Erectile Dysfunction is one of the medical conditions that we treat here at Assured Pharmacy. To help our clients understand the services we offer and their medications and medical conditions, we’ve written a series of articles on our blog that covers different conditions and medications.
This article is about Erectile Dysfunction (ED). To help you understand the subject, we’ll cover what ED is, the incidence of ED, symptoms, causes, when you should seek medical attention and the different treatment options available.
Erectile dysfunction (ED), sometimes referred to as impotence, is the persistent inability to get an erection firm enough to have satisfactory sexual intercourse and/or the failure to maintain an erection.
Please note that occasional ED is not uncommon. A lot of men may experience ED during times of stress. Persistent ED may be a sign that there are other health-related problems that may need medical treatment. It may also be a sign that there may be emotional and/or relationship problems that may need to be addressed by a professional.
The physiological mechanism that is responsible for the erection of a penis involves the release of nitric oxide (NO) into the corpus cavernosum when there is sexual stimulation eg sexual thoughts or direct contact with the penis. The nitric oxide then activates an enzyme known as guanylate cyclase. The activation of this enzyme leads to increased levels of cyclic guanosine monophosphate (cGMP) thereby producing smooth muscle relaxation in the corpus cavernosum and allowing the inflow of blood into the penis.
In simple terms, when a man gets excited sexually, the muscles in his penis relax thereby allowing an inflow of blood to the penile arteries. Inside the penis, there are two chambers called the corpora cavernosa. These chambers get filled up with blood too. As the chambers fill up, the penis grows rigid, thus forming an erection. An erection becomes flaccid when the penile muscles contract and the accumulated blood flows out through the penile veins.
ED may occur due to a problem at any stage of the erection process. For example, the penile arteries may be too damaged to open properly and allow blood in or there could be a narrowing of the blood vessels going to the penis due to high cholesterol.
What is the incidence of Erectile Dysfunction?
ED may occur at any age but it is more common in older men. However, that does not mean that ED in itself is inevitable as you age.
A large-scale survey was undertaken by Heruti R et al at the Staff Periodic Examination Center (SPEC), Israel between 2001 and 2003. 11,914 men reported to SPEC, with an average age of 34.8 +/- 7.1 years. Of these men, there was a compliance rate of 48.9% ie the percentage of men who chose to answer the Sexual Human Inventory for Males (SHIM) questionnaire. According to the SHIM scores, it was discovered that at least one out of three men (26.9%) suffered from ED (19%, 7%, and 1% had mild, moderate, and severe ED, respectively). ED was also prevalent amongst young adults: 22.1% of males under-40 had low SHIM scores (<21). There was a correlation between the severity of ED with age and diabetes mellitus.
The conclusion from the survey was that ED is a major health concern amongst young men as well as older men.
Paolo Capogrosso MD et al, conducted a study in 2013 to assess the sociodemographic and clinical characteristics of young men (defined as ≤40 years) seeking their first medical help for new onset ED as their primary sexual disorder. The complete sociodemographic and clinical data, taken from 439 consecutive patients, were analysed. Any health‐significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Patients also completed the International Index of Erectile Function (IIEF). During the study, descriptive statistics tested sociodemographic and clinical differences between ED patients ≤40 years and those >40 years. The results of the study found that new onset ED as the primary disorder was found in 114 (26%) men ≤40 years (mean [standard deviation [SD]] age: 32.4 [6.0]; range: 17–40 years). Premature ejaculation was more comorbid in younger men, whereas Peyronie’s disease was prevalent in the older patient group (all P = 0.03). At IIEF, severe ED rates were found in 48.8% of younger men and 40% of older men, respectively (P > 0.05). Likewise, rates of mild, mild‐to‐moderate, and moderate ED were not significantly different between the two groups.
The conclusion drawn from this study was that one in four patients seeking medical help for the first time for new onset ED was younger than 40 years. Also, almost half of the young men suffered from severe ED, with comparable rates in older patients.
What are the symptoms of Erectile Dysfunction?
You may have Erectile Dysfunction if you have consistently had any of the following symptoms for at least two months:
difficulty getting an erection at any time
being able to get an erection sometimes but not every time you want to have sex
difficulty maintaining an erection firm enough for sexual intercourse
reduced interest in having sex
Other sexual disorders that may be related to ED include:
anorgasmia (the inability to reach an orgasm after ample sexual stimulation)
What are the causes of Erectile Dysfunction?
