Erectile dysfunction – definition, diagnosis, treatment methods

Cialis and ED

Erectile dysfunction – definition, diagnosis, treatment methods

Erectile dysfunction - definition, diagnosis, treatment methods

erectile disfunction – it is the inability to achieve or maintain an erection necessary for sexual intercourse. Most cases of erectile dysfunction are associated with vascular, neurological, psychological or hormonal disorders; It may also be due to certain medications. Screening usually includes screening for potential causes and measuring testosterone levels. Treatment options include therapy with oral phosphodiesterase inhibitors, intraurethral or intracavernous administration of prostaglandins, the use of vacuum erectile devices, and surgical implantation of prostheses.

Erectile dysfunction (ED; former name — impotence) affects up to 20 million men in the United States. The prevalence of partial or complete erectile dysfunction is gt; 50% in men aged 40–70 years and increases with age. For most of these men, treatment can be effective.

Etiology

There are 2 types of ED:

  • Primary ED — a man could never achieve or maintain an erection.

  • Secondary ED — acquired later in life by a man who was previously able to achieve an erection.

Primary ED — rare and almost always occurs due to psychological factors or clinically obvious anatomical anomalies.

Secondary ED is more common and gt; 90% of cases have an organic etiology. Many men with secondary ED develop reactive psychological disorders that aggravate the disorder.

Psychological factors, primary or reactive, should be considered in each case of ED. Psychological causes of primary ED include guilt, fear of intimacy, depression, or anxiety. In secondary ED, the causes may be associated with anxiety, stress, or depression. Psychogenic ED can be situational, associated with a specific place, time, or partner.

The main organic causes of ED include:

  • Vascular Disorders

  • Neurological disorders

These disorders are often the result of atherosclerosis or diabetes mellitus.

Most frequent vascular cause is atherosclerosis of the cavernous arteries of the penis, which is often caused by smoking and diabetes. Atherosclerosis and aging cause a decrease in the ability of the arteries to expand and relax smooth muscles, which limits the amount of blood that can fill the cavernous bodies of the penis (Review of sexual dysfunction in men: An erection). Vein occlusion dysfunction makes venous leakage possible, which makes it impossible to maintain an erection.

Priapism, which is usually associated with the use of trazodone, cocaine abuse and sickle cell anemia, can cause fibrosis of the male penis and lead to ED, causing fibrosis of the penis, which prevents drainage.

Neurological causes include stroke, major epileptic seizures, multiple sclerosis, peripheral and autonomic neuropathies, spinal cord injuries. Diabetic neuropathy and surgical trauma are also common causes.

Pelvic surgery complications (for example, radical prostatectomy [even using nerve-saving methods], radical cystectomy, transurethral resection of the prostate, surgery to remove rectal cancers) are other common causes. Other causes include hormonal disorders, certain medications, radiation effects on the pelvic organs, and structural pathology of the penis (for example, Peyronie’s disease). Prolonged pressure on the perineal area (as occurs when cycling) or injury to the pelvis or perineum can cause ED.

Any endocrine disorder or aging associated with deficiency. testosterone (hypogonadism) may cause a decrease in libido and ED. However, erectile function is only rarely restored when the serum level normalizes. testosterone, since most patients also have neurovascular causes of ED.

Diagnostics

  • Clinical evaluation

  • Screening for depression

  • Level testosterone

The examination should include clarification of the history of taking medications (including prescription drugs and products of plant origin) and alcohol, pelvic surgery and injuries, smoking, diabetes, hypertension and atherosclerosis, and symptoms of vascular, hormonal, neurological and psychological disorders. Satisfaction with sexual relationships should be examined, including an assessment of partnering and partner sexual dysfunction (for example, atrophic vaginitis, dyspareunia, depression).

It is very important to screen for depression, which may not always be clinically obvious. The Beck Depression Scale or, for older men, the Yesavage Geriatric Depression Scale ( Depression Scale in the Elderly (Short Form)) easily applicable and can be helpful.

Examination should be focused on the genital area and extragenital signs of hormonal, neurological and vascular diseases. External genitalia inspect for abnormal development, signs of hypogonadism, fibrous ligaments or plaques (with Peyronie’s disease). A weak anal sphincter tone, perineal hypoesthesia, or a loss of the bulbocavernosal reflex may indicate neurological dysfunction. The weakening of the pulsations of the peripheral arteries makes us think about vascular disorders.

