Section headings and links:
3. Pathogenesis - the origins of the problem
4. Physical factors - contributing factors
5. Psychological factors - contributing factors
A holistic view is described for the management of erection problems (erectile dysfunction). The history, investigation and the joint choice of treatment by doctor and client is detailed, and including the client’s partner is encouraged. The increasing importance of good management for erection problems is indicated by the prevalence of the condition and the greater expectations of those effected by it.
Erectile failure is defined as a persistent inability to attain and maintain an erection adequate to permit penetrative sex. Kinsey in his classic survey estimated the prevalence of erectile failure as 2% before 40 years of age and 75% at 89 years if age. A more recent survey (Slag) of 1180 men attending a medical outpatient clinic found 34% to have erectile problems.
An extensive population study, the Massachusetts Male Aging Study (MMAS), surveyed 1290 men and showed the prevalence of complete erectile dysfunction increased from 5 % to 15% between the ages of 40 and 70. Age was the variable most strongly associated with dysfunction. The prevalence of erectile difficulty of all degrees (classified as nil, minimal, moderate and total) was 52% In diabetes the prevalence of erectile dysfunction increases from 15% at age 30 to 34 years to 55% at age 60 years.
Either physical or psychological factors may cause erectile dysfunction and as the means of investigation have improved physical factors have been identified more often. Currently there is thought to be a physical cause in about 75% of cases. There are always psychological (ie emotional) factors reactive to the physical problem and in some 25% of patients the psychological disturbance is the primary event.
Physical factors leading to erectile difficulty may be classified as vascular, iatrogenic (caused by medication), endocrinological or neurological. Otherwise the cause is psychological or a combination of physical and psychological ie a mixed type.
Feldman described an association of erectile dysfunction with heart disease, hypertension, diabetes and medication as well as with psychological factors (anger, depression, sub-dominance) and lifestyle factors (smoking).
1. Vascular There is an association of erectile dysfunction with myocardial infarction, coronary bypass surgery, cerebrovascular accidents and peripheral vascular disease. In untreated hypertensives 8-10% have erectile dysfunction at the time they present and vascular risk factors such as hypertension and cigarette smoking increase the likelihood of finding impaired penile vascular blood flow. Cigarette smoking is described as a risk factor in its own right for vasculogenic erectile dysfunction.
Distal vascular occlusion is more evident from the age of 50 onwards. Penile arterial disease is often part of a generalized atherosclerotic process. Proximal vessel occlusion of the aorta or pelvic arteries may also lead to vascular insufficiency distally. Vascular leakage refers to the loss of blood from the sinusoidal spaces due to a failure to the ‘venous flaps’ in the tunica albuginea to limit its escape. Erection is under parasympathetic control, mediated by acetylcholine which acts on endothelial cells to release a second carrier, nitric oxide, which in turn relaxes trabecular smooth muscle. During erection there is dilation of the arteriolar vessels leading to the sinusoidal spaces, and relaxation of corporeal smooth muscle. Detumescence is under sympathetic control which is also involved in mediating orgasm and ejaculation.
In Peyronie’s disease there is small vessel inflammation in the connective tissue adjacent to the corpora cavernosa leading to fibrosis and a palpable plaque. Trauma is a relatively rare causative factor. An asymmetric uncomfortable erection may then accompany arousal and if curvature of the penis is severe vaginal penetration may be difficult. The incidence of Peyronie’s disease is thought to be increasing. Correction of the deformity is most commonly undertaken by wedge resection of the plaque (Nesbit’s operation).
2. Iatrogenic Some drugs can lead to erectile difficulty (eg β blockers, tricyclic antidepressants, due to their anticholinergic action) and many other drugs rarely may do so (allopurinol, cimetidine, clofibrate, cyproterone acetate, haloperidol, meprobamate, metoclopramide, phenothiazines, spironolactone). It may be difficult to distinguish the effect of medication from the effect of the illness for which the medication is taken. Definite diagnosis of dysfunction due to medication is made where there is a reproducible dose related effect that disappears on stopping the drug. Stopping medication, if possible, may help to assess erectile function.
