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ERECTILE DYSFUNCTION : Present Management
Vijay Kulkarni
Honorary Andrologist, Bhatia General Hospital, Mumbai
INTRODUCTION
Erectile Dysfunction (ED) in a male can have a profound impact not only on the couple but on the entire family. Its fallout from interpersonal discord to divorce can devastate a traditional Indian family structure. The medical practitioner or the family physician may be the first medical person to sense the sexual discord existing in a couple. Early treatment prevents deterioration of interpersonal relationships and the consequent problems. Incidence of ED is surprisingly high. Shyness, ignorance, reluctance to confide about private matters, not knowing where to seek the help from prevent the practitioner from assessing a true incidence of ED in his practice. At 50 yrs of age 1 out of 10 men in America suffers from ED.
It is considered to be a single most common untreated disorder in the United States. Though Indian data is not available, it is easy to see why it is important for a medical practitioner to be aware of such common yet relatively neglected and undertreated health problem.
Fig. 1 Clinical Presentation
It can be extremely varied since sexuality is a very complex phenomenon and its problems are presented with psycho-social overtones. For example, unconsummated marriage can present as infertility case more than 5 years after the marriage. A young man unwilling for marriage under various pretexts may have just a "guilt complex" from masturbation or from an odd visit to a commercial sex worker. Hence, physician’s awareness is critical to sense the sexual dysfunctional problems.
The purpose of this article is to raise this awareness towards ED; its diagnosis, investigations and available treatment modalities.
Patient Profile
Any age!
A youngster in twenties about to be engaged or to be married, tense, anxious, confused c/o vague sexually oriented symptoms and/or querries.
A middle aged (35 to 55) stressed-out, busy executive, smoker, recent diabetic c/o loss of libido and recent episodes of failure at penetration or of premature ejaculation.
A senior citizen, retired, h/o myocardial ischaemic episodes, on medication for HT, DM, accepts low frequency of sexual desire and coital needs but feels he and his wife would be happier with once in a while satisfactory penetrative sex which he is unable to have for a long time.
It can be quite varied in terms of age and symptoms. A clinician needs to probe deeper to understand the exact problem and differentiatepsychogenic from organic nature of ED.
History
History goes a long way in understanding the nature of ED as well as the kind of disorder that is manifested.
I. Disorder of desire -Libido, does not feel interested in sex.
II. Disorder of arousal - Inability to attain penetrable erection.
III. Disorder of ejaculation - Premature ejaculation, Anejaculation.A detailed psychosexual, medical, marital and social history is vital for identifying the problem, its aetiological and perpetuating factors, patient’s expectations and therapeutic goals and therefore the appropriate therapy. While this is the domain of the expert managing the patient, it is important for a clinician to always include a few basic sex-related questions while evaluating a patient’s ED.
Distinguishing between the psychogenic and organic ED
Two main tests used to determine whether the problem is psychogenic or organic are-
1. Nocturnal penile tumescence and rigidity testing (NPTR)
2. Intra-cavernosal injection of vaso active drugs (ICIVAD)Nocturnal Penile Tumescence and Rigidity
NPTR testing is based on the fact that a normal man has two to four episodes of erections at night, usually in association with REM sleep. The NPT-R monitor records these nocturnal erections and presents them in the form of a graph like an ECG. A man with psychological ED will continue to have these nocturnal erections even though he does not get an erection when awake and sexually stimulated. On the other hand, a man with organic ED has impairment or absence of these nocturnal erections. Thus, NPTR monitoring provides an objective test for distinguishing between organic and psychogenic ED.
It was the widespread use of this test in the 1970’s that led investigators to realise that an unexpectedly large proportion of cases of ED were due to organic causes.
Fig. 2 Pharmaco-diagnostic testing with Intra Cavernosal Injection of Vaso Active Drugs (ICIVAD)
This simple office test has revolutionized the investigations of impotence. It involves an injection of vasodilator drugs like papaverine, phentolamine, chlorpromazine and prostaglandin E1 into the penis. This causes dilation of the penile cavernosal arteries and relaxation of the cavernosal smooth muscle (which creates veno-occlusion), thus producing an erection. ICIVAD bypasses the psycho-neurological pathways to act directly upon the penile vascular system. Hence, men with psychological impotence (as well as normal men) will develop a full and sustained erection following ICIVAD. On the other hand, men with a significant vascular problem will fail to achieve an adequate erection even after maximum dose of the VAD. Thus, ICIVAD provides a simple, quick and inexpensive method for distinguishing between psychogenic and organic (vasculogenic) impotence.
