Erectile Dysfunction

Erectile dysfunction (ED) means that in more than two-thirds of cases, a man can not get or maintain an erection sufficient for intercourse. The penis does not become hard enough or relaxes prematurely. These problems persist for at least six months. So, if it does not work out every now and then, it is not necessarily a disorder in need of treatment.

With age, erectile dysfunction becomes more common. Almost one in ten people is affected by the 40- to 49-year-olds, and one in three of the 60- to 69-year-olds. This was shown by a study by the University of Cologne in the year 2000. Many further investigations in numerous countries came to comparable results. Experts suggest that there is a large number of unreported cases. The actual numbers could be even higher.

Erectile dysfunction is colloquially called also potency disorder or "impotence". The latter term was formerly used in medicine, but is rarely used today. Because he "throws together" various disorders that do not necessarily belong together: on the one hand erectile dysfunction such as erectile dysfunction or premature ejaculation, on the other hand infertility, ie the inability to produce children (sterility).

Erectile dysfunction is often the first warning sign of vascular disease and thus a potential harbinger of heart attack or stroke. If an arteriosclerosis is detected and treated early, bad consequences can often be avoided. Not least for this reason, it is advisable to have a potency problems clarified by a doctor.

With increasing age, the testosterone level in the blood drops slightly in almost all men. This is nothing unusual and no reason for a therapy. However, a man suffering from erectile problems, a testosterone deficiency (hypogonadism) could play a crucial role. In this case, the doctor will advise to balance the hormone deficiency. Maybe this will already improve the potency problems. Often, erectile dysfunction medications (PDE-5 inhibitors, see below) are better or first-time in conjunction with hormone therapy.

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Erectile dysfunction (impotence) is the inability to get and keep an erection firm enough for sex. Having erection trouble from time to time isn't necessarily a cause for concern. 2020-03-13 Erectile Dysfunction
More About Erectile Dysfunction

Erectile dysfunction is more common with age. Affected are about 1 to 2% of 40 year olds and about 15 to 20% of 65 year olds. Smoking is the main risk factor for the occurrence of erectile dysfunction.

Erectile dysfunction may either be for no apparent cause, or as a consequence of another disease, e.g. as a sugar disease (diabetes mellitus), a vascular disease (arteriosclerosis), a nervous disease (polyneuropathy) or high blood pressure occur. In addition, an erectile dysfunction may occur as a result of taking different medications (high blood pressure, antidepressants, etc.).

Erectile dysfunction is also commonly known as a result of injury (e.g., pelvic fracture) or surgery (radical prostatectomy for prostate cancer, rectal surgery, e.g., rectal cancer).

Before the initiation of therapy, a thorough preliminary examination of the affected man should be carried out in order to be able to assess the causes and risk factors in more detail and treat them if necessary. This serves u.a. associated diseases, such as a heart attack, to prevent.

How is the male sex organ structured?

In the case of a man, as in the case of a woman, a distinction is made between the external and internal sexual organs. The external male genitals include penis and scrotum with testes and epididymis, the internal genitalia include vas deferens, seminal vesicles and prostate gland. Behind the bladder located within the small pelvis (behind the upper part of the pubic triangle) are the seminal vesicles responsible for the production of the seminal fluid, the vas deferens and the rectum. The prostate, located in front of the rectum and below the bladder, surrounds the male urethra, which directs the urine from the bladder through the penis to the glans. In addition, the prostate contains glandular fluid, which acts as a transport and activator for the spermatozoa. The seminal fluid enters the urethra via the seed mound. During ejaculation, spermatozoa enter the urethra via the vas deferens along with the glandular fluid of the prostate and are thrown from the bladder neck towards the penis and glans.

How does an erection come about?

The erection results from the complex interaction of nervous, mental, hormonal, vascular and anatomical factors. In the slack state, there is only a small supply of blood through the arteries in the penis, blood flow through the veins happens unhindered. The cavities of the Penisschwellkörper are small, the muscles are stretched. Due to certain external stimuli (optical, psychological, touch or smell), it comes to a relaxation of the corpora cavernosa, to an enlargement of the cavities and to an increased blood flow in and reduced blood flow from the penis. The penis becomes hard, thicker and bigger than normal - he erects.

What is Erectile Dysfunction?

The term erectile dysfunction describes a persistent or recurrent inability to achieve or maintain an erection sufficient for coitus. The libido is usually preserved, the hormone levels in the blood are usually normal. Erectile dysfunction can manifest itself at any age. In studies, about half of all 40-70-year-old men indicate potency disorders. The frequency of illness increases with age. Overall, it is a common problem of aging men with up to six million men in Germany alone. However, according to recent findings, only 8-10% of those affected suffer from their potency disorder and only one in two want a medical examination and therapy. The urologist is rightly the first consulted specialist. He has to assess whether there is an organic cause or whether a psychological conflict situation in the sexual sphere and a corresponding treatment is necessary. Importantly, erectile dysfunction not only compromises quality of life, but often precedes other vascular diseases, such as coronary heart disease, for years to come.

