What is Erectile Disfunction?
The diagnosis of erectile dysfunction (impotence) refers to the constant or repeated inability to achieve or maintain an erection for a sufficient amount of time to support sexual activity. It can occur at any age, but it is a more common diagnosis in older men. Sexual dysfunction does not only affect the man's sexual life. “The value of proper evaluation and management of erectile dysfunction diagnosis pertains not only to the affected individuals and their partners but also to society as a whole. Management of erectile dysfunction encompasses aspects related to physical and mental health, addressing or failing to address this sexual dysfunction, managing associated diseases, as well as the socio-economic burden it imposes,” says Dr. Bogdan Gusanu, Primary Care Urologist.
Diagnosed as such, erectile dysfunction is a disease of the 20th and 21st centuries not because it has only recently been discovered, but because its mechanisms are now well understood, and several therapies have been developed that yield positive results.
There are several major causes that ultimately lead to erectile dysfunction; however, it has been concluded that there is practically no single type of erectile dysfunction, but rather all types have multiple triggering causes, in varying proportions.
This medical condition is of major importance for human health, with implications that extend beyond treating the patient who occasionally presents with a problem of seemingly non-vital magnitude. The value of proper evaluation and management of erectile dysfunction (ED) pertains and has implications not only for the affected individuals and their partners but also for society as a whole. The management of ED includes aspects related to physical and mental health, addressing or failing to address this sexual dysfunction, managing associated diseases, and the socio-economic burden it imposes.
The management of erectile dysfunction has evolved into a mature clinical discipline in recent decades, due to continuous progress made in basic science, epidemiology, clinical research, and healthcare services research in this dynamic field.
The fundamental principles of ED management, based on the highest clinical standards of ethics, quality, safety, and cost-effectiveness, are now well accepted by the scientific and clinical community in sexual medicine. Epidemiological studies of this well-researched sexual issue estimate a global prevalence of ED among adult men (over 20 years old) ranging from 10% to 20%, with most studies reporting a rate closer to 20%. It is recognized that there is an age-related correlation for the prevalence of ED, with a global prevalence of 1% to 10% in men under 40 years old, rising to 15% in men between 40 and 49 years old, 30% in men aged 50-59, 40% in those aged 60-69, and 50% to 100% in men aged 70 and 80.
It is estimated that in 1995, there were over 152 million men experiencing ED, with the prevalence forecast to reach approximately 322 million men with ED by 2025. This trend remains consistent across race/ethnicity and geographical regions. Current data also confirm that the prevalence of ED increases in the presence of comorbid medical conditions, including type 2 diabetes, obesity, cardiovascular diseases, hypertension, dyslipidemia, depressive states, and prostate conditions/benign prostatic hyperplasia (prostate adenoma), as well as in the presence of harmful lifestyle habits (excessive tobacco and alcohol consumption, sedentary lifestyle). It is also known that 25% of all ED cases occur as a side effect of widely used medications for conditions such as hypertension, depressive states, and certain forms of cancer. In addition to associations with other conditions (comorbidity), ED is recognized for its negative impact on quality of life, reduced occupational productivity, and increased use of medical resources.
Because an adequate erection involves good functional status of the vascular system, it has also been found that the onset of ED can serve as an early indicator of future cardiovascular, myocardial, and cerebral conditions. Thus, the issue of ED itself provides a true clinical barometer of the overall health status of men, and efforts aimed at improving its management are also pursued for the prevention of diseases, promotion of health, and enhancement of quality of life.
The primary goal of ED management is to tailor it in an individualized manner, aiming to allow the patient or couple to make an informed selection of the preferred therapy for sexual fulfillment based on a solid understanding of all treatment options, following an in-depth discussion with the attending physician. This approach recognizes that patients vary in terms of acceptance of sexual disorders and their interest in continuing prescribed treatment. Their decisions appropriately reflect their individual preferences, needs, and expectations regarding management options. Clearly, a preference for the least invasive treatment methods has been observed.
Causes
They can be classified into:
Organics:
- vascular (arterial or venous)
- neurogenic
- anatomical
- endocrinological
Psychogenic- generalized (primary lack of libido or decreased libido caused by age)
- situational (related to the partner, certain conflict situations, or psychopathological conditions)
Mixts
It is important to note that in all cases, ED does not have a single mechanism but rather one that predominates (organic or psychogenic), with varying degrees of interference.
