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Erectile Dysfunction

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Iqra Mazhar

Overview

The inability to maintain an erection firm enough for satisfactory sexual intercourse is called erectile dysfunction, or ED.

Problems with erections are not unusual and can affect men for a variety of reasons. However, if it progressively worsens and affects a person&#39;s sexual performance, it becomes a concern.&nbsp;

The prevalence of ED varies among countries. In the United States, approximately 30 million men suffer from sexual dysfunction<a href="#accordion">[1]</a>. Whereas, in Pakistan, the prevalence rate of ED among men attending primary care clinics was 80.8%<a href="#accordion">[2]</a>. It is estimated that by 2025 approximately 322 million men will be affected by ED<a href="#accordion">[3]</a>.&nbsp;

Although it can occur at any age, ED affects 50% of men aged 40 to 70 years<a href="#accordion">[4]</a>. It can result from a wide variety of diseases, the use of certain medications, and even emotional factors. Moreover, often at times, the presence of ED can indicate an underlying disorder such as <a href="https://www.merisehat.pk/disease/atherosclerosis" target="_blank">atherosclerosis </a>(hardening of the arteries).&nbsp;

While ED is a physical problem, it can cause significant psychological stress; reducing a person&#39;s quality of life. Furthermore, the stigma surrounding sexual health and sexual dysfunction makes it difficult for men to reach out for help. However, ED is a highly treatable condition, and seeking treatment can improve one&#39;s overall quality of life.

&nbsp;

Signs And Symptoms

ED does not always mean a complete inability to achieve an erection. Instead, either one is unable to get an erection when they want to have sexual intercourse or are unable to maintain it long enough for intercourse. Moreover, some people may be unable to get an erection at any time. Other sexual disorders such as premature ejaculation and delayed ejaculation can also occur in ED. Along with these physical symptoms, people also suffer from depression, low libido, and low self-esteem due to the condition. 
&nbsp;

Causes

Typically, sexual arousal results in an increased blood flow to the penis. As blood flows through the two erection chambers, the spongy tissue within the penis relaxes. Thus, trapping more blood and increasing blood flow to the penile arteries. As a result, the chambers fill up and the penis becomes firm, causing an erection. Problems at any stage of the erection process can result in erectile dysfunction.&nbsp;

There are several possible causes of ED ranging from physical to psychological conditions. Some common causes of erectile dysfunction include: 
&nbsp;

<ul>
	<li>Chronic Diseases - The existence of certain diseases are associated with a higher risk of ED. For example, people with <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">diabetes </a>have a 6 times higher risk of developing ED than non-diabetics<a href="#accordion">[5]</a>. Other conditions such as <a href="https://www.merisehat.pk/disease/hypertension-57" target="_blank">hypertension</a>, <a href="https://www.merisehat.pk/disease/coronary-artery-disease" target="_blank">coronary artery disease</a>, and high <a href="https://www.merisehat.pk/disease/cholesterol#causes-5532" target="_blank">cholesterol </a>can block or reduce the blood flow to the penis, contributing to ED.</li>
	<li><a href="https://www.merisehat.pk/disease/obesity" target="_blank">Obesity</a><a href="https://www.merisehat.pk/disease/obesity" target="_blank"> </a>- Obesity itself can result in diseases such as <a href="https://www.merisehat.pk/disease/hypertension-57" target="_blank">hypertension</a>, <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">diabetes</a>, and hypertriglyceridemia; the resulting damage to blood vessels can lead to ED. Moreover, hormonal imbalances in obesity also contribute to ED&#39;s development.&nbsp;</li>
	<li>Neurological Disorders - In diseases such as multiple sclerosis or <a href="https://www.merisehat.pk/disease/stroke" target="_blank">stroke</a>, nerve impulses from the brain or spinal cord to the penis are disrupted. Thus, resulting in ED.</li>
	<li>Psychological Factors - These include anxiety, <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a>, stress, low self-esteem, fear of failure and other emotional issues.</li>
	<li>Trauma - Any injury or surgery to the pelvic area can cause damage to the nerves and in turn cause ED.&nbsp;</li>
	<li>Alcohol And Smoking - Smoking, alcohol use, and recreational drugs such as marijuana and cocaine suppress the central nervous system and can also damage blood vessels.&nbsp;</li>
	<li>Medications - Certain medications can impact a person&#39;s nerve signals or blood circulation; thus, increasing the risk of ED. These include diuretics, antidepressants, muscle relaxants, anti-hypertensives, appetite suppressants, and chemotherapy drugs.</li>
	<li>Peyronie&rsquo;s Disease - Trauma to the penis results in scar tissue formation which then results in painful or soft erections.&nbsp;</li>
</ul>