Psychological causes must be excluded in young healthy men with a sharp appearance of ED, especially if the debut of the disease is associated with a certain emotional experience or if the dysfunction manifests itself only under certain circumstances. Anamnesis of ED with spontaneous improvement also indicates psychogenic etiology (psychogenic ED). In men with psychogenic ED, normal night and morning erections are usually observed, while in men with organic ED – not.

Commonly used drugs that can cause erectile dysfunction

Class of drugs

Medications

Erectile dysfunction - definition, diagnosis, treatment methods

Antihypertensive drugs

β-adrenergic blockers, clonidine, loop diuretics (possibly), spironolactone, thiazide diuretics

Drugs affecting the central nervous system

Alcohol, anxiolytics, cocaine, monoamine oxidase inhibitors, opioids, PPRI, tricyclic antidepressants

Other

Amphetamines, inhibitors 5α-reductases, antiandrogens, chemotherapeutic drugs for cancer treatment, anticholinergics, cimetidine, estrogens, agonists and antagonists of the hormone that releases luteinizing hormone

 

Laboratory and instrumental studies

Laboratory tests should include level determination testosterone in the morning time; if the level is low or below normal, levels should be determined prolactin and luteinizing hormone (LH). Examination for latent diabetes mellitus, dyslipidemia, hyperprolactinemia, thyroid disease, and Cushing’s syndrome should be carried out on the basis of clinical indications.

Currently, duplex ultrasound is most commonly used to evaluate vasculature of the penis after intracavernous injection of vasoactive drugs such as prostaglandin Eone. Normal values ​​include peak systolic velocity gt; 20 cm / sec and resistive index gt; 0.8 Resistive index — this is the difference between the peak systolic velocity and the final diastolic velocity divided by the peak systolic velocity. Rarely, in individual patients for whom surgery to revascularize the penis after a pelvic injury is considered, dynamic cavernosography and cavernosometry may be performed.

Treatment

  • It should treat the underlying causes.

  • Medications, usually oral phosphodiesterase inhibitors.

  • Vacuum devices for maintaining an erection or intracavernous or intraurethral administration of prostaglandin Eone (treatment of the 2nd line).

  • If other treatment methods are ineffective, surgical implantation of prosthetic penis is performed.

Primarily, further therapy consists of taking oral phosphodiesterase inhibitors. Then, if necessary, use another non-invasive method, such as a vacuum device to maintain an erection or intracavernous or intraurethral administration of prostaglandin Eone. Invasive procedures are used only when non-invasive methods are not effective. All drugs and devices must be applied at least 5 times before stating their inefficiency.

Preparations for the treatment of erectile dysfunction

First-line drugs for the treatment of ED – these are usually oral phosphodiesterase inhibitors. Other drugs include prostaglandin Eone for intravenous or intraurethral administration. However, since almost all patients prefer oral medication, these drugs are used if they are not contraindicated and are well tolerated.

Oral phosphodiesterase inhibitors selectively inhibit cyclic guanosine monophosphate (cGMP) -specific phosphodiesterase type 5 (PDE-5), the main isoform of phosphodiesterase in the penis. These drugs include sildenafil, vardenafil, avanafil and tadalafil ( Oral phosphodiesterase inhibitors of the 5th type for the treatment of erectile dysfunction). By preventing the hydrolysis of cGMP, they contribute to cGMP-dependent relaxation of smooth muscles, which is necessary for normal erection. Although vardenafil and tadalafil act on the vessels of the penis more selectively than sildenafil, the clinical efficacy and side effects of these drugs are similar. In comparative clinical trials, these drugs demonstrate comparable efficacy (60 versus 75%).

Oral phosphodiesterase inhibitors of the 5th type for the treatment of erectile dysfunction

Drug

Erectile dysfunction - definition, diagnosis, treatment methods

Dose*

Start of action

Note

Avanafil (not registered in Russia)

50, 100 or 200 mg

30 min

Can be taken 15 minutes before intercourse

Sildenafil

Initial: 50 mg

Supportive: 25–100 mg (most men respond best to 100 mg)

60 min

Duration: ≈ 4 h

Tadalafil

10-20 mg

60 min

Duration: 24‒48 h

Tadalafil, low dose

2.5‒5 mg

60 min

For daily use, taken at the same time every day, regardless of the time of sexual activity

For daily use in patients who also require treatment for benign prostatic hyperplasia

Vardenafil

10-20 mg

60 min

Erectile dysfunction - definition, diagnosis, treatment methods

Duration of action: ≈ 4 h

Vardenafil oral disintegrating tablet

10 mg

30 min

You can take 30 minutes before intercourse

* PDE-5 inhibitors should be taken on an empty stomach, at least 1 hour before sexual intercourse, with the exception of certain instructions. Maximum frequency of reception – Once a day, unless otherwise noted.

