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Male Sexual Health

Erectile Dysfunction (ED)

ED is defined as difficulty in achieving or maintaining an erection sufficient for satisfactory sexual intercourse.It is a common male disorder often affecting older men that significantly impacts quality of life and well being. ED affects 50% of men older than 60 years of age. Younger men typically report a great degree of bother than older men which leads them to seek treatment at the earliest. Risk factors and co-morbid conditions for cardiac diseases like hypertension, diabetes, hypercholesterolemia, work related stress, depression and metabolic syndrome contribute to ED. Lifestyle factors including smoking, obesity and lack of exercise are also significant predictors of ED.

Physiology of Penile Erection and Detumescence

Erection and flaccidity of the penis is a vascular phenomenon. The penile erectile tissue or the corpora cavernosa plays a key role in the erectile process. Sexual stimulation triggers the release of chemicals which cause relaxation of smooth muscles. This increases blood flow in the arteries and the smaller arterioles. The incoming blood is trapped by the vascular spaces. The venous outflow is reduced by compression of the veins. The partial pressure of oxygen in the blood rises from 35 to 90mm/hg and the pressure in the cavernosa climbs to 100mm/hg which erects the penis. A rigid erection occurs with further contraction of the pelvic floor muscles. The rigid penis becomes flaccid with a slow opening of the venous channels and then a fast pressure decrease with a fully restored venous outflow.

Causes of ED

  • Aging
  • Psychological- Depression /Anxiety
  • Neuropathy/Pudendal Nerve injury
  • Hypogonadism/HyperProlactinemia/HypoThyroid/Cushings
  • Ischemic Heart Disease/Atherosclerosis
  • Medications-Antihypertensives/AntiDepressants/Estrogens
  • Alcohol/Smoking/Obesity
  • DiabetesMellitus/Hypertension/Chronic Obstructive Pulmonary Disease

Evaluation of the patient with ED

It is important to understand that both organic and psychosocial factors play a role in the etiology of erectile dysfunction. Hence a thorough detailed history without too many prying questions is key. Sometimes patients may feel embarrassed to answer direct questions and hence a self administered questionnaire may help. Sometimes picture cards explaining the anatomy of erection may also be used for explaining.
A thorough gentle physical examination of the genito urinary system is done. It is important to remember that ED and heart disease share certain comorbidities and hence a thorough evaluation of the heart lungs and abdomen is done. The penis is examined for plaques, curvatures, and the position of the meatal opening. Presence and size of both testis is determined. Features suggestive of hypogonadism(testis size, body hair, voice) are looked for.

Algorithm for the Evaluation of ED

algorithm

 

Lab Tests

If not previously done, some basic studies should be considered to identify unrecognized systemic conditions that may predispose to erectile dysfunction. These include a complete blood count, urinalysis, renal function, lipid profile, fasting blood sugar, and thyroid function. Hormone testing for prolactin and testosterone the male hormone should be done.

Additional testing

Penile Doppler
ED can be Psychogenic, Neurogenic or Vasculogenic. In order to identify a potential cause, a Penile Doppler Ultrasound testing is often employed. As ED is due to vasculogenic reasons in 50-70% individuals, the test serves to identify arterial or venous abnormalities which contribute to the same. The test is done by injecting a small quantity say 2ml of vasodialting agent such as Papaverine into the cavernosa. The Peak Systolic Velocity and The End Diastolic Velocities are noted.

Penile biothesiometry
This test involves the use of electromagnetic vibration to determine sensitivity and nerve function. A decreased sensitivity to these vibrations may indicate nerve damage.

Treatment of ED

Lifestyle Modification
Losing weight, keeping fit, sleeping well, reducing stress and anxiety are some of the lifestyle changes that go a long way in helping people with ED.

PDE5 Inhibitors
These drugs form the mainstay of treatment in the management of ED.These drugs act by increasing the blood flow into the penis. There are various medications that can be prescribed based on the duration of action, bioavailability of the drug and side effect profile.

Hormone Replacement
Testosterone is the male hormone that helps with erection and sometimes Total Testosterone levels can be misleading as most of this hormone is bound to a protein called sex hormone binding globulin. The free hormone is the active form and testosterone supplements help with erectile function.

Vacuum devices
This is another tool that can be used for men with ED. The device is a hollow cylinder which helps draw blood into the penis.

Penile Implants
These are devices which are implanted into the penis to help achieve erection. It requires a surgical procedure under regional or general anaesthesia. There are noninflatable and inflatable devices.