Male Sexual Function Disorders
Erectile Dysfunction
Erectile dysfunction, or as physicians prefer to call it, “erectile dysfunction,” is a common problem that affects one in every ten men throughout their lifetime. Sexuality is an important aspect of human life, extending beyond its biological reproductive function and impacting the quality of life significantly. Therefore, problems related to sexuality can have a profoundly negative impact on social relationships. Here, you will find answers to some common questions about the causes, diagnosis, and treatment methods of erectile dysfunction.
What Is Erectile Dysfunction?
In male sexual function disorders, erectile dysfunction is defined as the inability to achieve the level of hardness required for successful sexual intercourse or the inability to sustain this level of hardness adequately. It does not equate to premature ejaculation or infertility. It is more commonly seen in men over the age of 40. Men experiencing erectile dysfunction often have normal functioning of other sexual aspects. For example, a patient with erectile dysfunction may still experience sexual desire and ejaculate without any issues.
How Common Is Erectile Dysfunction?
Erectile dysfunction is a highly prevalent problem, ranging from occasional difficulties in achieving an erection to a complete loss of erectile function. Most men experience problems related to erections at some point in their lives, especially during times of stress or serious illness. If this problem persists for an extended period, medical assistance should be sought. It has been found that 30% of men between the ages of 40 and 70 experience some form of erectile dysfunction. The frequency and severity of erectile dysfunction tend to increase with advancing age. Risk factors for erectile dysfunction include smoking, alcohol consumption, hypertension, diabetes, elevated blood lipids, heart disease, depression, and medications used to treat these conditions.
How Does Erection Occur in Male Sexual Function Disorders?
Erection is the result of a complex mechanism involving the brain, spinal cord, nerves, blood vessels, the smooth muscle of the penis, and hormones. To achieve an erection, stimulation through visual, mental, tactile, olfactory, auditory, or combined sensory inputs is required. Upon stimulation, the brain sends activating signals to the nerves of the penis. These signals reach the erection chambers known as the corpora cavernosa. As a result of these signals, the penile tissue relaxes, and the arteries expand. The corpora cavernosa are two cylinders located side by side within the penile tissue, surrounded by an elastic connective tissue called the tunica albuginea.
When the penile tissue relaxes and the arteries dilate, there is an increased flow of blood into the erection chambers. Consequently, the penis becomes larger and elongated. Veins that allow blood to exit the penis are compressed by the inner wall of the tunica albuginea, trapping blood within the penis. Continued sexual stimulation maintains this process and, as a result, the level of hardness. Erection persists until ejaculation or a decrease in sexual interest. Afterward, the penis returns to its previous flaccid state.
What Are the Causes of Erectile Dysfunction?
Erectile dysfunction often has multiple underlying causes. These causes can be psychological, physiological, or a combination of both. Distinguishing between psychological and physiological causes is important for treatment decisions. The causes of erectile dysfunction can be categorized into three main groups:
- Psychological Causes
- Physical Causes
- Psychological and Physical Causes (a combination of both)
1-) Psychological reasons:
Among the psychological reasons for male sexual dysfunction, stress and anxiety are the most prominent. For example, a sexually active man may experience sudden erectile dysfunction after being fired from his job due to stress and anxiety. In times of stress and anxiety, penile mechanisms are normal. However, the signals sent from the brain to the penis can be inhibited. The fear of failure is another significant cause of erectile dysfunction. A patient who is worried about their ability to achieve successful sexual intercourse, if unable to achieve it, becomes even more anxious. Psychiatric illnesses such as depression can also lead to erectile dysfunction.
