Ways to deal with erectile dysfunction

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1502381

This is an interpretation of the main points of that article.

The causes of erectile dysfunction (ED) are often thought of as mostly organic. Phosphodiesterase-5 inhibitors such as Viagra have been of great importance in the treatment of ED and have promoted research and understanding of the etiology of ED - and this research has shown the close association of erectile problems with cardiovascular disease. Endothelial dysfunction is often revealed initially by problems with erection, and should there for be a warning sign for investigation into cardiovascular risk. ED is much more than a quality-of-life issue.

During the past three decades the connection between erectile dysfunction and organic disease has become clear. Before this, aside from advanced diabetes, pelvic trauma, the after-effects of pelvic radiation, surgery and spinal cord injury, the cause of ED was not always apparent.

But it has gradually become clear that ED is strongly associated with cardiovascular disease processes. Anecdotal, experimental, and scientific evidence now shows a clear link between erectile dysfunction and the risk factors for atherosclerotic cardiovascular disease.

In one study of 154 men with ED, 44% displayed hypertension, 23% showed diabetes mellitus, 16% were tobacco users, almost 80% had a body mass index greater than 26 kg/m2, and 74% had unhealthy levels of LDP cholesterol level (in excess of 120 mg/dL.2)

Also, the 10-year study of the MMAS has demonstrated that the original findings linking ED with cardiovascular risk factors were correct.

The development of intracavernosal and intraurethral prostaglandin and Viagra therapies may have led to the belief in the medical community that there was no real need to understand the etiology of ED. If the recommended therapy worked, why understand the etiology? Many urologists were goal-directed and de-emphasized the importance of diagnosis: the man was given information on the therapeutic options and left to make a decision.

But, by the end of 1998, three fourths of new Viagra prescriptions were being written by ordinary physicians: this required a  "Process of Care" model to guide non-specialist physicians in the treatment of Erectile Dysfunction.

This was written by experts in the area of male sexual dysfunction, so that non-urologists were correctly guided through the clinical approach to ED. In many ways, ED is still seen as a quality-of-life issue. And that is understandable. The problem is that research shows few men are willing to bring the subject up unless their doctor raises the issue first. Even though there is much more knowledge about erectile problems, may men and partners are still embarrassed by the subject. The result? A horrendous statistic: fewer than 25% of men with ED seeking medical care for this problem.

Yet when we ask what the significance of ED might be as a possible diagnostic clue for peripheral vascular disease, the whole issue begins to look much more serious.

The Penis And The Endothelial System

The penis is responsive to both sympathetic and parasympathetic nerve system stimulation, and it also responds to active vascular flow and passive venous occlusion. There is a significant endothelial surface which is interlaced with smooth muscle fibers. An erection involves lowering of the sympathetic smooth muscle contraction, and an increase in the  parasympathetic smooth muscle relaxation. There is an associated flow of blood into the penis which causes the endothelial spaces to fill, with a concomitant compression of the small veins which emerge from the tunica albuginea.

The whole process is regulated by the level of nitric oxide, produced in response to the activity of neuronal and endothelial nitric oxide synthase (nNOS and eNOS, respectively). The penis contains a high level of Nitric Oxide, so any disease which reduces the level of NO or the enzymes responsible for its synthesis will have a negative impact on erectile function.

Endothelial NOS levels are usually reduced when there is manifest cardiovascular disease and endothelial dysfunction. The scientific evidence which links NOS deficiency and ED is very compelling. But despite the strong link between ED and endothelial dysfunction, ED is not necessarily related to decreased NOS levels.

For example, a young man who suffers from sexual performance anxiety and loses his erection on the occasion of his first sexual experience is in difficulties because his sympathetic nervous system is overactive, which means the smooth muscles in his penis cannot relax; therefore, his penis never gets erect - or if it does, it loses the erection quickly.

Indeed, in men aged 35 or younger, men with no significant endothelial disease or neurologic risk factors, provided they are not using drugs or medications known to interfere with erectile function, most erectile problems are psychological. The finger of blame for erectile issues points firmly at performance anxiety in men of this age group.

But for older men, where there is a strong relationship between ED and endothelial dysfunction, the question needs to be asked if penile dysfunction is an indicator of endothelial dysfunction.

