Erectile dysfunction – or popularly impotence (ED) is the inability to achieve and maintain an erection sufficient for satisfying sexual intercourse.
Many epidemiological studies conducted in different parts of the world have proven that erectile dysfunction is a major health problem, negatively affecting an individual’s overall sense of health and quality of life, regardless of cultural differences. It is not a life-threatening illness, but it interferes with a man’s self-esteem, destroys his mental stability, can cause depression and fear, and disrupts relationships between partners. So it affects not only men but also their partners and family.
The first major study to indicate the magnitude of the problem was in the United States, in the Massachusetts borough. According to him, more than 52% of men aged 40-70, who were not institutionalized, suffer from ED permanently or occasionally. Of these, 10% of the population had a severe problem, 25% moderate, and 17% mild dysfunction. A similar study conducted in Cologne (men 30-80 years) showed a prevalence of 20%, ranging from 2.3% in those aged 30-40 to 53.4% in those aged 70-80 years. A recent study in the USA shows a prevalence of 31%. Today, it is considered that the number of men with erectile problems is the closest to 35%.
If we distribute it a little over the years, e.g., In Italy, a telephone survey yielded the following results:
40-44 years-5%
45-50 years-9%
50-54 11%
55-59 20%
60-65 24%
65-70 55%
According to expert estimates, around 40 million men in Europe have erectile dysfunction today, and it is predicted that this number will double by 2025. Patients come for an examination 6-12 months after the onset of the first symptoms, while before the Viagra era, they came for an examination only after 2 years. Better treatment options, knowledge about the disease, and numerous marketing campaigns increased the number of visits to the doctor and the number of diagnoses ED, at 15% in Europe and 20% in America.
Men are not easy to understand
One of the reasons why some men still do not decide to seek the help of a urologist or general practitioner comes from the English study, according to which 45% of those who sought help consider a general practitioner insufficiently professional and only 12% of those examined were treated. In an Australian study, of all patients who sought medical help, only 11.6% were treated…
Today, many doctors are involved in decisions about diagnosis and treatment. Some of them are without sufficient knowledge about the problem of erectile dysfunction, often without experience. For this reason, there is a possibility that drugs are prescribed without a diagnosis, which can lead to some patients not recognizing the underlying disease that causes the problem. Of course, then such disease remains untreated.
Men perceive the problems they have differently. At the age of 50-59, 29% of men state that they have reduced limb hardness, and only for a third of them, this is a problem. At the age of 70-80 out of 70% active, 53% have ED, but only 7.7% perceive this as a problem. The partners’ opinion should also be taken into account because, in many situations in adulthood, they are not always interested in penetration, i.e., it is not the most important thing to them in sex itself.
How things normally work
The physiology of a normal erection consists of three systems. The CNS (central nervous system), the peripheral nervous system, and the vessels and trabeculae with smooth muscle cells in the limb. While the sympathetic nervous system controls flaccidity (limb relaxation), rigidity is controlled by the parasympathetic nerve. During the stimulus, the parasympathetic nerve relaxes smooth muscle cells and accumulates blood in the cavities of the penis. This compresses the small veins under the sheath of the corpora cavernosa (two of the three cylindrical bodies that make up the panis) and creates additional tension because it prevents blood from escaping from the penis (a veno-occlusive mechanism).
Erection is initiated by visual and auditory stimuli, smell, touch and smell, and imaginary (imagining) stimuli. Impulses from these regions, and stimuli from higher centers of the brain, accumulate in the hypothalamic nucleus (it is believed that activation of dopamine receptors causes an erection) that goes through the spinal cord parasympathetic nucleus in the sacral region (S2-S4) and lead to erections. Through the center in the thoracolumbar part (thoracolumbar) of the spinal cord from Th10-L2 through the sympathetic maintain a flaccid state (relaxed penis). Motoneurons for striated muscles, ischiocavernosus, and bulbospongiosus (muscles that support erection) also pass through the spinal cord.
