Let’s begin by clarifying the problem.
As the name suggests, erectile dysfunction (ED) is a problem that affects your penile erections and many men find it awkward to talk about their ED for the first time.
ED is a common male sexual dysfunction condition, affecting men of all ages, but with an increased incidence among 40-70 group of age.
ED is an important condition affecting 140 million men worldwide.
If you ever have any questions to ask your health care provider about erectile dysfunction, making a short list of questions helps to clarify some aspects. Here are some hints:
Question 1. Is ED only happening to me?
Data from an observational survey called the Massachusetts Male Aging Study (MMAS), including non-institutionalised men reported that 52% of men aged 40-70 years reported ED.
It is believed that ED affects most men at one time or another during their lives.
ED onset is strongly related to ageing and ED symptoms are more frequent in men over 35 years of age.
The first symptoms are mild and transitory, and you may neglect them, because they can be frequently associated with fatigue, drinking alcohol or coffee.
Most often, your health care provider will diagnose ED after a physical exam and talking with you.
Question 2. How do I know whether my ED has an emotional cause or is the result of an underlying medical condition?
The following conditions can contribute to the onset of ED:
- Heart disease
- High cholesterol
- High blood pressure
- Nerve damage
- Cancer treatment (such as prostatectomy – removal of the prostate gland)
- Thyroid disorders
- Low testosterone
- Medication side effects
- Attention deficit (especially in young men)
The priority is to make sure your ED is not caused by a serious medical condition, such as heart disease, high blood pressure, high cholesterol, kidney disease, or diabetes.
ED can also be a result of performance anxiety. The anxiety triggers the production of stress hormones (such as epinephrine and norepinephrine) which can narrow blood vessels in the penis and make it difficult for blood to flow in and form an erection.
If that is the case, then you should see a sex therapist.
Nerve damage or diseases affecting the nervous system can interfere with the body’s ability to process sexual stimulation signals, also causing ED. Stroke, multiple sclerosis and Parkinson’s Disease Nerve damage from strokes or spinal injuries, and other neurological disorders, like multiple sclerosis and Parkinson’s, change the brain’s ability to respond to sexual stimulation, potentially preventing an erection.
Diabetes is a disease that affects both the vascular and nervous systems. Approximately 50% of diabetic patients, irrespective of type, have ED.
Inhibition of the blood flow the penis, that can characterize the damage of the nerves or arteries and can also result from a fractured or crushed pelvis can produce ED.
Likewise, some types of pelvic surgeries and radiation therapies, such as those used in the treatment of prostate, bladder or rectal cancer, can cause ED.
Endocrine disorders such as low levels of testosterone, or thyroid or pituitary gland problems, can also cause a hormone imbalance and erectile problems.
Diseases such as Peyronie’s disease, an inflammatory condition that produces scarring within the penis, causing it to curve or bend, can also contribute to ED.
Sometimes, medications taken to treat illnesses are behind ED. Blood pressure therapies like beta-blockers, some heart medications, some peptic ulcer medications, sleeping pills, and antidepressants fall into this classification.
Question 3. Which are the signs that characterize ED
The following signs are usually described in ED:
• Gradual development
• The hardness of the penis is not enough for coitus
• Erection is weakened during sexual intercourse
• It takes too long to achieve an erection
• Spontaneous nocturnal erections are absent
• The absence of erection when it’s needed.
Question 4. Is ED just an inevitable part of getting older, or should it be treated at any age?
The supposition that the ED only appears in older men is far from being true.
ED increases in incidence with age, but its true incidence is probably underestimated owing to embarrassment about seeking help.
ED should be treated at any age.
Question 5. Do you think my ED is related to cardiovascular disease or another serious medical condition?
We must into consideration that ED is a significant marker for future cardiovascular events.
Vascular ED and cardiovascular disease (CVD) share common risk factors including obesity, hypertension, metabolic syndrome, diabetes mellitus, and smoking. ED and CVD also have common underlying pathological mechanisms, including endothelial dysfunction, inflammation, and atherosclerosis.
Periodic visits at the cardiologist are recommended, especially if you have any of the following risk factors: age, smoking, hypertension if you are sedentary or obese, especially abdominal obesity if you have a strong family history of premature cardiovascular disease if you have diabetes and elevated LDL cholesterol and triglyceride levels.
You can also check the SCORE charts for the evaluation of cardiovascular risk and cardiovascular diseases prevention.
