Erectile Dysfunction- a Major Concern in Sexual Wellbeing

Erectile dysfunction (ED) may be defined as the consistent inability to attain or maintain penile erection for satisfactory sexual intercourse. It is recognized as a common problem, the prevalence of which increases with age. An overall prevalence of 10% has been reported.

Aetiology:
ED is a hidden condition with patients’ rarely volunteering information due to a variety of factors including embarrassment and a feeling that little can be done. It is associated with significant morbidity and can impair the patient's quality of life.

In 2007, BJU international conducted a study on 10,000 men through a 35-item questionnaire to assess the prevalence of ED, the population’s knowledge and general attitudes towards seeking the treatment. Of the 3124 responses, 2499 were included since they practiced well established heterosexual partnerships. In this population 40.1% had ED, although only a minority used treatment. The researchers found ED significantly reduced sexual life quality (p<0.01). While 96% of the population knew about phospho-diesterase type 5 (PDE-5) inhibitor by name (e.g. Sildenafil, Tadalafil etc), only 53% considered taking one and 9% actually used them.

The aetiology of ED may be categorized as follows:
· Organic
· Psychogenic
· Mixed causes

ED due to organic causes such as diabetes, drug therapy e.g. thiazides, b-blockers, or with other risk factors mentioned below, often has an insidious onset with progressive worsening until no erection is obtained. Initially, there is a loss of rigidity and/or difficulty sustaining an erection. Later, there is a complete inability to penetrate.
Psychogenic ED is more likely to have an abrupt onset. Commonly there are good quality spontaneous/waking erections but early collapse of erection occurs. It is often related to a distinct precipitating event e.g. a psychologically traumatic episode of sexual failure.

Risk Factors for Erectile Dysfunction:
· Age
· Diabetes Mellitus
· Vascular disease- like peripheral arterial occlusive disease, DVT
· Hypertension
· Angina and Ischemic heart disease (CAD)
· Hyperlipidaemia
· Medication use e.g. beta-blockers, thiazide diuretics
· High Alcohol intake
· Liver disease
· Heavy Smoking
· Depression and anxiety or Mixed Anxiety-depressive disorder
· BMI (Body Mass Index) and Physical Activity (as per trial published in International Journal of Obesity 2007) - the trial concludes that ED is affected by BMI and physical activity independently. BMI has greater effect when there is little exercise. Physical activity has a more pronounced benefit in those with high BMI. Underweight may also be a risk factor for ED.
Diagnosis
Patient’s history on ED, particularly about the onset and duration, information on other co-morbid diseases, including psychological problems and medications, in addition to attentive and thorough physical examination especially about the genitalia, signs of vascular disease, and neurological disease – are all very important to diagnose the cause of ED. Sometimes pathological investigations of blood, urine analysis, Color Doppler study, Angiogram, TMT are necessary to establish the presumptive diagnosis.

Treatment of ED
The success of various drugs used in erectile dysfunction depends on accurate diagnosis of the cause. If empirical treatment is prescribed as most doctors do, it often does not achieves permanent cure. These sex tonics & ayurvedic medicines can improve your sexual life temporarily but they cannot give permanent cure. Above all, treatment of ED is to be tailored to each and every patient as per cause and diagnostic evaluation.
Interventions may be classified as non-pharmacological and pharmacological.

NON-PHARMACOLOGICAL
Non-pharmacological treatment options for ED consist of:
1) Psychosexual Counseling and Sex Therapy: The contribution of emotional factors should not be underestimated. May be useful for both organic and psychogenic ED even if a physical intervention is planned.
2) Vacuum Devices : Composed of a plastic cylinder, a vacuum pump and elastic constriction band. Useful for ED due to a variety of aetiologies. May have low patient acceptability rate as they limit spontaneity. Have a low incidence of side effects.
3) Surgery: Venous surgery is now rarely performed and arterial surgery has a limited role.
4) Insertion of penile prostheses is usually only considered when all other options have failed.

PHARMACOLOGICAL
1) Hormone Therapy-
a) Oral testosterone preparations,
b) Transdermal Testosterone given as scrotal patch or Testosterone gel applied on any part of the skin,
c) Sublingual Testosterone cyclodextrin,
d) Local application of D.H.T. gel is new preparation for male hormone replacement
e) New human androgen receptor modulators
f) DHEAS tablets
g) Treatment of hyperprolactinemia with Cabergoline & Bromocriptine
2) Medicines to increase blood supply to penis (Oral & Local Gels) –
I. Yohimbine: By acting on alpha-receptors it dilates the penile blood supply.
II. Phentolamine: The effect of this drug increases manifold when it is used along
with other commonly used vasodilators. It is used as oral,
sublingual tablets. In advance cases it is given as injectable also.
III. Sublingual Apomorphine
IV. Trazadon works on sex centre & increase penile blood supply.
V. Oral Prostaglandins.
VI. Gene Therapy: In this modality of treatment blood supply to penis is increased by gene therapy. By the introduction new genes in body the generation of penile blood increasing substance nitric oxide generation increases in penile blood tissue leading to more blood supply & hardness of penis. This is a slower process but gives permanent cure to ED.
3) Phosphodiesterase type 5 (PDE-5) inhibitor drugs – e.g. Sildenafil, Tadalafil, Vardenafil. These drugs are good but temporary method of treatment because it does not treats the basic cause. They have certain serious side effects also especially on CVS, many deaths had occurred after misuse of these drugs. Hence they should be consumed only after expert advice.
4) Injection Therapy – Injection of Papaverine, ProstaglandinE1, & Phentolamine is used alone or in combination (bimix or trimix). This is a very effective mode of treatment of impotence. Recent advances are
- Injection of Moxisylyte and Injection of Vasoactive Intestinal Polypeptide (VIP).
5) Treatment of any underlying co-morbidities like DM, Hypertension, Hyperlipidemia, depression & anxiety, use of drugs that may cause ED.