could prevent a person from being sexually active until the age of 70 and beyond.

A disease called ‘impotence’ does not exist.

Erectile dysfunction is not a disease, but a symptom that can indicate that a person has other illnesses.

For example, there is sufficient evidence to suggest that erectile dysfunction may be an early manifestation of problems with coronary arteries and peripheral vessels, so it is not only considered from the perspective of a man’s quality of life, but also as a potential marker of cardiovascular disease.

Furthermore, the same risk factors that lead to hypertension and heart disease also contribute to erectile dysfunction. They are mainly related to lifestyle factors. These include:

• tobacco use;
• alcoholism;
• drug use;
• hypodynamia;
• obesity.

It turns out that erectile dysfunction is an important health indicator. Especially when you consider that cardiovascular disease is the leading cause of death in men worldwide.”

Why does erectile dysfunction occur?

Erection is an involuntary reaction that can happen during sleep. In an alert person, an erection can be caused by two types of stimuli: psychological – such as fantasies, or tactile – such as touching the penis.

The process itself is rather complex. To initiate an erection associated with imagination, a coordinated work of the brain and spinal cord, nerves and penile blood vessels is required. The reflex, i.e. touch-related, erection is simpler, because the brain is not involved. However, peripheral nerves must activate the nerve center responsible for erection in the roots of the sacral spinal cord. If something “breaks,” an erection cannot be achieved.

Urologists believe that the causes of erectile dysfunction can be both psychogenic, that is, not related to disorders of the functioning of organs and tissues, and organic. In some cases, there are mixed causes.

Psychogenic factors can be either situational, that is, related to the characteristics of the partner, a sense of guilt or anxiety, or may be related to neuroses. For example, with phobias, anxiety disorders, or the effects of drugs.

Organic factors are divided into four major groups:

1. Vascular problems, such as cardiovascular diseases, diabetes, high cholesterol levels, and even smoking, which causes spasms of the penile vessels.
2. Neuronal problems, such as stroke, head injuries, multiple sclerosis, diabetes, and alcoholism.
3. Hormonal regulation problems, such as hypogonadism when the ovaries produce insufficient testosterone or hypothyroidism when the thyroid gland is insufficient.
4. Problems related to drug use, such as some diuretics, antidepressants, and psychotropic substances that can lead to erectile problems.

The most common cause of erectile dysfunction is psychogenic, accounting for about 40% of cases. Organic causes account for 29% of cases. Sometimes the problem is related to a combination of psychological and organic causes. And in 6% of patients, the cause of the dysfunction remains unknown.

Scientists have not yet come to a consensus on which orientation is more likely to suffer from erectile dysfunction. According to American and French studies, gay people are more likely to have this problem than heterosexuals. However, according to Chinese data, the problem is not dependent on orientation, so erectile dysfunction occurs equally often in gay and heterosexual people. I couldn’t find any Russian articles on this topic.

As a rule, erectile dysfunction is related to psychogenic causes, hormonal, vascular, or neurogenic disturbances, or caused by several factors at once.

How to understand it’s time to see a doctor

Occasional problems with erections happen to 52% of men. However, one such episode does not mean that erectile dysfunction has developed.

Before seeing a doctor, it makes sense to observe your well-being for three months. If the problem does not go away on its own, you need to see a specialist who deals with restoring erections, a urologist-andrologist. No preparation is needed for the visit. Just come for an in-person appointment and describe the problem in detail.

As there are many reasons that lead to problems with erection, it is not surprising that about half of men aged 20-77 years face erectile dysfunction. Moreover, every third man has mild erectile dysfunction, 7% have moderate, and another 7% have severe erectile dysfunction. The severity is determined by the number of points a patient scores on the IIEF-5 questionnaire. The statistics in the USA, the European Union, and other countries are similar to the Russian one.

The doctor will ask about previous illnesses and sexual health, assess the appearance of the patient and his genital organs. This allows to detect hidden diseases, such as Peyronie’s disease or hypogonadism. The doctor will also measure blood pressure, heart rate, and for patients with excess weight, determine the body mass index and waist circumference, and give directions for tests.

How the appointment with an urologist-andrologist goes

Urologist-andrologists often ask patients to come to an appointment with a permanent sexual partner – this way more useful information can be obtained. Therefore, if this is possible, it is better to plan the visit for two people right away.

