How to manage Erectile Dysfunction in 2022?

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What is Erectile Dysfunction?

Erectile dysfunction is the persistent inability to achieve or maintain an erection for satisfactory sexual activities. Formerly called impotence, now the two terms have been given separate identities. While erectile dysfunction is specifically directed towards the erectile problems of a man, impotence covers a wide range of factors concerned with sexual intercourse and reproduction apart from erectile dysfunction. Erectile dysfunction is more common in men above 65 years of age, but it can occur in any age group. Depending on the severity of the condition, erectile dysfunction may be-

  • Occasional inability to obtain an erection
  • Inability to maintain the erection during intercourse
  • Complete inability to achieve an erection

Incidence of Erectile Dysfunction in Australia

Erectile Dysfunction in Australia is especially high at an incidence of 40%. Australia being a community of long-living men, the problem has been known to escalate with age. Out of 100 million people with erectile dysfunction throughout the world, Australians occupy a whopping 1 million in the list. Based on a telephonic survey on common health problems in Australian men, 21% out of 78% verified responses were related to erectile dysfunction. Another study has also proved that 52% of Australian men between the ages of 40-70 experience some degree of dysfunction in their active sexual life. At the same time, risk factors and systemic conditions are the main responsible factors; lifestyle changes like exercise, a healthy diet also aid towards dysfunction.

What causes Erectile Dysfunction and how does it happen?

Penile erection is achieved as a result of relaxation of the smooth muscles lining the penis walls-factors like spinal reflex coupled with mental and sensory stimulus aid to the process. The balance between these factors determines the tone of the penile vasculature and smooth muscles of the corpus cavernosum.

In all kinds of primates, including humans, the L-arginine-nitric oxide-cGMP pathway is the key mechanism of penile erection. Nitric oxide is produced from oxygen and L-arginine. During sexual arousal, neural pathways are stimulated, resulting in nitric oxide and endothelial cells directly released into the penis. Through penetration into smooth muscles, this nitric oxide binds with guanylyl cyclase and interacts with it to form the cyclic cGMP, the intracellular trigger for penile erection. Certain physical, psychological, and traumatic conditions affect nitrous oxide formation with the neural pathway obstruction resulting in erectile dysfunction.

The table below shows the causes of erectile dysfunction

Causes of Erectile dsyfunction

     Reference (https://iashindia.com/erectile-dysfunction-causes/) 

Treatment options

Once diagnosed, there are a number of treatment options for the condition. Some of the main treatment options for Erectile Dysfunction are:

Lifestyle modification

Smoking, alcohol intake, and obesity affect penile erection by causing clinical inflammation with constriction of the muscles responsible for erection. Studies have shown that targeting these lifestyle factors can steadily contribute to decreased erectile dysfunction in men. A study comparing lifestyle factors with penile erection found that nitrous oxide imbalance is the main culprit behind erectile problems. Improving nitrous oxide through a healthy lifestyle like exercising and quitting cigarettes and alcohol promotes erectile function quickly and effectively. A healthy diet with a high content of whole-grain foods and legumes with vegetables and fruits promoted amelioration of endothelial dysfunction and insulin resistance, the primary risk factors for erectile dysfunction.

Removal of the drug causing erectile problems

Antidepressants, anti-ulcer medications, tranquilizers, and diuretics are some of the main drugs causing erectile dysfunction. At the same time, these medications help in providing psychological and analgesic relief with the treatment of heart, liver, and kidney conditions. They also interfere with the cGMP pathway and nitrous oxide production. Substituting these drugs for those medications not interfering with your erectile function can effectively treat the condition, which is easier said than done. As of now, clinical experience in switching medications for ED has not yet yielded satisfactory results. This needs to be combined with other methods for satisfactory results.

Oral medications

Oral medications for erectile dysfunction come under the category of PDE-5 inhibitors. PDE-5 enzymes play an important role in regulating the cGMP pathway of the erectile system. PDE-5 inhibitors or Phosphodiesterase-5 inhibitors are vasodilating drugs. These work by inhibiting or blocking the degradative cGMP-PDE5 action on the smooth muscles of the penis. This results in an increased production of extracellular PDE5 enzymes facilitating erections. Additionally, the corpus cavernosa (sponge-like part of the erectile region containing most of the blood in the penis during erection) is dilated by these medications. This helps in facilitating erection during sexual stimulation with serving as an effective treatment for erectile dysfunction.

Vacuum constriction devices

Vacuum constriction devices consist of an acrylic cylinder placed over the penis with a lubricating agent forming a seal between the penile body and the cylinder. Using a vacuum mechanism, erection is achieved, after which a constriction band is applied to the penile base to maintain the same. Following this, the cylinder is removed, and the patient is free to engage in sexual activity. This erection is different from other technique-induced erections in the way that there is generalized swelling of the entire penis due to the band occluding the blood vessels. The band can stay for almost 30 minutes, but after that, it needs to be removed.

This method, though approved by a lot of users, has some shortcomings. Firstly, it needs dexterity of hands to practice the method. Secondly, complications like ecchymosis (bleeding) and trapping of ejaculate can occur with prolonged vacuum-induced erection.

Intraurethral pathway stimulation

This is achieved in following two ways-

  1. Through intraurethral suppository that is absorbed through massaging spongy tissues of corpus cavernosum.
  2. Through subcutaneous injections applied directly into the cavernosa.

