Erectile dysfunction (ED in men) impotence is defined as an inability to obtain or maintain an erection sufficient for penetration and for the satisfaction of both sexual partners.
ED in men can be caused by many factors and may have a gradual or sudden onset. It can be very upsetting and result in a lot of stress and worry. It can feel embarassing to discuss this with your doctor but it is important that you do, so that you can receive the appropriate help. Erectile dysfunction can also be a sign of other illnesses such as heart disease or diabetes, so it is important that you seek medical advice.
- ED in men becomes commoner with increasing age and is seen in 50 – 55% of men between 40 and 70 years old;
- It is often associated with obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health;
- Investigation is only indicated if both partners wish to pursue treatment;
- Most treatable causes can be identified by a clinical history, physical examination and routine blood tests;
- If there is no treatable cause, treatment with tablets is the first option for most men;
- Other methods of treatment are only indicated if medication proves ineffective, causes side-effects or cannot be used because of specific medical conditions.
A psychological component, often called “performance anxiety”, is common in men with impotence. However, a purely psychological problem is seen in only 10%.
Of the 90% of men who have an underlying physical cause, the main abnormalities found are:
- Cardiovascular disease in 40%;
- Diabetes in 33%;
- Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%;
- Neurological disorders in 10%;
- Pelvic surgery or trauma in 3-5%; and
- Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie’s disease, inflammation, penile curvature).
TREATMENT:
Improvements in your lifestyle, such as a eating healthy diet, reducing alcohol intake, losing weight and increasing your exercise can dramatically improve erectile dysfunction. More specific treatment usually involves:
- weight loss and increased exercise (this may reduced the risk of erectile dysfunction by up to 70%)
- treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal);
- lifestyle modification (e.g. reduce stress, stop smoking, reduce alcohol consumption & stop illicit drugs);
- treatment of any anatomical abnormality if present (e.g. circumcision, frenuloplasty, penile straightening);
- psychological support if necessary.
First line treatment will be medication with a phosphodiesterase inhibitor such as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) or avanafil (Spedra). These drugs only work when used together with sexual stimulation and will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be used if you are taking nitrates (e.g. GTN, isosorbide) for angina
Phosphodiesterase inhibitors
- The commonly used PDE-5 inhibitors are sildenafil (generic or ViagraTM), tadalafil (CialisTM), vardenafil (LevitraTM) and avanafil (SpedraTM)
- They increase blood flow into the penis by blocking the naturally- occurring enzyme (PDE-5) which turns off an erection
- You should only obtain PDE-5 inhibitors by prescription
- Side-effects occur in approximately 1 in 9 patients (11%) but only3% stop treatment because of them
- You should not use PDE-5 inhibitors of you are taking nitratemedications for angina or heart disease
These drugs boost the body’s natural mechanism for getting an erection. This allows erections to be achieved and maintained more easily but they do require sexual stimulation to be effective.
They may not work in severe ED in men or where the natural erectile mechanism has been irreversibly damaged. The drugs work by dilating (opening) the blood vessels supplying the penis; this causes a greater blood flow into the penis and improves your erection.
How should they be taken?
Depending on the medication you are prescribed, a tablet should be taken between 30 minutes and 1 hour before anticipated sexual intercourse. Some of the drugs are affected by eating a heavy or fatty meal before taking the drug. We normally advise you to take them on an empty stomach, or two to three hours after a meal.
You should read the manufacturer’s instruction leaflet carefully because this gives you full instructions. You are advised not to take more than one dose per day. Treatment is usually long-term.
Because of its long half-life, Tadafil (CialisTM) may be taken at a lower, daily dose so that the drug is always in your system to provide a background boost to erections. This can help with night-time and morning erections.
We normally advise you to try treatment for four to six weeks to see whether it works. Your urologist, GP or specialist will suggest a starting dose for you and you will be followed up to see if an increased dosage is needed.
When should they not be taken?
You must not use PDE-5 inhibitors if you take nitrate medications (GTN spray, isosorbide or amyl nitrate) for angina, heart disease or other reasons. If you are not sure whether you are taking these medications, please check with your doctor. PDE-5 inhibitors interact with nitrates and can cause a dangerous drop in blood pressure. This may result in cardiac arrest, or even death.
You should probably avoid taking these drugs with alcohol. If you are unsure as to whether PDE-5 inhibitors are safe for you, consult your GP, specialist or cardiologist who will be able to advise you.
PDE-5 inhibitors are not appropriate if you have been told that sexual activity is inadvisable (e.g. if you suffer from unstable angina or severe heart failure). They should not be used at the same time as other treatments for ED in men, unless you have been advised to do so by a specialist.
What are the side-effects?
The most common side-effects include headache (12%), flushing (10%) and indigestion (7%). Some patients develop altered (blue-tinged) vision and dizziness (3%). If dizziness does occur, you should not to drive or operate heavy machinery. It is important that you report any severe side-effect to your doctor, and consider stopping the drug until you discuss it with your doctor.
PENILE INJECTION THERAPY
Self-administered injections of prostaglandin E1 (Caverject® or Invicorp®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.
Medicated Urethral System for Erection (MUSE):MUSE offers an alternative route for administration of prostaglandin using a small pellet inserted using an applicator into the tip of the urethra (water pipe opening). Once massaged the prostaglandin is released and helps the blood to flow into the penis to gain an erection. Some men experience a mild burning sensation afterwards in the water pipe but this is a good alternative option for men who do not like the idea of using injection therapy.
Vacuum Erection Assistent Devices (WEDs)
VEDs provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.
PENILE PROSTHESIS
Insertion of a penile prosthesis (implant) (pictured) is an end stage solution when all other treatment options have failed. It involves a surgical procedure through a small incision in the junction between the penis and scrotum. Patients go home the following day if the procedure is uncomplicated, and the prosthesis can be used for sexual intercourse at 6 weeks following the operation. Complication rates are low in centres that conduct the surgery in large numbers. The risk of infection is <2% and over 85% of the devices are still functioning at 10 years.