2-) Physical reasons: Vascular diseases: The most common physical cause of erectile dysfunction in male sexual dysfunction is diseases related to blood vessels. Vascular diseases affect the amount of blood reaching the penis and thus the ability to achieve an erection. It can also affect the retention of blood in the penis and, therefore, the maintenance of the erection. Vascular hardening and any disease affecting the vascular system are risk factors for erectile dysfunction. Vascular hardening (atherosclerosis) is a serious problem, especially for men over the age of 50. It narrows the arteries and reduces blood flow to the penis. Smoking, high blood pressure, diabetes (diabetes mellitus), heart disease, and high blood lipids are other important risk factors. Nervous system diseases: In this group of diseases, messages from the brain to the penis are blocked. Examples include spinal cord injuries, diseases related to brain blood vessels, multiple sclerosis, bladder, prostate, and colorectal surgical procedures. Some diseases, such as diabetes, can affect both the vascular and nervous systems, leading to erectile dysfunction. Medications: Many medications used for high blood pressure, heart disease, and psychiatric illnesses can be the cause of erectile dysfunction. Hormonal reasons: The relationship between low levels of testosterone produced by the testicles and erectile dysfunction in male sexual dysfunction has not yet been clearly established. Studies have shown that low testosterone levels do not always have a negative impact on erections. However, having lower-than-normal testosterone levels can reduce sexual desire. As men age, the frequency of erectile dysfunction increases. It is not aging itself that is the cause, but rather the presence of diseases that affect the blood vessels, such as high blood pressure and diabetes, which are more common in older patients, as well as the drugs used to treat these diseases. Smoking and alcohol consumption also play a role. Pelvic bone fractures or traffic accidents can also lead to erectile dysfunction. The blood vessels that supply the penis and/or the nerves that stimulate the penis can be injured as a result of an accident. Some surgical methods and radiation therapies also negatively affect erections. For example, surgical treatments for prostate, bladder, and rectal cancer pose a risk for erectile dysfunction. As mentioned earlier, erectile dysfunction often has multiple causes. A diabetic patient may also smoke and consume alcohol. The same patient may also have hypertension and high blood lipids. All of these can affect the blood vessels and/or the nervous system. Each of them is a separate risk factor for erectile dysfunction. Why Should You Insist on Treatment
When You Have Erectile Dysfunction?
Today, almost all men who suffer from erectile dysfunction in male sexual dysfunction can be treated in a way that satisfies both the patient and their partner. It is important to know that there are many treatment alternatives and that the success of treatment can vary depending on the severity of the disease. Therefore, if the first treatment approach does not solve the problem, secondary treatment alternatives should be considered. During diagnostic interventions, diagnoses such as diabetes, high blood pressure, neurological diseases, and heart disease can be made. Improvements in erection can also be achieved while treating these diseases.
How Is Erectile Dysfunction Diagnosed?
Erectile dysfunction can only be diagnosed by a doctor after a medical examination. Therefore, it is important to discuss the issue with a doctor and seek treatment. Most of the time, a diagnosis is made through patient information and physical examination. Some simple tests may be requested to aid in the diagnosis. Advanced tests come into play in young patients and in the presence of certain specific diseases.
How Is Erectile Dysfunction Diagnosed?
The evaluation begins with taking the patient’s history. Risk factors are examined in the history section. Diabetes, high blood pressure, and heart disease should always be questioned. It is important to know if the patient has had surgery, been exposed to radiation therapy, had serious accidents, smoked, and consumed alcohol, and to obtain information about the medications they have used and have used in the past.
It should be asked whether the patient feels pain when the penis is erect or if there is any deformation or curvature. If the answer to any of these questions is “yes,” Peyronie’s disease should be considered. Psychological reasons should also be questioned. After the history, the next step is a physical examination. Attention should be paid to the genital area. Vascular and nervous functions should be tested. At the same time, Peyronie’s disease should be investigated. Digital rectal examination can be performed to obtain information about the prostate.
Some blood and urine tests should be performed. Testosterone and blood sugar levels should be measured in the blood. Blood lipid levels should be known. Color Doppler Ultrasonography is a sensitive test that provides information about the penile arteries using sound waves. The injection of drugs that induce erection into the penis and the response of penile tissue to this application can be observed. If there is no problem with blood flow, an erection occurs. In some patients, advanced tests may be necessary. One of these is bulbocavernosus reflex measurement, a neurological test. During this test, the doctor places a finger in the anus and squeezes the head of the penis with the other hand. Under normal conditions, the muscles around the anus contract. Another test provides information about the presence and degree of erection during sleep. Normally, every man experiences 3-5 erections during sleep. If the problem is physical, the frequency and degree of erections decrease. In the presence of psychological reasons, the patient continues to experience these erections. This test provides important information to the doctor in distinguishing between psychological and physical causes.
Male Sexual Dysfunction How Is Erectile Dysfunction Treated in Male Sexual Dysfunction?
The choice of treatment method depends on whether the cause is physical or psychological. For example, if a young patient has erections during sleep, physical examination, and blood/urine tests are normal, and their overall condition is good, the cause is most likely psychological. In such a case, the assistance of psychologists specialized in sex therapy should be sought. Meetings with the patient’s partner can also be arranged.