PDE-5 = Type 5 phosphodiesterase.

 

All PDE-5 inhibitors cause direct coronary vasodilation and increase the hypotensive effect of other nitrates, including those used to treat coronary heart disease, as well as recreational amyl nitrate («poppers»). Thus, the simultaneous use of nitrates and PDE-5 inhibitors can be dangerous and should be avoided. Patients who use nitrates only occasionally (for example, in rare attacks of angina) should discuss the risks, the choice of drug and the appropriate time for using the PDE-5 inhibitor with a cardiologist.

Side effects of PDE-5 inhibitors include flushing, visual impairment, hearing loss, dyspepsia, and headache. Sildenafil and vardenafil can lead to a violation of color perception (blue haze). The use of tadalafil has been associated with myalgia. In rare cases, ischemic optic neuropathy not associated with arteritis (NAION) has been associated with the use of a PDE-5 inhibitor, but a causal relationship has not been established. All PDE-5 inhibitors should be taken carefully and at a low initial dose for patients taking α-blockers (for example, prazosin, terazosin, doxazosin, tamsulosin), because of the risk of hypotension. Patients taking α-blockers should wait at least 4 hours before taking a PDE-5 inhibitor. In rare cases, PDE-5 inhibitors cause priapism.

READ  Cialis for potency: men reviews

Alprostadil (prostaglandin Eone), self-administered intraurethrally or in the form of intracavernous injections, can cause an erection with an average duration of 30–60 min Intracavernous administration of alprostadil can be combined with papaverine and phentolamine to increase efficacy when necessary. Excessive dosing may result in priapism at le; 1% of patients and pain in the genital or pelvic region in about 10% of patients. Training and monitoring by a physician helps to achieve optimal and safe use, including minimal risk of prolonged erection. Intraurethral therapy is less effective for obtaining a satisfactory erection (in 60% of men) than intracavernous injections (in 90%). Combined therapy with a PDE-5 inhibitor and alprostadil for intraurethral administration may be useful for some patients who do not respond to monotherapy with an oral PDE-5 inhibitor.

Mechanical devices for treating erectile dysfunction

For men, in whom an erection may occur, but cannot be maintained, it is possible to use a narrowing ring to maintain an erection; An elastic ring is placed around the base of the erect penis to prevent early loss of erection. Men who cannot achieve an erection can first use a vacuum device, which increases blood flow to the penis by suction, after which the elastic ring is placed on the base of the penis to maintain an erection. The appearance of bruises on the penis, the cold in the head and the lack of spontaneity of erection are the disadvantages of this technique. If necessary, the use of these devices can be combined with medical therapy.

Surgical treatment of erectile dysfunction

If drugs and vacuum devices are not effective, surgical implantation of penile prostheses can be considered. Prostheses include semi-rigid silicone rods and multi-component inflatable devices filled with saline. Both models are associated with the risk of general anesthesia, infection and erosion or malfunction of the prosthesis. If the procedure was performed by experienced surgeons, the long-term level of infection or malfunction is significantly below 5%, and the level of patient and partner satisfaction gt; 95%.

Main provisions

  • Vascular, neurological, psychological and hormonal disorders, and sometimes the use of drugs, can jeopardize the achievement of satisfactory erections.

  • All men with ED should be screened for hormonal, neurological, and vascular disorders and depression.

  • Need to measure levels testosterone and consider other testing based on clinical data.

  • The underlying disorders should be treated and the oral PDE-5 inhibitor should be used if necessary.

  • If these measures are ineffective, intracavernous or intraurethral administration of prostaglandin E should be considered.one or using a vacuum device; surgical implantation of prosthetic penis is the last measure of treatment.

Leave a Reply

Your email address will not be published. Required fields are marked *