Erectile dysfunction (ED, impotence) is a common problem among men. There are many factors among the reasons. It is generally seen in advanced ages and as a complication of systemic diseases. Today, it can also be seen at younger ages. Previously, erectile dysfunction was thought to be mostly due to psychological causes, nowadays this problem is mostly due to organic causes. In this article, I will give general and up-to-date information about the erection problem.

What is erectile dysfunction?

Erectile dysfunction (impotence, sexual dysfunction, erectile dysfunction) is defined as the inability to achieve or maintain an erection sufficient for sexual intercourse.

It is not a very serious problem to have erectile dysfunction problems from time to time rather than constantly. If it is a constant and progressive problem, it stresses the person, causes a loss of confidence and negatively affects relationships. Erectile dysfunction may be a symptom of an underlying disease, and the treatment of this disease also corrects the erection problem.

What is the incidence of erectile dysfunction?

Studies have reported that 52% of men between the ages of 40-70 have erectile dysfunction. Of these, 17% are mild, 25% moderate, and 9% severe. In a study conducted in Turkey, it was shown that 69% of men experience erectile dysfunction and this becomes more severe as they age.

ED can also be seen in young people. Studies have shown that 26% of men under the age of 40 have erectile dysfunction. In another study, it was reported that erectile dysfunction (impotence, impotence) was 14% in healthy and non-obese men under 40 years of age.

What are the causes of erection problem?

Erection is a complex event that concerns the brain, hormones, mood, nervous system and cardiovascular system. Any problem arising from these systems can cause erectile dysfunction. Sometimes, psychological and organic reasons can be the cause of sexual problems together.

Organic causes: Organic diseases that often cause erectile dysfunction in men are;

• Cardiovascular diseases (cardiovascular causes)
• Hardening of the arteries (atherosclerosis seen in advanced age)
• High cholesterol level
• Hypertension (high blood pressure)
• Diabetes (diabetes)
• Obesity (obesity)
• A still life
• Advanced age
• Metabolic syndrome (high blood pressure, diabetes, obesity, high cholesterol)
• Parkinson’s disease
• Multiple sclerosis
• Some drugs (such as cholesterol drugs, heart medications…)
• Excessive smoking
• Penis diseases (such as Peyronie’s disease)
• Excessive alcohol use
• Drug use
• Sleeping disorders
• Drugs that lower the testosterone level (drugs used in prostate enlargement)
• Past surgeries: Pelvic surgeries such as prostate, bladder and bowel surgeries (radical cystectomy, radical prostatectomy)
• Low serum testosterone level (hypogonadism)

Psychological reasons: Psychological factors are very important in erection. Psychological reasons that cause erection problems are as follows;

• Mental problems such as depression, anxiety
• Excessive stress
• Matching problems between spouses

What are the risk factors that cause erectile dysfunction?

There are some risk factors that negatively affect erectile functions in men. We can summarize these risk factors as follows:

• Medical reasons: such as diabetes and cardiovascular diseases.
• Excessive smoking: Smoking causes erection problems due to its effects on the arteries and veins of the penis, especially by adversely affecting the vascular system.
• Excess weight: Obesity is one of the important causes of sexual dysfunction.
• Some medical interventions: such as prostate and bladder cancer surgery, pelvic radiotherapy (radiation therapy).
• Traumas: Traumas that damage the vascular and neural structures of the penis.
• Various drugs: Antidepressants, antihistamines, cholesterol-lowering drugs, drugs that lower testosterone levels, some drugs used for cardiovascular diseases.
• Psychological reasons: Stress, depression and anxiety caused by problems in the working environment or family negatively affect people’s normal life and sexual life.
• Various drugs, drugs and alcohol use: Especially chronic and excessive alcohol use has a negative effect on sexuality.
• Age: Sexual problems increase with age. With a healthy life, sexual activity can be maintained in advanced ages.

What kind of complaints are there in patients with erectile dysfunction?

Erection problem is a common problem in urology outpatient clinics. While patients used to hide their complaints in the past, today there has been a significant increase in the rate of consulting a doctor. Patients with erection problems often apply to the doctor with the following complaints:

• Hardening problem
• The problem of not being able to maintain an erection
• Lack of sexual desire

What are the negative effects of erectile dysfunction?

