Diagnosis and treatment of erectile disorders in men

Erectile dysfunction, or ED, can refer to a total inability to achieve erection, firm enough for sexual intercourse, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult. In older men, ED usually has an underlying physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age; about 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. However, it is not an inevitable part of aging.

ED is treatable, irrespective of the age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatment of ED.

What Causes Erectile Dysfunction (ED)?

Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence of events includes generation of nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues as well as vasculature in and around the corpora cavernosa. Causes of ED include the following:

  • Diseases: Diseases such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience ED.
  • Lifestyle Choices: Lifestyle choices that contribute to heart disease and vascular problems also increase the risk of erectile dysfunction. Smoking, obesity and sedentary lifestyle are possible causes of ED.
  • Surgery: Surgery (especially radical prostate and bladder surgery for cancer) can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.
  • Medications: Many commonly used medicines such as antihypertensive drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (drug used in management of peptic ulcer) can produce ED as a side effect.
  • Psychological Factors: Experts believe that psychological factors such as stress, anxiety, guilt, depression, low self esteem, and fear of sexual failure cause 10 to 20 percent of ED cases. Men with a physical cause for ED frequently also experience some sort of psychological reactions (stress, anxiety, guilt, and depression).
  • Smoking: Other possible causes of ED are smoking, which affects normal blood flow in veins and arteries.
  • Hormones: Hormonal abnormalities, such low levels of testosterone, may also be responsible for ED.

How is ED Diagnosed?

The diagnosis of erectile dysfunction (ED) involves the following steps:

  1. Patient History: Medical and sexual histories help define the degree and nature of ED. A medical history can disclose diseases that lead to ED, while a simple recounting of sexual activity might distinguish among problems with sexual desire, erection, ejaculation, or orgasm. Using certain prescription or illegal drugs can suggest a chemical cause, since drug effects account for 25 percent of ED cases. Cutting back on or substituting certain medications can often alleviate the problem.
  2. Physical Examination: A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to touch, it may indicate a problem in the nervous system. Abnormal secondary sex characteristics, such as hair pattern or breast enlargement, can point to hormonal problems, which would mean that the endocrine system is involved. The examiner might discover a circulatory problem by observing decreased pulses in the wrist or ankles. Unusual characteristics of the penis itself could suggest the source of the problem for example; a penis that bends or curves when erect could be the result of Peyronie's disease.
  3. Laboratory Tests: Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of free testosterone in the blood can yield information about problems with the endocrine system and is indicated especially in patients with decreased sexual desire.
  4. Other Tests: Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than psychological cause.
  5. Psychosocial Examination: A psychosocial examination, using an interview and a questionnaire, reveals psychological factors. A man's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

How is ED Treated?

Erectile dysfunction (ED) can be treated by employing conservative or non-surgical methods and surgical methods.  Conservative treatment measures to treat erectile dysfunction are always considered before invasive measures such as surgery.

Some conservative treatment measures include the following:

Lifestyle Changes: For some men, making a few healthy lifestyle changes may solve the problem. Abstinence from smoking, weight loss, and increased physical activity may help some men regain sexual function.

Medication Changes: The next step is cutting back on any drugs with harmful side effects. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of antihypertensive medicine.

Psychotherapy: Experts often treat psychological factors for ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED from physical causes is being treated.

Drug Therapy: Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis.  Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes.

Vacuum Devices: Mechanical vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body. One variation of the vacuum device involves a semi rigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse.

Surgical therapy: Surgical Treatment for ED usually has one of three goals:

  • To implant a device that can cause the penis to become erect
  • To reconstruct arteries to increase flow of blood to the penis
  • To block off veins that allow blood to leak from the penile tissues

The most common surgery performed for ED is Penile Implant surgery. Implanted devices, known as prostheses, can restore erection in many men with ED.