3. Endocrinological The action of androgens to increase libido and sexual behaviour is well recognised, but their beneficial effect on the mechanism of erection, orgasm and ejaculation is less well known.
a. Primary testicular failure: peak levels of testosterone occur in the 20s and decline gradually thereafter. Premature decline in free testosterone levels from the 40s onwards may be accompanied by loss of libido, erectile failure and symptoms similar to the female menopause (flushes, sweating, aches and pains, stiffness, loss of energy, dry skin, depression), The patient sometimes gives a history of testicular trauma, torsion of the testis, viral orchitis, high alcohol intake or non-descent of the testis. More often none of the above have occurred.
b. Testicular failure secondary to pituitary disease: vasectomy may be followed by erectile difficulty after 10-15 years, possibly due to altered immune mechanisms such as anti-sperm and anti-testicular antibodies and circulating immune complexes. In the testosterone resistance syndrome normal testosterone levels in the blood may be associated with a poor response at the peripheral receptor sites. The reason for this is unknown.
c. Diabetes: in insulin dependent (type 2) diabetes vascular and neurological damage occurs and there are renal, hormonal and psychosocial factors. There is narrowing of arteries due to atherosclerosis and damage to the autonomic nervous system. About 40% of male diabetics will develop erectile dysfunction. Onset is earlier than in the general population often within 10 years of the diagnosis being made, whether of insulin dependent or non insulin dependent type.
d. Hypothyroidism: may lead to a loss of sexual desire and poor erections. Erectile failure also occurs with an increase in sex hormone binding globulin (SHBG).
4. Neurological Erectile dysfunction is not usually the presenting event. In younger people multiple sclerosis is relatively often associated with erectile dysfunction. Damage to the autonomic system supplying the penis occurs with spina bifida, fractures of the pelvis and with radical prostatectomy, less often with transurethral prostatectomy or after radiotherapy to the prostate. Erectile failure has been reported in temporal lobe epilepsy.
5. Other Factors
a) Alcohol and drug abuse: the influence on sexual functioning of moderate alcohol consumption is initially relaxation and loss of social inhibitions. The MMAS subjects showed only a slight association of alcohol intake with erectile failure though a single bout of heavy drinking may lead to an episode of erectile dysfunction. when drinking is heavy and long term the effects are: impaired liver function, elevated oestrogen with breast development (gynaecomastia) and testicular atrophy, reduced testosterone levels and loss of libido.
Sexual problems, mostly erectile dysfunction, were reported in 63% of 100 male alcoholics attending a treatment centre. In the long term social and psychological factors also adversely affect sexual functioning.
Erectile dysfunction is reported with the long term (daily) use of marijuana in 20% of those studied. Heroine and morphine have marked inhibitory effects on sexual functioning and erectile problems occur in nearly half of a group of heroin addicts while taking the drug.
b) High-density lipoproteins: an increase in HDL (‘good’) cholesterol was accompanied by a reduction in the likelihood of erectile failure in the MMAS subjects. Negative effects of inactivity and obesity on sexual functioning were reported.
c) Chronic disease. Chronic diseases of the liver or kidney and any severe illness (eg 50% of those with myocardial infarction) may temporarily have impaired erectile functioning.
These may be immediate or remote: ie. arising within the patient’s current life situation or from adverse childhood experience. Once a pattern of failure is established it is more difficult to break the cycle of anticipation and failure. Performance anxiety with frustration and guilt about failure, perpetuate the pattern and is compounded by pressure or over concern from a partner. Avoidance of possible sexual scenarios is common.
Remote causes: Understanding the early origins of a current sexual problem may respond to individual or couple therapy whether humanistic or psychodynamic in approach. A discussion of these is beyond the scope of this article but sexual problems including erectile dysfunction often improves with a cognitive ‘here and now’ approach despite underlying problems (eg personality or character disorders).