Technique of ICIVAD
Using an insulin syringe with an ultrafine needle, the chosen drug/drugs is injected into any one corpus cavernosum. The injection site is squeezed for a few seconds. The patient is then left alone with adequate privacy, and is instructed to stroke the penis and fantasize sexually. The resulting erection is assessed every 5 minutes for 30 minutes. If there is only a partial response, the injection is repeated at the next visit using a higher dose. If there is a full erection the patient is monitored till detumescence occurs. If the erection persists beyond 4 hours the erection is detumesced by aspirating 50 ml of blood and injecting 50 mcg of diluted adrenaline or 100 mcg of phenylephrine.
In most of the cases, these two tests are adequate to distinguish between psychogenic and organic ED.
In cases where this differentiation is still unclear or not adequate to chart out the future therapy, special tests are required for further management. Commonly used special tests are:
I. Penile duplex ultrasound study
II. Cavernosography and cavernosometryPenile duplex ultrasound study
The use of duplex ultrasound allows simultaneous ultrasonic visualization of the penile structure and Doppler measurement of arterial blood flow. The sonographic mode is used to scan the corpora for fibrosis or calcification which would indicate cavernosal damage. The cavernosal arteries are studied for changes in vessel diameter after ICIVAD. Minimally dilating (diameter < 0.5 mm) vessels would indicate penile arterial insufficiency. The Doppler mode gives information on the arterial waveform and provides measurements of the peak systolic velocity and the end diastolic velocity. A slow PSV (< 25 cm/sec = abnormal, 25-30 cm/sec = equivocal) indicates arterial insufficiency. Persistent end diastolic flow (> 5 cm/sec) indicates venous leak.
Fig. 3 : Cavernosometry and Cavernosography
These tests are used to confirm veno-occlusive insufficiency in men who have difficulty in sustaining an erection. Cavernosometry is performed by perfusing the penis with saline till it becomes erect. If there is "venous leak" a rapid inflow of saline will be required before the penis becomes erect. Cavernosography is then performed by injecting contrast into the penis and seeing which veins are "leaking". These tests are invasive and are indicated only when vascular surgery is being contemplated. Since "venous ligation" surgery is no longer popular, these studies are now performed only infrequently.
Other Special tests
Penile arteriography is an invasive study that is indicated only when revascularization surgery is being contemplated.
Numerous neurological tests are available but are not of practical relevance. Hormone assays are widely prescribed but are of very limited value. Marginally low testosterone levels do not cause ED. In fact, even significantly low levels of testosterone are compatible with good erectile function. Low testosterone is significant only in those cases where there is decreased libido and arousal. Similarly, marginally elevated prolactin levels are usually due to stress or medication and are not the cause of ED. Hyperprolactinaemia is the cause ofED only when more than thrice normal.
Remember, ED can be a presenting symptom of diabetes! Screen every case for diabetes!
Therapeutic Options
A wide range of options are now available. A medical practitioner can help the patient to choose from different modalities of treatment, and, can play an active role in the management. The treatment options can be broadly classified as under-
I. Sex education and counseling and sex therapy
II. Medical
III. Non-surgical
IV. Surgical
Sex education and counseling and sex therapy
Sex education and counseling are very important in our patients since sexual myths and misconcepts are very prevalent. Every clinician dealing with ED must be prepared to offer some counseling and reassurance.
Sex therapy aims at relieving performance anxiety through "sensate focus" exercises. These emphasize non-demand pleasuring and allow erections to happen automatically as the male relaxes and relearns how to enjoy sensuality without intercourse. However, formal sex therapy modeled on Masters and Johnson requires privacy and cooperation of both partners, which are often not available to our patients.
Since even organic ED usually has some element of psychogenic overlay, sex therapy and counseling have a role to play in all patients; and are often used in combination with other therapies.
Medical
a) Hormonal treatment
b) Psychiatric Therapy and Psychotropic drugs
c) Medications for other medical problems
d) Aphrodisiacs and sildenafil (Viagra)
a) Hormonal therapy : Men with hypogonadism and low libido may benefit from testosterone replacement. Men with proven hyperprolactinaemia will respond to bromocriptine therapy. Testosterone replacement restores libido and erections in men with definite hypogonadism. Empirical testosterone therapy is not of value. Similarly, bromocriptine therapy cures ED only when prolactin is significantly raised (Carrier, 1994).
b) Psychiatric Therapy and Psychotropic drugs : i) Psychiatric Therapy : Depression is an important cause of ED. When clinical depression is associated with ED it is important that the depression be treated with appropriate psychiatric measures. Severe anxiety, obsessive neurosis, sexual phobias, personality disorders, and psychosis can cause ED and need to be treated.
ii) Psychotropic drugs : Men with depression or anxiety will need appropriate medication. Hence the psychotropic drugs may need to be given as a part of the treatment of ED. We have found simultaneous use of ICIVAD extremely useful as a confidence booster in some depressed patients.
c) Medications for other medical problems : In diabetics, strict control of blood sugar is important in preventing and reversing neurovascular complications which cause ED and other problems. Sometimes better control of diabetes or change of anti-hypertension medication may improve erections.
d) Aphrodisiacs and Sildenafil (Viagra) : "Aphrodisiacs" have existed since centuries but have not been subjected to systematic study. A strong placebo effect is seen in impotence therapy and this is probably the source of improvement sometimes seen with these preparations. A popular oral drug is yohimbine and double-blind studies have demonstrated an advantage over placebo (Vogt, 1997). However, in actual practice the results are unpredictable and disappointing. Some studies have claimed significant benefit with this drug. However, our own experience, and that of many other clinicians, has been unfavourable and we do not recommend the drug.
