Erectile Dysfunction (ED)

WHAT IS ERECTILE DYSFUNCTION?

Erectile dysfunction (ED) is the inability to initiate and maintain an erection satisfactory for sexual intercourse.

Large studies (such as the Massachusetts Male Aging Study) suggest that many men suffer at some point in their lives with ED. Many men often live with this problem for years. As the male suffers, many in silence, the partner is similarly concerned that she is no longer sexually attractive or has concerns regarding the implications for treatment.

There are 2 main types of erectile dysfunction (ED):

Organic ED responsible for about 80%-90% of all cases of erectile dysfunction (due to a specific cause like atherosclerosis ad reduction of blood flow, nerve injuries, diabetes, hypertension, drug-induced, etc)
Psychogenic ED responsible for about 10%-20% of all cases of erectile dysfunction, (due to psychologic or interpersonal factors which include marital discord, discord with spouse or partner, work stress, etc.)

Psychogenic erectile dysfunction may coexist with other sexual dysfunctions, notably hypoactive sexual desire, and with major psychiatric disorders, particularly depression and anxiety disorders.

Causes
Diagnosis and Evaluation
ED Questionnaires
Treatment
Informative links

Causes

There are many underlying physical and psychological causes of erectile dysfunction.

Reduced blood flow to the penis and nerve damage are the most common organic causes.

Other underlying conditions associated with erectile dysfunction include the following:

Psychological conditions like anxiety, stress, depression
Spinal and pelvic trauma
Pelvic surgery and radiation therapy, like in operations after prostate cancer.
Penile deformity like Peyronie’s Disease which causes bending of the penis on erection
Certain medical diseases – diabetes mellitus, hypertension, high cholesterol
Drugs used for hypertension and depression
Hormonal disorders like low testosterone as in andropause / late-onset hypogonadism

The common psychological causes of ED include:

Stress: Stress can be job-related, money-related, or the result of marital problems, among other factors.
Anxiety: Once a man experiences ED, he may become overly worried that the problem will happen again. This can lead to performance anxiety, or a fear of sexual failure, and consistently lead to ED.
Guilt: A man may feel guilty that he is not satisfying his partner.
Depression: A common cause of ED, depression affects a person physically and psychologically. Depression can cause ED even when a man is completely comfortable in sexual situations. Drugs used to treat depression may also cause ED.
Low self-esteem: This can be due to prior episodes of ED (thus a feeling of inadequacy) or can be the result of other issues unrelated to sexual performance.
Indifference: This may come as a result of age and a subsequent loss of interest in sex, be the result of medications or stemming from problems in a couple’s relationship.

The common psychogenic ED seen in young males are usually seen when they are recently engaged, just married or 1-2 years after marriage when the parents and in-laws exert pressure for children from the partners. This is due to performance anxiety.

Diagnosis and evaluation

ED is diagnosed based on the history of the patient based on the inability to initiate and maintain an erection satisfactory for sexual intercourse.

Further evaluation include evaluation of underlying medical diseases, lifestyle habits, underlying neurological problems, psychological issues, injuries, previous radiotherapy and current medications among others.

Important points in the evaluation include a detailed medical, sexual and social history; a focused physical examination, and laboratory tests for any unrecognized medical diseases and hormonal tests.

Sexual Function and Related History

They include description of erectile dysfunction
	Age at onset and duration
	Association with specific event
	Progression (rapid vs. gradual) of dysfunction
	Quality of erections
		Partial, unable to sustain
	Frequency of dysfunction
		Mild (occasional), moderate (often), complete absence
	Setting of erectile dysfunction
		Presence or absence of nocturnal erections
		Presence or absence of dysfunction with different partners
		Presence or absence of dysfunction with self pleasuring
	Other sexual problems (loss of libido, ejaculation problems)
Presence of chronic disease
Use of prescription, over-the-counter, or recreational drugs
Cigarette smoking
Social issues
	Relationships
	Life stressors
Expectations of patient and partner
Knowledge of sexual function

Various questionnaires are available to assess the severity of ED.

