This article, written by Dr Tom Kelly of the Everyman Centre, was published in “Modern Medicine”, The Irish Journal of Clinical Medicine, Volume 41, Number 3 2011.
Erectile dysfunction ( ED ) can be defined as the consistent inability to attain an erection when one is sufficiently sexually aroused.
This definition excludes those men – usually young- who cannot attain and/or maintain an erection because of lack of sexual arousal or diminution of arousal. Though these men’s presenting complaint is often that of erectile dysfunction they usually experience consistent, spontaneous, nocturnal and/or morning erections and erections when they masturbate. They may also experience erections with a partner so long as they avoid certain forms of penetrative sex. The treatment of these men will, in my opinion, be different to that of men who suffer from “true” erectile dysfunction.
Let us concentrate initially on men who suffer from erectile dysfunction as defined in the first sentence above.
The history is usually that of a gradual, progressive decline in quality of erection despite a normal libido and sufficient sexual arousal. These men also report lack of spontaneous nocturnal/morning erections and erections of poor quality when they masturbate when sexually aroused. These men are usually in the older age group.
Sometimes the history is that of a sudden onset. In this instance there is usually a history of trauma, a surgical procedure or commencement of certain medication shortly prior to the onset.
ED AND QUALITY OF LIFE
Many studies (references available on request) show that ED may be associated with depression, loss of self esteem, poor self-image, increased anxiety or tension with one’s partner and avoidence of sexual intimacy. Partners often feel puzzled, rejected and unloved. These types of issues- especially tensions/conflict in the relationship- will often have to be addressed to ensure a satisfactory treatment outcome. By the time most men with ED consult a doctor – usually months or years after onset- both partners have suffered in some way and this suffering is often exacerbated by poor communication and misunderstanding between them. At this stage the ED problem has snowballed and a prescription for medication for ED alone will not suffice. Where a man suffering from ED is in a relationship, the ideal is to see both parties.
A detailed history is probably the most important aspect of patient assessment. It will help to accurately define the patient’s specific complaint and provide key clues as to its origin.
It will provide an opportunity to explore what effects, if any, the condition has had on each partner and on their relationship. This, in my opinion, is often the most important part of the consultation in terms of helping the man and/or couple achieve the intimacy they desire. For example, the onset of ED may lead to a couple avoiding sexual intimacy. The man suffering from ED may feel his partner would not be interested in sexual intimacy if he cannot get/maintain an erection. His partner may feel that he no longer desires him/her. Providing the couple with the opportunity to address such attitudes, misconceptions and misunderstandings will go a long way to restoring an intimacy they both miss and desire.
It will indicate where more detailed examination and investigation is appropriate.
It may reveal treatable causes of ED such as depression, hypogonadism and drug abuse such that treatment of these conditions leads to amelioration of the erectile dysfunction.
It will reveal the use of medication which can cause ED and it may be possible to change or alter this.
Since ED may be a “marker” for present or future cardiovascular disease it provides an opportunity to advise the patient on how to modify any risk factors for these diseases.
For the majority of patients examination can be limited to blood pressure measurement and examination of the genitalia.
Further examination or referral may be appropriate where indicated by age or findings in the history, with particular reference to the cardiovascular, neurological, endocrine and urinary systems.
The precise investigations indicated for any individual will depend on the history and examination findings. However, all patients should have a dipstick urine examination for glucose.
Following history-taking, examination and investigations (if indicated) the probable cause/s of the ED may be clear. Often there is more than one possible cause.
It may be a cause, such as depression or hypogonadism, which when treated will lead to a significant improvement in the erectile dysfunction.
It is not yet clear whether treatment of most causes ( see table 1 ) of ED will directly lead to an improvement in the condition. At present it appears that it will not. Where this is the case , as well as treating the underlying cause/s, treatment options for the ED itself will be discussed with the patient.
Prior to discussing specific treatment options for ED it is important that psychological and/or relationship problems which have arisen as a result of the ED be explored and resolved as alluded to above.
For the vast majority of patients the final selection of treatment will be according to the patient’s choice.
1. Peripherally acting drugs
PDE5-inhibitors enhance penile smooth muscle relaxation and penile erection in response to sexual stimulation. Three members of the PDE5 inhibitors class are currently available for clinical use – sildenafil, tadalafil and vardenafil.
There is variability of onset of action ( with adequate sexual stimulation ) of the three drugs – 15 minutes to 1 hour.
The duration of action is about five hours for sildenafil and vardenafil and up to 36 hours for tadalafil. Sildenafil should be taken on an empty stomach.
Contraindications include patients taking nitrates, hypotension, hereditary degenerative retinal disorders, recent stroke or myocardial infarction, severe hepatic impairment, loss of vision in one eye due to non-arteritic anterior ischaemic optic neuropathy and , possibly, alpha blockers (follow label instructions ).
Mainly because PDE isoenzymes are present in organs other than the penis. Include headache, dyspepsia, nasal stuffiness and facial flushing. ( most common ). Less common side effects include abnormal vision, myalgia and priapism. Advise attend A & E if priapism persists beyond four hours. Most common side effects are predominently mild to moderate.