Causes of erectile dysfunction
The causes of erectile dysfunction can be psychogenic or organic, and often the two causes are intertwined.
Psychogenic factors (nervousness, depression, and social factors) predominate in younger people up to 35 and in older people who start a new relationship. Diseases of the elderly, e.g., diabetes and vascular disease in half of the men older than 50, lead to vascular cause ED. Slightly rarer are neurological and endocrine causes.
The organic disease usually begins gradually, it is permanent, it also appears at graduation, and it is not situational (it does not depend on the partner, the place). Psychologically enchanted erection starts abruptly. It is there, and it is not there. Situational (depending on the partner, mood), there are often morning erections, and erection also occurs during masturbation.
The most important risk factors for erectile dysfunction are
1st year
2. high blood pressure
3. cigarettes
4. thickness
5. diabetes
6. higher amounts of alcohol
Other risk factors
1.psychological factors, depression
2. Arteriosclerosis (calcification of blood vessels)
3. pelvic, perineal, and limb injuries
4. operations in the small pelvis (radical op. Prostate bladder, op colon)
5.neurological diseases
6. hormonal diseases
7. too little exercise
8. Drug side effects
9. drug use (heroin, cocaine, methadone)
Drugs that more often cause erectile dysfunction are (beta-blockers, diuretics, antiarrhythmics, antidepressants, antiandrogens), penile injuries or diseases (Mb. Peyronei, priapism), chronic diseases (diabetes, high blood pressure, cardiovascular disease, liver or kidney failure) ), endocrine diseases (thyroid, testis, pituitary) and neurological diseases (spinal cord injuries, multiple sclerosis, disc herniation) and surgical procedures (radical prostatectomy, major op. procedures in the pelvis) and pelvic radiation.
Review
Physical examination should include at least a detailed examination of the genitals, examining secondary sexual characteristics (breast augmentation. distribution of hair throughout the body, distribution of fat), and blood pressure measurement.
From laboratory tests, determination of blood sugar, lipid profile (if this has not been done in the last 12 months), and testosterone in the blood (which must be determined in the morning by 10 am) are the basis of diagnosis. Today, free testosterone is also determined (indirectly). If the findings are low, the hormone’s correction (its compensation) restores a normal erection very quickly.
If patients do not respond to oral Ed therapy and have normal hormone levels, additional hormonal treatment is required (prolactin, FSH, LH sometimes, and thyroid hormones TSH).
Vascular examinations are performed less frequently today. Most often for:
-patients who are candidates for reconstructive penile surgery (very rare)
-because of medical-legal cases (insurance after injuries …)
-at the patient’s request
most commonly used:
-Color Doppler of the penile arteries is done with the application of prostaglandins (alprostadil 10 mcg.) In the limb 10 minutes after application. It gives the best data in penile microcirculation and can distinguish whether it is an arterial or veno-occlusive disease.
and rarely :
-cavernosography (imaging of the cavernous bodies of the penis with monitoring of the departure of contrast from the penis)
-foam arteriography
other tests
-night trigonometry (with a special device, the number and strength of night erections are measured)
-intracavernous application of prostaglandins
With the progress of oral therapy and inferior vascular surgery results, today, patients are increasingly undergoing therapy, and extensive diagnosis is performed only in a small number of patients.
Who can be treated for erectile dysfunction
Today, almost every patient can be treated, but this treatment must be successful and best suits the person being treated and his partner. In the treatment itself, a good treatment result, safety, time to effect, side effects, invasiveness, spontaneity, ease of use, and of course, the price is important.
Today’s first therapy line is drugs are taken by mouth (tablets and linguals), education, i.e., changing life habits, and sexual counseling.
The second line includes intracavernous injections (injections prepared for administration to the limb), injected drugs into the urethra (intraurethral PGE), and vacuum devices.
The third group includes surgical procedures.
