Erectile Dysfunction

What is it?

Erectile dysfunction consists of the impossibility of achieving an erection or, if it is achieved, it is not maintained with sufficient rigidity for satisfactory sexual intercourse. Usually this alteration has a constant and progressive development, with a minimum duration of about 3 months. It affects up to 50% of patients between 40 and 70 years of age (data vary according to different studies). Its frequency clearly increases with age, but there are cases and types that can be observed in younger people.

Risk Factors

There are a number of risk factors predisposing to this pathology. Some of them are inherent to the patient, i.e. it is not possible to modify them (advanced age, neurological diseases, alterations of the penile anatomy). Other risk factors are modifiable, i.e. we can act on them to prevent or delay the onset of ED: obesity, diabetes mellitus, high cholesterol and triglyceride levels, sedentary lifestyle, smoking, metabolic syndrome. These risk factors are the same ones that predispose to the development of cardiovascular diseases related to generalized vascular disease (myocardial infarction, cerebral infarction, large vessel disease). This relationship is due to the fact that in the early stages of atherosclerosis there is a loss of nitric oxide in arteries throughout the body. Nitric oxide is necessary for the achievement of erection and is therefore affected. Research in this field has shown that the onset of erectile dysfunction can predict the occurrence of cardiovascular events within 2-3 years on average.

Causes

The causes of Erectile Dysfunction are very varied. Vascular, nervous and psychogenic mechanisms are involved in the development and maintenance of erection. The failure of any of them can condition the appearance of this disease.

• Vascular alterations: arteriosclerosis (hypertension, high cholesterol, diabetes mellitus, smoking).
• Nervous system disorders (central or peripheral).
• Hormonal disorders (diabetes, decreased testosterone, increased prolactin, thyroid and adrenal disorders).
• Secondary to surgery (radical prostatectomy, radical cystectomy, colon surgery).
• Other causes (drugs, alcoholism, drugs of abuse, alterations of the penile anatomy, psychogenic).

Diagnosis

In a clinical interview with a super-specialized andrologist, a personal history possibly involved will be assessed, the course of the disease will be investigated and the possible cause will be established. It is also important to investigate ejaculatory function and sexual desire.

• Clinical interview with a super-specialized andrologist. Personal history possibly involved will be assessed, the course of the disease will be investigated and the possible cause will be established. It is also important to investigate ejaculatory function and sexual desire.
• Internationally validated questionnaires. They help to establish as objectively as possible the severity of the situation.
• Laboratory studies (lipid profile, glycemia, hormonal profile, renal and hepatic function, prostate pathology). In addition to differentiating different causes, they allow us to investigate the presence of other pathologies (hypercholesterolemia, diabetes, prostate cancer) not known until now.
• Penile Doppler: this technique is increasingly used in the diagnosis and management of ED. It is essential that it be performed by a specialist in it, since otherwise the information it provides is very limited. In the first part, a regular ultrasound of the penis is performed, observing its structure and discarding the presence of fibrous plaques or other alterations that may lead to suspect other pathologies. In a second part, a standardized amount of a drug that causes an erection is injected into the penis with a fine needle and, after reassessing the penile structure, arterial and venous flows are measured after a certain period of time. It is extremely useful in differentiating vascular, neurological and psychogenic causes of ED, as well as in determining the severity and helping to decide on the most appropriate treatment.
• Rigiscan: During sleep, erections occur that are completely natural and oxygenate the penis. The Rigiscan is a device that measures the degree and frequency of these erections to assess whether the vascular mechanism that enables erection is preserved. It is simple to operate and consists of two strips that are placed at the base and tip of the penis, attached to a recording device. The information it provides makes it possible to differentiate with great precision, an ED of vascular origin from one of psychogenic origin.

Treatment

After the diagnostic study, and once the cause of the disease has been established, you will be offered the most appropriate therapeutic alternative for your case. In general, several treatment steps are defined, as follows:

• Shock waves
• Intracavernous injections
• Penile prosthesis implant

1. The first action is always to act on modifiable risk factors and make lifestyle changes (weight loss, healthy diet, exercise). This is fundamental for treating ED, avoiding its worsening, and also for the prevention of cardiovascular disease.

2. Phosphodiesterase-5 inhibitors. These are orally administered drugs. For their effectiveness, sexual stimulation is necessary. The first to appear was sildenafil, commercially known as Viagra. Since then, a multitude of drugs of this family have been developed. All of them show satisfactory results in more than 50% of the cases and one or the other will be chosen according to the patient’s characteristics and preferences. These drugs have a good safety profile, although they are contraindicated in some cases, such as in patients taking nitrates (nitroglycerin), due to the risk of severe hypotension.