Question 6. Which is the common pathway between cardiovascular diseases and ED?
Endothelial dysfunction is a condition in which the endothelial layer (the inner lining) of the small arteries fails to function normally. As a result, several bad things can happen to the tissues supplied by those arteries.
The common pathway linking cardiovascular disease and ED probably involves endothelial dysfunction and small vessel atherosclerosis, which impairs smooth muscle relaxation within the penis.
Question 7. Do I need to see a different type of health care provider, such as a urologist, an endocrinologist, a psychiatrist, or a sex therapist? What does each specialist treat?
To begin treating your ED you can visit first your primary care physician. Even if your regular doctor doesn’t specialize in sexual medicine, he or she can guide you to the right specialists.
Your primary care physician can give you a complete physical and run tests to address any physical causes. He or she can also answer preliminary questions, help you determine your options, and, if necessary, refer you to a specialist. Many specialists work in conjunction with primary care physicians. The primary care physician will identify risk factors such as diabetes or hypogonadism and relevant lifestyle factors such as excessive alcohol, smoking, recreational drugs, and lack of regular exercise that might precipitate ED. He or she can use this information to ensure appropriate referral to secondary care for more specialized investigations where necessary (a urologist or a mental health professional who specializes in sexual dysfunction, depending on the case).
Next, the urologist. Even if urologists primarily treat urinary tract issues for both men and women, they are also specialists in the male reproductive organs: penis, testes, scrotum, prostate gland, and ejaculatory ducts. Urologists can help with issues like erectile dysfunction (ED), benign prostate hyperplasia, and Peyronie’s disease. They are specialists in ejaculatory disorders such as premature ejaculation (PE), retrograde ejaculation, and an ejaculation.
Psychiatrists and therapists can help to address the psychological issues that cause sexual problems. For example, psychological counselling might help you work through difficulties in your relationship with your partner or help you cope with past sexual trauma or abuse. In some cases, you might choose to have couples’ therapy with your partner.
Sex therapists focus more on direct sexual issues than the underlying psychological causes. They can help you better understand the physiological aspects of sex. Sex therapists might recommend strategies that you and your partner can try in the bedroom, too.
Question 8. Is smoking a risk factor for ED?
Tobacco smoke contributes to ED through the development of atherosclerosis and endothelial dysfunction. A meta-analysis of four prospective cohort studies and four case-control studies (28 586 participants) concluded that smoking was a risk factor for ED in current smokers (odds ratio 1.81) and ex-smokers (1.25).
Question 9. How much of a role do things like diet, alcohol consumption, smoking, exercise, and amount of sleep play in either causing or treating ED?
Lifestyle choices contribute a lot to ED onset.
A sedentary lifestyle is also associated with a higher risk of ED, so patients should be advised about the benefits of regular exercise even when prescribed treatment. Results from a meta-analysis of seven studies concluded that moderate or high physical activity confers a lower risk of erectile dysfunction (odds ratio 0.63 for moderate activity and 0.42 for high activity).
Alcohol or other drug abuse, a poor diet and smoking may be associated with vascular disease, hardening of the arteries and high blood pressure–all of which are, in turn, associated with ED.
Other chronic-disease states associated with ED include chronic renal failure; hepatic failure; Alzheimer’s disease; sleep apnoea; and chronic obstructive pulmonary disease.
Very often, a combination of several factors causes ED.
Lifestyle changes also lower the frequency of your ED episodes. Here are some bits of advice:
- Walk. According to one Harvard study, just 30 minutes of walking a day was linked with a 41% drop in risk for ED.
- Eat right. In the MMAS, eating a diet rich in natural foods like fruit, vegetables, and fish decreased the likelihood of ED.
- Pay attention to your vascular health. High blood pressure, high blood sugar, high cholesterol, and high triglycerides can all damage arteries in the heart (causing heart attack), in the brain (causing stroke), and leading to the penis (causing ED).
- Quit smoking.
- Have a healthy diet. A healthy is contributing to healthy sex life. Research published in January 2016 found that men who ate foods high in antioxidants called flavonoids had a lower risk of ED than those who didn’t eat a flavonoid-rich diet. Flavonoids can be found in certain plant-based foods like citrus fruits, blueberries, strawberries, apples, pears, cherries, blackberries, radishes, and blackcurrant. Some teas, herbs, and wines also have flavonoids in them. Past studies have shown that consuming flavonoids could reduce a person’s risk for diabetes and heart disease, both of which can lead to ED.
