ERECTILE DYSFUNCTION - "IMPOTENCE" DIAGNOSIS & TREATMENT

Erectile dysfunction, sometimes called "impotence," is the repeated inability to get or keep an erection firm enough for sexual intercourse. Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent or situational ability to do so, or a tendency to sustain only brief or partial erections. In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age: About 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. But it is not an inevitable part of aging and mostly people remain sexually active till 80 to 85 yr age. ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful and safer treatments for ED. Psychiatrist & Urologists with specialization in sexology have traditionally treat ED; however mostly people take non-approved over-counter medications or treatment from fake so-called doctors with-out proper diagnosis or knowing basic cause for the problem. Mostly drugs or doctor working on advertise are not effective or fake/ unproved. They take advantage of stigma attached with these problems.

How does an erection occur?

The penis contains two chambers called the corpora cavernosa, which run the length of the organ and spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum. Erection begins with sensory or mental stimulation, or both in sexual area of brain. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

What causes erectile dysfunction (ED)?

Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa. Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Kidney and liver disease, Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of erectile dysfunction. Smoking, being overweight, and avoiding exercise are possible causes of ED. Also, surgery can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

Primary couses of ED

• Vascular disease

• Psychological problems

• Diabetes

• Drugs, alcohol or tobacco consumption

• Hormone imbalances

• Neurologic conditions

• Pelvic trauma, surgery, radiation therapy

• Peyronie's disease

• Venous leak

Vascular Disease Arteriosclerosis, the hardening and narrowing of the arteries, causes a reduction in blood flow throughout the body and can lead to impotence. It is associated with age and accounts for 50% to 60% of impotence in men over 60. Risk factors for arteriosclerosis include: • Diabetes mellitus • High blood pressure • High cholesterol Smoking, which can lead to any of the above risk factors, is perhaps the most significant risk factor for impotence related to arteriosclerosis.

Diabetes Mellitus Chronic high levels of blood sugar associated with diabetes mellitus often damage small blood vessels and nerves throughout the body, which can impair nerve impulses and blood flow necessary for erection. About 60% of men with diabetes experience impotence.

Drugs Over 200 commonly prescribed drugs are known to cause or contribute to impotence, including drugs for high blood pressure, heart medications, antidepressantsand psychiatric drugs, tranquilizers, and sedatives, antihistamines, appetite suppressants, and cimetidine (an ulcer drug)—can produce ED as a side effect. A number of over-the-counter medications also can lead to impotence. Long-term use of alcohol and illicit drugs may affect the vascular and nervous systems and are associated with erectile dysfunction. Using certain un ethically given prescription, over counter or illegal drugs without advise of doctor, also addictive drugs can suggest a chemical cause, since drug effects account for 25 percent of ED cases.

Hormone Imbalances Hormone disorders account for fewer than 5% of cases of impotence. Testosterone deficiency, which occurs rarely, can result in a loss of libido (sexual desire) and loss of erection. Among other conditions, an excess of the hormone prolactin, caused by pituitary gland tumor, reduces levels of testosterone. Hormone imbalances can also result from kidney or liver disease.

Neurologic Conditions Spinal cord and brain injuries (e.g., paraplegia, stroke) can cause impotence when they interrupt the transfer of nerve impulses from the brain to the penis. Other nerve disorders, such as multiple sclerosis (MS), Parkinson's disease, and Alzheimer's disease, may also result in impotence.

Pelvic Trauma, Surgery, Radiation Therapy Trauma to the pelvic region or spinal cord can damage veins and nerves needed for erection. Surgery of the colon, prostate, bladder, or rectum may damage the nerves and blood vessels involved in erection. Prostate and bladder cancer surgery often require removing tissue and nerves surrounding a tumor, which increases the risk for impotence. New nerve-sparing techniques aimed at lowering the incidence of impotence to 40% to 60% are now being developed and used in these surgeries. Temporary impotence is also associated with these procedures, even those in which nerve-sparing techniques were used. It can take as long as 6 to 18 months for full erections to return. Radical cystectomy (for bladder cancer) and prostatectomy (for prostate cancer) require cutting or removing nerves that control penile blood flow. These nerves do not control sensation in the penis and are not responsible for orgasms; only erection is affected by these procedures. Radiation therapy for prostate or bladder cancer also can permanently damage these nerves.