Sildenafil (Viagra)
Sildenafil has captured the attention of the press and the fascination of the public unparalleled by any other drug. It is the first truly effective oral medication for the treatment of ED and the first of a series of newly coming impotence drugs that will soon flood the market. It is not an aphrodisiac in the correct sense of the word as sildenafil does not of itself produce an erection, but only enhances an existing erection or tumescence. It does not increase libido nor does it prolong normal erection. Sildenafil is a selective inhibitor of the phosphodiesterase type 5 (PDE-5) enzyme. Inhibition of PDE-5 results in accumulation of cGMP in the penis. Since cGMP causes smooth muscle relaxation and erection, an increase in cGMP levels facilitates erection. This explains why sildenafil does not by itself produce an erection, but can only enhance an erection once the nitric oxide-cGMP pathway has been activated by sexual stimulation (Boolell, 1996).
Sildenafil is taken in a dose of 25 mg to 100 mg, on a relatively empty stomach, one hour before intercourse is desired. The peak effect is between one to two hours after taking the tablet. Success rates range from 50 to 80% depending on the patient group studied (Goldstein et al, 1998). Side-effects are usually mild and include headache (13.8%), facial flushing (10.5%), dyspepsia (6.5%), nasal congestion (4.2%), and altered vision (mild, transient colour tinge, photosensitivity or blurring 2.7%). The drug should be used with caution in men with retinitis pigmentosa or diabetic retinopathy due to its effect on retinal PDE6.
Nitrate contraindication : When patients take organic nitrates they have high levels of nitric oxide (NO) in the circulation. Since sildenafil amplifies the NO-cGMP pathway it markedly potentiates the vasodilatory effect of the circulating NO leading to severe, and potentially fatal, hypotension. Hence sildenafil is strictly contraindicated in patients who are taking, or could need to take, organic nitrates in any form. Men taking sildenafil should be warned that if they do develop chest pain during sex they should not take nitrates and should inform the attending doctor or emergency medical personnel that they have taken sildenafil.
Non-surgical
a) Self-injection therapy
b) Vacuum erection device
c) MUSE
Self-injection therapy
Home self-injection of vaso-active drugs to achieve an erection became popular in the mid-80s and ushered in a new era in the management of ED. Self-ICIVAD provided the first highly successful and consistently reliable method for achieving a "natural" erection (Linet and Ogring, 1996). It has been used in a variety of situations including unmarried men with sexual anxieties not responding to counseling, couples unable to consummate their marriage, men with stress-induced ED, men with neurogenic ED and in elderly men with mild to moderate vasculogenic ED.
First, therapeutic dose of a suitable drug/drug-combination is determined by a clinician with an expertise in this field. Then the patient is given a preloaded syringe for self-injection at home. Self-injection is easy to learn and safe to use. The injection is taken at home 5 to 10 minutes before intercourse. The effect lasts for 30 to 120 minutes. Success rates are 50 to 70% in organic cases and over 95% in psychogenic cases. It is free of thesystemic side-effects of sildenafil. The major disadvantage is the need to inject the penis. The main side-effects are the risk of priapism (prolonged erection beyond 4 hrs-incidence 1 to 10% depending on the drug) and penile fibrosis (5% to 15%).
Priapism, if not treated urgently, can cause irreversible damage to erectile function. Hence the concerned clinician must be willing to treat and capable of tackling this problem.
Fig. 4 Vacuum Erection Device
Vacuum erection devices (VEDs) can help produce an erection in those men who are unwilling for more invasive therapies. A VED consists of a cylinder, a pump and elastic retention bands. To obtain an erection, the cylinder is placed over the penis and the pump is activated to evacuate the air within the cylinder. This produces a vacuum around the penis. As a result, blood is sucked into the penis producing an erection-like state. The erection is retained by slipping the elastic bands on to the base of the penis. VEDs are safe, easy to operate, non-invasive, and can be used by any patient without the need for any investigations. The main disadvantages are the fact that they are somewhat cumbersome and that the erection produced does not feel natural. Also, the retention bands tend to obstruct the ejaculation.
Fig. 5 MUSE
Medicated urethral system for erection (MUSE) is a new proprietory system for administrating a PGE-1 pellet into the urethra. The drug is absorbed through the urethral mucosa into the corpus spongiosum from where it is transported retrograde into the corpora cavernosa. Here the PGE-I induces vaso-dilatation which results in an erection (Padma-Nathan et al 1977). Onset of action is in 5 to 15 minutes and the erection lasts for 20 to 60 minutes. MUSE works like self ICIVAD, its main advantage is that it avoids the ‘prick’ of an injection. Main disadvantages are reduced efficacy (works in only half the patients in whom ICIVAD is effective) and the penile pain.
Surgical
Fig. 6 a) Penile implants
b) Vascular surgery
a) Penile implants
A penile implant/prosthesis consists of a pair ofrods which are permanently implanted into the penis to render it rigid enough for intercourse.
Two types of implants are available :
i) Non-inflatable
ii) Inflatable
Non-inflatable - This device is of constant length and girth, hence the penis remains in a state of constant erection but can be bent for concealment.
The length, girth and rigidity do not change but the penis can be bent for concealment.
Inflatable - The cylinders of this device can be inflated or deflated by a connected pump, thus activation or de-activation of the device can make the penis erect or flaccid, mimicking natural erections.
Orgasm, ejaculation and fertility are not impaired by a penile prosthesis and several of our young patients have fathered children.
Penile prosthesis implantation has proven to be a highly successful form of therapy with good patient satisfaction rates. The main problem has been their high cost! From Rs. 30,000 to Rs. 40,000 for imported non-inflatable to Rs. 1,20,000 to Rs. 1,70,000 for the inflatable devices; cost can be prohibitive. This limitation has now been overcome with the development of indigenously designed and manufactured Shah Indian Penile Prosthesis costing only Rs. 7000. This is now the most commonly used implant in India.
All implants carry a small risk of infection for which adequate precautions need to be taken peri-operatively.
Non-Inflatable Inflatable b) Vascular SurgeryTwo types of penile vascular surgery are performed in men with ED.
i) Venous ligation
ii) Penile revascularisation
Venous Ligation
This surgery is performed in men diagnosed as having venous leak. These are men in whom there is adequate arterial inflow but a defective veno-occlusive mechanism. As a result they are unable to trap blood in the penis and therefore have ill-sustained and incomplete erections. Venous ligation surgery is an attempt to cure this excessive venous outflow by tying off the veins that drain the penis. This surgery was very popular a few years ago but has now been given up since long-term results have been disappointing (NIH. 1993).
Penile Revascularisation
Just as a coronary bypass is done to bring more blood to an ischaemic heart, so too, penile revascularisation can be done to increase blood flow into the penis in cases of arteriogenic impotence (Shah and Kulkarni, 1995). In the Michal II procedure the inferior epigastric artery is joined to the dorsal artery of the penis. This procedure is useful in young men who are impotent due to damage to the internal pudendal artery following fracture pelvis. Erections can be restored in 70% of the men. Another group of men have congenitally dysplastic arteries - in such cases arterio-arterial anastomosis is not possible. Instead, the epigastric artery is anastomosed to the deep dorsal vein of the penis, blood flows retrograde through the vein and its emissaries into the corpora. Success rates are around 50 per cent.
CONCLUSION
Erectile dysfunction is quite prevalent. Its impact on marital harmony is enormous. The treatment is easily available. Hence its awareness is important on the part of the people as well as the family physician.
REFERENCES
- Boolell M, Alien MJ, Ballard SA, et al, Sildenfil : an orally active type 5 cyclic GMP - specific phosphodiesterase inhibitor for the treatment of penile erectile dysfunction. Int J Impotence Res 1996; 8 : 47.
- Carrier S, Zvara P, Lue TF. Erectile dysfunction. Endocrinol Metab Clin N Am 1994; 23 : 773.
- Linet OI, Ogring FG. Efficacy and safety of intracavernosal alprastodil in men with erectile dysfunction. NEJM 1996; 334 : 873.
- Masters W, Johnson V. Human Sexual Inadequacy. Little, Brown Boston. 1976.
- NIH concensus development panel on Impoetence. JAMA 1993; 270 : 83.
- Shah RS, Kulkarni VR. Penile revascularisation : an overview. Ann Acad of Med 1995; 24 : 749.
- Shah R. Male sexual dysfunction. Recent Advances in Obstetrics and Gynaecology 4 : ed. S. Dasgupta, Jaypee N. Delhi 1999; 1999 : 152-67.
- Vogt HJ, Brandi P, Kockott G, et al. Double-blind, placebo controlled safety and efficacy trial with Yohimbine Hydrochloride in the treatment of non-organic erectile dysfunction. Int J Impotence Res 1997; 9 : 155.
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