Be prepared for the doctor to ask you to fill out a questionnaire – the International Index of Erectile Function (IIEF-5). This will help objectively assess the severity of erectile dysfunction in the last month. The questions in the questionnaire are roughly like these:

• How do you assess the degree of your confidence in achieving an erection and maintaining it?
• How often does an erection that occurs in you during sexual stimulation suffice for inserting the penis into the vagina?
• How often after inserting the penis into the vagina can you maintain an erection?
• Is it difficult for you to maintain an erection until the sexual act is completed?
• How often do you experience orgasm during sex?
• To not waste time during the appointment, the questionnaire can be filled out at home.

How is erectile dysfunction diagnosed

The set of tests and examinations for erectile dysfunction can vary significantly from patient to patient. However, there is a list of tests that are assigned to everyone: they help to understand if the patient has diabetes, atherosclerosis or hypogonadism (insufficient testosterone).

The diagnosis of erectile dysfunction involves an ultrasound pharmacodopplerography of the genital vessels. During the examination, a prostaglandin E1 is introduced into the non-erect penis, known as “intracavernous injections.”

Pharmacodopplerography allows for the evaluation of blood flow in the genital vessels at different stages of erection. However, not everyone needs to undergo it, only patients who have indications such as:

• Primary erectile dysfunction;
• Previous trauma or surgery on the pelvic organs or perineum;
• Deformation of the genital member;
• Complex endocrine, psychological or neurological disorders;
• The examination is needed before penile prosthesis.

How to treat erectile dysfunction

The treatment of a specific person will depend on what is happening with them. There are three approaches.

Normalize lifestyle. This advice is given to all patients, both Russian and international clinical recommendations. Many people who switch to a rational diet and start exercising regularly, erectile dysfunction goes away on its own, without treatment.

If the patient is taking medication whose side effect is worsening of the erection, switching medication may help. If lifestyle changes and medication switching do not help, patients are prescribed symptomatic therapy.

Remove the cause of erectile dysfunction. If it has been accurately determined, treatment begins with this. For example, in case of psychogenic erectile dysfunction, patients are prescribed rational psychotherapy, and if the problem is due to testosterone deficiency, the doctor may prescribe hormone therapy. Testosterone problems are much less frequent than psychogenic erection disorders.

Turn to symptomatic treatment. In treating erectile dysfunction, the approach is “from simple to complex.” They start with prescription of medications. If it doesn’t help, they resort to the next line of therapy: injections of drugs into the penis. Doctors teach patients to do such injections independently.

Non-medication treatments are also used: low-energy shockwave therapy, vacuum erectors. If this does not help, the patient may be offered surgery, that is, to install a penile prosthesis. The surgical method is the final line of treatment for erectile dysfunction. As a rule, the results of the operation satisfy both men and their partners.

Medications for Erectile Dysfunction Treatment

Phosphodiesterase-5 (PDE-5) inhibitors in tablets. These are drugs that allow you to control an erection as desired. The tablets should be taken approximately an hour before sexual activity: it takes time for the drug to enter the bloodstream. The duration of time the medication should be taken and the dosage required for a specific person depend on the medication.

It works like this. When a healthy person sees something exciting or feels a touch to the penis, an electrical signal is carried along nerves that collect information from the sense organs. This signal stimulates specialized nerves that begin to secrete nitric oxide. The gas penetrates the walls of the penis’s arteries and triggers the synthesis of cyclic guanosine monophosphate (cGMP) – a substance under the influence of which the arteries dilate.

As a result, the cavernous bodies – two chambers inside the penis – fill with blood, become engorged, and squeeze the veins to prevent blood from leaving the penis. An erection occurs. After sexual intercourse, the enzyme PDE-5 breaks down cGMP and the erection ends.

Many smokers, men with diabetes, and with testosterone deficiency have decreased levels of the enzyme responsible for producing nitric oxide. As a result, this gas is produced in small amounts and there is not enough cGMP to produce a full erection. However, if you take a medication that temporarily stops the destruction of cGMP, the substance will accumulate and the erection will be more durable. However, the medication does not cause an erection by itself; you still need a sexual stimulus and a healthy penis with healthy blood vessels.