Erectile Dysfunction can have physical and/or psychological causes. Erectile dysfunction could also be a side-effect of some drugs like antihypertensives, antidepressants, antipsychotics, cytotoxic drugs and/or recreational drugs, including alcohol. Concerns about work, money, relationship, family, and even worrying about not getting an erection can all be factors that contribute to ED.
Physical problems that result in ED may include any or all of the following:
conditions that alter the flow of blood to your penis – vasculogenic
conditions that affect your nervous system ie your brain, nerves and spinal cord – neurogenic
conditions affecting your hormone levels – hormonal
conditions that affect the physical structure of your penis – anatomical
Physical causes can include heart disease, diabetes and raised blood pressure. A physical cause for ED may manifest itself as an inability to get an erection under any circumstances. Other physical causes include injury to penile tissue and/or hormonal problems.
A psychological (or stress related) cause of ED may manifest itself as being able to get an erection sometimes, but not all the time. For instance, you may be able to get an erection when you masturbate but not when you want to have sex with your partner. Psychological causes of ED include anxiety and depression.
It is possible for some people to have both a physical and a psychological cause for their ED. For instance, if you have diabetes, it may be difficult for you to get an erection. This could lead to you becoming anxious. So the combination of your diabetes and your anxiety could lead to an episode of ED.
There are a number of emotional issues that may also affect your physical ability to achieve and/or maintain an erection that remains firm for long enough for you to have satisfactory sexual intercourse. These emotional issues include (but are not limited to):
problems in your relationship
lack of sexual knowledge
past sexual problems
history of sexual abuse
being in a new relationship
When should you seek medical help?
You should speak to your GP (or make an appointment at a sexual health clinic) if your ED persists for more than a few weeks. This will give your doctor a chance to assess your general health to ensure that your ED is not a sign of a more serious health condition eg heart disease.
At your appointment, the doctor or nurse will ask you about your general health and well-being and any problems you may be having. They will carry out some basic health checks like checking your blood pressure, heart and lungs. Your genitals will be examined so that a physical cause can be ruled out.
Here at Assured Pharmacy, we have our own in-house doctor with whom you can have a remote consultation to start the process. Depending on your individual circumstances, you may need to have a physical examination.
Should your doctor make a diagnosis of ED, the treatment options offered will be dependent on the underlying cause of your ED. Your choice as a patient will also be considered in the final treatment plan. Your doctor will explain the merits of any treatment options and any potential side effects you may experience.
If your ED is caused by a medication you are taking for another health condition, your doctor may change the dose or change the medication altogether.
Please note that you should not stop taking any prescribed medications unless told to do so by a doctor or other suitably qualified healthcare professional.
If your ED has a psychological cause, your doctor may refer you to a psychosexual therapist. The success of your psychosexual therapy will be dependent on you, your motivations and how well you work with the therapist to enable him/her to understand what prevents you from experiencing normal sexual arousal. Psychosexual therapy has been used in combination with physical therapies.
The advantages of psychosexual therapy in treating ED are that it is physically non-invasive, your partner could get involved thereby improving a couple’s communications as well as address any concerns your partner may have. In turn, this can lead to sustained sexual function and satisfaction.
The disadvantages are that it is not available on the NHS in every locality. Your partner may not want to get involved, it is time-consuming and has a variable success rate.
Depending on your individual circumstances, lifestyle changes may be recommended. These changes may include regular exercise, weight loss, smoking cessation, and reducing alcohol consumption.
If your ED has a physical cause, different therapeutic options will be discussed with you. For instance, if you have a narrowing of your arteries due to high cholesterol, cholesterol-lowering medications like statins may be prescribed. If you have high blood pressure, medications to lower your blood pressure may be prescribed.
Any medication that is taken orally and is known as a phosphodiesterase type-5 inhibitor is the first-line drug treatment for erectile dysfunction irrespective of the cause of the ED. These medications do not initiate an erection, sexual stimulation is required i.e. sexual thoughts and/or direct contact with the penis.
The choice of oral phosphodiesterase type-5 inhibitor is dependent on your frequency of sexual intercourse and your response to the treatment. Avanafil, sildenafil and vardenafil are short-acting drugs and are suitable for the occasional use as and when required. Tadalafil is a longer-acting drug and can be used as required but can also be used as a regular lower daily dose to allow for spontaneous (rather than scheduled) sexual activity or in those who have frequent sexual activity.
A patient with erectile dysfunction should receive six doses of an individual phosphodiesterase type-5 inhibitor at the maximum dose (with sexual stimulation) before being classified as a non-responder to that individual phosphodiesterase type-5 inhibitor. Patients who fail to respond to the maximum dose of at least two different phosphodiesterase type-5 inhibitors should be referred to a specialist.
