Erectile Dysfunction

Symptoms: Trouble getting an erection, trouble keeping an erection, decreased sexual desires, inability to achieve orgasm despite stimulation

Causes: Heart diseases, high cholesterol, obesity, diabetes, tobacco & substance abuse, hormonal imbalance, depression, stress and anxiety, and trauma from injury

Risk Factors:  Cardiovascular disease, hypertension, hypothyroidism, obesity, low testosterone, kidney disease, age, certain medications, metabolic syndrome, sleep disorders, alcohol addiction, prostate surgery, colon and bladder cancer, damage to the pelvic area

Severity: Mild to severe

Which doctor to consult: Urologists, Endocrinologists, Psychiatrists, Cardiologists, Andrologists and Diabetologists

Overview

Erectile dysfunction (ED) is a condition that leads to the inability to get an erection in men. It causes reduced firmness during sexual intercourse. Usually, there are two kinds of erectile dysfunction - occasional and frequent. Occasional ED is common in people experiencing stress, lifestyle or diet changes. On the other hand, frequent ED indicates underlying health problems.

Typically, erectile dysfunction occurs with age. But, other factors like excessive smoking and alcohol consumption can cause ED at a young age. Certain medical conditions like cardiovascular diseases, prostate surgery, and traumatic injuries causing pelvic nerve damage can lead to ED. Even specific medications like Thiazide can cause erectile dysfunction.

Additionally, day-to-day stress is a leading cause of erectile dysfunction in men. Any psychological condition can cause a change in sexual activity, which inadvertently affects erectile capacity in men.

The main reason behind erectile dysfunction is the abnormality in blood flow in the penile vessels. In some cases, ED occurs due to blocked flow, while in others, the faster draining of blood from veins leads to dysfunction. This can happen because of hormonal disturbances and physical obstructions in the penile system.

Since ED can occur for multiple reasons, its diagnosis involves a physical examination and sexual and health history assessments. In addition, your urologist can also request further tests involving ultrasound, blood assay, urine tests, nocturnal tumescence test, psychological assessment and more to analyse the condition's severity.

If left untreated for a long time, ED can lead to psychological trauma, low self-confidence and frustration.

When to Consult a Doctor?

On Symptoms: The right time to seek medical assistance is as soon as the patient starts feeling a change in sexual performance. The diagnosis is necessary if the patient is dealing with recurring ED. If the patient has faced or still facing difficulty getting or maintaining an erection or have had trouble with ejaculation for more than four encounters, consulting a urologist is crucial. Not only can the doctor help treat the issue but also assist with the underlying causes.

Bi-annual Screening: Depending upon the medical history, urologists recommend ED assessment every six months. If the patient have a record of ED condition, it's important to keep his sexual health in check with regular screenings. Besides, the development of psychological and physiological factors also contributes to the recurrence of ED. So, it's best to ascertain the likely impact of the comorbidities on sexual health.

Diagnosis

Preliminary Discussion: The initial assessment of erectile dysfunction involves analysing the root cause of the issue. In this test, urologists enquire about the patient’s medical and sexual history. The patient is advised to inform about previous surgeries, routine medications and lifestyle preferences. In the sexual history, the doctor will need information about the patient’s relationship troubles and libido, which might lead to dysfunction.

Physical Exam: To check for physiological problems, urologists will carefully examine the different parts of the patient’s penis. It involves checking the glans, corpus, prepuce and testicular analysis. Additionally, to look into hormonal imbalances, the specialists will also study the changes in the patient’s breast size, hair problems and circulatory well-being.

Psychosocial Exam: In this assessment, the doctor analyses the factors responsible for the patient’s sexual performance. It can involve questioning the patient’s sexual partner to check the expectations and experiences during intercourse. This test provides a complete picture of the patient’s emotional health, to screen for anxiety, stress and depression, if any.

Diagnostic Tests

• Blood tests: To check for existing conditions affecting the patient’s sexual health, urologists recommend different blood analyses. It involves checking the complete blood count, blood sugar level, and hormonal proportions of thyroid, FSH and LH. The levels of testosterone and prolactin are also checked.
• Urine tests: The urine assay or urinalysis checks the presence of diabetes in the blood. These tests comprise dipstick analysis, microscopic examination and visual observation. Usually, doctors prescribe these analyses to check for infections, kidney diseases, stones or cancer in the reproductive system.
• Ultrasound: This testing method checks for problems in the internal structure of the penis. It observes tissue scarring, which usually happens in Peyronie's disease. Additionally, it also diagnoses priapism and penile trauma.
• Nocturnal Penile Stamp Tumescence Test: This is a self-test which involves attaching multiple stamps to the patient's penis overnight. If the stamp changes position, the severity of ED is considered mild. Even though this test doesn't provide conclusive proof, it still acts as primary evidence.

Treatment

Medications: The primary treatment for ED depends on the underlying causes behind the symptoms. Depending upon the reason, urologists prescribe a range of medications to ease the symptoms.