What are Causes of Erectile Dysfunction?

In the 80s, 80% of cases were thought to be due to a psychic cause of impotence, but today (following the introduction of modern diagnostic methods), the picture is different: in 50-80%, there is a purely organic cause for erectile dysfunction , in 30% a purely mental and in 20% a mixed form. Especially younger patients are affected by a mental cause of their potency disorder. The diagnosis results from an exact survey of the patients and the exclusion of organic causes. Typically, involuntary nocturnal and morning erections remain unchanged in this group. The organic causes of erectile dysfunction are only 1.5-3% hormonal disorder. Nevertheless, each patient should have their testosterone levels in the blood. The main causes of potency disorders are smoking, hypertension, diabetes (50% of patients experience erectile dysfunction over their lifetime) and lipid metabolism disorders. In addition, certain medications and conditions such as multiple sclerosis can lead to potency disorders.

How is Erectile Dysfunction diagnosed?

In the diagnosis of a potency disorder, the collection of the medical history with a detailed conversation about the sexual behavior and the mental condition plays a crucial role. In addition, a physical examination and the determination of hormone levels in the blood should always be done. After a nightly penile tumescence and rigidity measurement (measurement of involuntary erections during sleep), an electromyography of the corpora cavernosa (derivation of electrical impulses in muscle contractions) or a Doppler sonography (measurement of the blood flow in the arteries), most patients can be given suitable therapy. Controversial direct drug therapy is discussed without prior clarification of the cause of erectile dysfunction, since in such a case, other diseases such as diabetes could be overlooked.

How can Erectile Dysfunction be treated?

In addition to the treatment of underlying causes (good attitude of diabetes, nicotine stop), the treatment of erectile dysfunction has experienced a tremendous development in recent years. Therapeutic nihilism has given way to efficient, low-side-effects and individualized treatment. There are various therapy options available.

Oral medication

The first PDE-5 (phosphodiesterase-5 inhibitor) was approved in 1998 Viagra ©. Originally, the drug was developed for the treatment of pulmonary hypertension. In the studies, however, patients reported an improvement in erectile function as a "side effect", so to speak.

Thereafter, the active ingredient sildenafil was also tested and approved for the treatment of erectile function.

In subsequent years, other PDE-5 inhibitors, such as vardenafil (Levitra ©) and tadalafil (Cialis ©) for approval, which are similar in the mode of action, but differ by the duration of action and metabolism in the body (pharmacokinetics).

The effect of the drugs is aimed at a greater expansion of the blood vessels supplying the penis, so that the erectile ability is improved.

Common side effects of these medications may be headache, low blood pressure and blurred vision (blurred vision, color vision problems).

For other side effects, read the package leaflet and consult your doctor or pharmacist. In particular, a doctor should examine if there are reasons and risk factors (for example, drug incompatibilities) that speak against taking such medicines.

Since June 2013, sildenafil is now also available from various generics manufacturers. The purchase of unclear sources (such as unclear source on the Internet) is again discouraged at this point.

Vacuum pump

As an alternative to using medications, the use of a vacuum pump to treat erectile dysfunction can be tried. Here, a cylinder is placed over the penis in which a vacuum is generated. As a result, the erectile tissue expands and blood flows into the penis. Once the erection has occurred, a rubber ring is placed over the base of the penis, which should prevent the flow of blood.

Intracavernous injection

If the use of the tablets available in tablet form have not led to a sufficient improvement in erectile dysfunction, the use of drugs which are injected directly into the corpora cavernosa be tried. Here, the first application is usually carried out by the urologist to assess the first therapeutic success and, if necessary sonographically to be able to measure the blood flow of the penile erectile tissue.

Should a therapeutic success be detectable here, the application can be carried out by the patient himself. Self-injection is necessary about 10-20 minutes before intercourse. The pharmaceutical companies offer individually dosed pre-filled syringes (for example CAVERJECT ©). The needles used here are very thin and comparable to those of an insulin pen in diabetics. The application is therefore not painful.

Alternatively, the active ingredient used here can also be introduced into the urethra via an orodispersible tablet (MUSE ©).

Which method is chosen, the doctor should decide together with the patient in an individual interview.

Prosthese

If the previously mentioned treatment options were unsuccessful, the last option is the implantation of a cavernous prosthesis.

Here, the cavernous bodies are replaced by semi-solid (semiregid) or hydraulic prosthesis legs. In the case of hydraulic prostheses, a valve mechanism makes it possible to activate and deactivate the cavernous prosthesis and thus to control the erection.