Changing bad life habits and avoiding risk factors must accompany ED treatment and treatment. First of all, weight loss and increased physical activity. Increase the patient’s psychosocial security and eliminate all medications that may be a potential cause of discomfort.
A cause that can be cured
Endocrine causes, i.e., lack of testosterone in the blood or, more precisely, free testosterone, can cause ED and decreased libido. With its substitution (today Nebido in. Injection whose action lasts 3 months or Androgel and Testogel applied daily to certain areas of the skin), the patient can quickly regain erectile function.
Post-traumatic arterial ED arising from injuries to art. in the small pelvis. Surgical revascularization leads to success in 60% of cases—vein ligation due to the so-called. Venoocclusive disease is today op. which is rarely implemented due to short-term results.
With psychosexual therapy alone or in combination with other therapies, mental disorders yield very variable results but are of great importance to a particular group of patients.
Oral pharmacotherapy-
Three PDE5- inhibitors
Sildenafil (Viagra, Dinamico)
Tadalafil (Cialis)
Vardenafil (Levitra)
Erectile enhancing varnishes
Vardenafil – (Levitra)
it relaxes the smooth muscles of the penis, which allows it to fill with blood
Drink 25-60 minutes before intercourse. It works for up to 8 hours. It would help if you avoided it after consuming foods high in fat.
Advantages and disadvantages
-biochemically most potent drug (a drug with the best possible effect)
-proven effective, especially after prolonged use
-effective in diabetics and after radical prostate surgery
-not recommended with alpha-blockers except Omnica 0.4 (the drug has been registered in Croatia since this year)
Side effects
-Facial redness 10-11%
-headache 6-7%
-Rarely heartburn, bloating, abdominal pain
-The results are similar or the same as with sildenafil (Viagra and Dinamico)
Tadalafil-Cialis
Side effects
-backs in the back and muscles 7%, probably due to prolonged action of the drug
-headache 15%
-nose fullness 6%
-less reddening of the face
Our experiences
Same as before. It is preferred by patients who have more frequent intercourse due to prolonged action.
Sildenafil (Viagra and Dynamic)
Side effects:
-headache
-redness
-full of nose
-blue vision
Advantages
The action’s effectiveness has been proven in numerous studies, many of them in the first category. Viagra has been on the market for ten years and has been taken by more than 35 million patients in 120 countries. 120 randomized studies were conducted. 1.8 billion tablets have been sold so far. Several studies show its safety in heart patients. The drug has shown good results in people with diabetes and somewhat weaker after radical prostatectomy. It would help if you did not take it with nitro preparations.
Our experiences
Viagra is certainly the drug we have the most experience with. The results are good. Patients who stop taking the drug do so because they no longer need it or do not need sex, and less often due to the ineffectiveness of the drug and exceptionally due to side effects.
Complications and deaths, which appeared in large numbers in newspapers and on the Internet, were not confirmed by profession. The blindness reported in 30 cases is associated with patients already predisposed to the disease.
Erection with Viagra, according to some studies, is improved in people with diabetes in 59-63%, in psychogenic patients in 84%, after radiation in 66%, after radical prostate surgery in 20-30%, in depression in 76%.
Non-responders are those patients who:
do not react, i.e., they have no improvement in erection after trying the drug
1. with 6-8 maximum doses
2.respecting the recommended time of taking
3.with good sexual stimulation
4.and avoiding the possible effect of food, drink, or other medications
Apomorphins (Ixence, Uprima)
A drug given sublingually-centrally is an active drug that amplifies central erectile signals. It is given under the tongue .in doses of 2 and 3 mg. It is registered in many European countries (France, Germany, Austria, and Italy) but not in the USA:
Its efficiency is 27-55%. Erections occur in most people after 20 minutes.
Method of application:
Put it under your tongue and melt. Expected erection after 20 minutes
Advantages and disadvantages
– Very few side effects. – He’s not addicted to food
– It can also be taken by patients taking nitro preparations
– Desire is not improved
-It has slightly worse results than other pills
-recommended in younger patients with minor ailments, soon after the onset of symptoms
– where PDE5 does not work
-In some studies, good results in combination with alpha-blockers and Sildenafil.
