Medicine for Africa - Medical Information Service

MPOTENCE -

Definition:

Erectile Dysfunction (ED), also called ‘impotence’, is the inability to achieve and/or sustain a penile erection that is sufficient for normal sexual activity.  ED includes cases, where the penis may become partly erect, but not hard enough to conduct sexual intercourse.  At times, the penis does not achieve any swelling or fullness at all.

The most common cause of ED (in 7 out of 10 cases) is due to insufficient blood flow into the swell bodies (corpora cavernosae) of the penis due to narrowing of the blood vessels, secondary to atherosclerotic plaques (e.g. cholesterol).

ED should not be confused with other conditions that can interfere with male sexual intercourse, such as e.g. ‘ejaculatory dysfunction’, which includes physiological problems with ejaculation and achieving an orgasm, or decreased libido (lack of sexual desire), which may be due to hormonal imbalance. 

Psychological problems can also result in temporary loss of proper sexual function and often be mistaken for physiologically based ED.  However, once the psychological problems have been resolved, the ‘temporary ED’ will be cured as well. 

ED varies in severity – while some men experience an occasional inability to achieve an erection, others may have lost this ability entirely, or may only be able to have a very short lasting erection.  Often, men are embarrassed regarding their ‘increasing sexual incompetence’ and thus, reluctant to discuss ED with their doctor.  Thus, ED is gravely under-diagnosed in every civilization and culture.  Studies have shown that ED increases from about 5% among men 40 years of age to about 20% at the age of 55, to up to 50 % of men in their 70s.

Risk factors that can cause ED may include one or more of the following:  

• Advanced age (see above);
• Diabetes mellitus – one of the most common causes of ED;
• Hypertension – high blood pressure, also a common cause of ED, especially if treated inappropriately;
• Cardiovascular disease – atherosclerosis, the hardening and narrowing of blood vessels can reduce the blood flow to the penis;
• Stroke;
• High cholesterol levels – because of the development of atherosclerosis;
• Cigarette smoking – also worsens atherosclerosis and thus, increases the chance of developing ED;
• Diet;
• Overweight;
• Inactivity;
• Metabolic syndrome – is a condition that involves increased blood pressure, high insulin levels, high cholesterol levels and body fat around the waist;
• Nerve or spinal damage – due to trauma (e.g. car accident – fractured pelvis), surgical procedures (prostate surgery for benign hyperplasia [BPH] or cancer), radiation to the prostate (for the treatment of cancer), or multiple sclerosis (MS), Parkinson’s disease, etc.;
• Drug abuse – especially cocaine, heroin, marijuana, methamphetamines, crystal meth;
• Alcohol abuse;
• Bicycling – prolonged cycling tours can result in ED due to pressure on the nerves that are leading to the penis, caused from sitting on the saddle for long periods;
• Hormonal imbalance – rare; low testosterone levels due to hypogonadism (diminished function of the testes to produce testosterone);
• Medications – many commonly used medications can produce ED as a side effect – these include many drugs used for the treatment of high blood pressure (hypertension), antidepressants, tranquilizers, antihistamines and appetite suppressants;
• Psychological factors such as:
• Depression;
• Stress – job related problems (e.g. unemployment), difficult home situations (children, spouse), etc.;
• Anxiety;
• Guilt feelings;
• Low self-esteem or feeling of (sexual) inadequacy;
• Performance anxiety – fear of sexual failure;
• Posttraumatic stress syndrome.

In the case of psychological causes, ED usually develops quite suddenly, and may resolve again when the mental state has improved.  However, at times, men may become even more anxious and depressed, when they notice that they also develop ED, resulting in a vicious circle, if the interrelationship between mental problems and ED is not recognized and resolved.  As mentioned above, many medications that are used for treating depression or other psychiatric disorders may also cause ED or other ejaculatory problems.

Note: A psychological cause is more likely the basis for your ED, if there are times when you can get a good erection (e.g.when you masturbate, or wake up in the morning with an erection), even though most of the time you cannot, when you are with a woman.

Symptoms:

Erectile dysfunction is the inability to maintain a penile erection that is firm enough to have sex.  Symptoms that are related to ED may include:

• Difficulty to get an erection;
• Trouble to keep an erection sufficient to have sex;
• Reduced sexual desire.
   
  

Diagnosis:

A diagnosis of erectile dysfunction is made when a man experienced repeated inability to achieve and/or maintain an erection that was sufficient to conduct satisfactory sexual performance over a period of at least three months.

For the establishment of a proper diagnosis, an open discussion between the patient and his doctor is necessary, in order to assess its severity and to find the underlying cause/ disease that may be the cause of your ED (see above).

A physical exam, including a careful examination of the penis and testicles and checking their sensitivity (nerve involvement) and the recording of the medical history can often be sufficient to recommend an appropriate treatment. 

