Erectile Dysfunction in Men-Causes, Treatment and Options available

In the general population about 15% people are considered to be infertile for not able to achieve pregnancy in one year of unprotected married life. 40% of the problems are contributed by the male alone. There are several causes for male infertility. Among them erectile dysfunction or impotence is a common problem. Erectile dysfunction is defined as the inability of the male to attain erection sufficient to perform normal intercourse. The frequency of this problem increases with age. Some men experience erectile dysfunction temporarily. Generally it is caused due to severe stress, anxiety, strained relations in the family or the partner and stressful conditions in the working place. This is a common feature and most of the men experience this. However prolonged erectile dysfunction needs thorough investigation and should be treated. A proper history should be taken from both the partners before going into detailed investigations. Before going into the details of the causes etc it is better to understand the structure of the penis and the physiology of erection.

Structure of the Penis:
The penis or the male copulatory organ consists of three parts. 1. Root of the penis not visible from outside is firmly attached to the pubis bone. 2. Shaft of the penis visible outside is mostly made up of erectile tissues which are spongy in nature and are called corpora cavernosa and corpora spongiosam. The corpora spongiosam contains the urethra in the center. 3. Glans penis is the exterior part situated at the end of the shaft. The corpora spongiosam expands into a round structure and the external urethral meatus is located in the centre of the glans. The penile urethra is a common passage for the urine and the semen. The shaft and the glans are covered with a smooth fold of skin and the skin fold on the glans is called the prepuce. The skin protects the male organ. The skin at glans is attached by means of a fold called frenulam.

How Erection takes place:
The two sponges like tissues of the penis play an important role in erection of the penis during intercourse. Due to the sexual stimulation more blood is rushed into the two tissues and the sponge like tissues is filled with blood and they swell. Due to this the penis gets engorged with blood and becomes stiff, turgid and erect. The process of erection is complex involving neurological, vascular and hormonal systems of the body. Any disturbance in these three systems results in erectile dysfunction.

What are the common causes of Erectile Dysfunction (E.D)?
Psychological Causes: It is the most common form of impotence frequently seen due to anxiety, stress, prolonged work etc. The nocturnal and early morning erections will be normal. A careful examination and history from the patient should be collected to find out the exact cause of the problem. Psychological evaluation has to be done in both the partners to find the exact causes for the problem.

Hormonal disturbances causing Erectile Dysfunction:
A reduction in the testosterone production in the body causes loss of libido and erection. Decreased production of testosterone and sex hormone binding globulin are related to aging. Measuring the blood levels of both these hormones reveals the cause of the condition.

High levels of prolactin (Hyper prolactenemia) and renal failure are also common causes for erectile dysfunction.

Cavernosal Muscle Dysfunction: This is also a common form of impotence. Along with the cavernosal muscle dysfunction neuroendocrinal causes are also associated with this condition. The erectile tissues fail to relax consequent to the formation of fibrous tissue. This is very common in persons, undergoing prolonged treatment of impotence by injections of papaverin

Arteriosclerosis: Reduction in the blood supply to the penis due to arteriosclerosis (Thickening of arteries) found in cigarette smokers is also a cause to erectile dysfunction. Sometimes damage to the penile arteries may also happen during surgery in the perineal region resulting in lowered blood supply and impotence.

Damage to the spinal cord, intravertebral disc prolapse, or the presence of tumors is also responsible for erectile dysfunction.

Drug induced erectile dysfunction: The drugs used for reduction of blood pressure like beta blockers produce lowered blood supply to the cavernous tissues of the penis. Change of the drug usually improves the condition. Ranitidine and other drugs commonly used for hyperacidity and peptic ulcer also cause impotence. Drug abuse especially cannabis also suppresses testosterone production and increases the prolactin levels in the blood circulation and cause erectile dysfunction.

Diseases like diabetes, Hypertension, heart problems, uremia and depression also cause erectile dysfunction.

How the Erectile Dysfunction can been diagnosed:
Diagnosis can be made by careful history collection from both the partners, physical examination of the male, Laboratory investigations like blood tests to assess the hormone levels of testosterone, prolactin, LH, FSH, cholesterol and the lipid profile.

Color Doppler studies can also be made to assess the blood supply to the testis, penis. Venous leakage studies can also be made to assess the back flow of blood during erection.

Treatment options to over come erectile dysfunction:

• All the problems related to psychological disturbances causing erectile dysfunction can be relieved by counseling. Both the partners should be counseled either individually or jointly. Before evaluation careful assessment of the underlying problem is important.
• Use of Sildenafil citrate: A new drug under the trade name Viagra became popular in the recent years to treat erectile dysfunction. Sildenafil citrate restores the erection in a natural way to the sexual stimulation. A dose of 25- 100 mg is usually sufficient to produce erection and the erection is maintained up to 10 -15 hours. It causes relaxation of smooth muscle of the erectile tissues and enhances erection. It is a safe drug however it should be used under medical advice only. Patients with known Angina who are on nitrites should not take Sildenafil since it may cause fall in blood pressure and even it may become fatal.
• Use of mechanical devices: A vacuum constriction device is used and the penis is inserted into the device. The air inside the devise is pushed out with a small hand pump. By making like this blood is sucked into the penis and into the cavernous tissues resulting erection. Backflow of the blood is prevented by a placing a rubber band at the base of the penis. This devise works well if properly used and the purpose is served. Both the partners should co operate each for maximum benefit with this devise.
• Intra cavernous injections: Papaverin injection is given into the cavernous tissues to create erection Long term use of the drug causes fibrosis in the cavernous tissue and prevent the relaxation of the smooth muscle of the erectile tissue reducing the action of the drug. Formation of haematoma is another complication and in overall the injection is very painful. Some times prolonged erection also occurs and the erection even persist 3-4 hours or more and the condition should be treated immediately. Also the recent drug Sildenafil is replacing this injection.

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