Erectile Dysfunction:Review

“Man survives earthquakes, experiences the horrors of illness, and all of the tortures of the soul. But the most tormenting tragedy of all time is, and will be, the tragedy of the bedroom.”
Tolstoy

Erectile dysfunction is the inability to produce and maintain a functional erection because of pathology of the nervous or vascular system or deformation of the penis.
Potency always has been something special in human culture. Impotency has far-reaching consequences, which includes social stigmatization, societal standing within the community, and legal ramifications on such issues as claims on wills and considerations of the legitimacy of heirs. The potency plays a large part in men's self-image and affects the relationship with their partners.
The Massachusetts Male Aging Study estimates that men in their early fifth decade of life have a 20% ED rate, and, by their eighth decade of life, close to 45% of men have impotence problems. The worldwide incidence of erectile dysfunction estimated at over 152 million men, with a forecast of 322 million men by the year 2025.

Penile tumescence is a complex integration of vascular and neurophysiologic events that culminates in the accumulation of blood under pressure. Fundamentally, the erectile components are surrounded by a thick fibroelastic sheath called the tunica albuginea, which allows a hydraulic effect in which intrapenile blood volume may increase 8-fold. The effect is an increase in intracorporal pressure that approaches systemic blood pressure and produces both penile volume and rigidity.
The causes of impotence are multifactorial, but diabetes and vascular disease are the most common etiologies. They are usually classified as hormonal, neurologic, psychological, arterial (ie, insufficiency), and venous (ie, venous incompetence). Injury to nerves and blood vessels can result from trauma, radiation therapy, pelvic surgeries, and longstanding medical conditions (eg, diabetes, hypertension). Neurologic causes include multiple sclerosis, tabes dorsalis, etc. Hormonal imbalance or deficiency, such as primary testicular failure, diabetes mellitus,. Sometimes, adverse effects of drugs can also result in impotence.
Many tests can be used to assess ED. However, the actual practice of evaluating ED proves to be not only quite varied but also controversial. It depends on the practice of the individual urologists. Some practitioners argue that etiology is insignificant and that ED is treated in a stepwise fashion—from least to progressively more invasive treatments. Others argue that, from a medicolegal standpoint, basic evaluation and documentation should be instituted regarding the diagnosis of ED.
In my experience, a screening testosterone level should be obtained especially in older patients and in patients with decreased libido. ED diagnosis is confirmed with pharmcopenil ultrasound Doppler scan. In addition to a careful history taking, physical examination, and the combination of biochemical test or tests with radiographic/physical findings, the diagnosis of ED is more reassuring to both patient and physician.The potential causes like hyperlipidemia, hypogonadism can be taken care of.
Before 1960, urologic therapy for erectile dysfunction (ED) was rare. ED was branded a psychiatric disorder with little surgical role. More recently, the pathophysiology of male sexual dysfunction has been elucidated, and both medical and surgical treatments of ED are now common.
Goal Directed Therapy
 Find out what the patient wants(old settled couple may opt for injection therapy or Vacuum Erection Device but a young man may go for Penile implant because of embarrasssment to use bulky Vacuum Erecton Device or injection therapy infront of a new sexual partner)
 Try to tailor the treatment to the patients needs and wants(Cardiac patients may not be suitable for Viagra,tadalafil instead may go for Injection therapy or Vacuum Erection Device) while obese patient may go for injection therapy with wife injecting drug into penis(Four Hand technique-husband streching the penis and wife injecting the drug)
 Etiology rarely affects treatment choice for the patient(Final goal is erection )
Lue TF, World J. Urol 8:67,1990

Sexual counseling:
Is an important part of erectile dysfunction management. Men are frequently reluctant to discuss their sexual problems and need to be specifically asked. Opening a dialogue allows your doctor to begin the investigation or refer you to a consultant..
Options include sexual counseling, medications, external vacuum devices, hormonal therapy, penile injections or intraurethral suppositories. In highly selected cases under the supervision of a urology specialist in ED, combination therapy using several of these methods together can be used. If none of these therapies is satisfactory, penile prosthesis implants can be considered.
• Vacuum devices: They are safe and relatively inexpensive. They work by using a manually generated vacuum to draw blood into the penis to create the erection. When used successfully, their other significant benefit is a high degree of reliability compared to drug treatments, which tend to be less predictable. The typical vacuum device consists of a plastic cylinder that is placed over the penis, tension rings of various sizes, and a small hand pump. Once an erection is obtained, a tension ring, which acts like a tourniquet to keep the blood in the penis and maintain an erection, is placed at the base of the penis. This technique is effective in 60-90% of men. It is not recommended to leave the tension ring in place longer than 30 minutes.
o These devices are generally safe, but bruising can occur. Other unwanted effects include pain, cold penis, numbness, painful ejaculation,