CYP 3A4 inhibitors such as Erythromycin, Ketoconazole and Protease inhibitors can increase the levels of PDE5 inhibitors. In patients taking these drugs consider administering the lowest available dose of PDE5 inhibitor.
PDE5 inhibitors should not be used more than once daily.
Intracorporeal pharmacological therapy
PGE1 is the most widely used agent for intracorporeal injection. Though many men baulk at the idea of injecting a drug into their penis, this method is associated with good efficacy and tolerability. The technique is simple and relatively painless. The solution is injected slowly with a very fine, short needle into the side of the shaft of the penis with the syringe held perpendicular to the skin. The needle is removed and pressure is applied to the injection site. The drug is massaged gently throughout the shaft for approx. 30 seconds. Erection normally occurs within 5 to 10 minutes.
The initial dose must be estimated. Neurogenic or psychogenic impotence can respond to small doses of 2.5 to 5mcg of PGE1. Patients with severe vasculogenic ED may fail to respond to even high doses. So patients should be taught to inject themselves safely and effectively in the surgery initially.
ADVERSE EVENTS are mainly local and include penile pain, bruising, penile scarring(long-term) and priapism(approx. 1%).
CONTRAINDICATIONS: Sickle-cell anaemia, myeloma, leukaemia and penile deformity.
PGE1 injections can be used up to three times weekly.
INTRAURETHRAL PGE1 THERAPY
Here the drug (PGE1) – in the form of a small pellet – is inserted into the urethra by means of an applicator (MUSE). The patient then massages the penis to aid distribution of the medication.The patient should urinate just prior to insertion.
Erection starts within 15 to 30 minutes and lasts 30 to 60 minutes.
Efficacy is inferior to PDE5 inhibitors or intracavernosal injection therapy.
CONTRAINDICATIONS: Abnormal penile anatomy, balanitis, urethritis, sickle-cell anaemia, multiple myeloma, polycythemia, predisposition to venous thrombosis, thrombocythaemia or priapism.
ADVERSE REACTIONS include penile or testicular pain, urethral irritation, swelling of veins, dizziness and, rarely, priapism.
With this method a condom should be used during sexual intercourse with a pregnant woman since the level of PGE1 in the ejaculate could be dangerous.
2. VACUUM TUMESCENCE DEVICE
A vacuum tumescence device consists of a plastic cylinder which is placed over the penis and held firmly against the pubis to obtain an airtight seal: a vacuum pump by which suction is applied to produce negative pressure leading to engorgement of the penis: a constriction ring which is slipped from the cylinder onto the base of the penis to maintain engorgement, once it is achieved. The vacuum is then released via a valve and the cylinder removed.
Time taken to achieve “erection” is about 3 minutes. The ring should not be left on for more than 30 minutes.
A study of 300 men who choose this treatment showed a continuation rate of 13% .
It is contraindicated in those with bleeding disorders or on anticoagulants.
Its advantages are:- Low incidence of side-effects.
Effective for all aetiologies of ED
“Erections” can be uncomfortable
Ejaculation may be impeded
Penis is cold and pivots at base
3. PENILE PROSTHESES
Penile prostheses are the last resort when all other treatments have failed or are contraindicated.
There are two types of prostheses: malleable and inflatable
MALLEABLE Malleable prostheses consist of a pair of flexible silicone rods which are inserted inside the corpora cavernosa. They have an adequate rigidity for penetration and can be bent when not being used.
They are the most widely used and are the easiest to insert into the penis.
INFLATABLE These consist of two inflatable cylinders inserted into the corpora cavernosa, a fluid reservoir (attached to the cylinders or placed beneath rectus abdominus muscles) and an inflating and deflating pump placed in the scrotum.
Thechnical success rates and patient satisfaction rates are high.
ADVANTAGES Long-term result
Particularly useful in men with Peyronie’s disease or
Mechanical failure ( <5% in first year)
Malleable devices may protrude
In the second part of this article I will return to the diagnosis and treatment of those men who do not suffer from “true” ED, as discussed above, but whose erectile difficulties are more a reflection of absence of or diminution of arousal due to psychogenic factors. I will also discuss the management of those men whose erectile problems do not have a clear aetiology.
Dr Tom Kelly
Practitioner of Sexual Medicine
CAUSES OF ERECTILE DYSFUNCTION
Aging Peyronie’s disease
Hypertension Multiple sclerosis
Peripheral vascular disease Guillain-Barre syndrome
Sickle cell anaemia Hypothyroidism
Prostate cancer Antidepressants
Kidney failure Cimetidine
Liver cirrhosis ? Hyperlipidaemia medication
Scleroderma Recreational drugs
Aortoiliac or aortofemoral bypass Abdominoperineal resection
Proctocolectomy Radical prostatectomy
Cystectomy Radiation therapy – pelvis
Pelvic trauma Prolonged cycling