Side effects
– urge to vomit, weakness, and headache less than 5% of respondents
-can lead to alcohol intolerance
-DAV hours after taking it is not recommended to drive a car
Our experiences
-because of the good results of other drugs, we rarely use them. It should be left as an alternative to non-responders
Medicines on the black
In Croatia, of the drugs used in the treatment of erectile dysfunction on the market Viagra and Dinamico, Levitra, and Cialis (20mg) On the prescription of a urologist, general practitioner, or another specialty, the drug can be obtained in all pharmacies. Caverject (prostaglandin E1) – a drug from Pfizer for the treatment of erectile dysfunction by injections into the limb itself, probably the most effective tool in our pharmacies can not be obtained. Therefore, doctors and patients often use diluted Prostin VR, which is not the most correct. Various combinations with phentolamine and other substances are hazardous and often lead to priapism (unwanted painful prolonged erection), and the result can be permanent impotence.
Viagra, Cialis, and Levitra are sold on the black market (various newspaper ads). There are a certain probability and empty substances or generics8questioned source India)… Products advertised in the media as dietary supplements and claimed to be completely natural, unfortunately, patients and we have not given any results. At least that’s not proven. I think that if you really want to throw money away, then that’s the right thing to do. What they say you had good intentions. However, you should know that the possible biological action methods are not known, which can have unwanted consequences.
For those who are afraid of the doctor
We advise these patients to avoid some restrictions before buying if they avoid doctors for some reason. Do not buy or take medicine:
1. Those who are not able to walk 1600 meters in 20 minutes, without this being a problem for them,
2. Having pressured less than 90/50 or more than 170/110 mmHg
3. If they have had a heart attack, stroke in the last 6 months, or have had a severe heart rhythm disorder
4. Those taking nitro preparations (preparations used to treat angina pectoris)
5. Having eye disease (Retinitis pigmentosa)
6. Those taking alpha-blockers
We are young and we have a problem with impotence
Impotence can be one of the first signs of cardiovascular or other chronic diseases, and the cooperation between urologists and internists should be better than before. Erectile dysfunction is present in 8% of men under the age of 40, 6-9% between the ages of 40 and 49, and about 16% between the ages of 50 and 59. They are especially to look for diabetes, high blood pressure, cardiovascular disease, high cholesterol, or signs of depression. Sexual counseling, in addition to oral medication, should be the therapy of choice for younger patients.
A patient who has erection problems for more than 6 months is recommended to see a urologist or their general practitioner.
Female sexual dysfunction a new challenge
A new area that is coming to the fore is female sexual dysfunction. While in recent years, one could hear here and there about women’s problems and solve these problems, at this congress, lectures and papers on the subject were numerous and very well attended. It has been found that as many as 43% of women have occasional or permanent sexual problems, compared to 31% in men.
Dysfunction is considered to be: the decreased desire for sex (permanent or permanent), disturbance of the sense of comfort (disorders of wetting, etc.) and arousal, disturbance of orgasm (difficulty in achieving or lack of orgasm), and pain during intercourse (dyspareunia and vaginismus).
The causes can be psychogenic and organic. Of the organic ones, the hormonal cause is common,
certain anatomical abnormalities, inflammation of the vagina (fungal and bacterial), vascular and neurological causes. Diagnosis and treatment are performed by psychologists, gynecologists, or urologists who deal with this problem. Androgen and estrogen replacement is on-trend.
Which is small and which is not
As for a man’s known phobia about a small penis, here are some old views. A penis measuring 7.5 cm or less in erection is considered hypoplastic.
Extension operations have so far yielded no results. Surgery that initiates fat cells into the subcutaneous tissue is considered obsolete (they should no longer be done). Such results are achieved in increasing the volume of the penis, but these are still experimental operations.
