Erectile Dysfunction

Introduction to Erectile Dysfunction

Erectile dysfunction (ED) is the persistent inability to achieve and maintain an erection sufficient for satisfactory sexual intercourse. It results from disorder in any of the factors involved in the complex processes that lead to erection which involves the brain, hormones, blood vessels, emotions, and muscles.
It can occur at any age, but is uncommon in boys, common in the elderly. By the age of 45 years, most men have experienced ED at some time. Generally, 40% of men experience some degree of ED at 40 years, and 70% at 70 years.
Complete ED occurs in approximately 5% of men at 40 years and 15% at 70 years.

Types of Erectile Dysfunction

  1. Organic – Physical
  2. Psychogenic-Emotion and mental health
  3. Mixed-occasionally

Risk factors for Erectile Dysfunction

  • Advanced age
  • Diabetes mellitus
  • Cardiovascular diseases e.g. hypertension, coronary heart disease
  • High cholesterol (dyslipidaemia)
  • Tobacco intake-smoking, snuffing
  • Recreational drug use -Indian hemp, cocaine etc
  • Depression and other psychiatric illnesses

Clinical features of Erectile Dysfunction

  • Difficulty in keeping an erection
  • Difficulty in getting erection
  • Reduced sexual drive
  • History suggestive of possible causes- e.g. drugs, systemic diseases
  • Focused history to confirm it is ED and not any other sexual dysfunctions
  • Focused physical examination to identify significant abnormalities, e.g. gynaecomastia, penile deformity or plaques, impaired sensations etc

Differential diagnosis

  • Ejaculatory Dysfunctions (premature ejaculation, delayed ejaculation, anejaculation, anorgasmia)
  • Long refractory period
  • Peyronie’s Disease
  • Decreased libido

Complications of Erectile Dysfunction

  • Psychological disturbance-stress and anxiety
  • Unsatisfactory sex life
  • Embarrassment and low esteem
  • Relationship problems
  • Infertility

Investigations

  • FBC + ESR
  • Urinalysis
  • Blood glucose screening
  • Blood lipid profile (Fasting)
  • Hormone assay – Total and free testosterone, prolactin, FSH, LH

Specialist Investigations:

  • Nocturnal penile tumescence testing (Rigidscan)
  • Colour Duplex Ultrasound for suspected vascular cause.
  • Cavernosogram – suspected venous  leak

Treatment of Erectile Dysfunction

Treatment Objective

  • To achieve and sustain erection

Non active treatment:

Life-style and home remedies

  • Quitting smoking,
  • Losing excess weight
  • Exercising regularly
  • Reducing or stopping alcohol and
    hard drugs
  • Couples or marriage counselling, if relation problem
  • Adjusting medications:

Important part of ED treatment

  • alpha methyl dopa, Beta blockers & Hydrochlorothiazide cause ED
  • Calcium channel blockers & ACEs have no effect
  • ARBS may increase libido, improve ED and sexual, performance.

First line active treatment – Drugs

Oral phosphodiesterase-5 inhibitors (PDES-5) 
Sildenafil citrate, 50 or 100 mg 30 minutes to 1 hour before coitus

Or

Tadalafil, 20 mg 30-60 minutes before coitus

Or

Verdanafil, 10 or 20 mg 30-60 minutes before coitus.
Note 

These medications require sexual stimulation for optimal results.
Prostaglandin E1 must only be used under specialist care.
Drugs for erectile dysfunction e.g. sildenafil, tadalafil or vardenafil (PDE5 inhibitors) can be prescribed as first line treatment after careful cardiovascular evaluation. They are contraindicated in ischaemic heart disease and those on nitrates.

Referral Criteria

Referral to a specialist centre is necessary for proper evaluation and
management in most cases