Peyronie's Disease Peyronie's disease is a rare inflammatory condition that causes scarring of erectile tissue. Scarring produces curvature of the penis that can interfere with sexual function and cause painful erections.

Venous Leak If the veins in the penis cannot prevent blood from leaving the penis during erection, erection cannot be maintained. Venous leak can be a result of injury, disease, massaging of penis with oil or damage to the veins in the penis.

Psychological Conditions Experts believe that psychological factors such as stress, worry, anxiety, guilt, depression, schizophrenia, personality disorder, low self-esteem, and fear of sexual failure cause 10 to 20 percent of ED cases and also loss of libido. Men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, depression). If a man experiences loss of erection, he may worry that it will happen again. This can produce anxiety associated with performance and may lead to chronic problems during sex. If the cycle is inescapable, it can result in impotence. Psychological factors in impotence are often secondary to physical causes, and they magnify their significance. Problems in your relationship with your sexual partner can also cause erectile dysfunction. Improving your relationship may help your sex life. If you decide to seek therapy, it will probably be most effective if your sex partner is included. Couples can learn new ways to please one another and to show affection. This can reduce anxiety about having erections. Feelings that can lead to erectile dysfunction • Feeling nervous about sex, perhaps because of a bad experience or because of a previous episode of impotence • Feeling stressed, including stress from work or family situations • Being troubled by problems in your relationship with your sex partner • Feeling depressed • Feeling so self-conscious that you can't enjoy sex • Thinking that your partner is reacting negatively to you

How is ED diagnosed?

Patient History Medical and sexual histories help define the degree and nature of ED. A medical history can disclose diseases that lead to ED, while a simple recounting of sexual activity might distinguish among problems with sexual desire, erection, ejaculation, or orgasm also psychological or organic problem.

Physical Examination A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to touching, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics, such as hair pattern or breast enlargement, can point to hormonal problems, which would mean that the endocrine system is involved. The examiner might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem—for example, a penis that bends or curves when erect could be the result of Peyronie's disease.