Erectile dysfunction may result from one or a combination of the above factors.

&nbsp;

Diagnosis

A complete medical and sexual history is often the first step toward diagnosing ED. Doctors will ask questions regarding sexual activity, past surgeries, drug use, psychosocial history, use of any prescription medicines, and history of trauma. Along with history, additional tests are also performed to reach a definite diagnosis. These include: 
&nbsp;

<ul>
	<li>Physical Exam - A physical exam includes checking the person&#39;s vitals, lungs, and heart, and examining their penis and testicles. Doctors will look for signs of any underlying disease, trauma, or surgical scars. Moreover, a rectal exam is also conducted to examine the prostate.&nbsp;&nbsp;</li>
	<li>Blood Tests - Blood tests help identify diseases such as diabetes, hormonal imbalances, kidney disease, high cholesterol, thyroid disorder, and coronary artery disease.</li>
	<li>Urinalysis - A urine test helps look for markers of diabetes, kidney disease, or other health conditions.&nbsp;</li>
	<li>Doppler Ultrasound - During the test, individuals may receive an injection in their penis to create an erection. The imaging method then allows examination of the blood vessels and measurement of blood flow through the penile vessels.</li>
	<li>Nocturnal Penile Tumescence Test - Individuals are fitted with a battery-powered device on their thighs. This evaluates the quality of nighttime erections. Doctors can later view this data. A simpler version of the test also exists, and it measures the number of erections a man gets while asleep. Normally, men have 3 to 5 erections per night. This can help doctors determine whether the person&#39;s ED has a physical or psychological cause.</li>
	<li>Injection Test - Also called intracavernosal injection, it involves injecting medicine directly into the penis to induce an erection. The duration and quality of the erections are then evaluated.&nbsp;</li>
</ul>

&nbsp;

Treatment

Treatment is generally aimed at treating the underlying cause. Doctors may use oral medications, non-surgical options, injections, or surgical treatments.&nbsp; 
&nbsp;

