If you are reading this page then you probably have faced at least once the symptoms of worst enemy men could have: erectile dysfunction (ED).
The supposition that erectile dysfunction only appears in older men is far from being true.
It is a well-known fact that stress is bad for your health. Lack of stress management leads to stress-related problems like high blood pressure, depression and anxiety, gastrointestinal problems, diabetes, cardiovascular disease and yes, erectile dysfunction.
It’s believed that every man at least once in his life experiences problems with erection.
What was thought to be related only to psychological causes (e.g. depression, anxiety and stress involving the workplace) was demonstrated the primary factor in only a few cases. However, secondary psychological problems are expected in all cases associated with erectile dysfunction.
ED and sexual performance anxiety, are they really the same?
No, but they are much alike.
Erectile dysfunction, also called impotence, is defined as the inability to attain and maintain an erect penis with sufficient rigidity for sexual intercourse, has become an increasingly common complaint that affects 140 million men worldwide.
On the other hand, wondering about the ability to get an erection and worrying about the ability to please the partner sexually is called sexual performance anxiety. The sufferer becomes unsure and concerned about his sexual performances and is constantly questioning himself…
- Will I have an orgasm?
- What if I ejaculate too quickly?
- Does my partner find me attractive?
and so on.
Massive pornography use can develop sexual performance anxiety.
Comparing the real-life experiences with the performances from pornographic movies (unrealistic expectations) can end up with low self-esteem and lack of sexual desire.
ED can be a result of performance anxiety. The anxiety triggers the production of stress hormones (such as epinephrine and norepinephrine) which can narrow blood vessels in the penis and make it difficult for blood to flow in and form an erection.
The following conditions can contribute to the onset of erectile dysfunction:
- Heart disease
- High cholesterol
- High blood pressure
- Nerve damage
- Cancer treatment (such as prostatectomy – removal of the prostate gland)
- Thyroid disorders
- Low testosterone
- Medication side effects
- Attention deficit (especially in young men)
Developing ED and neglecting it can result in aggravation of sexual functioning and lead to performance anxiety.
A man who has had trouble with erections in the past may become anxious about his ability to perform sexually in the future.
While it’s possible to have both sexual performance anxiety and ED, it doesn’t always happen this way. Men who feel confident in the bedroom and in their relationships can still develop ED.
How do we recognise ED?
ED symptoms advance with age.
Its symptoms are more frequent in men over 35 years of age.
The first symptoms are mild and transitory, and you can associate them with fatigue, drinking alcohol or coffee.
If you are having frequent issues with achieving and/or keeping an erection, this can involve an organic cause of the ED disease, such as cardiovascular problems, high blood pressure or diabetes, and the next thing you can think of is scheduling an evaluation from a specialist in cardiology or metabolic diseases.
However, if you experience ED not so often and you are able to engage in sexual activity most of the time, there might not be a medical concern.
Do take care of the signs and symptoms. Engage your partner in discussing this problem. Get in touch with a physician that you trust.4
The two main categories of ED are psychogenic erectile dysfunction and organic erectile dysfunction.
Young men are more disposed to psychogenic erectile dysfunction. It involves a psychic component and it usually develops immediately after a psycho-traumatic and stressful situation. Thoughts about sex are usually accompanied by anxiety.
Psychogenic dysfunction has the following characteristics:
- Problems in romantic relationships
- A sudden development of ED with a rare incidence of episodes
- No problems with spontaneous nocturnal erections
- Solving the problem that causes erectile dysfunction restores normal erectile function
- Definition of erectile dysfunction (ED) can be different for every guy.
Organic causes that are predominant for the onset of erectile dysfunction are trauma to the penis, vascularization, and other pathologies such as diabetes mellitus, renal failure, heart disease, hypogonadism (or as low testosterone).
Signs that characterize organic erectile dysfunction:
- Gradual development
- The hardness of the penis is not enough for coitus
- Erection is weakened during sexual intercourse
- It takes too long to achieve an erection
- Spontaneous nocturnal erections are absent
- Absence of erection when it’s needed
Managing erectile dysfunction
Stress and/or anxiety are one of the biggest enemies of a healthy sex life.
There are also some lifestyle habits that influence the onset of erectile dysfunction, such as smoking, drinking large amounts of alcohol, consuming marijuana, cocaine, heroin, and amphetamines.
Also, poor exercise habits can associate with other health conditions that can get you in the wrong direction with your sex life, contributing to the onset of erectile dysfunction.
Once the other hand, a healthy diet is contributing to a healthy sex life. A research published in January 2016 found that men who ate foods high in antioxidants called flavonoids had a lower risk of erectile dysfunction than those who didn’t eat a flavonoid-rich diet.5
Flavonoids can be found in certain plant-based foods like citrus fruits, blueberries, strawberries, apples, pears, cherries, blackberries, radishes, and blackcurrant. Some teas, herbs, and wines also have flavonoids in them.
Past studies have shown that consuming flavonoids could reduce a person’s risk for diabetes and heart disease, both of which can lead to erectile dysfunction.
Eating healthy, particularly a Mediterranean diet can go a long way in preserving erectile function, however.