•MEDICAL LINE OF TREATMENT: Sildenafil citrate (Viagra): It is a prescription medication for the treatment of erectile dysfunction. Since its introduction in March 1998, no other therapy for ED has achieved such wide public recognition. Viagra doesn't improve erections in normal men, only in those with difficulty in achieving or maintaining erections sufficient for sexual intercourse due to a true medical problem. It is not an aphrodisiac and will not increase sexual desire.
o Viagra works successfully in about 65-70% of all impotent men. The greater the degree of damage to the normal erection mechanism, the lower the overall success rate. Men with diabetes reported between 50-60% responding successfully to treatment with Viagra. Viagra works best if taken about 1 hour before sexual activity.
 The most common side effect of Viagra use is headache, affecting about 16% of users. A drop in blood pressure, transient dizziness, and facial flushing are reported in 10%. Indigestion occurs in 7%, and nasal congestion in 4%.
o Viagra is absolutely not to be taken by men with heart conditions who are taking nitrates such as nitroglycerine or isosorbide
o Ecstasy is a street drug that may increase sexual desire but interferes with performance. This has prompted some men to combine ecstasy with Viagra. This mixture ("sextasy") can improve erection ability but also causes severe headache and priapism. (Priapism is an abnormally painful prolonged erection and may result in permanent damage to the erection mechanism.)
o Other PE-5 inhibitors like Verdenafil(not available in Indian Market),Tadalafil sometimes help when one group of PDE-5 inhibitors doesnot help.
o Long term treatment with PDE-5 inhibitors not only treat the erectile dysfnction but also alleviate endothelial dysfunction .This may reduce future cardiac and brain catastrophe.

• Injection therapy:
o Self-injection of these agents has been of enormous benefit because they represent the most effective way to achieve erections in a wide variety of men who otherwise would be unable to achieve adequate rigid erections.
o If the structure of the penis is healthy, the use of injectable drugs is almost always effective. The doctor will teach you how to perform the injections. The dosage is adjusted to achieve an erection with adequate rigidity for no more than 90 minutes.
o The main side effects are pain , priapism (persistent or abnormally prolonged erection), and scarring at the site of the injection.



Andropause and androgen replacement therapy:
Andropause is debatable topic but it exists only problem is like menopause it doesnot have fixed symptoms.Instead a variety of symptoms like:lack of libido,loss of energy,fatiguability,feeling sleepy,lack of motivation,muscle asthenia,mood irritability etc would bethere.It is really challenging for andrologist to find genuine patient who needs testosterone replacement therapy.Vaguely hypogonadism is defined as total testosterone value less than <285ng/dl.The replacement can be done either with Injectable form – 200mg testosterone (cypionate, enathate, propionate), q2-3 weeks or patch/gel.


Surgical therapy
The history of modern ED surgery began with the development of the inflatable penile prosthesis by Scott and Bradley. The most fundamentally basic prosthesis is the semirigid rod prosthesis, which consists of 2 rodlike cylinders that are implanted in the corpora cavernosa. The prosthesis can have a mechanically jointed "backbone" or have a malleable one that allows the phallus to be dressed in the upward or downward position. This prosthesis is generally considered for patients who are significantly obese, who have limited manual dexterity, or in whom abdominal hardware such as reservoir balloons cannot be implanted (ie, patients undergoing extensive abdominal/perineal surgery )
The selection of the appropriate device for the individual patient is very important. Penile prosthesis placement is indicated in a motivated patient with ED who desires reconstitution of penile function adequate for intercourse and in whom conservative treatment has failed.
Considerations include patient's preference and underlying medical condition, surgeon's preference, and cost of the device. The advantages of the semirigid devices include easier placement, less dependence on patient manual dexterity, lesser chance of mechanical failure, and lower cost. The disadvantages include higher risk for device erosion, less concealability, and inability to change girth.
The ideal penile prosthesis would result in a normal-appearing penis when flaccid and erect. Younger patients with good hand dexterity often choose the 3-piece prothesis which tends to give almost natural erction and flaccidity. This especially is important for those engaged in social settings, such as health club showers, or who wear form-fitting clothes. However, prospective patients should be counseled that penile prostheses do not achieve the full length achieved by natural erections.

Men with Peyronie disease, which is characterized by a fibrous scar of the tunica albuginea, who have penile curvature may benefit from an inflatable penile prosthesis.
Many techniques for the placement of penile prosthesis exist, including infrapubic, penoscrotal, perineal, and subcoronal approaches.I prefer the penoscrotal approach because it provides very good exposure to the corporal bodies, allows for concomitant repair and excision of Peyronie plaque near the base of the penis, and facilitates the placement of scrotal pumps. The surgery takes about 3 hours time and usually patient is discharged 3 day after the surgery. The patient is instructed to refrain from sexual activity for 6 weeks after the surgery.
After the prosthesis is placed, patients may experience modest penile shortening in the range of about 2 cm. This must be discussed with the patient and partner prior to any surgical intervention. Patients also should be aware that they may never achieve their most youthful length and girth due to underlying pathology such as fibrosis and plaque formation. Other issues that should be addressed include possible erosion of the device over time and the possibility of implant infection despite careful preoperative preventive means. An average infection rate ranges from 2-4% over a 2-year period .These things should be discussed with the patient and the partner so that they should not have unrealistic expectations from the surgery. Of men who have undergone this procedure, 95% are happy about their decision to have surgery. Patient satisfaction with surgery is bolstered by supportive staff and low infection and malfunction rates.
On average, patients may wear-out their prosthesis in 4-8 years. Revisions become more common as time passes. Some of the older patients have undergone as many as 4 revisions over 2 decades of use.




>