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Melbourne Bladder Clinic
Bladder control and general urology

Erectile Dysfunction (ED)

05-Mar-2012 05:26 PM

What is it and how common is it?

Erectile dysfunction (ED) or impotence is the inability to achieve or maintain an erection strong enough for sexual intercourse. It becomes more common with age, affecting up to 67% of men by age 70. A Perth study looked at 1240 men (age > 18 years) and asked them to fill out a questionnaire. About 40% of the men reported having ED, with 18.6% reporting complete ED. Only 11.6% of men with ED received treatment.  ED is a medical condition that can be treated, and should not be viewed as an unavoidable part of the ageing process.

What are the causes of ED?

ED is multifactorial; there are many causes for it:

The most common cause is that of vascular (blood vessel) disease. The incidence of ED is higher in men with hypertension (26%), ischaemic heart disease (38%), peripheral vascular disease (57%) and diabetes (34%). That is why the presence of ED in an otherwise healthy man may indicate some underlying vascular disease.

What is involved in the assessment of ED?

History taking:

A thorough history should be obtained including medical and sexual history. The medical risk factors for ED should be checked for, in particular heart disease, diabetes and vascular disease. The medications being taken, smoking history, and psychological factors should all be ascertained. In terms of the ED, medical causes can often be differentiated from psychological causes by some of the symptoms.

Medical causes (organic)

Psychological causes

Gradual onset

Fast onset

Older man

Younger man

Morning erections poor

Morning erections normal

Consistent, persistent ED

Intermittent, variable erection

Has risk factors

No risk factors

Masturbatory erection poor

Masturbatory erection good

A useful questionnaire called the IIEF-5 (International Index of Erectile Function) contains five questions that can help the doctor identify and assess the severity of the problem.

Physical examination:

The physical examination should cover the external genitalia (penis and testes), prostate, peripheral pulses and secondary sexual characteristics.

Investigations:

Some blood tests may be indicated:

Other tests are more uncommonly done:

How do I know if I am fit enough to resume sex?

One’s overall fitness should also be assessed before resuming sexual intercourse. High risk patients are those with heart risk factors like uncontrolled hypertension, unstable angina, recent heart attack or stroke (< 6 weeks), severe heart valve disease and irregular heart rhythm. In general, a man is fit enough for sex if he can do the following without chest discomfort or undue breathlessness:

What are the treatments?

Treatments should always start with non-invasive to more invasive ones. They range from lifestyle modifications, treating reversible medical conditions, oral drug therapy, penile insertion therapy, penile injection therapy, vacuum device and penile prosthesis surgery.

Lifestyle modification:

Treat reversible medical problems:

Oral medications (PDE5 inhibitors):

The mainstay of oral drug treatment is a class of medications called PDE5 inhibitor. Some examples of these drugs are Viagra, Cialis and Levitra. They work by enhancing the natural response to sexual stimulation, not by directly inducing an erection as with injectable therapies. They cause the blood vessels in the penis to relax and engorge with blood and thus an erection will ensue. They are effective in about 8 out of 10 men with ED.

Side effects include:

Some men should not have PDE5 inhibitors:

There are a few instructions to follow when taking PDE5 inhibitors to increase their efficacy:

Insertion therapy:

A small soft pellet containing alprostadil (MUSE) can be inserted into the tip of the penis and the penis massaged gently to release the medication. This can result in an erection. Some possible side effects are burning, penile pain and urethral bleeding. This route of administration is not as effective as that of injection therapy of the same drug.

Penile injection therapy:

This is an effective (70% - 80% effective) method of achieving an erection and is used when oral medications do not work. Alprostadil (Caverject) can be injected into the side of the penis and an erection usually occurs within 5 to 15 minutes. The first injection should be given under direct medical supervision to ensure the correct technique and dosing. The dosing can be adjusted by the patient so that priapism (prolonged erection) does not occur. Other medications can be mixed with alprostadil if it is not effective or is too painful. These mixtures are ‘bimix’ (alprostadil plus phentolamine) and ‘trimix’ (alprostadil, phentolamine and papaverine) and can be prepared in approved pharmacies.

The side effects of injection therapy are:

Some patients should not have injection therapy because their pre-existing medical conditions can predispose them to priapism (see below). Some of these medical conditions are:

Vacuum erection device:

The device is a cylinder that is placed over the penis to create a seal and by extracting air from the cylinder, a vacuum is created. An erection then ensues and a rubber constriction ring is rolled over the cylinder onto the base of the penis to maintain the erection after the cylinder is removed. This technique requires practice and sometimes assistance from the partner. It is effective in creating an erection but penile sensation may be altered and the penis may pivot at the ring. Ejaculation (but not orgasm) is restricted by the ring.

Penile prosthesis implantation:

If earlier approaches fail or are inappropriate, then penile prosthesis implantation surgery can be considered as a last resort. The success rate is high (about 85%). Two inflatable cylinders are implanted into the shaft of the penis, together with a pump in the scrotum and a fluid reservoir in the lower abdomen. When an erection is required, the patient squeezes on the pump to inflate the cylinders. Possible complications are infection and mechanical failure. Semi-rigid malleable rods can also be implanted but tend to be less acceptable to patients as compared to the inflatable prosthesis, because they are less cosmetic and physiological.

Video : Hopeless to Wholeness : Penile Prosthesis

What is priapism?

A prolonged erection (> 4 hours) that does not go away despite conscious attempts by the patient is called priapism. Most cases of priapism are ‘low-flow’ and caused by inability of the penile blood to drain back to the body, usually as a result of over-effective ED treatment. All patients on ED treatments should be aware of this possible complication and it is considered a ‘medical emergency’. Patients should present to the emergency department for further treatment. ‘Low-flow’ priapism is painful and can cause scarring of the penile tissue, compromising further erectile function.

‘High-flow’ priapism is more uncommon and is usually caused by previous penile trauma. The trauma caused the formation of a connection between inflow and outflow blood vessels in the penis. When the inflow is more than the outflow, priapism occurs. This is less painful as compared to ‘low-flow’ priapism. Treatment involves radiological placement of a small substance to block off the abnormal blood vessel connection.


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