Erectile dysfunction affects people’s family life, work life and normal daily life negatively. The negative effects caused by this situation are as follows;

• Stress and anxiety
• Problem of adaptation to social life
• Inability to concentrate on work
• Decreased self-confidence, sense of shame
• Relationship or family problems
• Ending of marriages (separation)
• Unrest in sexual life
• Infertility in severe cases

Advice for men with erection problems

Preventive treatment, that is, the elimination of the conditions that cause the disease, is very important in patients with sexual problems. What these patients should do:

• Against chronic diseases (if there are problems such as diabetes, high blood pressure, heart disease, to strictly comply with the recommendations regarding them)
• Having regular health checks
• Cessation of alcohol, smoking and drug use
• Coping with situations that cause stress, anxiety and depression.
• Doing sports regularly
• Healthy eating
• Overweight patients to reach their ideal weight by losing weight

How is the diagnosis of erectile dysfunction made?

In order to diagnose erectile dysfunction patients, a detailed evaluation should be made. The actions to be taken for this purpose are as follows;

• Detailed questioning: The situations that may cause stress are investigated by asking questions about the problems in the work environment, family environment and other social environments.
• Examination: Genital examinations of the patients are performed. The penis and testicles are evaluated. The development of secondary sex characters is examined.
• Laboratory tests: For this purpose, serum kidney function tests, liver tests, fasting blood sugar, hormones such as testosterone, prolactin, and serum cholesterol levels are requested.
• Urinalysis: Urinalysis does not give direct information about the cause of erectile dysfunction, but it can sometimes show an underlying disease. Like diabetes.
• Colored Doppler ultrasonography of the penis: In patients with erection problems, the condition of the arteries that bring clean blood to the penis and the veins that carry dirty, that is, oxygen-free blood, are evaluated in color Doppler USG. If there is an arterial insufficiency, it can be detected here. This USG is usually done after injecting into the penis, which helps to develop an erection.
• Neurological tests: If neurological factors are considered as the cause of erectile dysfunction, neurological tests are performed on these patients.

Treatment of erectile dysfunction

Treatment of erectile dysfunction should be done as a result of a detailed evaluation. After the conditions that cause the disease are revealed, step-by-step treatment planning is started. It would be more appropriate to inform the spouses together, especially if surgical treatment is being considered.

 Oral treatment and drugs used for this purpose: In these patients, the first-stage treatment is to start treatment with oral drugs, depending on the patient’s condition and the underlying cause. Today, very effective products are used for this purpose. Oral medications in patients with erectile dysfunction are as follows;

• Sildenafil (Viagra)
• Tadalafil (Cialis, Hardcis, Lifta)
• Vardenafil (Levitra)
• Avanafil

The mechanisms of action of these drugs are similar to each other. In general, oral drugs are effective by increasing the effect of nitric oxide (NO), a very important mediator molecule in erection. These preparations do not show the same efficacy in every patient, even they may show different effects in the same patient at different times. These are not drugs that are taken like normal painkillers and show their direct effects, sexual stimulation should definitely be in the patients. The doses and duration of action of each of these and their interactions with different drugs are important. The relevant urologist should pay attention to these issues.

The main side effects of oral erection drugs:

• Facial redness
• Congestion due to increased blood supply in the nose
• Headache
• Vision problems
• Back pain and stomach problems

Conditions to be considered while taking medication:

• Those who take drugs containing nitrite-nitrate (drugs taken to treat angina)
• Heart patients
• These drugs can be dangerous for those with severe low blood pressure.

Healthy eating: How should patients with erectile dysfunction be fed? Nutrition is very important in these patients. The Mediterranean diet is known to be very effective in ED patients. This diet is also recommended for cardiovascular diseases. Recommended diet to reduce erection problems:

• Whole grain products, fruit-vegetable-based diet
• Avoiding excessive red meat, fatty dairy products and processed sugar
• Cut off if you have excessive alcohol intake

Alcohol, cigarette, drug use: Alcohol, smoking and drug use cause serious erection problems, especially in long-term and excessive users. First of all, these patients need to quit these habits.

