Erectile Dysfunction Treatment

Anatomy of the penis

To understand impotence, it’s essential to first grasp the normal anatomy and function of the penis.

The penis comprises three cylinders:

• Two corpora cavernosa,  located on the top

• and one corpus spongiosum, which surrounds the urethra underneath.

The corpora cavernosa are composed of spongy tissue containing muscles, veins, arteries, and fibrous tissues. This tissue contains sinusoids, or spaces that can fill with blood, enabling the penis to become erect.

The tunica albuginea, a tough, elastic layer of tissue, surrounds the corpora cavernosa and plays a role in maintaining erections by compressing veins to trap blood within the penis.

How an erection is achieved

Erections are complex neurovascular actions involving blood vessels, chemical signals, and nerves.

• Stimulation: Sexual arousal—triggered by physical touch or mental stimuli—activates nerves in the penis, releasing nitric oxide.

• Chemical cascade: Nitric oxide will increase cGMP (cyclic GMP) production, causing the muscles in the corpora cavernosa to relax.

• Blood flow: Relaxed muscles allow more blood to flow into the penis, filling the corpora cavernosa and causing the penis to expand and become erect.

How is an erection sustained?

As the corpora cavernosa gets filled with blood, they expand, compressing veins beneath the tunica albuginea and trapping blood within the penis. This pressure maintains the erection until the chemical cGMP breaks down, allowing the muscles to contract and the blood to drain out.

Causes of erectile dysfunction

Erectile dysfunction occurs when one or more of the systems involved in achieving or maintaining an erection fail. Key contributing factors include:

• Cardiovascular diseases**:** Atherosclerosis, or the hardening and narrowing of arteries, reduces blood flow to the penis and is a leading cause of ED. There is a strong correlation between the severity of ED and coronary artery disease.

• Ageing: Age-related changes in the muscle and tissues of the penis can impair its function. Older men are more likely to develop diseases such as cardiovascular conditions and diabetes, which are linked to impotence.

• Hypertension: High blood pressure damages arteries and reduces nitric oxide production, impairing blood flow to the penis. Certain blood pressure medications may also cause impotence as a side effect.

• Diabetes mellitus**:** Men with diabetes are ten to fifteen years more likely to become impotent later in life due to changes in penile muscle function, nerve damage (diabetic neuropathy), and reduced blood flow.

Lifestyle Factors

• Obesity, excessive alcohol consumption, and recreational drug use (e.g., marijuana, cocaine) also heighten the risk.

• Hormonal Imbalances: Low testosterone levels can decrease libido and reduce nitric oxide production, affecting erection quality

• Smoking contributes to atherosclerosis and vasospasms, increasing the risk of ED.

Psychological Factors

• Surgery or Trauma

• Stress, anxiety, depression, and low self-esteem can contribute to ED.

• Pelvic injuries, spinal cord damage, or surgeries (e.g., prostatectomy) can damage nerves and blood vessels critical for erections.

• Psychological ED is often associated with performance anxiety or relationship issues and may be indicated by the persistence of morning or spontaneous erections.

Risk factors for impotence

Common risk factors include:

• Trauma or surgical interventions in the pelvic region

• Depression and psychiatric conditions

• About 52% of men aged 40–70 experience some form of ED, according to the Massachusetts Male Aging Study.

• High cholesterol and hypertension

• Smoking and alcohol abuse

• Cardiovascular disease or atherosclerosis

• Diabetes and metabolic syndrome

• Advanced age

Prevalence of erectile dysfunction

Erectile dysfunction is highly prevalent, with varying degrees of severity:

The prevalence of complete ED increases from 5% in men aged 40 to 15% in men aged 70 and older.

Erectile dysfunction symptoms

The primary symptoms include:

• In some cases, ED may coexist with an ability to orgasm or ejaculate.

• Difficulty achieving or maintaining an erection sufficient for penetration.

• Erections that do not last long enough for sexual activity.

Diagnosis of erectile dysfunction

Healthcare professionals diagnose ED by evaluating a patient’s:

• By identifying the underlying cause, physicians can tailor a treatment plan to address both physical and psychological contributors to impotence.