The International Index of Erectile Function (IIEF-5) Questionnaire:

An IEEF-5 questionnaire is available to help patients and doctors to determine if ED is present and how severe it is.

This IIEF-5 questionnaire helps in assessing the severity of ED and a score of 21 or less indicates the patient has a problem with his erection.

Over the past 6 months:

1. How do you rate your confidence that you could get and keep an erection?

Very low

Low

Moderate

High

Very high

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

Almost never/never 1

A few times (much less than half the time)

Sometimes (about half the time)

Most times (much more than half the time)

Almost always/always

3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

Almost never/never

A few times (much less than half the time)

Sometimes (about half the time)

Most times (much more than half the time)

Almost always/always

4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

5. When you attempted sexual intercourse, how often was it satisfactory for you?

Almost never/never

A few times (much less than half the time)

Sometimes (about half the time)

Most times (much more than half the time)

Almost always/always

IIEF-5 scoring:
The IIEF-5 score is the sum of the ordinal responses to the 5 items.
22-25: No erectile dysfunction
17-21: Mild erectile dysfunction
12-16: Mild to moderate erectile dysfunction
8-11: Moderate erectile dysfunction
5-7: Severe erectile dysfunction

The Erection Hardness scale:

The Erection Hardness Scale (EHS) involves a 1–4 response to a single question to assess firmness of erection, where 3 is sufficient for penetration and 4 is a rigid erection.

The tool asks men to consider the question ‘How would you rate the hardness of your erection?’ and select one of the following options:

0	Penis does not enlarge
1	Penis is larger, but not hard
2	Penis is hard, but not hard enough for penetration
3	Penis is hard enough for penetration, but not completely hard
4	Penis is completely hard and fully rigid

Treatment of erectile dysfunction

Underlying causes of erectile dysfunction must first be determined. Effort tolerance should be evaluated. It has been said that erectile dysfunction is the window to a man’s heart. Erectile dysfunction is an early warning sign of heart disease and may provide a window of opportunity to prevent heart attacks and strokes. Hence a cardiology assessment would be warranted if necessary.
Psychotherapy – done by the psychiatrist / psychologist / sex counsellor, this is indicated in stress or depression related ED. However with oral treatment (tablets), most psychogenic ED will respond to oral drugs.
Drugs – Current first-line treatment of erectile dysfunction is oral medications which improve blood flow to the penis. These include drugs such as Viagra®, Cialis® and Levitra®. Care should be taken that this drug is not taken together with any nitrite-containing drugs. Also, the drug needs to be taken 1 hour before sex, and has to be followed by foreplay and sexual stimulation for 1 hour before sexual intercourse. Men should not buy these drugs over the counter without advice and evaluation by the doctor first.
The second line treatment for erectile dysfunction (not responsive to oral medication) is penile injection therapy. Using a thin syringe and a very tiny needle, a drug called Alprostadil (prostaglandin E1) is injected into the shaft of the penis, to facilitate an erection. Caution is advised that these drugs should not be bought over the counter without advice and proper evaluation by the doctor first.

Pic of Caverject injection

5. Devices – a vacuum pump consists of an external pump with a band on it that a man with erectile dysfunction can use to get and maintain an erection. The device consists of an acrylic cylinder with a pump that may be attached directly to the end of the penis. It may be used to suck out blood into the penis and thereafter, a ring placed round the base of the penis prevents the blood from draining out. This will achieve an erection.

Vacuum pump for erectile dysfunction

6. Surgery – involves tying up leaking veins in case of erectile dysfunction as a result of venous leak and penile venous insufficiency.

7. Penile prosthesis implantation – The implant consist of a synthetic mechanical device which is inserted into the spongy tissue of the penis. It may be a 2-piece or a 3-piece penile prosthesis.

The 3-piece device has three parts – the inflatable rods, the balloon reservoir and the pump.

Surgery involves making a small cut at the junction between the penis and scrotum and inserting the three-piece device into the penis.

When needed, the pump is activated and fluid flows from the reservoir into the inflatable rods, resulting in turgidity and rigidity of the penis.

When not in use, the pump is squeezed differently and fluid flows back to the balloon reservoir and the penis becomes soft again.