Lots of people keep it a secret. Many who admit to it would not attribute it to a medical condition. And the few who seek medical advice, believe it to be an isolated problem, due to old age and expect a ‘pill’ that cures the problem.
Despite various beliefs erectile dysfunction could be a presentation of a more generalised disease process. Thus there could be many approaches and also many treatment methods. And the positive note is about 90 percent of people with erectile dysfunction could be successfully treated, says Dr. Ajith P. Malalasekera, Consultant Urological Surgeon.
Erectile dysfunction (ED) is common: Even though statistics are not available in Sri Lanka, Western statistics indicate that it affects about 50% of the male population between 40-70 years of age. It can affect any age group, although it is commoner in older people. “Many people think it is part and parcel of growing old. But this is not true in each and every patient. For the majority, there is hope,” says Dr. Malalasekera.
Treating erectile dysfunction does not mean prescribing sildenafil (Viagra) to everyone. The treatment modality is essentially determined by the cause of ED - the patient’s age, other medical problems, expectations and the motivation of the patients.
While there are certain instances where erectile dysfunction can be due to localised problems (e.g. Peyronie’s disease, surgery or trauma of the pelvis), in the majority it is due to generalised risk factors or disease conditions. Therefore it is important to identify the underlying disease process and correct this, while treating ED.
“Addressing psychological factors is an important issue in dealing with ED. Even when there is an underlying organic disease process, psychological factors play a major role in aggravating the problem. Counselling and other psychological interventions are of immense value even when the primary cause of the problem is another disease process,” says Dr. Malalasekera, stressing the importance of psychological support.
Erection of the penis, usually is a response to stimulation. Hence, it needs precise coordination involving nerves, blood vessels and muscles. This involves transmitting impulses between the brain, various sensory organs like eyes, skin, ears, the spinal cord, and the nerves communicating messages between them and the male organ or the penis. When there is visual, auditory, tactile or mental stimulation, impulses from the brain act via the spinal cord, on the nerves in the pelvis.
These nerves send messages to the smooth muscles surrounding the blood vessels supplying the penis, which leads to increased blood flow to the penis. The large blood filled cavities in the penis widen and accommodate the inflow of blood. This creates the rigidity of the penis and also causes the blood vessels draining the penis (veins) to be compressed. Maintenance of the erection is due to this mechanism.
The hormonal environment should also be conducive for achieving a satisfactory erection. The male hormone testosterone is important in this respect. Problems can occur in the brain, spinal cord, or pelvic nerves, and pelvic and penile blood vessels, and also in the hormonal environment. The failure of any of these steps would lead to erectile dysfunction, which means the inability or difficulty in achieving and maintaining an erection of the male organ (penis) to permit satisfactory sexual performance.
Thus patients with high blood pressure, diabetes, high cholesterol levels, and also who smoke and have a sedentary lifestyle are more at risk of erectile dysfunction. These same risk factors would increase someone’s risk of cardiovascular disease like heart attacks. But erectile dysfunction in this situation is a warning sign. The blood vessels in the heart are larger than the penile vessels. Thus narrowing of blood vessels of the penis due to deposition of cholesterol would occur much earlier, than the vessels in the heart. But only few seek treatment at this stage, may be due to embarrassment or thinking the problem is not a ‘disease’.
“ED could be a symptom of many other diseases, for which effective treatment is available. Early treatment of the underlying disease would improve the symptoms,” added Dr. Malalasekera.
Moreover, the disease processes affecting the nerves, like strokes, injury to the spinal cord, major surgery or radiotherapy involving the pelvis, can cause erectile dysfunction as these can damage the nerves that supply the sexual organs.
In addition to all these factors the hormones also play a crucial part in developing sexual organs and maintaining sexual function. Testosterone which is called the male sexual hormone is the most important in men. This hormone is produced by the testis. In the rare event of the testes not being developed properly or if it has been surgically removed, testosterone production gets impaired leading to problems related to reproductive and sexual function. However commercial preparations are available for these patients when indicated.
When a patient presents with erectile dysfunction after the initial clinical evaluation the majority of patients need to check their blood sugar levels and blood cholesterol levels. If the problem lies there, it is essential to treat these generalised disease processes, to slow down the deterioration. This will improve the sexual function as well as the general wellbeing of the patient.
Further investigation would be required as appropriate and may include serum testosterone (male hormone) level assessment, ultrasound with doppler to assess blood flow of the penis etc.
Many patients (about 90%) with erectile dysfunction can be treated successfully. The treatment method will depend on the choice of the patient (and partner), associated illnesses and medications being taken, and the cause of the erectile dysfunction.
The treatment options:
- Oral medication e.g. sildenafil, tadalafil
The introduction of these drugs in the late ’90’s revolutionized the treatment of ED. These drugs generally have a good safety profile when used scientifically. These are used as and when required before sex. These tablets cause increased blood flow within the penis. Unfortunately 30-40% percent of patients will fail to respond to these medications. Also it is not wise to use sildenafil in every case of ED without medical advice.
- Injections to improve blood flow to the penis e.g. papaverine, alprostadil. These injections are made directly to the blood containing spaces (cavernous sinuses) of the penis. This again is used as and when required.
- Intraurethral instillation of medication (e.g. alprostadil).
- Vacuum erection devices -These are manually or battery operated machines used to create a vacuum around the penis and assist in drawing blood into the penis.
- Penile implants / prosthesis - Surgery can be done to insert prostheses (implants) into the penis to enhance rigidity. This can be in the form of malleable devices, which keep the shaft of the penis rigid continuously, or as inflatable devices, which can be inflated and deflated when required. In properly selected patients this gives the best satisfaction rates. The complications could include infection and mechanical failure of prostheses.
ED, therefore is a treatable condition in the majority. This needs a systematic approach to identify and manage any organic diseases leading to ED. After addressing the roots of the problem, ED still has many treatment methods, to be chosen from, to suit the individual patient.
When to seek medical advice
See your family doctor if:
- Erectile or other sexual problems are an issue for you or your partner
- You have diabetes, heart disease or another known health problem that may be linked to erectile dysfunction
- You have other symptoms along with erectile dysfunction that may not seem related
Symptoms of ED could be
- Trouble getting an erection
- Trouble keeping an erection
- Reduced sexual desire
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