Synthetic analogue of prostaglandin E1 (alprostadil) in injections. Before sex, the drug must be administered directly into the cavernous bodies: it helps to relax the walls of blood vessels, which makes it easier to fill the cavernous bodies with blood. The drug has contraindications and side effects, so the dose should be selected with the doctor. Alprostadil is sold with a prescription.

What should not be used

Herbal stimulants – food supplements and medicinal herbs. Unlike drugs, supplements and herbs have not been tested for safety and effectiveness. The concentration of active substance in them may vary from package to package, so they either do not work at all or work unpredictably. Like drugs, supplements have contraindications and side effects, and can also interact with other drugs, distorting their action. Using supplements and herbs can be harmful to health.

Auxiliary methods of treatment for erectile dysfunction

Vacuum erectors. These devices are recommended for elderly people, patients who cannot use drugs, or those for whom they do not work.

The principle of the method is that the penis is placed in a cylinder and a bell is used to create a vacuum inside the cylinder. As a result, blood flows to the cavernous bodies, causing an erection. To preserve the erection, a constricting erection ring is placed on the base of the penis, which does not allow blood to prematurely leave the cavernous bodies. This works, but about 30% of people refuse to use erectors due to pain, subcutaneous bleeding, problems with ejaculation, and decreased sensitivity of the head of the penis.

Incorrect use of vacuum erectors can cause penile trauma. Patients who want to try the device should ask their doctor to teach them how to use it.

The cost of a vacuum pump depends on the manufacturer. It is important to choose a pump that comes with an erection ring, otherwise achieving a sustained erection will not be possible.

Low-energy shockwave therapy (LiSWT). The method may be suitable for patients with mild erectile dysfunction and for people who do not benefit from PDE-5 inhibitor tablets.

The most common treatment plan is two procedures a week for three weeks, followed by a three-week break and repeating the course. To achieve the effect, different people may need different numbers of procedures, so it is necessary to discuss these details with the treating physician before starting treatment.

The essence of the method is to act on the cavernous tissue of the penis with acoustic waves, that is, a “sound massage” that works not on the surface, but inside the penis. According to some data, this improves the formation of nitric oxide and promotes the growth of new blood vessels in the cavernous bodies.

What methods do not help

Some private clinics offer treating erectile dysfunction with magnetic-laser therapy and ozone therapy. However, these methods are experimental and their effectiveness and safety on humans have not yet been seriously tested, and they are not included in clinical recommendations. Until reliable data is obtained, it is safer not to use them.

Surgical treatment of erectile dysfunction

Surgery is only recommended in extreme cases if pills, pumps, or injections do not work.

Implantation of a prosthesis – penile prosthesis. There are two types of prostheses. Flexible rods with shape memory are surgically placed in the penis, so the patient can manually give it shape. The second type is prostheses filled with sterile fluid. These are two- or three-component hydraulic systems that work almost like the patient’s own cavernous bodies, simulating a natural erection. Most patients prefer three-component prostheses, as they allow for the most natural erection and satisfy almost everyone.

The heaviest complication associated with installing a prosthesis is prosthesis infection. However, frequently operating surgeons rarely have this problem, and modern prostheses with antimicrobial coating have reduced the risk of this complication from 5% to 2%. Modern implants serve for more than 15 years, there are devices with a lifetime warranty. But if the prosthesis still breaks, the operation is repeated.

When choosing an operating urologist, it is important to pay attention to experience and the number of operations he performs per year. Success largely depends on the doctor’s skills and knowledge of all the nuances of the main stages of the operation. Only an experienced surgeon will be able to perform phalloplasty without complications, including infectious ones.

Remember

• Erectile dysfunction is not a separate illness, but a symptom of other diseases. To restore the ability to have an erection, it is necessary to start by solving the main problem.
• There are many causes of erectile dysfunction, so there is no single treatment method that would suit everyone.
• The therapy should be selected individually with the urologist.

Sources:

• Erection – How it works – MSD
• Erection problems – this is not normal – Uptodate
• The American Research from 2010
• The French Research from 2013
• Chinese article from 2016
• How to tell when it’s time to visit a doctor – National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK)
• The Causes of Erectile Dysfunction – Uptodate
• Laser treatments – studies on rats with diabetes