June 13th to 19th is Mens Health Week. We are delighted to thank our colleague and friend Rowland Rees, Consultant Urologist, Hampshire, Wessex Andrology for this expert blog focussing on Erectile dysfunction (ED).
Frequently referred to as impotence, ED is the inability to attain or maintain an erection sufficient for sexual activity.
How common is erectile dysfunction?
In one study from North America, almost half of all men over 40 suffered from a degree of erectile dysfunction at some point or another, with 1:10 suffering complete ED. Regrettably, only about 10% of sufferers actually receive treatment. The number of men suffering erectile dysfunction increases with age.
What causes erectile dysfunction?
The erectile mechanism is a complex mechanism involving the brain, spinal cord, nerves and blood vessels supplying the penis, as well as the muscles and other structures within the penis itself. A problem with any of these elements may bring about ED.
Few men go throughout life without experiencing occasional failure to attain or maintain an erection. This usually results from stress, tiredness, anxiety, or excessive alcohol consumption. This is nothing to worry about, and lifestyle changes will often resolve the problem. However, worrying about it may set the scene for a more persistent problem due to "fear of failure", and a vicious circle can occur based on anxiety.
Although ED was originally thought to be psychological in origin, we now know that the primary cause in 75% is physical. However due to the vicious circle described above, almost any man with ED will develop a psychological element too, making matters worse.
One of the commonest causes is deficient blood flow to the penis, which in turn can be due to cardiovascular disease. This is a condition that increases with age, and is the same process that causes coronary artery disease, strokes and peripheral vascular disease. These problems are increased in diabetes, high blood pressure, smoking, high cholesterol and lack of exercise.
Diabetes is a major cause of ED, and diabetics usually get ED at an earlier age, and with greater severity. They may therefore require more invasive treatments to deal with the problem.
A number of medications can also cause ED – particularly those used to treat high blood pressure, but also psychiatric medications and those used to manipulate male hormones eg some prostate medications. Regular use of recreational drugs such as alcohol and Marijuana can also bring on ED.
Nerve problems or injuries can also cause significant damage to the erectile mechanism. Following prostate cancer treatments, eg radical prostatectomy, the nerves supplying the penis are often injured, resulting in high rates of ED. Other neurological problems such as spinal injury, MS or stroke also impair erectile function.
Other causes of ED are hormonal problems, Peyronie’s disease, chronic kidney or liver disease, heavy smoking and venous leaks.
What should you do if you develop ED?
Although not always possible, it is preferable if you can discuss the problem openly with your partner, as their understanding and support will make treatment a lot easier. Next you need to consult your GP, and he or she may well assess and initiate treatment themselves. Alternatively they may prefer to refer you to a dedicated erectile dysfunction clinic locally.
Assessment and tests
The doctor will take a history of the problem, as well as establish your medical history and any medications that you may be taking. There will also be a general examination including blood pressure, and urine examination for diabetes. It is also common to measure cholesterol levels if they have not been done already, and sometimes also a testosterone level.
First of all, and not unsurprisingly, weight and exercise has been linked to ED. Men that exercise more regularly improve vascular (blood vessel) function in their body, and therefore the first bit of advice I give is to do some regular exercise.
It is also wise to change any adverse lifestyle factors such as excessive stress, lack of sleep etc.
Following that, there are a number of treatments available for ED, and most men with ED can ultimately be successfully treated one way or the other.
The starting point is with oral medication such as Sildenafil (Viagra) or similar medication – there are currently 3 other similar medication available in the UK – Tadalafil (Cialis), Vardenafil (Levitra) and Avanafil (Spedra).
These four medications are very similar in terms of overall success rate, which is around 80% of all new patients. However they have different side-effect profiles and durations of action. Cialis takes longer to wash out of the bloodstream, and may therefore be effective for a longer ‘window’ lasting into the following day, whereas the other 3 medications tend only to be effective within the first 4 or so hours after taking it.
It is important to give these medications more than one attempt, and up to 4 times is advised before judging the response. The dose may need to be adjusted also. Potential side-effects include headache, blurred vision or flushing, and they should not be taken by anyone who is also taking nitrate therapy (a type of heart medication).
If a trial of medication fails, then you will need to be referred onto discuss further options with a Urologist or other specialist specializing in sexual dysfunction.
At this point it is useful to review the results again, including the testosterone level.
If the testosterone is low, and there are relevant symptoms as well as the ED (eg low sex drive, low energy, low mood etc), it may be appropriate to consider a trial of testosterone replacement therapy. This can sometimes improve the response to the tablets described above, as well as treat the symptoms that can be quite debilitating.
There are three key second-line treatment options, and they are injection treatment, vacuum erection device (VED) or a pellet that is dropped down the urethra (water-pipe).
Injection treatment involves a similar chemical to that in the medications, but the dose to the penile muscle is higher and as a result considerably more effective. You will be taught the technique by the urologist, and once happy, you or your partner can give this at home, in a similar way to how diabetics inject insulin.
The vacuum erection device is a pump that generates an erection by creating a vacuum, then a ring is applied to the base of the penis to hold the erection. This is remarkably effective, has been around for nearly 100 years, and is popular with older men in stable relationships, but can potentially be used by anyone with ED who is sufficiently motivated. It has the advantage of no systemic side-effects or risk, and no ongoing cost beyond the initial purchase of the device.
MUSE is a pellet that is dropped down the urethra using a special applicator supplied with the medication. It is effective in approximately 50% of those trying it, and potential side effects include stinging or injury to the urethra.
In a minority of people, none of the above options are sufficiently successful, and it may be necessary to consider surgical therapy for the ED. This is sometimes in the case of sever diabetes, or following prostate or other pelvic surgery, or where there is significant penile scarring (eg Peyronie’s disease).
Penile implants (or prostheses) have been around for over 30 years, and are plastic devices that are inserted into the body of the penis to generate a mechanical erection. The newer devices are highly effective and have a low complication rate, and generally score very highly in patient and partner satisfaction scores. This is mainly because they consistently and reliably produce a rigid erection at the time that it is required. I have inserted over 50 of these devices over the last 6 years, with no infections or removals, but there is a need for an additional procedure later in around 25% for usually minor problems with the device.
20,000 penile implants are inserted per year in the USA, but in the UK the use of these devices is lower that that of the USA and most other European countries. The reason for this are manifold, but include cultural, financial reasons, but also a historic lack of trained urologists.
Finally, where there is significant psychological distress or a primary relationship or psycho-sexual cause to the erectile dysfunction, it may be best to seek referral for psycho-sexual counseling. This is available across the UK through RELATE or the British Association of Sexual and Relationship Therapists (BASRT). This can be used in conjunction to, or separately from the physical therapies described above, but in my experience tackling the problem on all fronts simultaneously yields the best results.
Rowland Rees, consultant urologist, Hampshire
For initial assessment, and referral to Rowland Rees, please contact Winchester GP on 01962 776010.
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