Erectile Dysfunction

Erectile dysfunction or impotence is the inability to initiate or maintain an erection that allows for satisfactory sexual performance.

Erection Mechanism: İn relation to the release of hormones and neural stimulation that occur with sexual stimulation, the blood vessels carrying blood to the penis enlarge and the blood collecting vessels close, and the blood is stored in the penis. Erection occurs due to the filling of the penis with blood. Hormonal, nervous, vascular and penile tissue compartments must work in a coordinated and proper manner for a healthy erection.

What are the Incidence and Risk Factors?

In a large series worldwide study (Massachusetts Male Aging Study), it was found that 52% of men between the ages of 40-70 were erectile dysfunction. In a study conducted in our country, it was found that 69% of erection problems were observed in this age group. It is thought that approximately 16% of men between the ages of 20-75, that is an estimated 152 million men worldwide, have erection problems. It is estimated that the number of men with erectile dysfunction worldwide will reach 322 million by 2025.

CAUSES

Erectile dysfunction can develop due to many reasons. But it can basically be of organic and / or psychogenic origin. Organic causes are due to vascular, nervous, hormonal or penile tissue disorders. It is important to reveal the underlying cause exactly for effective treatment.

1. Vascular causes: Cardiovascular diseases, hypertension, diabetes (DM), hyperlipidaemia, smoking, radiotherapy, vascular disorders (arterial insufficiency, veno-occlusive dysfunction)
2. Neurogenic (neural) causes: Parkinson’s, multiple sclerosis, stroke, brain tumors, spinal cord trauma and tumors, diabetes, kidney failure, polyneuropathy, previous surgeries
3. Penis Diseases: Congenital penile disorders (hypospadias, epispadis, micropenis), Peyronie’s disease, penile cancer
4. Hormonal causes: Deficiency of testosterone hormone, under or over functioning of the thyroid gland cause erectile dysfunction.
5. Medicines: Drugs that affect the hormonal mechanism, blood pressure and neural stimulation along with some blood pressure medications can cause sexual dysfunction and impotence.
6. Psychogenic: People’s stressful lifestyle, worries, problems in work, family and environmental relationships can affect their sexual life and erection quality.

DIAGNOSIS

Anamnesis and Physical Examination: Both medical diseases should be questioned in detail and sexual history should be taken from the patient and his partner. A systemic examination should be performed for each patient in terms of genital, urinary, hormonal, vascular and neurological diseases.

Laboratory Tests: In patients evaluated with a prediagnosis of erectile dysfunction according to the NIH consensus panel, it is recommended to check complete urinalysis, complete blood count, creatinine, fasting blood glucose or glycated hemoglobin, liver function tests, serum lipid profile and serum testosterone level.

Specific Diagnostic Tests: Nocturnal Penile Tumescence Test (NPT), Vascular Tests (Penile Doppler, Cavernosometry, Arteriography) and a number of Neurological Tests are advanced examinations used for this purpose.

TREATMENT

Lifestyle Changes and Identifying Risk Factors: Quitting smoking, consuming less alcohol and exercising regularly are among the main recommendations. However, restriction of sugar, salt and fatty foods, nutrition in a way that protects cardiovascular health will both increase the quality of sexual performance and improve the general health and quality of life.

Primary Care Therapies

• Oral Medication: The first recommended treatment in the treatment of erectile dysfunction is phosphodiesterase 5 inhibitor (PDE-5) drugs. These drugs cause enlargement of the veins in the penis and increase blood flow.
  The main side effects of PDE-5 inhibitors are: headache, nasal congestion, facial flushing, heartburn, temporary visual impairment and numbness. It should be kept in mind that the use of PDE-5 inhibitors may cause sudden low blood pressure in patients using nitrate-containing drugs. Since these drugs have cardiac and systemic side effects, a doctor’s control is required before treatment.

• ESWT (Extracorporeal Shock Wave Therapy): It is an application that provides a permanent solution to the erection problem by providing tissue regeneration and new vessel formation in the penis with low intensity sound waves.
  It is a procedure that does not require anesthesia and is applied in 6 sessions of 20 minutes in polyclinic conditions. The patient can continue his daily life after the application. It is seen that successful results are obtained in 70-80% of the patients with this procedure. It has taken its place among the treatment methods recommended in the first step of the European Association of Urology Guidelines due to its high efficiency and not involving any risks.

• Vacuum Devices: These cylindrical-shaped devices placed on the penis, with the effect of negative pressure, collect the blood in the penis and provide erection. It is a safe and effective method in the treatment of erectile dysfunction. It is not recommended to use the tightening ring placed on the root of the penis after the vacuum process for more than 30 minutes. Otherwise, side effects such as numbness in the penis and loss of sensation are reported.

Second Line Therapies

• Intracavernosal Injections: It is an effective treatment method for many erectile defects of vascular, neural or psychological origin. It is based on the patient himself injecting medication into the penis with the help of a fine-tipped injector. The drug given expands the blood vessels, allowing the penis to fill with blood and get an erection. The three most commonly used drugs for this purpose are papaverine and phentolamine.

  The most common side effect is fibrosis in the area where the drug is applied. Very rarely, it occurs in patients who report dizziness and hypertension after injection. If the erection does not end within 4 hours after drug administration, it is called priapism and urgent intervention is required.

Third Line Therapies

• Penile Prostheses: Penile prostheses are silicone alloy implants that are surgically placed into the tissues (cavernous structures) that allow the penis to harden. There are 2 types, flexible and inflatable.
• It is applied in cases where the erection problem cannot be adequately responded to from other treatments or when the patient’s expectations are not met, and in patients with erectile dysfunction of organic origin.
• The biggest advantage of this procedure is that the patients will not experience erection problems in their next sexual life and that their performance will continue in the same way in their old age.