In cases of erectile dysfunction due to physical causes, treatment targeted at the cause can be applied.
If the cause is pelvic injury, surgical intervention may be necessary; if testosterone levels are low, testosterone replacement therapy may be used. However, in general, there are four main treatment methods used for erectile dysfunction:
Oral medications Vacuum device Penile injection Penile prosthesis
These treatment methods do not eliminate the cause, but they allow the achievement of an erection sufficient for sexual intercourse. The first-line treatment for erectile dysfunction in male sexual dysfunction is oral medications taken by mouth, which are known as phosphodiesterase type 5 enzyme inhibitors. The first member of this group is sildenafil citrate. Vardenafil and tadalafil are other recent.
Why is there a pelvic injury, surgical intervention can be applied, and if testosterone levels are low, testosterone replacement therapy can be used. However, there are generally four main treatment methods used for erectile dysfunction:
- Oral Medications
- Vacuum Device
- Penile Injections
- Penile Prosthesis
These treatment methods do not eliminate the underlying cause. However, they help achieve the level of erection necessary for sexual intercourse. In the management of male sexual dysfunction, oral medications known as phosphodiesterase type 5 enzyme inhibitors, taken by mouth, constitute the first-line treatment for erectile dysfunction. The first member of this group is sildenafil citrate. Vardenafil and tadalafil are other group members recently introduced to the market. Men with erectile dysfunction take these medications before initiating sexual activity. These drugs enhance the natural signals that occur during sexual contact, resulting in a higher quality and longer-lasting erection. These drugs are reliable and highly effective. They resolve erectile dysfunction in approximately 80% of patients. Phosphodiesterase type 5 enzyme inhibitors have mild and generally transient side effects. The severity of side effects decreases with continued use. The most common side effects include headache, nasal congestion, flushing, and muscle pain.
- Oral Medications: Phosphodiesterase Inhibitors:These drugs came into the spotlight in the late 1990s. The introduction of sildenafil led many patients to seek treatment. Sildenafil was first clinically tested in 1991 for the treatment of ischemic heart disease. During these studies, patients reported an unexpected side effect of improved erections.
Sildenafil:
Sildenafil is an inhibitor of phosphodiesterase type 5 enzyme that increases levels of cyclic Guanosine Monophosphate (cGMP), thereby facilitating erections. An advisable dosage of sildenafil is 25, 50, or 100 mg. It is taken one hour before sexual intercourse. The effectiveness of the drug varies between 65-70% depending on the cause of the erectile dysfunction. It has been proven effective in various disease groups causing erectile dysfunction (diabetes, endocrine, neurological, psychological, post-pelvic surgery, arteriogenic, veno-occlusive, idiopathic). It does not have a stimulating effect on sexual desire. Sildenafil reaches its maximum blood level within 1 hour and is primarily excreted from the body through the liver. Its effect lasts for 4 hours. The drug is completely eliminated from the body within 8-12 hours. Although it reaches its maximum blood level within 1 hour, its effects can be observed in 20 minutes in 50% of patients. To enhance effectiveness, patients are advised not to eat or drink water up to 1-2 hours before using sildenafil. For heart patients not using nitrate medications, sildenafil is a reliable and effective treatment option.
Vardenafil:
Vardenafil is another phosphodiesterase type 5 enzyme inhibitor. Vardenafil and sildenafil have some pharmacological similarities. It has been shown that vardenafil inhibits the phosphodiesterase enzyme 10 times more strongly than sildenafil. Vardenafil is more specific to phosphodiesterase type 5 enzyme and inhibits phosphodiesterase type 6 enzyme less than sildenafil. Vardenafil is absorbed more rapidly than sildenafil and reaches its maximum level in the blood in 0.7-0.9 hours. Vardenafil, used in doses of 5, 10, and 20 mg, has success rates of up to 80%. It appears to be superior to other PDE5 inhibitors in patients with diabetes and those who have undergone surgery for prostate cancer.
Tadalafil:
Tadalafil also acts by inhibiting phosphodiesterase type 5 enzyme. Its structure is different from other group members. Tadalafil is absorbed more slowly than sildenafil and vardenafil. It reaches its maximum blood level in 2 hours. Additionally, tadalafil has a longer half-life (the time required for the blood level to decrease by half) compared to competitors (17.5 hours). Therefore, tadalafil provides effectiveness for up to 36 hours. The fact that tadalafil is effective for 36 hours has led to it being called the “weekend pill.” Tadalafil’s absorption is not affected by age, alcohol consumption, or meals. Tadalafil is used in doses of 5, 10, and 20 mg.