3. The third step is occupied by intracavernous injections with protaglandin E1 (alprostadil). This treatment has a different mechanism of action than oral drugs and is used when the latter have not been effective. It consists of puncturing the corpora cavernosa of the penis moments before sexual intercourse. Erection appears in a few minutes without the need for sexual stimulation. When prostaglandins alone are not effective, they are combined with other drugs and administered in a single injection.There may be complications such as fibrosis, hematomas, priapism (sustained and painful erection), but these are rare and satisfaction with this treatment is generally good.

4. In recent years, other methods of administering prostaglandins (alprostadil) have appeared on the market. They can be applied as a “paste” into the urethra by means of a “swab” or in the form of gels that are spread on the glans penis. This is more convenient for the patient, who avoids injection, although their efficacy may be lower depending on the case.

5. Vacuum devices are another treatment option offered when oral treatment has not been effective or cannot be administered. It is a device in the form of a tube that allows the introduction of the penis and perform the vacuum with it inside. Its use is limited and pain and small hematomas may occur.

6. Finally, when none of the above treatments has been effective, surgical implantation of a penile prosthesis is offered. More information on penile prostheses is provided in the corresponding section.

PENILE PROSTHESIS

The penile prosthesis is a device that is implanted inside the penis in order to give it the ability to have rigidity. This way you will be able to have sexual intercourse with penetration.

It consists of two cylinders that are inserted inside the corpora cavernosa and act as a substitute for them to achieve a state of erection.

A surgical intervention is necessary for its placement, and because once implanted it is not possible to resume other treatments, it is the last step among the therapeutic options for erectile dysfunction.

It presents, however, the best satisfaction rates among all erectile dysfunction treatments.

Its implementation by expert centers and surgeons has been shown to reduce complications associated with the procedure. Our group is recognized by the Ministry of Health as one of the two groups accredited in Spain to perform these procedures.

There are different types of prostheses currently available:

1. Malleable prostheses: they are composed of two silicone cylinders with a rigid but malleable skeleton (usually silver) inside. Each cylinder is inserted into the corpora cavernosa after making an incision in them. In this way the penis is left with the necessary consistency to carry out penetration. The disadvantage of these prostheses is that the penis remains constantly rigid and can only change its position. However, they have two great advantages: they are cheaper and simpler to use, since it is not necessary to activate and deactivate them. The postoperative period and recovery are also usually faster.

2. Hydraulic prostheses: In these prostheses the cylinders are hollow and, by means of a hydraulic mechanism, they are filled with serum to achieve erection. Depending on the complexity of the mechanism, they are divided into:

1. Two-component: The cylinders are joined with a pump that will be housed in the scrotum. Thus, when the patient presses the pump, the serum will pass into the inflatable cylinders, thus achieving rigidity. To deflate the prosthesis, it is enough to press on the corpora cavernosa until it is completely emptied.
2. Three-component: they are the most functional. They resemble natural erection and achieve an almost physiological state of flaccidity. In addition to the cylinders, they consist of a pump (placed in the scrotum) and a reservoir (behind the pubis) connected to each other. This pump has two buttons for emptying and filling the cylinders. During the emptying phase, the serum remains in the reservoir. They are, on the other hand, the most economical.

There are several routes for the placement of the prosthesis. The incision can be made subpubic (behind the pubis), subcoronal (under the glans) or penoscrotal (between the base of the penis and the scrotum). The choice depends on the surgeon and the type of prosthesis.

As in other interventions, the placement of a prosthesis can present complications, such as urinary retention, or the appearance of hematomas or edema, which will not entail long-term problems. However, the most feared complication is infection of the device, which can lead to its removal. For this reason, infection prevention measures are very strict and make infection infrequent, affecting only 1-8% of cases. The mechanical failure rate at 5 years is approximately 10%.

One of the most frequent questions asked by patients who are considering prosthesis implantation is whether sexual desire, orgasm sensation and ejaculation may be affected. Prosthesis implantation surgery does not interfere with any of these three aspects. Also, the patient should know that the length of the penis is not increased, in fact in some cases a shortening of 1-2 cm is observed.

Satisfaction after placement of a penile prosthesis is among the highest of all the therapies described for erectile dysfunction. Patients with three-component hydraulic prostheses achieve the highest degree of satisfaction. Some studies indicate that 92.5% of the cases maintained at least 1.7 weekly relations at 5 years after surgery.