Why Diagnose ED?

Assessing The Degree Of Underlying Disease

We know Erectile Dysfunction can be a sign of a more serious underlying disease. A man with ED is likely to be hypertensive, hyperlipidemic, obese, diabetic, or aging. However, the key thing here is that erectile issues are an early sign of diseases, and it is obvious long before coronary arterial stenosis, retinopathy, hypertensive cardiomyopathy, or diabetic peripheral neuropathy.

For example, the presence of ED in a man of 52 is a sign that his endothelium is in bad health, and that drug therapy rather than diet or lifestyle changes may be needed. Therefore, enquiring about ED is a comparatively simple way to establish the severity of a man's endothelial disease.

ED As A Side-effect Of Drugs

Many of the medical conditions from which we suffer remain out of our awareness, so for example you might not be aware of your diastolic pressure or cholesterol level: but what you will know about is the side-effect of any treatment for these conditions.

So, for example, almost half of men with hypertension have ED which they ascribe to the drugs they take for Erectile Dysfunction. And, when a man knows he is going to have sex on a regular basis, he may stop taking his mediation to accommodate his sexual schedule. This will, of course, affect the effectiveness of treatment of his hypertension.

The reason why medication can cause erectile problems remains unclear. It's probably a combination of factors such a lowered blood pressure, organic effects of the medication, and the side-effects of the disease itself. 

But, whatever the cause, the outcome is limited compliance with drug therapy. One way to avoid this is to ensure the doctor takes account of the side-effects and discusses the treatment options with the patient thoroughly. There is no necessity - in most cases - for drug treatment to cause ED. Further more, use of the Sexual Health Inventory for Men before treatment for high blood pressure will help to identify men with latent ED, and their medication may be adapted accordingly.

Most conditions have a defined progression, and must be treated: so, for example, control of hypertension and dyslipidemia are definitely linked with the prevention of cardiovascular disease. For the doctor, physical examination and patient history may reveal very obvious symptoms of disease: for example, ED is a powerful indicator of endothelial disease.

A man may avoid sexual intimacy with his partner, but he knows that his penis is not working correctly. When his doctor asks him about heart disease, it is possible and probably necessary to explain how the two conditions may be linked to questions about angina and claudication. The doctor needs to take the chance to educate the patient about the connection between erectile dysfunction and cardiovascular disease. It is also a useful strategy for demystifying and reassuring the patient about the origin of his disease.

When Viagra Does Not Work

But making the diagnosis and recommending Viagra is not enough. In many cases, Viagra does not work. About 25% of cases, in fact. Having said that, it does improve quality of life for the men for whom it does work.

Nonetheless, treatment failures with this class of medication needs to be regarded with more gravity than they have previously been - some of the failures are attributable to relationship issues which need to be resolved or cannot be resolved; others are attributable to endothelial disease which is so advanced that the success rate of PDE-5 inhibitors is drastically reduced. The more serious the underlying endothelial disease, the less the bodily response to Viagra and other PDE-5 inhibitors. In short: if drug therapy (Viagra or its counterparts) fails when a man is complying with all the instructions, there is either a powerful psychological component to his problem or he has severe peripheral vascular disease.

How To Tell The Difference?

A man with psychogenic ED and a man with severe vasculopathy have different histories: and the man with vasculopathy may be a "walking time bomb." In other words, it's wise to regard PDE-5 inhibitor failures as the consequence of severe peripheral vascular disease until evidence merges to the contrary. Endothelial disease is often a forerunner of clinically manifest vascular disease. "The penis is an endothelial organ. Its failure to respond to PDE-5 inhibitors should be treated as a serious symptom."

Summary

The treatment of ED is more advanced now than ever before: only a decade or two ago, less than than 6% of men with erectile dysfunction were receiving treatment. Now, the figure is up to one man in four, and most of these men receives care from general practitioners.

For the author of this website, the main factor here is that the stigma of erectile dysfunction is still so great that both doctors and patients often avoid the topic. Time and embarrassment are the key reasons for this.

But because ED is sometimes an early sign of endothelial disease, and because men prescribed medication for other conditions may not take the medication if it induces ED, care and scrutiny by the doctor is needed. The functioning of a man's penis can truly be a measure of the health of his endothelial system.

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