Since the surgery damages the spongy structure of the cavernous body, it is not possible to switch back to other treatment options (tablets, SKAT) after such an intervention.

Corresponding operations are carried out in specialized centers.

What is infertility?

Infertility (inability to conceive) is referred to when, despite regular intercourse without contraception, there is no pregnancy after one year (WHO definition). In Germany, unintentional childlessness now affects every sixth marriage (1.5 million couples). In about 40% of cases, male infertility is the sole cause, and in 10% the cause is to be found in both partners.

Due to the simpler examination options should be started with the man with the clarification. In male infertility, different forms can be distinguished:

  • Oligospermie: decreased sperm count in the ejaculate
  • Azoospermia: no sperm in the ejaculate
  • Asthenospermia: decreased sperm motility
  • Teratospermia: increasingly abnormal sperm forms
  • Oligoasthenoteratospermia (OAT syndrome)
  • Combination of oligo-, astheno- and teratospermia

Also important is the fructose content of sperm fluid, as fructose is responsible for the nutrition of sperm.

How is male infertility diagnosed and treated?

When investigating male infertility, a targeted survey of the medical history with a family history, testicular development in childhood, possible infections and medication take a central role. In addition to a targeted physical examination (hair, body development, surgical scars, testicle size, epididymis and spermatic cord, prostate and urine) and hormone levels in the blood and an examination of the ejaculate (spermogram) are important. Unfortunately, if there is no inflammatory cause of male infertility, the range of possible drug or other therapy is still very limited today. Often the so-called intracytoplasmic injection of sperm into the egg (ICIS), a form of artificial insemination for childless couples is the last resort.

What is a varicocele?

Also, a spasmodic dilation of the testes-supplying veins, the so-called varicocele, can lead to an impairment of semen quality and thus to infertility. Symptoms are often a heaviness in the scrotum and an increasing swelling, especially when standing. Sufferers affected by the complaints or childlessness, a therapy can be envisaged: An operative transection of the vein (spermatic vein). Thus, the quality of the sperm can be improved by eliminating the overheating in the testes and the blood drainage disorder in many cases. However, the pregnancy rate is only marginally increased (10-40%), which is why the therapy is controversial.

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Latest News in Erectile Dysfunction

Erectile dysfunction and decreased work productivity?

28.10.2021

It is believed that over 50% of all men between the ages of 40 and 70 suffer from erectile dysfunction. Recent research in eight countries focused on whether this condition also affects productivity in the workplace.

A 1995 study estimated that 152 million men worldwide were already suffering from erectile dysfunction at this point in time. At the time, the researchers suspected that this number would increase to 322 million by 2025.

Due to the worldwide increase in erectile problems, the authors of the current study were interested in the extent to which the issue of insufficient productivity in the workplace, restrictions in general activities and health-related quality of life affects. To do this, they used data from the USA, Germany, Great Britain, Spain, Italy, France, China and Brazil.

Previous studies have looked at the negative impact of erectile dysfunction on overall quality of life, but little research has been done on work productivity. According to the researchers in the current study, they wanted to develop a more robust, more consistent approach to determining the effects of erectile dysfunction on everyday life.

For their investigations, the researchers turned to 52,697 men between the ages of 40 and 70 using a questionnaire. In this, they asked the test subjects about symptoms of erectile dysfunction in the past six months, impairments at work and other activities, and self-reports about their quality of life.

The survey also took into account factors such as age, income, work activity, marriage status, education, general health, BMI, tobacco and alcohol consumption, and other health issues.

The subject of productivity in the workplace was assessed using a questionnaire, which included factors such as absence for health reasons and excessive presence at the workplace in order to attract attention. In all the countries considered, an average of 49.7% of the respondents were affected by erectile dysfunction. The prevalence ranged from 45.2% in Great Britain to 54.7% in Italy.

According to the survey results, men with erectile dysfunction were more likely to be overweight, tobacco addicted, excessive alcohol consumption and a lack of exercise. This group was also more likely to have other medical problems. Since all of these factors can affect productivity in the workplace, the researchers also considered them for their analysis.

Taking other variables into account, the research team found that erectile problems had a significant impact on labor productivity. The authors wrote, "After checking for covariates, men with erectile dysfunction in the US had significantly more impairments. In terms of workplace productivity, it was 2.11 times that of men without erectile problems." This was most noticeable in the UK, where productivity was affected 2.66 times more often.

In all eight countries, men with erectile dysfunction had lost more work time to illness than those without disorders (7.1% vs. 32%) in the last seven days. The situation was similar with excessive presence in the workplace (22.5% vs. 10.1%).

The researchers summarized: "Absenteeism, excessive attendance at work, general loss of work productivity and impairment in other activities were more than twice as high in men with erectile dysfunction as in men without erectile dysfunction."