Reliability of Phosphodiesterase Type 5 Enzyme Inhibitors:
Clinical studies and experience have shown that phosphodiesterase inhibitors are reliable drugs. Complaints such as headache, flushing, or nasal congestion may occur due to the dilation of blood vessels. Vision-related problems may arise, and this effect is associated with the inhibition of phosphodiesterase type 6 enzyme. Studies with tadalafil have observed unwanted side effects such as back pain and muscle pain in approximately 15% of patients, rather than visual complaints. Phosphodiesterase inhibitors do not increase the risk of heart disease events. These drugs should never be used in conjunction with nitrates.
- Vacuum Device:Vacuum devices consist of a plastic cylinder, a vacuum pump, and an elastic compression band. Lubricating substance is applied to the penis. The penis is inserted into the cylinder. Air is pumped out of the cylinder, creating a vacuum effect and causing an erection. The compression band at the open end of the cylinder is placed at the base of the erect penis to maintain the level of hardness. The cylinder is removed from the penis. The compression band can remain on the penis for up to half an hour, sustaining the erection until it is removed. This technique can be easily learned, and many individuals have achieved successful results with this treatment.
- Penile Injections:Vasoactive drugs are injected into the corpora cavernosa using a fine needle to dilate the blood vessels. These drugs work by relaxing the penis tissue and expanding the blood vessels, increasing blood flow to the erectile rings and facilitating an erection. Penile injections are administered to a group of patients who have previously tried and failed oral medications. This technique can be easily learned by the patient for use at home. The appropriate dose is determined individually for each patient. The patient self-injects 0-15 minutes before sexual intercourse, and an erection lasting approximately half an hour is achieved as a result of adjusting the appropriate dose. The drugs injected into the penis are usually combined with each other. Papaverine/fentolamine, papaverine/fentolamine/PGE1, and PGE1 are combinations used in treatment. Vasodilatory drugs can also be used to measure the response of the penis to these drugs. Patients who inject into the penis may experience pain during erections, and long-term use may lead to the development of scar tissue in the penis. Therefore, patients should be regularly monitored by urologists.
- Penile Prosthesis:A penile prosthesis consists of two synthetic cylinders implanted into the penis through surgical intervention. The prosthesis does not affect urinary function or sexual functions such as ejaculation and orgasm. There are two types of prostheses used: bendable (malleable) semi-rigid prostheses and inflatable prostheses. Inflatable prostheses, in addition to the cylinders in the penis, contain a pump and a reservoir. Fluid is pumped from the reservoir to the cylinders, causing the penis to become erect. By pressing a button on the base of the pump, the fluid collected in the cylinders returns to the reservoir, and the penis becomes flaccid again. Inflatable prostheses have higher success rates and provide a more natural appearance. Penile prostheses are mainly applied to a group of patients who have not benefited from the treatment methods listed above. This group includes patients with uncontrolled diabetes, those who have undergone surgery or radiotherapy due to prostate or bladder cancer. The placement of a penile prosthesis in this group of patients has resulted in patient satisfaction rates of up to 90%.
- Vascular Surgery:The goal of this treatment is to increase blood flow and blood pressure in the penis. It is mainly applied to young patients who have had accidents that have obstructed normal blood flow. This treatment method is based on redirecting a healthy artery to the penis. It is used in a very limited number of cases today.
- Urethral Medication Application:In this treatment method, alprostadil is applied to the urethra by inserting a small plastic cylinder into the tip of the penis. The active substance reaches the penile tissue enough to provide an erection. It is applied 10-15 minutes before sexual intercourse and succeeds in 43% of patients. It can cause a temporary burning sensation in the urethra.
- Psychological Counseling:Even if the cause is physical, those who experience erectile dysfunction in the context of male sexual function disorders will be psychologically affected. Psychological counseling provides significant benefits in identifying and resolving the problem. Especially in young male patients where physical causes are rarely observed, psychological counseling is needed.
Conclusion:
In any case of erectile dysfunction, it is essential to consult a doctor and provide as accurate and detailed information as possible. It should be known that this condition is widespread and not something to be ashamed of. New treatment methods are developed every year, and the treatment of all types of erectile dysfunction is possible.
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