• Physical examination: Doctors assess penile anatomy, any signs of nerve damage or atherosclerosis, and blood flow.

• Medical and sexual history: This includes discussing their severity, associated risk factors like stress, cardiovascular conditions, or smoking, and when symptoms began.

• Nighttime erections: Tests may be used to differentiate psychological from physical causes of ED, as men with psychogenic ED often retain spontaneous nocturnal erections.

Treatment options for ED (erectile dysfunction):

First-line treatments

• Medication adjustments:

If current medications contribute to ED, switching to alternatives under a doctor’s guidance may help.

• Lifestyle modifications:

Weight loss for overweight individuals.

Regular exercise.

Managing hypertension and blood sugar levels for diabetics.

Reducing alcohol consumption.

Quitting smoking.

• ** Psychotherapy:**

Addressing psychological causes of ED such as anxiety, depression, or stress.

• Oral treatment:

PDE5 (Phosphodiesterase type 5) inhibitor:

• Avanafil (Stendra)

• Tadalafil (Cialis)

• Vardenafil (Levitra, Staxyn)

• Sildenafil (Viagra)

These medications enhance the flow of blood to the penis by relaxing smooth muscles. They require sexual stimulation to work effectively.

Second-line treatments

• Vacuum erection devices (VEDs): A pump creates a vacuum around the penis, drawing blood into it, followed by a constriction ring to maintain the penile erection.

• Intraurethral suppositories (MUSE): Medication is inserted directly into the urethra to induce an erection.

• Intracavernosal Injections: Injecting drugs like phentolamine, alprostadil, or papaverine into the corpora cavernosa.

Third-line treatments

• Vascular surgery: Rarely performed; aims to improve blood flow to the penis.

• Penile prostheses: Surgically implanted devices that allow manual control of erections.

 ### ED Treatment for Men with Cardiovascular Disease

Men with cardiovascular conditions (e.g., angina or heart attack history) must consult their doctor before treatment. The risk of heart attack during sexual activity should be assessed, especially for those with multiple risk factors like hypertension, diabetes, obesity, or smoking.

PDE5 inhibitors may not be suitable for men taking nitrates (for angina) or alpha-blockers (for prostate issues), as these can cause dangerously low blood pressure.

Common impotence medications

• Sildenafil (Viagra):

Taken 1 hour before sexual activity.

Works best on an empty stomach.

Available in 25 mg, 50 mg, and 100 mg doses.

• Tadalafil (Cialis):

It can be taken daily in low doses.

Approved for both ED and benign prostatic hyperplasia (BPH).

• Vardenafil (Levitra, Staxyn):

Available in various formulations, including a dissolvable tablet (Staxyn).

• Avanafil (Stendra):

Fast-acting and effective with fewer side effects.

Precautions with PDE5 Inhibitors

Contraindications: Men taking nitrates or certain alpha-blockers should avoid these drugs.

Those on medications affecting CYP3A4 (e.g., protease inhibitors, antifungals) require dosage adjustments.

Side effects of PDE5 inhibitors**

Rare: hearing loss, vision changes, or priapism (prolonged erection).

Common: upset stomach, nasal congestion, flushing, headache.

Seek medical care if an erection lasts over four hours or if there is sudden vision or hearing loss.

• Testosterone therapy: For men with low levels of testosterone, therapy can improve impotence and libido, but it may not fully resolve the issue. It’s not recommended for men without low testosterone and needs careful monitoring.

• Tadalafil (Cialis): It is a PDE5 inhibitor used to treat benign prostatic hyperplasia (BPH) and impotence. Tadalafil can be taken as needed or daily and lasts up to 36 hours. Side effects include muscle aches and back pain. It’s not suitable for men with certain health conditions, such as unstable angina or severe liver disease.

• Intracavernosal Injections: Direct injections into the penis can help achieve erections. Medications like papaverine and prostaglandin E1 are used, but this treatment can be painful and has potential side effects like priapism and fibrosis.

• Avanafil (Stendra): A newer PDE5 inhibitor, effective for ED. It works faster than others, with a starting dose of 100 mg taken about 15 minutes before sexual activity. Men with liver or kidney disease should be cautious.