Immediate Causes: These include cultural taboos and myths, ignorance and poor social skills. Examples of taboos are: ‘Don’t talk about sex’, ‘sex is (only) for having babies’, ‘older people don’t do sex’, ‘don’t make a noise’. Examples of myths are: ‘We should know what to do sexually without learning it’, ‘men are active, woman passive’; ignorance of anatomy eg. genitals leads to poor technique. Poor communication skills include: not dealing with negative feelings, not asking for what we want, mindreading, interrupting, blaming. Erectile problems are more likely to occur where there is fear of being emotionally close (‘engulfment phobia’), and when there are control issues (‘top dog, bottom dog’).
Precipitation factors: There is often a ‘trigger’ event. This may be physical (tiredness, illness), emotional (anxiety over performance, adjustment to a new baby), life events (redundancy, retirement, extramarital relations, pain on intercourse or loss of desire).
The presenting problem: The ‘story’ is to be listened to with care and there is relief for the client in its sharing. A client may themselves also know what is wrong and why and the help that is needed.
Often there are feelings of failure, and shame. The client may be depressed or obsessive. Because of the risk of failure the couple may avoid closeness. A single man may avoid meeting females or dump a partner when intimacy arises.
A partner may feel anger or self blame. Needs for affection may be expressed on the children and all sexual contact avoided. Help may only be sought at the point of separation. Treatment of the man alone may collude with his reluctance to look at relationship factors. Leiblum and Rosen warn against the neglect of dynamics of couples and emphasises issues like status and dominance, sexual attraction, intimacy, trust and sexual scripts (messages) from childhood.
In homosexual relationships the physical factors leading to erectile dysfunction are often the same as in heterosexual relationships. Sometimes a ‘gay’ man will enters a ‘straight’ marriage and when their orientation is denied sexual function is impaired.
Medication, sexual, relationship and childhood history.
It is easy to get details of medication and factual details of the family (names, ages etc) but a history (for example of sexual abuse) may be withheld or beyond conscious recall. As doctor or/therapist there is a need to register feelings in response to a client (unengaged, warm, defensive). These so called counter-transference feelings provide the basis for recognizing what has not been said.
Diagnostic ‘pointers’ have been described for a cause which is (a) psychological: nocturnal or spontaneous erections occur. Erections occur with masturbation (‘Can you get yourself an erection by any means?’); (b) hormonal: the patient is usually over 40, symptoms tend to be progressive with a reduced libido; (c) neurological: waking and nocturnal erections are absent, and there is a progressive, unvarying course, with intermittent diarrhea and impaired orgasmic sensation. Erection with central stimulation (eg fantasies) is absent, while reflex erection from direct stimulation to the penis may remain’ (d) vascular: with generalized small-vessel disease due to atherosclerosis there is a progressive loss of spontaneous and nocturnal erections. Erectile response to central stimuli (fantasy) or to direct stimulation to the penis is absent. In the pelvic steal syndrome there is initially an erection followed by detumescence as arteriovenous shunts in the pelvic vascular bed divert the blood supply
Where the cause is psychological signs of physical disease are absent. If hormonal there may be breast swelling (gynaecomastia), female hair distribution and small (atrophic) testes. Neurological signs may include postural hypotension, impaired sweating, visual field loss, impairment of cremasteric, anal and pubocavernosal reflexes and reduced testicular sensation. There is evidence of other neurological disease: multiple sclerosis, diabetes, or a spinal cord lesion. If vascular the pulse is reduced in the penile arteries and depending on how extensive the lesions are they may be impaired proximally to the level of the dorsal, popliteal, and femoral arteries. The penis and possibly the lower extremities is pale and cold. Evidence of vascular disease is often present elsewhere (eg heart vessels).
Blood tests are done of hormonal status: the pituitary axis (FSH, LH, prolactin, TSH), oestradiol, testosterone, SHBG, and free testosterone; and fasting or 2-hour postprandial blood sugar.
It is essential that prostate function is assessed by measuring prostatic specific antigen (PSA) and a rectal ultrasound of the prostate is done. It is now accepted that androgen supplementation does not induce prostate cancer but may promote one already present.