Other underlying causes can often be revealed via laboratory tests, which should include:

• A complete blood count – CBC;
• Urinalysis – may point to diabetes mellitus and kidney damage;
• Blood glucose levels – may indicate diabetes;
• Serum creatinine – may point to kidney damage due to diabetes;
• Lipid profile – high levels of LDL (low density lipoprotein) cholesterol (the bad cholesterol) may have promoted arteriosclerosis;
• Liver enzymes and liver function tests – increased results may indicate advanced liver disease (fatty liver, cirrhosis) and cause hormonal imbalance;
• Blood hemoglobin A1c – abnormal high levels in patients with diabetes mellitus indicate poor therapeutic control of blood glucose levels;
• Total testosterone levels – low levels suggest hypogonadism (see above);
• Thyroid levels may reveal hypothyroidism (insufficient thyroid hormone production) or hyperthyroidism (increased thyroid hormone production) with subsequent ED; 
• Other hormone tests may include luteinizing hormone (LH), prolactin and cortisol levels may direct the diagnostis search to other underlying causes of testosterone deficiency, such as pituitary disease or adrenal gland abnormalities;
• PSA levels – Prostate Specific Antigen blood levels in connection with a physical prostate examination may indicate prostate related problems, such as hyperplasia or cancer; prostate cancer has to be excluded prior to starting testosterone treatment for ED, because this treatment can aggravate prostate cancer.

 At times, X-rays, especially following pelvic trauma, may reveal bony abnormalities, or an ultrasound may be performed to check for testicular size or structural abnormalities.

An overnight erection test is a simple test to find out whether an erection has occurred at night – most men have erections during sleep (in the REM cycle of sleep).  A special tape is wrapped around the penis before going to sleep – if the tape is separated from the penis in the morning, it indicates that an erection has occurred during the night, which indicates that the cause of ED is most likely psychological rather than physical in nature.

 
Treatment:

Today, erectile dysfunction is treatable in any age group.  However, treatment depends on the underlying cause of your particular form of ED.

If your ED is caused by lifestyle related problems, it could markedly improve by:

• Cutting back on drinking alcohol;
• Stop smoking;
• Increase regular exercise (especially of your pelvic muscles);
• Eat a healthy diet (less fat);
• Reduce overweight;
• Pelvic floor muscle exercises (see below);
• Decrease your stress levels (may require psychological support);
• Psychotherapy.

In many ‘temporary ED’ cases, the above lifestyle changes can make a long-lasting impact on your ‘perceived’ erectile dysfunction.

If there is an underlying disease present, such as e.g. diabetes mellitus, depression, anxiety, heart disease or other cardiovascular problems, hormonal imbalance, etc., it is important to primarily treat the underlying disease first.  Successful treatment of the underlying disease in combination with the above listed lifestyle changes will have a considerable positive influence on your erectile function, sustainability and love life.

Also, if you are on any kind of medication for any of the above mentioned or other healthcare problems, it is important to evaluate your current medications and their side effects, as many drugs may cause ED as one of their adverse side effects.  Thus, changing your current medication may help to improve your erectile capacity, especially in connection with the above lifestyle changes.

           Pelvic floor muscle exercises:

The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum. One of these muscles (the bulbocavernosus muscle) also partly wraps around the base of the penis. This muscle is involved with preventing blood from escaping out of the swell bodies during an erection; it is also active during ejaculation and when emptying the urethra of ‘the last drop of’ urine.
How to identify your pelvic floor muscles:

• First, contract the muscles that you would use to stop passing wind from your anus;
• Secondly, contract the muscles that you would use to stop the flow of urine.

These are the muscles that can be trained and strengthened. Ideally, discuss with your doctor, whether this option is appropriate for you.

Other treatment options for ED include:

• Lifestyle changes (see above);
• Oral medication – ‘phosphodiesterase type 5 inhibitors’ (PDE5):
• Sildenafil (Viagra);
• Vardenafil (Levitra);
• Tadalafil (Cialis);
• Apomorphine (Uprima);
• Intra-urethral suppositories;
• Injecting medications into the swell bodies (corpora cavernosae) of the penis – intracavernosal injections;
• Vacuum pumps – vacuum constrictive devices;
• Testosterone replacement;
• Penile prostheses;
• Psychotherapy
• Counseling – couple counseling or sex therapy are useful, if certain psychological problems are the cause of your ED.

The oral medications Viagra, Levitra and Cialis work rather similar by enhancing the effects of nitric acid, a natural chemical that causes muscle relaxation in the penis, thus allowing for increase blood inflow and subsequent erection upon sexual stimulation.

Recent studies have shown that regularly taken Viagra in small doses may have a long-term positive effect on erection problems.

Apomorphine works by increasing the level of certain chemical compunds in the brain, sending signals to the nerves of the penis, when you are sexually aroused.