The advantages of oral phosphodiesterase type-5 inhibitors are that they are effective and non-invasive. However, they are not suitable for everyone, especially those with some pre-existing medical conditions and they may interact with some other medications.
The legal category for all currently available oral phosphodiesterase type-5 inhibitors is POM. This means that these medications are prescription only medicines and they can only be supplied or sold according to the instructions in a prescription issued by a duly qualified and registered doctor or non-medical prescriber.
You should not buy these or any other prescription-only medication without first speaking to a duly qualified and registered healthcare professional like a doctor or non-medical prescriber.
Intracavernosal, intraurethral or topical application of alprostadil (prostaglandin E1) is recommended as second-line therapy under careful medical supervision. Intracavernosal or intraurethral preparations can also be used to aid the diagnosis of ED.
The advantages of intracavernosal injections of alprostadil are that it is rapidly effective, it is suitable for a lot more patients due to few contra-indications or interactions and there have been higher rates of patient and partner satisfaction reported. The disadvantages are that it is invasive, there is a penile pain on administration of the injection, can cause priapism (an erection that lasts longer than 4 hours) and patients need reasonable manual dexterity and eyesight to be able to administer it.
Intraurethral alprostadil has the advantages of providing erections adequate for satisfactory sexual intercourse, has a lower incidence of priapism, compared to intracavernosal alprostadil and it is suitable for a wide range of patients, including those who have a fear of needles. Its disadvantages are that studies have shown that it has lower efficacy and higher side effects compared to the intracavernosal injections. Mild penile pain is a common side effect and it may cause discomfort in pre-existing lower limb varicosities. It also causes penile urethral discomfort and possible vaginal discomfort for the partner. It requires manual dexterity, good eyesight, and insertion after micturition. It is slower acting compared to the intracavernosal injections.
A vacuum device consists of an external cylinder fitted over the penis to allow air to be pumped out, resulting in engorgement of the penis with blood. A constriction ring is then fitted to the base of the penis to maintain this “erect” state. Vacuum therapy is suitable for a wide range of patients with chronic or occasional erectile dysfunction, whatever the cause. One study quoted an overall clinical success rate of around 90%, with more than 80% of patients continuing with the device, but in another study, only 23% of patients asked for a prescription after a two-week trial and only 53% of these reported complete or reasonable satisfaction.
Vacuum devices have the advantages of having a low incidence of side effects; suitable for long-term use; suitable for a wide range of patients, including those who have failed other therapy. The disadvantages of vacuum devices are that it is not suitable for use by those with bleeding disorders. There is a lack of spontaneity and it is cumbersome to use. Erections may be uncomfortable and ejaculation may be impaired.
If there’s a hormonal cause for your ED, you may be referred to an endocrinologist that specialises in the treatment of hormonal conditions.
Surgery may be recommended as a very last resort, if it is appropriate and if all other treatment options fail.
Figure 1: Suggested treatment pathway that would be considered by your doctor
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https://www.ncbi.nlm.nih.gov/pubmed/16422958 – Prevalence of erectile dysfunction among young adults: results of a large-scale survey by ⦁ Heruti⦁ R1, Shochat T, Tekes-Manova D, ⦁ Ashkenazi I, ⦁ Justo D. ⦁ J Sex Med. 2004 Nov;1(3):284-91.
https://onlinelibrary.wiley.com/doi/abs/10.1111/jsm.12179 – One Patient Out of Four with Newly Diagnosed Erectile Dysfunction Is a Young Man—Worrisome Picture from the Everyday Clinical Practice by ⦁ Paolo ⦁ Capogrosso⦁ MD, ⦁ Michele ⦁ Colicchia⦁ MD, ⦁ Eugenio Ventimiglia MD, ⦁ Giulia ⦁ Castagna⦁ MD, ⦁ Maria Chiara Clementi MD, ⦁ Nazareno⦁ ⦁ Suardi⦁ MD, ⦁ Fabio Castiglione MD, ⦁ Alberto Briganti MD, ⦁ Francesco ⦁ Cantiello⦁ MD, ⦁ Rocco Damiano MD, ⦁ Francesco ⦁ Montorsi⦁ MD and ⦁ Andrea ⦁ Salonia⦁ MD. First published: 07 May 2013 in the Journal of Sexual Medicine
Assured Pharmacy is not liable for the currency or accuracy of the information contained in this blog post. For specific information about your personal medical condition, please contact our doctors or pharmacists for advice on [email protected].