Medihub - Medical Information - Urology

Erectile dysfunction (ED) is the constant inability to attain or maintain erection sufficient for satisfactory sexual intercourse. The causes of ED are advancing age, diseases like hypertension, diabetes mellitus, neurological diseases, pelvic surgery / injury (especially prostate surgery), and medications.

The basic process of erection requires blood to enter the penis as well as remain in the penis until the act of intercourse is completed. This requires a good blood supply, intact nerves, normal testosterone levels, and libido.

Hence, any disease that affects the blood vessels, nerves, (esp. diabetes, hypertension, drugs) hormone levels (esp. aging) and mental health (esp. stress, depression, alcohol, drugs) can cause ED. Because of this strong association, ED can also be a harbinger of neurovascular diseases and should not be viewed as a disease in isolation.

Indeed, many men have subsequently been found to have significant heart disease and early diabetes upon further evaluation. An unfortunate few may subsequently develop catastrophic heart attacks or stroke after taking medication for their ED, and may wrongly blame the medication as the cause of the event.

Diagnosis

How is ED diagnosed? This is mostly based on the history of the patient but a questionnaire has also been developed to help patients and doctors determine if ED is present and how severe it is based on a scoring system.

This is the IIEF-5 questionnaire and a score of 21 or less indicates the patient has a problem with his erection. [Fig 1] There are also xray studies that can be done to verify ED, like, ultrasound colour doppler and venous cavernosography, but nowadays, they are reserved for those who do not respond to treatment, and in those whom surgery is needed.
Fig 1. The IIEF-5 questionnaire

Treatment

The treatment of ED falls into 4 groups:

Psychotherapy this is for those whom the doctor has assessed to have stress or depression related ED.
Drugs [Fig 2] in the form of injection of a drug called prostaglandin (PGE1) into the penis or oral medication like the PDE5 inhibitors
Devices [Fig 3]- the vacuum pump sucks out blood into the penis and thereafter, a ring placed round the base of the penis prevents the blood from draining out
Surgery [Fig 4]in the form of tying up leaking veins or putting in an implant to artificially create an erection.

Fig 2a. PGE1 injection into the penis

Fig 2b. The The current PDE5i drugs available : Viagra, Cialis and Levitra

The vacuum pump (Fig 3) is rather cumbersome to use because it requires the placement of a rubber ring (c) at the base of the penis and using a hand-held pump (b) to create a vacuum within the cylinder (a) so as to draw blood into the penis.
Fig 3. Vacuum pump device

Surgery is expensive and carries risks of complications and implant failure.

Fig 4. Penile prosthesis

PGE1 injections are painful to give and short-lived. Hence, not surprising, much research has been done to develop an oral drug that is simple to take and effective with minimal side-effects. This research began 10 years ago, and was rewarded with a breakthrough when a compound was found that prevented the active chemical, nitric oxide (which is responsible for erection), from being degraded. These are called PDE5 inhibitors (PDE5i). The first such drug was Viagra, which was launched in 1998. Subsequently, two other drugs, Cialis and Levitra came into the market. Viagra and Levitra lasts up to 4 hours. Cialis has the advantage of a longer duration of action, up to 36 hours, while Levitra has the fastest onset, lasts up to 5 hours and said to be the strongers.

Despite the initial fears and reports of deaths, these drugs are safe, as long as those who have severe heart disease and who are taking nitrate drugs do not take PDE5i. The main side effects are headache and flushing of the face. The recent reports of sudden blindness are rare occurrences and seen mostly in those with long-standing hypertension and diabetes mellitus.

What about natural remedies? Every country will have its share of herbs and plants that are reported to be effective. From ginseng to tongkat ali, these plants have been processed into pills and even added to beverages, like coffee and tea. Whilst it is hard to verify how effective they are, no medical study have conclusively shown them to be superior to PDE5i, which are already effective in up to 90% of men with ED.

What about premature ejaculation - is this a form of ED too? Currently, this condition is considered a form of anxiety state, although many patients who suffer form ED also seem to report having this. Hence, it may also be a precursor to ED related to some unknown abnormality within the penis. There are some drugs available, from anaesthetic gel like lignocaine applied to the penis head 30 to 60 mins beforehand, or oral drugs like clomipramine, taken 4 hours beforehand, which acts on the brain to delay ejaculation. New drugs are on the horizon and would be available in the coming years. In the pipeline are 3 more PDE5i drugs which would be marketed within the next few years.

One should not rely on drugs to restore one's sexual health. Preventing and controlling diseases, eg. hypertension, diabetes, hyperlipidaemia and correcting bad lifestyle, eg. smoking, drinking, work-stress, can prevent ED or delay its onset. Research is still ongoing with regards to better sexual health, female sexual dysfunction, and newer drugs.

At the end of the day, ED affects the couple and sufferers need not suffer in silence. ED treatment is now easily available from their family doctors, who are adequately trained to treat and counsel couples.

The temptation of many men is to buy drugs from private sellers or through the internet because of the cheaper price or convenient delivery. The advice is these so-called medications contain reduced doses of PDE5i or do not contain any active chemicals. They may also put their health at further risk through drug interactions with their concurrent medicines or not screened for underlying yet significant medical illnesses.

In the event of a serious occurrence, it would be impossible to seek redress or compensation because these illegal vendors would not be easy to trace or prove they were directly responsible. So, the advice is to seek proper medical evaluation before starting ED treatment.