Prostaglandin drugs are present in this procedure. They dilate the blood vessels and cause muscle relaxation by promoting intracellular accumulation of cyclic adenosine monophosphate. They also reduce the accumulation of intracellular calcium. The efficacy of this method has been proven to be around 50% through various research, studies, and trials. The only drawback of this therapy is that it comes with the risk of priapism associated with self-injections. That’s why it is administered under supervision.

Other methods

There were a lot of other methods like testosterone therapy, trazodone therapy, and a few herbal supplements to deal with ED. But with the introduction of oral medications and prostaglandin drugs, these methods became obsolete. Moreover, none of these methods are under the American Urological Association Guidelines for the treatment of Erectile dysfunction as of now.

Surgical Options

Prosthetic options are advised in the most severe cases of dysfunction when no other treatment works or produces satisfactory results. Surgical options for Erectile Dysfunction are available in the form of prosthetic penile implantation devices. These devices are available in the form of saline-filled silicone devices or any other malleable device. These devices are FDA-approved and considered safe for use in MRI environments. Through surgical intervention, they are attached to the penile area. The success rate of this method is affected by mechanical failure, surgery risks, and post-surgery infections.

Which one is the best method?

Out of all the methods mentioned above, oral medications are considered to be the safest and most successful treatment modalities. There are a number of PDE5 inhibitors available in the market these days. Sildenafil, Tadalafil, Vardenafil, and Avanafil are the four major ones.

Key characteristics of PDE5 Inhibitors

Reference

Sildenafil is the most preferred PDE5 inhibitor of all. It was patented in 1996 and approved for erectile dysfunction in 1998. Apart from aiding penile erection, Sildenafil also comes as a friendly option for patients with blood pressure and chest pain issues. That makes it an effective option for aged men above 45 years. Though Viagra is the most important brand version of Sildenafil, generic versions of the medication have also been introduced to the market in recent years.

Generic medications are not branded drugs but have the same ingredients, dosage, and effectiveness as their brand versions. As they lack sufficient lab tests to claim their efficiency compared to brand medications, they cost less and are easily accessible.

One such generic version of Sildenafil in growing used is Kamagra 100mg. Kamagra, like Viagra, is an endothelium-friendly PDE5 inhibitor. It reduces the progression of Erectile Dysfunction better than other inhibitors. It has added advantages of improving the urinary abilities through relaxation of the urethral muscles. That, with the heart-friendly mechanism of Sildenafil, increases self-esteem through improved sexual performances. Kamagra is available as tablets as well as in advanced form- like Kamagra oral jelly. Additionally, the oral jelly and effervescent versions as per the taste are also available. It is advised to take Kamagra an hour or two before sexual activity to prolong a penile erection for sexual satisfaction.

Is there a catch?

Kamagra and other PDE-5 inhibitors, despite their user-friendliness, cannot be recommended for everyone.  People with allergies and on nitrate medications are strictly prohibited from using these ED drugs. The user may feel a serious allergic reaction and hypotension as side effects. Additionally, concomitant use of PDE-5 inhibitors with other medications like Erythromycin, Ketoconazole, and Ritonavir can cause either medication’s adverse reactions or reduced effectiveness. The side effects associated with the use of these medicines are usually mild and limited to headache, indigestion, and back pain. Occasionally, serious adverse reactions like vision disturbances, prolonged erection, and dizziness can also occur, especially on overdosing on the medication.

Prevention is better than cure.

Sticking to this principle can save you from getting into drug abuse of these ED medications. A healthy diet and good lifestyle habits- such as regular exercise or short yet intense physical activities- can significantly improve the condition. Reduced intake of sugar or calorie-rich food with sufficient hydration can contribute to a better outcome in the long run. Avoiding smoking, limited intake of alcohol with the use of illegal drugs can contribute to your erection with the rest of the body in a positive manner.

Combination Therapy better than Monotherapy

Medications are an effective treatment option in themselves. Combining medication with preventive measures can further add to their effectiveness. Studies have shown that apart from preventive measures, combining PDE5 inhibitors with intraurethral stimulation can also help in favorable outcomes. It can also provide a temporary relief than with medications. While studying combination therapy, researchers concluded that it is especially helpful in cases of erectile dysfunction associated with hypogonadism. The study’s overall conclusion was that combination therapy is safe and can be considered a first-line treatment in complex and difficult to treat cases of erectile dysfunction.

Conclusion

With the advent of medical science, the lifespan of men has increased. Unfortunately, this has worsened the incidence of reproductive issues and other conditions. Erectile Dysfunction can occur on its own or be associated with other systemic conditions and drug interactions. Treatment of Erectile Dysfunction at an early stage can minimize most of the complications. Adding secondary treatment modalities can give favorable results, though. Most importantly, Counselling, preventive measures, and yearly evaluation can effectively minimize, prolong or deal with the situation in an effective manner while improving the self-esteem of the men in the first place.

References

  1. https://www.racgp.org.au/afp/2010/may/erectile-dysfunction-%E2%80%93-when-tablets-don%E2%80%99t-work/
  2. https://pubmed.ncbi.nlm.nih.gov/15224127/
  3. https://www.health.harvard.edu/mens-health/some-drugs-may-cause-your-erectile-dysfunction