In the diagnostic papaverine or prostaglandin E1 test, an intracavernosal injection of a vasoactive drug, such as papaverine hydrochloride or PGE1 is given. The initial dose of papaveriine is 8-15mg; of PGE1, 5μg increasing to a maximum of 60 mg and 20μg respectively. The size of the dose is titrated against the firmness of the erection graded on a scale of 0-4, a 3+ response being sufficient for penetration. The time taken to achieve an erection and its duration are noted. The induction of a firm erection effectively excludes a vascular cause, but 10% of patients do not respond because of anxiety which induces an increased sympathetic tone (a false-negative response).
PGE1 gives a fuller erection than papaverine. With either priapism, with a hard painful erection continuing for more than 4 hours, occurs rarely (less than 1:1000). Effective immediate treatment is the withdrawal of 50ml blood from the corpora cavernosa. Failure to treat may lead to irreversible cavernosal fibrosis. If a serious vascular problem is suspected a colour Doppler ultrasonograph and cevernosogram will demonstrate whether the cause is arterial or venous
After getting the history of a sexual problem, a physical examination, blood tests and sometimes other investigations are essential. The commonest first and least invasive line of treatment is with PDE5 inhibitors - sildenafil (Viagra), tadalafil (Cyalis) and vardenafil (Levitra) psychosexual and couple counselling, HRT, but alternatives intracavernosal injections of alprostadil, a vacuum pump and surgery with a penile implant.
Treatment can best be described from the perspective of the diagnostic categories: organic (endocrinological, vascular, neurological, other); and psychological (including mixed types).
(a) Testosterone deficiency. Replacement therapy is indicates where hormonal assay shows a total testosterone of less that 10nmol/Lree or the free testosterone index (FTI) is reduced. Testosterone may be given orally (eg testosterone undecanoate 40mg three times a day) by the administration of a depot preparation of testosterone ester every 2 weeks, or by long-acting crystalline testosterone as an implant about three monthly.
(b) Relative testosterone deficiency. In the androgen resistance syndrome there is a high FSH, high LH and high or normal testosterone. These figures indicate receptor site resistance to testosterone. Treatment is the same as for absolute testosterone deficiency.
(c) Low free testosterone. The proportion of circulating testosterone, which remains unbound by sex hormone binding globulin (SHBG), the free testosterone, is reduced. (Testosterone is about 98% bound to SHBG and 2% free)
(d) The ‘kick-start’. Androgens are sometimes used to kick-start an older person when erections have failed after a period of inactivity (such as after the death of a spouse) although hormone levels are within the normal range. A short course of testosterone may stimulate libido and gives an increased level of energy and well being.
The diagnostic test with papaverine or PGE1 indicates its therapeutic potential. A PDE5 inhibitor may give sufficient smooth muscle relaxation to allow erection to occur.
Venous leakage man be treated by penile vein ligation or by a vacuum device.
A penile implant with a solid or inflatable mechanism. The latter has a pump device in the scrotum and a reservoir in the placed in the pelvis.
Kegel’s exercises (alternating tightening and relaxing the pelvic floor muscles to increase their tone) promotes erectile function.
Neurogenic causes of erectile dysfunction may be associated with a prolonged response to medication. The technique of self-injection of intracavernosal Caverject is taught for home use. The rare side-effect of a prolonged erection (lasting more than 4 hours) can occur and is managed by the withdrawal of 50ml of blood from the corpora cavernosa. There is sometimes superficial bruising at the site of the injection and rarely reactive fibrotic nodules may occur leading to mild penile curvature.
External vacuum device: These offer a non-invasive alternative to intracavernosal injection. The device consists of a cylinder which is placed over the shaft of the penis and from which air is pumped to create a vacuum. An erection results and is maintained by slipping a band over the base of the penis before removing the pump. The vacuum device looks cumbersome but demonstration videos and an advisory service are available. (Examples are the Rapport System, Erec-Aid and Post-T-Vac)
Whether or not there is an underlying physical cause to erectile dysfunction repeated failure leads to shame (‘performance anxiety’) and avoidance of sexual activity.
The most frequently prescribed medication is with one or other of the PDE5 inhibitors: sildenafil (Viagra), tadalafil (Cyalis) or levitra (Vardenafil).
