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

Prevalence: According to one study, approximately 52% of men suffer from some form of Erectile Dysfunction (ED), and the prevalence of ED rises from 5 to 15% between the ages of 40 to 70. Even though the risk of ED increases with age, young men can still develop it.

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.

Types of ED:

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.

Symptoms:

ED is characterized by several symptoms, which may include:

• Trouble getting an erection

• Difficulty maintaining an erection during sexual activities

• Reduced sexual desire

These symptoms might be persistent and can lead to stress, affect self-confidence, and contribute to relationship problems. ED can also be a sign of an underlying health condition that needs treatment and a risk factor for heart disease. If you’re experiencing these symptoms, especially if they’ve lasted for 3 or more months, it’s important to consult a healthcare professional. They can help determine whether your symptoms are caused by an underlying condition that requires treatment.

Causes:

ED can be caused by a variety of factors, which can be broadly categorized into physical and psychological causes:

Physical causes may include:

Cardiovascular diseases
Diabetes
High blood pressure
High cholesterol
Obesity
Metabolic syndrome
Certain medications
Tobacco and alcohol use
Sleep disorders
Treatments for organs in the pelvic area
Neurological conditions such as Parkinson’s disease or multiple sclerosis
Hormonal imbalances, including low testosterone
Injury or trauma to the penis or spinal cord
Diseases of the penis

Psychological causes might involve:

Stress
Anxiety
Depression
Relationship problems.
It’s important to note that sometimes ED can result from a combination of both physical and psychological issues. For instance, a minor physical condition that slows your sexual response might cause anxiety about maintaining an erection, leading to or worsening ED.

Risk Factors of ED:

Risk factors for ED can increase the likelihood of developing the condition. These factors include:

Age: The likelihood of ED increases with age.
Medical conditions: Such as heart disease, diabetes, high blood pressure, and obesity.
Psychological conditions: Including stress, anxiety, and depression.
Lifestyle choices: Smoking, alcohol use, and substance abuse can contribute to ED.
Medications: Some prescriptions can have ED as a side effect.
Injuries: Damage to the nerves or blood vessels around the penis can increase risk.
Hormonal imbalances: Conditions like hypogonadism can be a factor.
It is important to address any risk factors with lifestyle changes and consult a healthcare professional for a personalized assessment and treatment plan.

Possible Complications:

• 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 lives. 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 to achieve 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 to remain dormant for a long time before turning severe. Disregarding such signs can be disastrous to the patient’s overall health. 

Prevention:

Preventing ED involves addressing its risk factors and maintaining overall health. Here are some strategies that can help:

Quit smoking: Smoking can damage blood vessels and restrict blood flow to the penis.
Maintain a healthy weight: Obesity can lead to conditions like diabetes and high blood pressure, which are risk factors for ED.
Exercise regularly: Physical activity can improve blood flow, reduce stress, and contribute to a healthy body weight1.
Eat a healthy diet: A diet rich in fruits, vegetables, whole grains, and fish can reduce the risk of ED.
Limit alcohol consumption: Drinking too much can cause ED.
Manage medical conditions: Keep diabetes, high blood pressure, and cholesterol under control.
Reduce stress: Psychological stress can affect sexual function, so finding ways to relax is important.
Get adequate sleep: Poor sleep patterns can contribute to ED.
Avoid anabolic steroids: These drugs can shrink the testicles and decrease testosterone levels.
Avoid illegal drugs: These can affect sexual function and overall health.
Seek help for mental health issues: Depression and anxiety can cause or worsen ED.
It’s also important to have regular check-ups with your healthcare provider to manage any existing health conditions and to discuss any concerns about erectile function or sexual health.

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 is still facing difficulty getting or maintaining an erection or has 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 has 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.

LabTests

• Blood tests: Urologists recommend different blood analyses to check for existing conditions affecting the patient’s sexual health. These involve 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 remains primary evidence.

Treatment:

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

Medications for treating ED typically work by enhancing the effects of nitric oxide, a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation. Here are some examples of ED medications:

Sildenafil: Often the first medication tried for ED.
Tadalafil: Known for its longer duration of action.
Vardenafil: Similar to sildenafil, with slightly different dosing.
Avanafil: A newer medication with a faster onset of action.
Alprostadil: Can be injected directly into the penis or inserted as a pellet through the urethra.

These medications are generally safe and effective but can have side effects and are unsuitable for everyone. They also can’t be used with certain medications, such as nitrates. It’s important to consult a healthcare professional to determine the most appropriate treatment for you. Lifestyle changes like exercising, quitting smoking, and losing weight can also help improve 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.

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

Erection Devices: If the patient doesn'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 alleviate ED. Doctors use two kinds of implants - 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.

Additional Information

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