Erectile dysfunction (ED) means the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.

Erectile Dysfunction could anticipate a heart disease or could be an early manifestation of it. Therefore, it should not be considered only as a quality of life issue but also as a potential warning sign of severe underlying heart morbidity.

The treatment depends on the causes of erectile dysfunction that can be organic or psychogenic. Lifestyle modifications, correction of underlying risk factors and specific medications may enhance the erectile response to sexual stimulation. Sexology counselling helps to treat psychogenic ED. In severe and unresponsive cases, a penile prosthesis may be the last resort.

Causes of Erectile Dysfunction

Some health conditions increase the chances of developing Erectile Dysfunction:

• Ageing;
• Diabetes;
• Dyslipidaemia;
• Hypertension;
• Cardiovascular disease;
• Metabolic syndrome;
• Elevated homocysteine in the blood;
• Lack of exercise;
• Smoking (quantity and duration of tobacco use hurts erectile function);
• pharmaco-therapeutic agents for cardiovascular disease;
• atrial fibrillation;
• hyperthyroidism;
• vitamin D deficiency;
• hyperuricemia;
• depression;
• sleep disorders;
• obstructive sleep apnoea;
• psoriasis;
• gouty arthritis;
• ankylosing spondylitis;
• non-alcoholic fatty liver disease;
• chronic liver disorders;
• chronic periodontitis;
• open-angle glaucoma;
• inflammatory bowel disease;
• chronic fatigue syndrome;
• allergic rhinitis;

Urological conditions related to ED:

• Lower urinary tract symptoms (frequent urination, urgent and painful urination) and benign prostate enlargement;
• Chronic Pelvic Pain Syndrome;
• Chronic prostatitis;
• Bladder pain syndrome and interstitial cystitis.

Procedures that may cause ED:

• Transrectal prostate biopsy (the procedure to diagnose prostate cancer);
• Radical prostatectomy (surgery to treat prostate cancer);
• Posterior urethroplasty (surgery for urethral strictures).

Diagnosis

The urologist or andrologist may order other tests to complete the diagnostic journey (advanced workup) like:

• The nocturnal penile tumescence and rigidity test (NPTR) applies nocturnal monitoring devices that measure the nocturnal erectile activity and may differentiate between organic and psychogenic ED;
• The intracavernous injection test;
• The penile dynamic duplex ultrasound is a test that we do, after the penile (intracavernous) injection of vasodilators, to assesses the vascular mechanism of erection and its abnormalities;
• Arteriography and dynamic infusion cavernosometry or cavernosography are infrequent tests required only in selected cases when the penile dynamic US scan results are consistent with vasculogenic ED;
• We require a psychiatric and psychosocial assessment in younger patients (< 40 years) with long-term primary ED; psychiatric examination may be helpful before any other clinical assessment.

  

Treatment

In most cases, we cannot radically cure and solve the ED. When the cause is psychogenic, post-traumatic arteriogenic (in young patients) or hormonal, then the ED is potentially reversible after treatment and leads to a stable recovery. However, we can improve most ED with a tailored, integrated and comprehensive strategy (controlling risk factors, pharmacologic erectile enhancement, psychodynamic/psychiatric treatment and sexology training).

Oral pharmacotherapy

We recommend oral medication to enhance natural erection. Since these medications are not initiators of erection, sexual stimulation is required to facilitate an erection. If the patient takes this medication will never have any erectile response without sexual stimulation.

These medications are considered safe without increasing the risk of myocardial infarction. However, the prescription is restricted and controlled in patients with cardiovascular disease and high cardiovascular risk.

Nitrate derived medications are an absolute contraindication to oral medication. We must use caution when the patient is under antihypertensive agents for a possible additive drop in blood pressure.

The patient must tell the urologist all his medical history to have a safe oral medication prescription.

Topical therapies

Topical therapies are medications applied externally on the surface of a part of the body (skin or mucosa). We treat selected patients with topical treatment through a specific formulation of alprostadil inserted into the urethra at the tip of the penis. Alternatively, in the same area, we can apply a cream formulation.

Shockwave therapy for ED

Extracorporeal Shockwave Therapy (ESWT) employs focused shock waves directed at the penis to improve erectile function. Standard treatment consists of 6 sessions, and we can repeat it if necessary.

We can consider this non-standard treatment option when patients do not want to take oral or topical treatment.

Penile injections (intracavernous injection therapy)

We offer this treatment in selected patients who did not respond to lifestyle changes and other conservative treatments (oral, topical, ESWT).

We usually train the patient to self-inject the medication into the spongy tissue in the penis to induce an erection.

Although self-injection scares many men, after feeling the benefits, they soon overcome the fear of it.

Vacuum Erection Device

The vacuum erection device (VED) is a cylinder-shaped device with a rubber constrictive ring that tightens around the penis. The vacuum effect makes it possible to get and maintain an erection.

We consider VED as an alternative treatment when others do fail.

Penile prosthesis

A penile prosthesis (penile implant) is a device implanted internally into the penis and allows the patient to have an artificially maintained erection. In severe ED or contraindications to all suitable treatments, we can consider this surgery a last resort.

External resources

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