Exercise: Lifestyle is a very important factor in the prevention of erectile dysfunction. Erectile dysfunction is more common in those who have a sedentary life, that is, those who have a very sedentary life. In this regard, patients are recommended to exercise regularly. The recommended ideal aerobic exercises are swimming and running at medium-advanced tempo. The recommended ideal aerobic exercises are swimming and running at medium-advanced tempo. Studies have shown that those who do aerobic exercise for 160 minutes a week for 6 weeks reduce the erection problem. Again, serum Testosterone level was found to be increased in those who do sports.

Yoga: Yoga can help relieve stress and relax people. Considering the negative effects of stress and anxiety on erection, it may be beneficial to recommend yoga to male patients with erectile dysfunction.

Psychological support: Psychological reasons play an important role among the causes of the disease. Therefore, in order to help these patients cope with anxiety and stress, it would be beneficial to receive support from relevant branches, if necessary.

Alternative medicine and alternative treatment methods: There are many products on the market for this purpose. Their contents, dosages and preparation methods are the subjects discussed all over the world. In developed western countries such as the United States, there is no herbal product approved for use for this purpose. As doctors, we do not prefer to use these products that have no scientific basis. Using these products can be dangerous for human health when there are drugs whose content is known, scientific and clinical studies and their effects-side effects are known.

Penile injection therapy: Drugs such as prostalandin E1 (PGE1) and papavrin are commonly used for this purpose. These are applied to the penis under sterile conditions with an insulin injector. They can cause pain, swelling and bleeding at the injection site. The most important side effects are prolonged erection. If the erection exceeds 4 hours, the patient must inform his doctor. This situation is not seen very often in the PGE1 application.

Gel application to the urethra: Alprostadil (Muse) is squeezed into the urethra (the urinary canal in the penis) and passes into the penile tissue and helps to harden.

Testosterone therapy: Testpsterone is an important hormone in erection formation and sexual desire. Some patients may have low serum testosterone levels (hypogonadism). If there is a low level of this hormone, it must be replaced.

Vacuum therapy: Vacuum devices are in the form of a cylindrical hollow tube. The penis is placed inside this tube to create an erection with pressure, at the end an elastic band is placed on the root of the penis to ensure that the erection does not go down. The patient has intercourse after the erection occurs, and after removing the tape at the end of the intercourse, the erection ends. It is a simple, inexpensive method without serious side effects.

ESWT (shock wave therapy to the penis): Low-intensity shock wave therapy to the penis (Li-ESWT) is a widely used treatment method in patients with erection problems. It is a method that does not have side effects, does not require anesthesia, and is applied under office conditions. The efficiency rate is between 60-80%. It is more effective in young and mild to moderate vascular disease. It is used for penile rehabilitation in patients who underwent radical prostatectomy and positive results are obtained.

PRP, stem cell therapy: Restorative treatments such as PRP and stem cell applications to the penis are not established treatment methods yet. There are different results in the literature. It is still in the experimental stage.

Surgical treatment in patients with erectile dysfunction (penile prosthesis surgery): If all other treatment options have failed, the last option for men with erection problems is to insert a prosthesis (happiness stick) into the penis. There are different types of penile prostheses:

• Malleable (one-piece): Flat, that is, one-piece, are structures made of cylindrical silicone that are placed directly on both sides of the penis in structures called corpus cavernosum. They remain in a permanent erection state.
• Inflatable: Two- and three-piece penile prostheses have pump systems. In this way, the patient can have intercourse by inflating the prosthesis at any time and can inflate it again at the end of the intercourse. With prostheses, patients can have normal sexual intercourse whenever they want, and they can enjoy normal intercourse. The most important complication for prostheses is future infections. The choice of prosthesis varies according to the patient.

In summary; erectile dysfunction is a disease that can be seen at younger ages, although its incidence increases with age. It is mostly of organic origin. Lifestyle changes, oral medications, penile injection treatments can be recommended to suitable patients. If there is no response to current known treatments, penile prosthesis surgery is the last option. Treatments such as PRP and stem cell therapies are still in the experimental stage.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY