What Is Erectile Dysfunction?

Erectile dysfunction is one of the common sexual problems, especially between the ages of 40 and 70. Because it is often short-lived, it is usually not a cause for worry, but if you experience this problem repeatedly, you should see a specialist because it may be a sign of a more serious disease.

Mechanism of erection

An erection is a complex neurovascular event influenced by psychological and hormonal factors. With sexual stimulation, neurotransmitters are released from nerve endings in the penis, from the corpora cavernosa. This relaxes the smooth muscles of the penile arteries and increases blood flow severalfold. At the same time, venous outflow is blocked. Together, these factors trap blood in the corpora cavernosa and transform the penis from a flaccid state into an erection. During a full erection, intracavernosal pressure reaches 100 mmHg. During this phase, arterial inflow and venous outflow are temporarily stopped.

Causes of erectile dysfunction

• Problems in the nerve supply to the penis (the erection signal does not reach the penis)

• Reduced or interrupted arterial blood flow to the penis (blood does not enter the penis adequately)

• Venous leak in the penis (blood that enters the penis does not stay there)

Physical diseases

• Vascular problems such as cardiovascular disease, high blood pressure, diabetes, high blood lipids, smoking, and pelvic surgery

• Neurologic problems such as spinal cord injuries, Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, and stroke

• Penile factors such as Peyronie’s plaque, penile fracture, and fibrosis of the penile corpora cavernosa

• Hormonal problems such as hypothyroidism and hyperthyroidism, hyperprolactinemia, hypogonadism, and adrenal hormone disorders

• Side effects of blood-pressure medicines, antidepressants, antipsychotics, anti-sex-hormone medicines, and alcohol

Psychological problems

• Anxiety

• Relationship problems between partners

• Stress

• Depression

Clues that may help you identify the likely cause of erectile dysfunction:

1. If erectile dysfunction starts suddenly, it may be caused by acute psychological stress or injury to the genital system, such as trauma or prostate surgery.

2. If an erection occurs but does not last, it is probably related to venous leak or anxiety.

3. If morning erections have disappeared, it may be related to vascular problems or neurologic disease.

The most common complications of erectile dysfunction

Reduced self-confidence

Effects on mood

Conflict and tension with the sexual partner, and even separation or weakening of the family relationship

How the examination and visit are done

The doctor will ask about your lifestyle, relationships, level of sexual desire, and any related problem that may affect erectile dysfunction. A general checkup, such as blood tests if needed, blood-pressure measurement, and genital examination to look for visible signs, is performed.

Treatment of erectile dysfunction

Treatment of erectile dysfunction can differ depending on the underlying cause. Treating or controlling the underlying disease is the first step in treating erectile dysfunction. A complete history taken by the doctor greatly helps identify the cause.

Effective medicines for erectile dysfunction

The first-line treatment for erectile dysfunction is phosphodiesterase inhibitor medicines. The most commonly used medicines in this class in Iran include sildenafil and tadalafil. Like other medicines, sildenafil and tadalafil have several brand names. Other medicines in this class that are not currently available in Iran include avanafil and vardenafil.

Sildenafil: It is available in 50 and 100 mg doses under brand names such as Viagra, Vizarsin, Erecto, SDF, Modagra, Silerect, Vigrodit, and others. It is best to take sildenafil about one hour before intercourse on an empty stomach.

Tadalafil: It is available in 10 and 20 mg doses under brand names such as Cialis, Jialixo, Tadagra, Procial, Tiafil, and others. Tadalafil has a longer duration of action than sildenafil.

Important note: These medicines (phosphodiesterase inhibitors) should not be used more than once per day.

Side effects of phosphodiesterase inhibitors

Side effects of phosphodiesterase inhibitors may include flushing, headache, indigestion, nasal congestion, visual problems such as blue-tinted vision, or hearing problems.

Although these medicines are available in pharmacies without a prescription, it is better for the patient to take them after consulting the treating physician, so the cause can be found, the likely effectiveness confirmed, and contraindications or drug interactions ruled out.

Although phosphodiesterase inhibitors dilate blood vessels and can lower blood pressure, studies show that using these medicines in people with a history of heart attack who are otherwise stable and in full health does not create a risk.

Common drug interactions of phosphodiesterase inhibitors

Nitrates: People who use any nitrate medicine should not use phosphodiesterase inhibitors at the same time, because this can cause a severe drop in blood pressure. If needed, nitrate medicines may be used 24 hours apart from sildenafil and 48 hours apart from tadalafil.

Alpha-blocker medicines: These medicines are used to treat symptoms of prostate enlargement and include prazosin, terazosin, and tamsulosin. Because these medicines can also lower blood pressure, it is recommended that treatment for prostate enlargement first be started and the dose stabilized, and then the phosphodiesterase inhibitor added.

Vacuum devices: A vacuum pump is placed over the penis, moves more blood into the penile circulation, and produces an erection. Because this device can be difficult to use, it is mostly suitable for men for whom oral treatments are not appropriate or have not worked.

Some patients do not respond adequately to oral medicines. The next treatment step is topical or local medicines. These include alprostadil suppository (a urethral suppository placed inside the penile channel) and papaverine injection or compounded Trimix injection (injection into the shaft of the penis) before intercourse. However, these medicines may cause unwanted side effects, including a prolonged erection known as priapism and scarring, which can lead to Peyronie’s plaque disease.

Testosterone

Low testosterone levels are common in middle-aged and older men. Testosterone is an important hormone regulating sexual desire and sexual function in men, so measuring testosterone is recommended in people with erectile dysfunction.

If no medicine is effective for erectile dysfunction, penile prosthesis implant surgery is used as the last treatment option.

Vascular surgery

This method is not recommended for most people with erectile dysfunction caused by vascular disorders because it has a low success rate. About 7% of these people are candidates for vascular surgery. This method is not suitable for people with atherosclerosis.

Psychotherapy

Psychological factors may contribute to the cause of erectile dysfunction either alone or together with organic causes. Erectile dysfunction is a common symptom of depression, and erectile function may be restored with psychotherapy or antidepressant medicines that improve depression.

However, some of the most effective SSRI antidepressants, such as fluoxetine, sertraline, and paroxetine, reduce both sexual desire and erectile function. SSRIs can also delay ejaculation, an effect that may be useful for men with premature ejaculation.
Psychological counseling, including the use of mindfulness exercises by both partners, can be helpful for men with performance anxiety. This is usually done by referral to a qualified sex-therapy counselor.