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The Erectile Dysfunction in Men


Semir A. S. Al Samarrai 

 

The persistent inability to achieve a penile erection of sufficient rigidity and duration to allow satisfactory sexual activity is a common and most distressing abnormality of male sexual function. 


Prof. Dr. Semir Al Samarrai
Dubai, U.A.E.

Introduction:

The persistent inability to achieve a penile erection of sufficient rigidity and duration to allow satisfactory sexual activity is a common and most distressing abnormality of male sexual function. Its successful treatment results in significant improvements in many aspects of quality of life for both the patient and his partner.

Erection occurs as a result of local genital or central sexual stimulation. In the penis cyclic guanosine monophosphate (GMP) is produced, resulting in relaxation of the corporal smooth muscle and influx of blood into the sinusoids. The rapid inflow of blood obstructs the venous outflow causing engorgement of the penis and an erection. The nerve pathways involved include non- adrenergic non-cholinergic and parasympathetic systems with nitric oxide, Prostaglandin E1, vasoactive intestinal polypeptide and, to a lesser extent, acetylcholine as implicated neurotransmitters. 

Etiology:

Although there is a direct relationship between aging and erectile dysfunction, it is not necessarily a consequence of age as young men with organic disease can also suffer from it.

In 80 % of affected men the cause is found to be predominantly organic. Many will also have a psychosexual element to their problem which is usually unrecognized and untreated, leading to long-term failure of many therapies which are aimed purely at achieving an erection.

The common organic causes include: 

  • Diabetes mellitus, especially patients with vascular or neuropathic complications.
  • Generalized vascular disease.
  • Hypertension and drugs used to control it.
  • Neurological disorders e.g. multiple sclerosis and spinal injury.
  • Trauma causing nerve or vascular damage (fractured pelvis, radial prostatectomy,abdominoperineal resection) and Hypogonadism


A number of drugs can also cause male erectile dysfunction

  • Central nervous system drugs like (tricyclic antidepressants, monoamine oxidase inhibitors, Phenothiazines, Benzediazepimes and Butyrophenones).
  • Antihypertensive drugs (Diuretics).
  • Others (Cimetidine, Finasteride, Oestrogens Antiandrogens). 

Assessment:

This is aimed at screening for disorder associated with erectile dysfunction, and the rare conditions for which specific treatments are available. Blood pressure should be checked and the urine tested for glucose.

The presence of gynaecomastia should be sought and local examination of the genitalia should identify induration with plaques in the penis and testicular size.

In men with lack of libido or those presenting after surgery or radiotherapy to the groin or scrotal contents, serum testosterone, sex hormone binding globulin (SHBG) and Prolactin should be measured.

Treatment:

The specific treatment used depends mainly upon the choice of the patient and partner, and can only be made after a full discussion of the treatment options available.


  • Systemic therapy: 1.) Testosterone: this should only be given to men with proven deficiency.
  • Sildenafil: This is a type 5 Phosphodiasterase inhibitor, which, by preventing the breakdown of cyclic (GMP), prolongs corporal smooth muscle relaxation. It is only effective when cyclic (GMP) is present in penile smooth muscle, its action is increased by local or central sexual arousal. In men with erectile dysfunction as a result of psychogenic, organic or mixed etiologies, Sildenafil (Viagra) 50-100 mg improved both the quality, frequency and rigidity of erections by about 30% that normally achieved. 


Concurrent use of Viagra with organic nitrate or nitric oxide donors e.g., amyl nitrite (Poppers) is contraindicated, because of the risk of severe hypotension. It should not be given to men with conditions predisposing to priapism e.g., Sickle cell disease or to men with severe hepatic disturbances, hypotension, a recent myocardial infarction or cerebrovascular accident.


  • Apomorphine and Pentoxyfylline.
  • Local therapy: Muse (Alprostadil): Following insertion in the urethra of pellet of Alprostadil, an erection satisfactory for intercourse will be achieved in 65% in men with organic erectile dysfunction.
  • Intracavernosal Alprostadil (Prostaglandin E1) Injection. But intracavernosal vasoactive intestinal polypeptide combined with phentolamine is awaiting licensing as intracavernosal therapy, which is painless than (Prostaglandin E1) (Cavarject) and particularly effective in patients with erectile dysfunction secondary to venous leakage.
  • Mechanical devices:Vacuum erection devices: Negative pressure around the penis increases corporal blood flow. The ensuing erection is maintained by the placement of a constriction ring around the base of the penis to decrease corporal venous drainage.
  • Penile Prosthesis:This should be considered for those patients, who failing to respond to less invasive therapies or who have developed problems with them, e.g., penile fibrosis they are suitable for men with erectile dysfunction secondary to Peyronie’s disease (Induration penis plastica) and those who have developed erectile dysfunction as a result of priapism.
  • Psychological therapy: The treatments described are aimed at producing an erection without addressing the social, marital and psychological problems that many men have, either as a cause of or as result of their erectile dysfunction. 

    Psychotherapy or counseling can often be effective in bringing fears and anxieties under control and in relieving depression. 

    Common problems helped by psychotherapy include the failure to realize that the ability to achieve an erection declines with age, unrealistic expectations resulting from mistaken beliefs about sexuality, an absence of manual sexual contact, anger, resentment and hostility and denial of sex as a part of power play. 


Conclusions:

  • Male erectile dysfunction is a common disorder associated with many diseases.
  • Failure to recognize its results in significant patient/partner leads to disharmony and marital breakdown.
  • Current therapies available are not universally successful in achieving an erection, nor do they deal the marital and social problems associated with erectile dysfunction.
  • A “holistic’ approach to treatment of the man and his partner will produce the best long-term results, with significant improvements in quality of life for both partners. 

Correspondence:
Prof. Dr. SEMIR AHMED SALIM AL SAMARRAI
Professor Doctor of Medicine-Urosurgery, Andrology, and Male Infertility
Dubai Healthcare City, Dubai, United Arab Emirates.
Mailing Address: Dubai Healthcare City, Bldg. No. 64, Al Razi building, Block D,
2nd floor, Dubai, United Arab Emirates, PO box 13576
Email: fmcalsam@emirates.net.ae