• Intraurethral Suppositories: Alprostadil can be inserted into the urethra to promote erections. It’s effective in many cases but may cause side effects like penile pain and dizziness.

Penile prosthesis

There are various types of penile prostheses, from the simple malleable to the three-piece inflatable prosthesis.

• Inflatable prosthesis;

The three-piece prosthesis includes cylinders, and fluid reservoir in the penis and a pump situated in the scrotum. Pressing the pump transfers sterile fluid to the cylinders, creating an erection, mainly by expanding the girth. A release valve returns the fluid to the reservoir.

• Malleable prosthesis consists of firm rods, surgically placed into the corpora cavernosa,  which can be manually adjusted for sexual intercourse. It is less prone to mechanical issues and offers the least natural appearance.

Surgery and effectiveness

The surgery is usually outpatient, requiring a single incision, with its components placed beneath the skin. Certain antibiotics are usually given to reduce the potential risk of infection. The prosthesis is highly effective, but future treatment options may be limited by scarring in the corpora cavernosa. They are, therefore, reserved for patients who can’t use other therapies.

Penile prosthesis placement complications

One of the primary concerns following the insertion of a penile prosthesis is the risk of infection, which occurs in 8%-20% of men who undergo the procedure. Signs of infection include pain, swelling, occasional discharge, and redness. If an infection develops, the prosthesis must be removed. Depending on the time and how severe the infection is, the medical doctor may opt for a thorough irrigation with antibiotic solutions and place a new prosthesis simultaneously, or the infected device may be removed with a plan to insert a new one once the infection has been cleared.

Another potential issue is a mechanical failure, though recent advancements such as protective coverings over the tubing and lock-out valves have significantly reduced the likelihood of such problems.

In some cases, the prosthesis may erode, pressing into the urethra through the corporal tissue. Symptoms of this include discharge, pain, malfunction of the prosthesis, changes in the urine stream, and blood in the urine. If erosion occurs, the device will need to be removed. In some instances, if one cylinder remains intact, it can be left in place, and a catheter will be inserted to allow the urethra time to heal.

Additional risks associated with the placement of penile prosthesis include incorrect sizing of the device, which can cause migration of the reservoir or pump to an unusual location or result in an abnormal appearance of the erect penis.

Penile arterial surgery

Penile arterial reconstructive surgery may help treat erectile dysfunction caused by blockages in the penile arteries. This option is most effective for younger men who have specific blockage due to an injury, such as a pelvic fracture. In older men or those with more widespread artery blockage, the procedure is less likely to be successful. Surgeons typically advise against surgery on the veins in the penis.

Over-the-counter and natural remedies for erectile dysfunction

The FDA (Food and Drug Administration) has listed 29 over-the-counter products that claim to treat impotence, but these should be avoided, as many contain harmful ingredients.

Various herbal or natural remedies, such as ginseng, Yohimbe, DHEA, and L-arginine, have been suggested for the treatment of this disease. However, researchers have not conclusively proven their safety and efficacy. Before using any of these supplements, it is advisable to consult with a healthcare professional. Additionally, acupuncture has not been shown to effectively treat impotence.

Some home remedies that may alleviate symptoms of erectile dysfunction include changes in diet, such as moderate consumption of red wine, blueberries, and citrus fruits.

Erectile dysfunction prognosis

Presently, there is no definitive cure for impotence. However, quite a few treatment options are available that enable individuals to achieve an erection when they please. The effectiveness of these treatments largely depends on the underlying cause of the condition, and some therapies may be more beneficial than the rest.

While data on lifestyle changes to manage impotence is limited, reducing risk factors such as diabetes, heart disease, and hypertension may help prevent the development of the condition.

Prevention of erectile dysfunction

Certain preventive measures can help reduce the risk of erectile dysfunction development. By lowering the chances of developing conditions like heart disease, high blood pressure, and diabetes, individuals can also reduce their risk of experiencing impotence.

Additional lifestyle changes, such as engaging in regular physical activity, maintaining a heart-healthy diet with sufficient vitamins, and quitting smoking, may further lower the risk of erectile dysfunction.

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