<ul>
	<li>Medicines - The discovery of drugs like Viagra (sildenafil) and Cialis (tadalafil) has made ED a highly treatable disease. These medicines relax the penile muscles and increase blood flow during sexual arousal. They&#39;re typically taken 1-2 hours before sexual intercourse. However, caution must be practiced when prescribing these in patients taking drugs such as nitrates and alpha-blockers due to drug reactions. It is best to consult with a doctor before starting or stopping any medicine.&nbsp; 
	&nbsp;</li>
	<li>Testosterone Replacement Therapy (TRT) - In patients with low levels of testosterone, doctors will prescribe TRT, because low testosterone levels are a cause of ED. 
	&nbsp;</li>
	<li>Counseling - Patients with psychological causes such as depression, anxiety, or stress are often referred to a psychologist. Addressing these feelings and developing a healthy thought process can prove beneficial in these patients. Moreover, some people may also benefit from sex therapy in coping with ED. 
	&nbsp;</li>
	<li>Vacuum Device - This mechanical aid consists of a plastic tube, a pump, and an elastic ring. The tube is placed around the penis and the pump helps create a vacuum. The creation of a vacuum draws the blood into the penis, stimulating an erection. The elastic ring can then be moved to the base of the penis to maintain the erection as the plastic tube is removed. Moreover, the ring can be left in place for up to 30 minutes. A vacuum device is generally preferred by patients not looking to take oral medications. However, correct use of the device requires proper training.&nbsp; 
	&nbsp;</li>
	<li>Injection Therapy - In men who don&#39;t respond to oral medications, doctors may prescribe Alprostadil injection into the side of the penis. After receiving self-injection lessons, individuals can administer these themselves. The treatment is highly successful at producing a firm enough erection that can last for 20-30 minutes. However, if the erection lasts longer than two to four hours, professional help must be sought.&nbsp; 
	&nbsp;</li>
	<li>Penile Implant - This surgical option involves the insertion of an inflatable or malleable implant into the penis. An inflatable implant can help the penis become wider and larger, while a malleable implant consists of a rod that can be manually adjusted. Penile implants are used in severe ED that does not respond to other treatments. 
	&nbsp;</li>
	<li>Vascular Surgery - Also called artery reconstruction, this surgery is usually done in men younger than 30 years of age. It allows the repair of arteries that may be blocked or damaged due to pelvic trauma.</li>
</ul>

&nbsp;

Since ED is associated with several chronic diseases, a healthy lifestyle can help prevent ED. Moreover, keeping your diabetes, hypertension, and blood cholesterol in check is also a good prevention strategy. Other steps include: 
&nbsp;

<ul>
	<li>Limiting smoking, alcohol consumption, and drug use</li>
	<li>Seeking psychological help if experiencing stress, <a href="https://www.merisehat.pk/disease/anxiety" target="_blank">anxiety</a>, or <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a></li>
	<li>Regular exercise</li>
	<li>Maintaining a healthy weight</li>
</ul>

Moreover, patients suffering from chronic diseases should do regular follow-ups with their doctors.

&nbsp;

Key Points

<ul>
	<li>Erectile dysfunction, or ED, is a highly treatable condition defined as an inability to maintain a firm enough erection for sexual intercourse.</li>
	<li>Existing diseases such as <a href="https://www.merisehat.pk/disease/diabetes-type-1-and-2" target="_blank">diabetes </a>and <a href="https://www.merisehat.pk/disease/hypertension-57" target="_blank">hypertension</a>, the use of certain medications, and psychological disorders like <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression </a>can all cause ED in men.</li>
	<li>Diagnosis is often based on a complete history, physical exam, and a doppler ultrasound. These help doctors identify the underlying cause of ED.&nbsp;</li>
	<li>Treatment is aimed at treating underlying health conditions and is achieved with medications such as Viagra, psychological counselling, vacuum device, or surgery in advanced cases.</li>
	<li>A healthy lifestyle aimed at maintaining a healthy weight, daily exercise, and quitting smoking or alcohol can help prevent ED.</li>
</ul>

&nbsp;

[1] Nunes, K. P., Labazi, H. & Webb, R. C., 2012. New Insights into Hypertension-Associated Erectile Dysfunction. Current Opinion in Nephrology and Hypertension, 21(2), pp. 163-170.

[2] Shaeer, K. Z. M. et al., 2003. Prevalence of erectile dysfunction and its correlates among men attending primary care clinics in three countries: Pakistan, Egypt, and Nigeria. International journal of impotence research, Volume 15.

[3] Ayta, I. A., McKinlay, J. B. & Krane, R. J., 1999. The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU International, 84(1).

[4] Johannes, C. B. et al., 2000. Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study. The Journal of Urology, 163(2), pp. 460-3.

[5] Saeed, R., Amin, F., Durrani, N. & Saif, S. M. A., 2021. Prevalence of erectile dysfunction and associated factors among males visiting family medicine clinics in a Tertiary Care Hospital in Karachi, Pakistan. Journal of Family Medicine and Primary Care, 10(3), pp. 1294-1300.