- Include fruits, vegetables, whole grains, and olive oil, nuts and fish in your diet.
- Vitamin D is an important nutrient for our overall health. And some experts believe that vitamin D deficiency might interfere with a man’s erections.
These lifestyle modifications also reduce long-term cardiovascular risk and improve endothelial function so should continue after drug treatment begins.
Question 10. What laboratory tests are needed?
Fasting serum lipid profile, fasting plasma glucose, and glycated haemoglobin are recommended as baseline tests for all new patients presenting with ED. Total testosterone, luteinising hormone, and sex hormone binding globulin are measured on a blood sample taken between 8 am and 11 am. A prostate-specific antigen test is recommended only if the digital rectal examination result is abnormal and the patient is over 50 years (if he is requesting a screening or has risk factors for prostate cancer) or if testosterone replacement is considered.
Question 11. What types of ED treatment are available?
Oral medications are a successful ED treatment for many men. They include:
All four medications belong to the class of drugs called phosphodiesterase type 5 inhibitors (PDE inhibitors) and act by enhancing the effects of nitric oxide, a natural chemical produced by your body that relaxes muscles in the penis. Releasing the nitric oxide will increase the blood flow into your penis and allows you to get an erection. These drugs do not automatically produce an erection without sexual stimulation. Oral ED drugs are not aphrodisiacs.
Possible side effects that may occur when taking PDE inhibitors include flushing, nasal congestion, headache, visual changes, backache and stomach upset.
Oral PDE inhibitors are a convenient, efficacious, and widely available treatment option for ED. They are contraindicated in patients taking nitrates, in patients in whom vasodilatation or sexual activity is inadvisable, and in those with a history of non-arteritic optic neuropathy. PDE inhibitors should be used with caution in patients with renal or hepatic impairment, recent stroke, myocardial infarction, or unstable angina and in those taking α blockers for lower urinary tract symptoms. These drugs inhibit type 5 PDE within the cavernosal smooth muscle and prevent the breakdown of cyclic guanosine monophosphate (cGMP) to guanosine monophosphate (GMP). Nitric oxide-mediated smooth muscle relaxation is therefore facilitated in both the corpus cavernosum and cavernosal arteries.
Question 12. Do you recommend any herbal remedies for ED?
In some parts of Asia, Africa, and some regions of Europe and North America, several herbal remedies have been used to treat ED. So far, only three herbal remedies have published data from studies in humans—Panax ginseng, Butea Superba, and yohimbine.
Clinicians have been retained to support herbal therapy owing to the fact that clinical evidence of safety and efficacy from clinical studies are lacking and these nutritional supplements can have side effects that were not adequately reported. From a regulatory point of view, these remedies are not clearly regulated. Panax ginseng contains ginsenosides which mediate both acetylcholine-induced smooth muscle relaxation as well as a release of nitric oxide in animal studies. Side effects at high doses include a headache, restlessness, and tachycardia. The active ingredient in Butea Superba is butenin, but the mechanism of action in ED is unclear. Yohimbine is an alkaloid that blocks presynaptic α2 adrenoceptors in the brain and spinal cord and enhances the sexual response. Side effects at lower doses include tachycardia, blood pressure changes, hallucinations, and dizziness.
If you have any questions related to ED or the drugs that treat ED, please write us an email at [email protected].
Key messages on erectile dysfunction:
- Causes are usually medical but can also be psychological;
- Organic causes are usually the result of an underlying medical condition affecting the blood vessels or nerves supplying the penis;
- Numerous conditions, ageing, prescription drugs, recreational drugs, alcohol, and smoking, can all cause ED.
Treatment for ED must be sought immediately and the underlying cause must be carefully analysed. Current treatments are aimed to provide temporary symptomatic relief but do not interfere with the progress of the disease itself.
The first-line treatment for ED is the class of phosphodiesterase type 5 (PDE5) inhibitors. PDE5 is a substance produced in the lungs and other parts of the body that breaks down another substance called cyclic guanosine monophosphate (GMP). Cyclic GMP causes the blood vessels (arteries) to relax and widen. These inhibitors enhance nitric oxide (NO)-mediated vasodilation in the corpus cavernosum by inhibiting cyclic guanosine monophosphate breakdown.
These drugs are safe for healthy hearts, but all men with cardiovascular disease should take special precautions, and some cannot use them under any circumstances.
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