According to the results of the survey, the self-perceived quality of life for men with erectile problems was also lower in all surveyed regions. Co-author Wing Yu Tang noted, "The study shows that erectile dysfunction remains a major problem. It affects both productivity in the workplace and sickness absenteeism."

Tarek Hassan, the lead study author, added: "Since the data come from eight different countries, our results suggest that this issue is of great importance worldwide."

Despite extensive investigations, the study also has some limitations. There is a possibility that test persons gave incorrect statements in their self-assessment. In addition, statements were made using a five-point scale and participants who rated themselves in the range of 2-5 were classified as men with erectile dysfunction.

In addition, since the researchers considered a large number of criteria, it could not be concluded 100% whether erectile dysfunction is responsible for the drop in productivity in the workplace. The study was funded by Pfizer.

Despite its limitations, the study shows great potential. With erectile dysfunction becoming more common, it is important to understand how the issue affects personal and social life.

Coronary heart disease and erectile dysfunction: Live longer with Viagra & Co.?

20.09.2021

Men with stable coronary artery disease (CHD) who are given a phospho-diesterase (PDE) -5 inhibitor for erectile dysfunction (ED) appear to have a longer life expectancy and a lower risk of new heart attacks. This is what Dr. Daniel P. Andersson from Karolinska University Hospital, Stockholm, and colleagues now in JACC. The basis is a nationwide observational study.

"The Scandinavian registers offer exciting opportunities to understand the effects of drugs in the real world," comments Prof. Dr. Oliver Weingärtner from the Clinic for Internal Medicine I at the Jena University Hospital. “There have been indications of positive effects in the cardiovascular system of PDE-5 inhibitors beyond the indication of ED for a long time. Now these are confirmed on a large scale or they are not contradicted."

Andersson and colleagues used Swedish patient and prescription registries to compare the data of over 18,500 men who had a heart attack between 1994 and 2013. All participants suffered from erectile dysfunction (ED) after their myocardial infarction. They received either an oral PDE-5 inhibitor such as sildenafil (Viagra®) or prostagladin E1 (alprostadil) as an injection.

Compared to the alprostadil group (n = 1,994), the mortality risk in the PDE5 inhibitor group (n = 16,548) was reduced by 12%. The risk of a new myocardial infarction was 19% lower and that of heart failure was even 25% lower than with alprostadil.

These values ​​were calculated after careful adjustment; Raw data were even significantly further apart. All information was based on an observation period of an average of 5.8 years, with ED therapy being started 6 months after the first heart attack in order to be able to assume that the CAD would stabilize.

"The comparison with alprostadil is a sensible approach to building up a control group," explains Weingärtner. "However, the patients in the alprostadil group were significantly more morbid despite the same age and on average received more extensive medications, including nitrates."

Nevertheless, after their adjustment for the PDE5 inhibitor group, the authors calculated a lower all-cause mortality, fewer cardiovascular-related deaths, fewer myocardial infections, fewer heart failure and fewer revascularizations. All differences between the groups were statistically significant. There were trends for reductions in non-cardiovascular deaths, peripheral arterial disease and strokes compared to the alprostadil group.

Since health insurance companies in Sweden reimburse medically prescribed drugs for ED therapy, the authors assumed that the prescription numbers documented in the register corresponded to the doses actually used. They therefore divided all patients into 5 quintiles according to the number of individual prescriptions.

A dose-dependent effect was shown in the PDE5 inhibitor group, since men with more prescriptions had a mortality risk reduced by up to 27% (5th quintile) compared to those with the fewest prescriptions (1st quintile). However, this effect was shown, albeit less clearly, in the alprostadil group.

"This outcome can of course also be a confirmation of the thesis that an active lifestyle with movement, which also includes sexual activity, generally reduces the risk of atherosclerotic diseases," says Weingärtner. "Or that patients with a better physical constitution are more likely to be prescribed a phosphodiesterase 5 inhibitor."

The authors made similar statements in their discussion and would therefore like a prospective comparison of patients with stable CAD who received either PDE5 inhibitors or placebo as a continuation of their retrospective analysis.

In an editorial, the pharmacologist Prof. Dr. Renke Maas (University of Erlangen-Nürnberg) should, however, bear in mind that, due to the setting, continuous exposure to ED medication cannot be assumed. In this respect, these results cannot be compared with conventional studies that are based on clear dosages. “Although this study cannot clearly show the reason for the positive effects of the PDE-5 inhibitors,” summarizes Weingärtner, “seems to be a medical prescription for patients with stable CHD in erectile dysfunction, taking into account all contraindications - such as the administration of nitrates - nothing to stand in the way and perhaps a rather positive prognosis can be expected."

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