Generally, the treatment begins with medications for enhancing blood flow in the penile region. The common medicines to treat this disorder contain salts like avanafil, sildenafil, vardenafil and tadalafil. These medications can be administered as oral prescriptions or injections at the base or side of the organ.

Moreover, if there's a deficiency of testosterone, doctors may also suggest hormone replacement therapy. 
Some prescription drugs can also cause erectile dysfunction by affecting hormonal secretion and blood circulation.

In this case, it's essential to consider replacing these medicines through a consultation with doctor. The doctor can then recommend a substitute for the existing medications if the side effects lead to ED.

Therapy: Since psychological factors can contribute to erectile dysfunction, urologists also recommend therapy. This method helps to reduce stress, anxiety, depression or post-traumatic stress disorder leading to penile problems.

Other than the normal therapy sessions, the patient can also consider relationship counselling to understand the stressors and their resolution with your spouse.

Erection Devices: If the patient don't suffer from ED regularly, doctors might recommend a vacuum erection device, also known as a constriction device or penis pump. This device consists of a plastic tube, an electric pump and a constriction band.

The pump’s main function is to create a vacuum around the penile shaft to draw blood into it. The band is placed at the penis's base while the tube covers the upper part of the organ. Once the erection is achieved, the band can be left on to maintain it.

Penile Implants: If the other treatment methods haven't provided successful results, implants are used for alleviating ED. There are two kinds of implants used by doctors - inflatable and semi-rigid prostheses.

In an inflatable prosthesis or 3-piece hydraulic pump, the pump and cylinders releasing saline mixture are placed in erection chambers. It helps by inflating to cause erection in the penis. In semi-rigid implants, bendable rods are positioned inside erection chambers. The patient can change the form of the penis from non-erect to erect using these devices.

Risk and Complications if Left Untreated

• Psychological Trauma: Sexual health is one of the main determinants of quality of life. In the absence of proper erection, individuals frequently face a lack of fulfilment in their personal life. In addition, it also evokes negative feelings like rejection, shame, feeling unloved and guilt. It also becomes a barrier to nurturing a healthy relationship with a partner. Further, these feelings can lead to serious mental health issues in a patient.
• Frustration: The disappointment and shame due to the inability in achieving an erection build up frustration in patients. Recurrent occurrences of failed erections lead to anxiety and self-pity in the patients. Since the patients find it difficult to voice their feelings, it can cause internalisation of frustration in different parts of their lives.
• Decrease in Confidence: Repeating ED leads to low self-esteem, confidence and satisfaction in sexual relationships. The prolonged presence of these negative feelings can also result in chronic depression and worsen the dysfunction.
• Health Complications: ED also occurs due to a range of underlying conditions such as heart diseases, obesity, hypertension, etc. The symptoms of these problems can occur in the form of erectile dysfunction. Usually, the diseases causing ED remain dormant for a long time before turning severe. Any disregard of such signs can prove disastrous to the patient’s overall health. 

Additional Information

• Types of Erectile Dysfunction

1. Organic Erectile Dysfunction

This is a common problem occurring in patients above the age of 45. It affects penile veins, arteries, or both leading to a problem in the blood flow. If the problem is in the penile arteries, it is caused by arteriosclerosis or hardening of the vessels in arteries. Usually, it happens due to injury or trauma to the arteries. The other factors contributing to arterial ED are obesity, reduced physical activity, high cholesterol, increased blood pressure and smoking.

In addition, the development of fibrosis or excess growth of smooth muscle tissues can also be a factor behind failed erections. Malfunction of smooth muscles or venous leak is directly related to penile problems.

• Drug-induced Dysfunction: Some medications can lead to changes in blood pressure in the penile region. This sudden drop in the blood flow can cause a disability to maintain or achieve erections. Generally, anti-anxiety and anti-depressant medications, glaucoma eye drops, and chemotherapy agents can cause ED.
• Hormone-induced Dysfunction: Hormonal imbalances such as an increase in prolactin can be the reason behind erectile failure. A disturbed secretion of thyroid hormone affects the ability to get erections. Additionally, steroid abuse for body weight gain and hormonal therapy for prostate cancer can lead to ED.

2. Premature Ejaculation (PE)

Premature ejaculation is said to occur when the ejaculation happens within one minute or before vaginal penetration. Any inability to delay PE is also considered a male sexual dysfunction under ED.

Generally, PE is divided into two types, i.e., lifelong PE and acquired PE. In lifelong PE, the patient faces premature ejaculation since the first intercourse. While in the acquired type, PE develops later in life.

What is the basis for the treatment of erectile dysfunction?

The treatment for dysfunction depends on the analysis of the urologist and endocrinologist. Treatment is initiated based on the overall assessment of the patient's condition. The primary factors considered for ED treatment are:

• Previous occurrence of erectile dysfunction 
• Current age 
• Severity of the disorder
• Overall well-being and medical history 
• Response to medications  
• Tolerance for procedures and therapies 
• Expectations from the treatment process 
• Preference for the type of treatment