Understanding Erectile Dysfunction

Galen was a second century Greek philosopher-physician born in 130 AD who rose quickly to fame with public demonstrations of anatomical and surgical skills. Penile erections were then thought to be due to ballooning of the organ due to air. The beginning of the Renaissance shows meaningful examples of scientific work on the penis and Leonardo da Vinci discovered that erections are actually caused by blood, from his observations of corpses and dissection of hanged men. He noted that hanged men, who often die with erections, exhibited a “large quantity of blood” filling the penis. His understanding of the anatomy of the penis and blood being the cause of erections was evident in his notes and anatomical drawings dating back to around 1492. And we now know that this is definitely not hot air. Pun intended.

Erections are often what a man would take for granted since it is a physiological phenomenon that takes place as a man reaches puberty and beyond. Erectile dysfunction is defined as a persistent inability to sustain penile erections hard enough for satisfactory penetrative sex. So when this happens in a relatively healthy man, it hits him really hard. Pun intended again.

In general, causes of ED are multi-factorial. We often hear of the cliché saying that the brain is actually the biggest sexual organ. This is very true as most men who present to me with ED would have some psychogenic component. Stress is the commonest cause of poor erections spanning all ages of men who have ED. The prevalence of ED has been estimated to be up to 40% in men above the age of 40 years and up to 70% in seniors above the age of 70. Other common causes of ED would include ischaemic heart disease (IHD), hypertension, hyperlipidaemia and diabetes mellitus (DM). Some men with undiagnosed IHD or coronary artery disease (CAD) may present with ED as their first symptoms. Men with testosterone deficiency may also present with primarily ED. And early detection of these diseases is potentially life-saving.

Performance anxiety for the husband is a common problem in couples who are trying to conceive. This is especially so when sexual activity starts to become a chore and the husband is expected to perform because the wife is ovulating. Itbecomes a vicious downward spiral when the man starts to doubt if he is able to initiate or sustain his erection every time he gets intimate with his spouse.

The increase in the prevalence of diabetes mellitus in Singapore would also mean that diabetic men present earlier with ED and with increased severity. ED in these individuals will be more challenging to treat as the response to oral medications may not be as encouraging. Men who have testosterone deficiency would also be counselled regarding testosterone therapy as returning the blood levels of testosterone to the normal range would potentially improve his erections and also improve his response to the oral medications for ED.

Hence, lifestyle modification with weight loss, healthy living with regular exercise, quitting smoking, avoiding excessive alcohol intake is what we would advise men to do to delay the onset of ED.

Other causes of ED would include pelvic surgery or radiotherapy for treatment of bladder cancer, prostate cancer and rectal cancer where the nerves that are responsible for erections would be damaged.

Prescription oral medications eg. PDE5 inhibitors (PDE5i) are the first line of treatment with concurrent lifestyle modification. The famous blue pill from Pfizer which was FDA approved in March 1998 gave hope to men afflicted with ED. Examples of PDE5i in Singapore include sildenafil, vardenafil, tadalafil and avanafil). These are prescription drugs and men must always have a formal consult, including a physical examination, as not all men are suitable to take this class of medication.

Intracavernosal injections with vasoactive agents are also used to treat ED. This entails the man injecting medication (Prostaglandin E1 analogue) via a syringe with a tiny needle into the penis. It is recommended that men who are considering this seek medical attention as the doctor would be able to instruct how to safely administer the medication and what the possible complications are.

Vacuum erection devices (VED) are medical grade instruments that aid in bringing blood into the penis to cause an erection. VED can be used as a form of penile rehabilitation where the man uses the VED daily to improve blood circulation and to induce a good erection so that the penis would not shrink with disuse. VED is used together with a penile constriction band/ring to enable the man to keep his erection by preventing the blood from leaking out of the penis so that he can have successful penetrative sex.

In the past 10 years, the penis has been successfully “shocked back to life” with the use of low intensity extracorporeal shockwave treatment (LiESWT). These shocks are administered to the penis by a trained doctor causing neovascularization ie. growth of new blood vessels. This would improve blood circulation and aid in more efficient delivery of blood into the penis during arousal. The treatment cycle is typically 6 sessions for 1 cycle of treatment.

The surgical treatment for ED would be the placement of the penile prosthesis. There are 2 types of penile prosthesis, the malleable vs the inflatable.

As the name suggests, the inflatable prosthesis can be inflated so that penis becomes erect for sexual activity and deflated so that the penis become flaccid or soft. This consists of 3 components connected by tubings, namely the cylinders (being sited in the muscle of the penis), the pump (sited in the scrotum) and the reservoir (containing saline and this will be placed in the abdomen). To cause an erection, the man would have the squeeze the scrotal pump and the saline in the reservoir would fill up the penile cylinders so that the penis becomes hard/turgid. The penis will then be returned to the non-erect state by pressing the “release” button on the scrotal pump.

Unlike, the inflatable prosthesis, the malleable prosthesis consists of 2 bendable rods which are placed in the penis and the man would just have to straighten the penis for penetrative sex and bend it downward or upwards when he is not.

Both prosthesis are made of silicone, which is well tolerated by the human body. These prosthesis are placed in the operating theatre as day surgery and most patients would only have to stay overnight for the procedure and would be able to start using it after 6 weeks.

ED no longer has to be hush-hush disease and men should not have to loiter around the back alley to purchase bogus medications, putting their lives in danger. There are various options which are safe if administered with the advice of trained medical professionals.