Management of erectile dysfunction

Dr Raja Langer
For centuries impotence has been presumed to be the result of psychogenic causes (mental) and countless patients have undergone ineffective psychiatric treatment or worse fallen prey to aphrodisiacs and other thoroughly useless forms of medications dispensed by quacks. Research has now conclusively shown that impotence have physical or organic causes in 90% patients and is eminently curable. It is unfortunate that the blame for this is put on woman and labeled as frigid instead of man addressing this problem.
DIAGNOSIS OF IMPOTENCE:
First level
The major etiologies of Impotence is organic (include vascular, neurologic, endocrine disorders, and medications) and psychogenic (mental). The first distinction of impotence that should be established is psychogenic from organic. Oftentimes the treatment plan for impotence can be formulated with a focused history, physical exam and select lab-work.  A detailed history is the first important step to the evaluation. There are barriers to discussing sexual habits and problems. A clinician must approach the topic delicately and caringly in order to earn the patient’s trust. Onset, duration, severity, and etiology should be elucidated. A psychosocial history should be included as unstable interpersonal relationships, or emotional stressors can play a huge role in sexual health. Clues to suggest a psychogenic etiology include sudden onset, good quality spontaneous or self-stimulated erections, major life events, or previous psychological problems. Conversely, gradual onset, lack of erections and normal libido are more suggestive of an organic etiology. The International Index of Erectile Function (IIEF) is the most famous and used questionnaire in clinical practice and it showed a high diagnostic specificity and sensibility. Physical examination should include careful evaluation of the cardiovascular, neurologic, and genital systems. The presence of obesity, high blood pressure, hypogonadism, deficiencies in perineal sensation or evidence of peripheral neuropathy may be indicators of a diabetic or neurologic etiology. Penile deformity such as fibrous plaques, micropenis, bending of penis lends to the possibility of a physical impediment to sexual intercourse. Laboratory tests like renal function tests, fasting glucose, Hb1Ac, complete blood count, lipid profile, and serum testosterone, FSH, LH, prolactin should be attained.
Second level
Second level diagnostic evaluation uses specialistic instrumental examination that can be helpful for accurate etiological diagnosis of impotence.
In case of suspected vasculogenic etiology, PENILE DOPPLER ultrasonography allows direct visualization of penile vessels and evaluation of possible strictures and dysfunctions, able to study both arterial and venous flow velocity, assess erectile hemodynamics. This exam is performed after injection of Bimix injection (Alprostadil 10 mg plus Phentolamine 1-2 mg),or Trimix (Alprostadil, Phentolamine and Papaverine) in order to achieve the best erection and get over anxiety-induced failure .The author uses 60 mg papaverine alone in his lab. Ultrasonoghrapy is performed 5-10 minutes after injection. Peak Systolic Velocity (PSV), the End Diastolic Velocity (EDV) and the Resistance Index are measured; the last one can predict venous leak probability in patients suffering with ED. This test is also performed to assess impotence in medico legal cases in institutional set up.  Penile angiography is a third-line study used for evaluation of the penile vasculature.
TREATMENT OF ERECTILE DYSFUNCTION
Non surgical management
1) Lifestyle modification
Avoid sedentary lifestyle ,increase physical activity, aerobic activity of 30 min/day or 150 min/week, 5-10% weight reduction, increase consumption of fruits and vegetables, limit red meat and processed food, increase intake of PUFA and avoid added sugar beverages. Cessation of smoking and limit alcohol use (1-2 drinks /day). Avoid long distance bicycling. Change in medications causing impotence. Lipid lowering drugs (statins) have beneficial role.
2)  Herbal Treatments
There are various herbs that are effective in the treatment of impotence. These sex herbs (being investigated) help maintain erection longer, increase sexual desire, raise testosterone levels and increase sperm count. Major herbs for ED treatment are: Ginseng (some role), Korean red ginseng(panax ginseng)(potential role  but quality control a serious issue), Ashwagandha (increase energy, stamina only), Yohimbine ( only psychogenic ED),Gingko (only blood thinning effect), Horny goat weed (Chinese medicine, may help raise low levels of testosterone and thyroid hormone.),Catuaba bark extract (restores nervous system function only), Cuscuta seed extract ( increase sperm production only) ,Gokhru (increase testosterone level only),Damiana (aphrodisiac), Shilajit(aphrodisiac) Author does not prescribe these drugs.
3) Hormonal therapy
Patients with testosterone deficiency can be benefited with number of testosterone preparations available; Injectables, Gels (androgel1%), Transdermal patch (Testoderm 5mg on skin), Buccal, Oral preparations etc.
4)  Pharmacological
PDE5 inhibitors: Sildenafil 25, 50,100mg (Viagra, Penegra, Juan, Caverta) These are selective PDE5 inhibitor, enhances the pro-erectile effect of nitric oxide, one dose should be taken 2-3 hours before intercourse in a 24-h period when ever required. It is well tolerated in patients with diabetes, cardiovascular disease; contraindicated in patients who use nitric oxide donors or nitrates in any form. Tadalafil 10 mg; once in 3 days only.
Dopamine agonists: Sublingual Apo morphine enhances central pro-erectile mechanisms, increase libido.
Yohimbine and Phentolamine: (Aphrodisiac and erectogenic drug promoting sexual behavior)
Second line therapy
Vacuum constriction devices (plastic cylinders connected with vacuum generating source to create negative pressure for penile engorgement. Intrapenile injections may be combined to enhance erections. These are used for penile rehabilitation and to access artificial erection for intercourse.
Vacuum constriction device
Third line therapy
Intra cavernosal injections: Intra penile injections of Papaverine, Phentolamine and Alprostadil alone or in combinations are taught by andrologists to the patients for home use.
Fourth line therapy (Surgical management)
Penile prosthesis implantation: When the initial therapies fail, penile prosthesis implantation is usually appropriate in small group of patients. Various prosthesis devices are manufactured by American medical system (AMS) like malleable devices, two piece inflatable device, and three piece inflatable devices. Of them the three piece device AMS Ultrex is widely used. These are implanted in penile tissues and made functional by producing artificial erections as when required for intercourse.
Penile prosthesis AMS 700 ULTREX
(The author is Consultant Urologist & Andrologist. For queries and feedback: drlangerraja@yahoo.co.in)

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