Laboratory Tests Blood Tests and Urinalysis to Diagnose ED Blood tests can indicate conditions that may interfere with normal erectile function. These tests measure hormone levels, cholesterol, blood sugar, liver and kidney function, and thyroid function. Excess prolactin (hyperprolactinemea) can lower testosterone levels, which can diminish libido. Both of these levels are measured, as well as levels of other sex hormones. If they are persistently low, an endocrinologist (hormone specialist) should be consulted. CBC–Complete blood count (CBC) of red cells and white cells is used to evaluate the presence of anemia. A low level of red cells limits the body's utilization of oxygen and can lead to fatigue and general malaise. The level of blood lipids (fats) such as cholesterol and triglycerides may indicate arteriosclerosis, which can reduce blood flow to the penis. Liver and kidney function tests–Liver and kidney disease can create horomonal imbalances. Blood tests for liver function involves analysis of enzyme and serum creatinine levels, which are indicators of kidney efficiency. Thyroid function tests–Thyroid hormones regulate metabolism and the production of sex hormones; a deficiency may contribute to impotence. Urinalysis–Urine is analyzed for protein (albumin), sugar (glucose), and hormone (testosterone) levels that may indicate diabetes mellitus, kidney dysfunction, and testosterone deficiency. Erectile Function Tests to Diagnose ED Tests that assess erectile function examine the blood vessels, nerves, muscles, and other tissues of the penis and pelvic region. Duplex ultrasound–Duplex ultrasound is used to evaluate blood flow, venous leak, signs of artherosclerosis, and scarring or calcification of erectile tissue. Erection is induced by injecting prostaglandin, a hormone-like stimulator produced in the body. Ultrasound is then used to see vascular dilation and measure penile blood pressure (which may also be measured with a special cuff). Measurements are compared to those taken when the penis is flaccid. Prostate examination–An enlarged prostate, which can be detected with a digital rectal examination or with sonography(USG) can interfere with blood flow and nerve impulses in the penis. Penile nerve function–Tests such as the bulbocavernosus reflex test are used to determine if there is sufficient nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger inserted past the anus. Specific nerve tests are used in patients with suspected nerve damage as a result of diabetes or nerve disease Nerve Conduction tests (NCT) with the help of machine. Nocturnal penile tumescence (NPT) or electro penile graph–It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). These erections occur about every 90 minutes and last for about 30 minutes. Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. Snap gauge involves wrapping three plastic bands of varying strength around the penis. Erectile function is assessed according to which bands break. Strain gauge involves placing special elastic bands at the base and tip of the penis. These bands stretch during erection and register changes in circumference. Penile biothesiometry–This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glands and shaft of the penis. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence. Vasoactive injection–When injected into the penis, certain solutions cause erection by dilating blood vessels in erectile tissue. Normally, these injections produce an erection lasting about 20 minutes. During this procedure, penile pressure is measured and x-rays may be taken of the penile blood vessels using a special dye (contrast agent). Magnetic resonance angiography (MRA) This is similar to magnetic resonance imaging. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. Doctors may inject a "contrast agent" into the patient's bloodstream that causes vascular tissues to stand out against other tissues. The contrast agent provides for enhanced information regarding blood supply and vascular anomalies.

Psychosocial Examination A psychosocial examination, using an interview and a questionnaire, reveals psychological factors. A man's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

How is ED treated?

Most physicians suggest that treatments proceed from least to most invasive. For some men, making a few healthy lifestyle changes may solve the problem. Quitting smoking, losing excess weight, and increasing physical activity may help some men regain sexual function. Cutting back on any drugs with harmful side effects is considered next. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of blood pressure medicine. Psychotherapy and behavior modifications in selected patients are considered next if indicated, medicatipons like L-Arzenin, pramirol, Zink, Vitamines, Yohimbin, suldenafil, Tadalafil, Diatery suppliments, treatment of basic couse with indicated yoga or exsersice then followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.

Psychotherapy – sex therapy

Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED from physical causes is being treated. Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Vacuum Devices Mechanical vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body . One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse.

Surgery Implanted devices, known as prostheses, can restore erection in many men with ED. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of technological advances. Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the crotch or fracture of the pelvis. The procedure is almost never successful in older men with widespread blockage. Surgery to veins that allow blood to leave the penis usually involves an opposite procedure intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

Hope through Research Advances in suppositories, oral and injectable medications, implants, and vacuum devices have expanded the options for men seeking treatment for ED. These advances have also helped increase the number of men seeking treatment. Gene therapy for ED is now being tested in several centers and may offer a long-lasting therapeutic approach for ED.

Points to Remember

• Erectile dysfunction (ED) is common but treatable condition, but couse for dysfunction should be known( with proper investigations). Patient should always ask for diagnosis and basic couse and why and for what medications are priscribed to treating doctors.

• ED increases with age, in young population diagnosis is easy and also treatment.

• ED usually has a physical cause , psychological couse can be primary or secondary to basic couse.

• ED is treatable at all ages.

. Oil, powder, non-labled medications given by doctor should not be taken. Patient should ask name of medicine, price if purchased from outside, expiry date and other questions.... Mostly ED increases due to unethical problems or fear produce by doctor in patients mind to make money. Keep options open, take second opinion from other MBBS,MD doctor, sexologist or medicine.

• Treatments include psychotherapy, drug therapy, vacuum devices, and surgery, DO NOT USE OILS .

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