This type of diet includes fruits, vegetables, whole grains, and olive oil. Nuts and fish are good additions.
Vitamin D is an important nutrient for our overall health. And some experts believe that vitamin D deficiency might interfere with a man’s erections.
Take into consideration that erectile dysfunction is a significant marker for future cardiovascular events.
Vascular erectile dysfunction (ED) and cardiovascular disease (CVD) share common risk factors including obesity, hypertension, metabolic syndrome, diabetes mellitus, and smoking. ED and CVD also have common underlying pathological mechanisms, including endothelial dysfunction, inflammation, and atherosclerosis.
It is important to treat ED and to have periodic visits at the cardiologist.
Treatment of erectile dysfunction:
As a rule, ED can be treated successfully with current treatment options, but it cannot be cured. The only exceptions are psychogenic ED, post-traumatic arthritogenic ED in young patients, and hormonal causes (e.g. hypogonadism and hyperprolactinemia, which potentially can be cured with specific treatment. Most men with ED will be treated with therapeutic options that are not cause-specific. This results in a structured treatment strategy that depends on efficacy, safety, invasiveness and cost, as well as patient preference.
Five natural ways to overcome erectile dysfunction
- Walk. According to one Harvard study, just 30 minutes of walking a day was linked with a 41% drop in risk for ED.
- Eat right. In the Massachusetts Male Aging Study, eating a diet rich in natural foods like fruit, vegetables, and fish decreased the likelihood of ED.
- Get slim and stay slim. A trim waistline is one good defence: a man with a 42-inch waist is 50% more likely to have ED than one with a 32-inch waist. Losing weight can help fight erectile dysfunction, so getting to a healthy weight and staying there is another good strategy for avoiding or fixing ED. Obesity raises risks for vascular disease and diabetes, two major causes of ED.
- Pay attention to your vascular health. High blood pressure, high blood sugar, high cholesterol, and high triglycerides can all damage arteries in the heart (causing heart attack), in the brain (causing stroke), and leading to the penis (causing ED).
- Move a muscle, but we’re not talking about your biceps. A strong pelvic floor enhances rigidity during erections and helps keep blood from leaving the penis by pressing on a key vein. In a British trial, three months of twice-daily sets of Kegel exercises (which strengthen these muscles), combined with biofeedback and advice on lifestyle changes: quitting smoking, losing weight, limiting alcohol, worked far better than just advice on lifestyle changes.
Erectile dysfunction has become an increasingly common complaint that affects 140 million men worldwide.
According to data from the Massachusetts Male Aging Study, up to 52% of men between the ages of 40 and 70 are affected by ED.
Phosphodiesterase type 5 inhibitors are considered the first-line therapy for erectile dysfunction, as they are the most effective oral drugs.
Four phosphodiesterase type 5 inhibitors are available on market: Sildenafil (Viagra®, Pfizer), Vardenafil (Levitra®, Bayer), Tadalafil (Cialis®, Lilly-ICOS) and Avanafil (Spedra®). These agents do not directly cause penile erections but instead affect the response to sexual stimulation. Sildenafil was the first in this series of phosphodiesterase type 5 inhibitors. The newest phosphodiesterase type 5 inhibitor is avanafil, which was approved in the UK in 2013. Each of these drugs is highly efficacious in the management of erectile dysfunction although pharmacokinetic and side-effect profiles differ and results for each drug may vary for individual men.
Patients with erectile dysfunction who do not respond to the treatment with oral phosphodiesterase type 5 inhibitors may be treated with vasoactive drugs administered intracavernosal. The intracavernosal administration of vasoactive drugs was introduced more than 20 years ago, it was the first medical treatment for erectile dysfunction.
The first and the only approved drug for intracavernosal treatment of erectile dysfunction is alprostadil. Studies have shown that alprostadil is most efficacious as monotherapy at a dose of 5-40 μg. After the administration of alprostadil, the erection appears after 5-15 minutes and lasts according to the dose injected.
The complications that may occur after intracavernosal administration of alprostadil include:
- penile pain,
- prolonged erection,
- mild hypotension at high doses.
The drug is contraindicated to be administered to men with a history of hypersensitivity to alprostadil, men at risk of priapism, and men with bleeding disorders.
Another approach in the treatment of erectile dysfunction with intracavernosal drugs is the combination therapy. Using the combination therapy enables the patient to take advantage of the different modes of action of the drugs being used, as well as alleviating side-effects by using lower doses of each drug. The following drugs may be used:
- Papaverine (20-80 mg): was the first oral drug used for intracavernosal injections and it is most commonly used in combination therapy due to its high incidence of side effects as monotherapy;
- Vasoactive intestinal peptides;
- Nitric oxide donors (linsidomine);
- Potassium channel openers;
- Calcitonin gene-related peptide.
Because of the side effects that may occur after intracavernosal injections, alprostadil may also be administered intraurethral. A specific formulation of alprostadil (125-1000 μg) in a medicated pellet (MUSE™) has been approved as a treatment for erectile dysfunction. Intraurethral pharmacotherapy is a second-line therapy and provides an alternative to intracavernosal injections in patients who prefer a less-invasive, although less-efficacious treatment.
