Erectile Dysfunction

What is erectile dysfunction? Erectile dysfunction is the inability of the male to attain or maintain erection of the penis sufficient for satisfactory sexual intercourse. It is well known that sexual function declines with old age and in our culture, erectile dysfunction is often gracefully accepted as part and parcel of growing old. However, even in our society, and irrespective of age, some men with this problem would admit to fear, uncertainty, loss of image and self- esteem and even depression because of it. Erectile dysfunction comprises a variety of physical aspects with important psychological and behavioral overtones. Many men with erectile dysfunction have normal desire for sex, orgasmic capability and ejaculatory capability and are only denied a normal sex life because of this disability. For social and cultural reasons, many troubled men with erectile dysfunction do not complain or come forth and seek medical help although a large proportion of them will admit to having the problem on direct questioning. In a recent study, it is estimated that up to 1.68 million Malaysian men above the age of 40 years may be experiencing some degree of erectile dysfunction.

What cause erectile dysfunction?

Although erectile dysfunction is often regarded as to be tolerated as part and parcel of growing old, many elderly men will tell you that their erectile dysfunction only comes about only after a specific illness or following taking certain medicine. Many drugs can cause or exacerbate erectile dysfunction and the prescribing physicians should advise patients of such a possibility.

A normal level of male hormone is necessary to maintain sex drive. Erection of the penis is resulted initially from dilatation of the arteries to the erectile tissue of the penis (figure 1). The erectile tissue is akin to a sponge, soaking up what blood that flows in and fills up the penis. The filling up of erectile tissue within the penis occludes the draining venous channels of the erectile bodies, helping to maintain the erection. This maintenance of erection is effected by a balance between total amount of blood flowing into the penis and that leaving the penis. If there is a problem in the mechanism of blood trapping within the erectile tissue, the erection may not be sustained. The whole cascade of event is mediated by the involuntary nervous system, which provides the stimulus for the dilatation of the arteries to the erectile tissue.

Figure 1

Damage of the nerves to the erectile tissue will result in erectile dysfunction. While this often results from surgery to remove the rectum or bladder and prostate, pelvic radiotherapy can also lead to the same conclusion. Diseases that affect the involuntary nervous system may have a similar effect. Examples include stroke, multiple sclerosis and spinal cord injury. Impaired blood supply as a result of any arterial disease also lead to erectile dysfunction. Hardening and narrowing of the arteries associated hypertension or as a result of heavy smoking or excess blood cholesterol are examples.

Psychogenic causes of erectile dysfunction include psychological problems, performance anxiety, relationship problems, depression, and domestic and work pressures.

 
What test can be done?

A screening blood sugar level should be done if diabetes is suspected. A serum cholesterol assay is often included as part of the screening investigation, particularly if there is a family history of heart disease. If necessary, the urologist will do a screening assay of male hormone level. Routine X-ray of arteries is seldom carried out except in young patients who had developed erectile dysfunction following pelvic trauma. Measurement of penile expansion at night is reserved only for a small group of patients. Doppler ultrasound scan of the penile blood supply and pressure measurement of the erectile tissue are largely used for research.

What treatment is there?

Irrespective of culture and age, most men who are troubled by their erectile dysfunction can be helped. Most urologists offer a stepwise approach to the management of erectile dysfunction. Removal of any obvious causes such as certain drugs would be the first option. In patients deficient of male hormone, replacement would bring about a good response. Many cases of erectile dysfunction can be helped by a very simple vacuum constriction device but most patient find this clumsy (figure 1). This device is placed over the penis before the air is drawn out of the cylinder, causing the penis to fill up with blood. A tight elastic band is then slipped over the root of the penis like a tourniquet to retain the blood. The use of these devices should be supervised by urologists and these devices can be obtained through practicing urologists.

Figure 2

Drugs that cause arteries to dilate can be used to treat erectile dysfunction. Sildenafil (ViagraŽ) is a drug that when taken by mouth, produces a localised dilatation of the arteries and erectile tissue of the penis. The tablet is taken approximately 1 hour prior to sexual intercourse and had been shown to be effective in 70-80% of erectile dysfunction sufferers, including Malaysian men. Because of its convenient administration, this drug is now the first line treatment in most erectile dysfunction sufferers. Men who are taking drugs containing nitrates MUST NOT take ViagraŽ as this may result in a severe and dangerous adverse reaction. ViagraŽ can be obtained through a doctor's prescription. The other commonly used drug treatment involves direct injection of prostaglandin E1 into the erectile body using a very small needle. In most patients, a good erection can be produced lasting a considerable period of time. Most patients inject themselves and urologists should be responsible for their training and supervision. When erection remains too long (priapism), it may have to be reversed to relieve the pain and preserve the normal characteristics of the erectile tissue. Finally, for those cases in which nothing works, a special device can be implanted into the penis to render it rigid. There are 2 main types of penile implants. Malleable devices (figure 3) are cheaper but render the penis rigid all the time. The penis has to be bent and tucked away at rest but concealability can be a problem.

Figure 3

The most satisfactory implants are of the inflatable design using a pump placed in the scrotum and a fluid reservoir within the abdomen. Although complications are encountered with the implants, the inflatable devices (figure 4) currently give the best patients and partners satisfaction.

Figure 4