It is fair to say that this group of drugs has revolutionized the management of erectile dysfunction in the past 15 years. They have in common the mechanism of their action which is by release of nitric oxide to vasodilate and increase penile blood flow, leading to erection when sexually aroused.
There is some variation in the strength and duration of their action, Sildenafil giving a slightly better erection while Tadalafil offers longer duration. Vardenafil ‘s benefits lie somewhere between those of Sildenafil and Tadalafil
Side-effects vary between individuals and rugs. They are most frequently visual (colour distortion), headaches and indigestion. These symptoms are dose related and it is recommended when starting any of these medications take a low initial dose. The most important contra-indications are the use of nitrites taken at the same time (the group of medications used for angina) and the use by a person who is at high risk of a cardiac event.
Yohimbine, first choice medication before the PDE5 inhibitors were available, is an α²-antogonist with an action on the central nervous system. Peripheral mechanisms for engorgement need to be intact for the drug to be effective, although improvement in erectile function has been reported with both psychogenic and organic forms of dysfunction. The therapeutic effect may be delayed 2 or 3 weeks. The usual dose of yohimbine is 6mg three times a day or as a single dose of 6mg 1 hour before intercourse. The drug is well tolerated, although anxiety, agitation and sweating may occur. Hypertension has been reported with it and is a contraindication to its use.
The distinction between physical and psychological causes is not always clear and a persisting wish to find an elusive physical cause is common.
There are a number of different approaches to the management of psychologically caused erectile problems. Most often a brief form of therapy is used (of about 12 sessions) that combine cognitive and behavioural approaches. It is important to listen to possible problems in a couple’s relationship.
Helen Kaplan gave a full account of therapy combining psychodynamic and behavioural techniques in her book the New Sex Therapy.
More commonly a brief, primarily behavioural, form of therapy is employed, an early example of which is the so-called PLISSIT model, described by Lo Piccolo. He considered, in sequence, the following:
1. Permission. In the context of erectile difficulty permission is given, for example, to relax and let go of pressure to perform, and to explore ways being together physically that are pleasurable but exclude penetrative sex. The permissive attitude and of the therapist helps counter prejudice and encourage exploration and communication - the sharing of feelings and ‘risking’ of new behaviours.
2. Limited information. The patient is informed about the anatomy and physiology of erections, the changes of ageing (eg the reduced frequency of penetrative sex, loss of a partner’s lubrication, extended duration of the latent period); the therapist is comfortable with a vocabulary about sex which helps couple’s communicate.
3. Specific suggestions. Examples are the adoption by the women of the superior position to facilitate vaginal entry, the use of Kegel’s exercises to gain control of the erectile process, breathing exercises to help relaxation, sensate focus therapy (see below) etc.
4. Intensive therapy. This is recommended to the minority of clients for whom longer-term therapy is appropriate.
Sensate focus therapy (first described by Master and Johnson in 1966) combines for couples the use of interpretation and the insights of dynamic therapy (in sessions), with a behavioural approach that sets a hierarchy of non genital and genital contact (as homework assignments). The principle requires repeated pleasurable experiences to extinguish anxiety before proceeding to a higher level in the hierarchy. Effective therapy is often gradual, the pace set by the couple, and the outcome is good in about 75% of cases.
Support in dealing with client material that’s highly charged emotionally is important in any treatment programme and may include issues of self esteem, control, sexual attraction, fear of intimacy, trust, abandonment and shame.
Performance anxiety often accompanies erectile difficulty that persists. Techniques to counter anxiety and encourage relaxation include: breathing exercises, massage, Ericksonian suggestion, hypnotherapy and visualization. To break the pattern of anticipated failure the use of a PDE5 inhibitor may be helpful in conjunction with ‘talking’ therapy.
Other buried feelings of anger and sadness (eg after a failure to mourn) can lead to withdrawal, depression and erectile difficulty and erectile failure and depressive illness may each reinforce the other. Acknowledgment and release of emotions may help the rediscovery of tenderness and love.
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