Discuss with your doctor, whether and if so, which of these drugs are appropriate for you – beware that they may not be effective or even dangerous for you, if:

• You are on a nitrate drug regime for the treatment of angina, including nitroglycerin, isosorbide mononitrate or isosorbide dinitrate;
• You take anticoagulant medication (blood thinning drugs), alpha blockers for benign prostatic hyperplasia (BPH) or certain high blood pressure drugs;
• You have a heart disease or heart failure;
• You had a stroke;
• You have hypotension (very low blood pressure) or uncontrolled high blood pressure (hypertension).

Penis pump – vacuum constriction device – is a hollow tube with a battery powered pump.  After the tube has been placed overt the penis, the pump sucks out the air inside the pump, creating a vacuum that pulls blood into the penis.  When you experience an erection, you have to slip a tension ring around the base of the penis, in order to keep the blood inside the penile body.  You remove the pump before having sex, then the tension ring after intercourse.  Usually, the erection achieved by this method will last long enough for one sexual encounter.

Penile implants – are surgically implanted devices into both swell bodies (corpora cavernosae) of your penis.  There are two types of implants:

• Inflatable implant – you can control, when and how long you want to have an erection;
• Semi-rigid rods – are made of silicone or polyurethane and keep the penis somewhat firm but bendable.

As with all surgery, they are expensive and are associated with a certain risk of complications, e.g. infections, not proper functioning, etc.

           Alternative medicine:

Alternative treatments can be used to treat erectile dysfunction; however, their effectiveness may be very selective, as not everybody will respond to them successfully, and their safety may be questionable. 

There are dozens of so-called impotence herbs available without prescription that are said to have sex enhancing properties, such as ashwagandha, catuaba, ginseng, horny goat weed, maca, mucuna pruriens, muira puama, tongkat ali, tribulus terrestris and yohimbine. It is quite impossible to predict which single herb or herb combination will be effective for you or whether it will provide a cure.

 Relatively safe forms of alternative treatment with potentially some effect include:

• Acupuncture;
• Yohimbine – yohimbine hydrochloride is a dietary supplement, herbal extract, with stimulant and aphrodisiac effects;
• Ginseng - Korean red ginseng (Panax ginseng) is the fleshy root of a family of slow-growing perennial plants;
• DHEA – dehydroepiandrosterone – is a hormone and compound of testosterone;
• Ginkgo – derived from tree leaves, can improve blood flow, including microcirculation in small capillaries; also used for dementia and in Alzheiner’s;
• L-arginine – an essential amino acid and a precursor to nitric oxide in the body, helps blood circulation and is important to normal sexual function in both men and women.

Herbal Viagra – the US Food and Drug Administration (FDA) has issued warnings regarding several types of “herbal Viagra”, because they contain potentially harmful drug compounds that are not listed on the label.  Some of these ‘drugs’ can interact with prescription drugs and result in dangerously low blood pressure; furthermore, they may be even more dangerous for men who take nitrates for heart problems.

Other so-called home remedies are less well known to be effective and should rather be avoided, since the adverse side effects may way outweigh the results.

            Final Note:

Erectile dysfunction can lead to mental and emotional stress for both you and your partner, no matter whether its cause is physical, psychological or a combination of both. Here are some suggestions:

• Even if you experience occasional erection problems, it is not necessarily a reflection on your health status or ‘virility’, and certainly does not have to be a long-term problem.
• If you have ED, talk to your partner – assure your partner that your inability to have an erection is not a sign of diminished sexual interest or love for your partner.  Treatment will be more effective and successful, if you communicate with your partner openly.
• Be aware of stress, anxiety and other mental health problems – discuss these situations with your doctor or seek psychological help, if indicated.

 
Prevention:

There is no one preventive measure for erectile dysfunction.  The best way to prevent ED is to lead a healthy lifestyle and to treat any arising health problems as soon as possible.

Based on the above causes for ED, you could do the following to prevent or delay the development of ED:

• Have regular medical checkups, in order to discover and treat potential health problems as soon as possible;
• If you have diabetes, heart disease or other chronic health problems, follow your doctor’s advice and your treatment plan closely;
• Prevent or reduce stress;
• Stop smoking;
• Stop or limit drinking;
• Don’t use illegal drugs;
• Exercise regularly;
• If you experience depression or anxiety – get professional help early.

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DISCLAIMER: The above article is only intended to provide general information regarding this topic. It is not intended and does NOT replace the need to consult a medical or other professional person, if you have or believe to have this disease/disorder. While the article was researched, written and reviewed by medical professionals, and Medicine for Africa, its staff and publisher made every effort to assure accuracy and correctness, it does not claim to be complete, correct or to reflect the very latest stand of medical/scientific knowledge in the disease’s/syndrome’s pathology, diagnostic and/or therapeutic development. Medicine for Africa, its founder, management, staff, writers, reviewers or publishers may NOT be made responsible or legally bound to any information provided above, and cannot be held liable to any conclusions or decisions the reader may draw after reading this article. The reader is explicitly advised to consult a licensed physician and to present his/her specific situation before making any health related decisions.