The most common adverse events of intraurethral alprostadil are:
- Local pain;
Very rare adverse events include:
- Penile fibrosis;
- Urethral bleeding (related to the mode of administration);
- Urinary tract infection (related to the mode of administration).
Another way of administering alprostadil is topical. Topical alprostadil is formulated as a cream that includes a permeation enhancer to facilitate absorption of alprostadil (200 and 300μg) through the urethral meatus. Side effects include:
- Penile erythema;
- Penile burning;
- Local pain.
The surgical implantation of a penile prosthesis represents the third-line therapy in the management of erectile dysfunction. This therapy may be considered only in patients who do not respond to pharmacotherapy or who prefer a permanent solution to their problem.
The penile implants are classified into two categories:
- Inflatable devices (2- and 3-piece);
- Malleable devices.
The 3-piece inflatable devices are preferred by the most patients due to the more natural erection obtained. This type of devices provides the best rigidity and the best flaccidity because they will fill every part of the corporal bodies. However, the 2-piece inflatable prosthesis can be a viable option among patients who are deemed at high risk of complications with reservoir placements. Malleable prostheses result in a firm penis, which may be manually placed in an erect or flaccid state.
The prosthesis may be implanted by two main surgical approaches:
The penoscrotal approach provides an excellent exposure. It affords proximal crural exposure if necessary, avoids dorsal nerve injury and permits direct visualization of pump placement. However, with this approach, the reservoir is blindly placed into the retropubic space, which can be a problem in patients with a history of major pelvic surgery (mainly radical cystectomy).
The infrapubic approach has the advantage of reservoir placement under direct vision, but the implantation of the pump may be more challenging, and patients are at a slightly increased risk of penile dorsal nerve injury.
Regardless of the indication, prosthesis implantation has one of the highest satisfaction rates (92-100% in patients and 91-95% in partners) among the treatment options for ED based on appropriate consultation.
The main complications of penile prosthesis implantation are:
- Mechanical failure;
Penile implants are an attractive solution for patients who do not respond to more conservative therapies. There is sufficient evidence to recommend this approach in patients not responding to less-invasive treatments due to its high efficacy, safety and satisfaction rates.
Take home messages
Erectile dysfunction (ED) is defined as the consistent or recurrent inability to achieve and/or maintain an erection sufficient to permit satisfactory sexual performance.
A Normal erectile function requires the coordination of psychological, hormonal, neurological, vascular and anatomic factors.
Alteration of any of these is sufficient to cause ED.
Main causes of ED are chronic systemic illnesses (diabetes mellitus, heart disease, hypertension and peripheral vascular disease), neurological disorders (post-traumatic spinal-cord injuries, multiple sclerosis) or post-surgical lesions (after radical prostatectomy).
Erectile dysfunction is a significant marker for future cardiovascular events.
There are several approaches to the management of erectile dysfunction: psychosexual counselling, hormonal therapy, mechanical devices, vascular surgery and pharmacological treatment (intracavernosal pharmacotherapy and intraurethral prostaglandin).
The current available pharmacological treatment of ED is based on inhibitors of the cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase (PDE) that increase penile blood flow and erection in response to sexual stimulation.
Address to your doctor if you have any of the ED symptoms.
If you have any questions related to the drugs that treat ED, please write us an email at [email protected].
- M Boolell M, MJ Allen, SA Ballard, S Gepi-Attee, GJ Muirhead, AM Naylor, IH Osterloh, C Gingell – Sildenafil: an orally active type 5 cyclic GMP-specific phosphodiesterase inhibitor for the treatment of penile erectile dysfunction
- Gray M, Zillioux J, Khourdaji I, Smith RP. Contemporary management of ejaculatory dysfunction. Transl Androl Urol. 2018 Aug;7(4):686-702. doi:10.21037/tau.2018.06.20. Review. PubMed PMID: 30211060; PubMed Central PMCID:PMC6127532.
- M Boolell, MJ Allen, SA Ballard, S Gepi-Attee, GJ Muirhead, AM Naylor, IH Osterloh, C Gingell – Sildenafil: an orally active type 5 cyclic GMP-specific phosphodiesterase inhibitor for the treatment of penile erectile dysfunction;
- Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB- Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study.J Urol. 1994 Jan; 151(1):54-61.
- Al-Shaiji TF, Brock GB. Phosphodiesterase type 5 inhibitors for the management of erectile dysfunction: preference and adherence to treatment. Curr Pharm Des. 2009;15(30):3486-95.
- Corbin J. Mechanisms of action of PDE5 inhibition in erectile dysfunction. International Journal of Impotence Research. 2004;16(S1): S4-S7.
- K. Hatzimouratidis, F. Giuliano, I. Moncada, A. Muneer, A. Salonia (Vice-chair), P. Verze EAU Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism.
Mens Pharmacy is not liable for the currency or accuracy of the information contained in this blog post. For specific information about your personal medical condition, please contact our doctors or pharmacists for advice on [email protected].