Vascular causes of ED represent a major segment in the etiology of this condition, as the mechanism of erection is, by definition, a vascular one. The physical support of the erection phenomenon is represented by the integrity of the penile vascular tree, specifically the normal reactivity of the arterial and venous blood vessels of the penis. Since the size of these vessels is relatively small, even minor changes in vascular diameter can cause serious difficulties in the erection process. Various pathological conditions (hypertension, diabetes, hypercholesterolemia) that cause a reduction in the diameter of blood vessels in many internal organs also inherently affect the penile blood vessels, reducing the normal arterial flow needed for a viable erection.
For this reason, an important step in evaluating a patient with ED is assessing the condition and vascular quality of the penile vessels (primarily the cavernous arteries, through which arterial blood enters in increased quantity into the two penile corpora cavernosa during an erection).
The evaluation of this parameter is primarily performed through a penile Doppler ultrasound examination, which will determine whether the blood flow of the cavernous penile arteries is sufficient, and if the penile veins react adequately to maintain an adequate amount of blood in the penile corpora cavernosa during an erection. 4o mini
Currently, patients with vascular erectile dysfunction have available both pharmacological remedies (oral or local medications) and invasive surgical methods.
The medications available on the market are part of the group known as phosphodiesterase 5 inhibitors (PDE 5 inhibitors), such as Viagra, Cialis, and Levitra. Through their local vasodilatory mechanism in the penis, they allow for an adequate erection if taken approximately one hour prior to sexual activity. However, this method is burdened by certain inconveniences, such as significant side effects (headache, blurred vision, dizziness, facial flushing), the contraindication of combining them with medications containing nitrates used in the treatment of angina pectoris, and often the lack of the body’s response to these vasodilating substances, making their administration ineffective.
Other groups of medications can be administered via injection by patients directly into the penis before sexual activity, to induce artificial vasodilation that facilitates erection. However, many patients are hesitant to self-inject the medication into the penis, fearing (rightly so) potential accidents during administration, such as perforation of an important artery with subsequent uncontrollable bleeding, urethral perforation, or the creation of an abnormal communication between an artery and a penile vein, leading to prolonged, painful erections (priapism), which can often pose a serious risk to life.
Invasive surgical methods (such as penile revascularization surgeries or the implantation of inflatable penile prostheses) also present significant disadvantages (high costs, aesthetic deficiencies). 4o mini
Symptoms
We are not wrong if we say that any man, absolutely any man, can experience what is commonly referred to as a sexual failure at some point in his life – he may be more tired or stressed, may consume more alcohol, may smoke excessively on a particular day, and it can happen. Not every isolated failure should raise alarms. However, after a natural self-assessment, if he notices that these failures begin to increase and repeat with a frequency that affects his sexual life, this is the moment when he should truly consult a urologist to identify the causes and receive an accurate diagnosis.
Medical consultation is required when:
- an erection cannot be achieved regardless of the nature of the stimuli (sexual activity or masturbation)
- the erection is not firm enough to begin sexual activity
- the erection cannot be maintained throughout the entire sexual act
Any of these symptoms that persist for more than three months require specialist medical evaluation.
Diagnosis
How is erectile dysfunction diagnosed at the urology office?
Early recognition of symptoms and the first visit to the urologist's office are important initial steps for the patient. The diagnosis of erectile dysfunction includes:
- Physical Examination of the Genital Organs
- Medical history of the condition
- Blood tests – these can detect the presence of other conditions such as diabetes or heart diseases, as well as determine testosterone levels, an important male hormone essential for the development of the reproductive system.
- Urine tests
- Performing a Doppler ultrasound – allows visualization of blood circulation in the penis.
- Psychological examination – to determine if erectile dysfunction is caused by a psychological disorder.
Considering the relatively high percentage of cardiovascular comorbidities, patients with ED are recommended to undergo an initial comprehensive medical evaluation, with cardiovascular risk stratification into high, medium, or low risk levels. Patients classified as having high risk would be those with unstable or refractory angina, a recent history of myocardial infarction, certain arrhythmias, or uncontrolled hypertension. For these patients, sexual activity with any ED therapy should be postponed until the cardiac condition is stabilized. Often, in evaluating the underlying causes of ED, the urologist will collaborate interdisciplinarily with other specialties such as endocrinology, neurology, cardiology, psychiatry, etc.
The urologist is responsible for accurately diagnosing the degree of ED (mild, moderate, severe), classifying its origin (psychogenic, organic, mixed), and – preferably – completing a personalized evaluation questionnaire for the ED patient, in order to establish the above-mentioned criteria as well as other psycho-social parameters related to the condition.
As part of the initial evaluation, it is recommended to conduct standard tests for important blood parameters such as blood glucose levels, cholesterol and its fractions, sex hormones (testosterone), thyroid and pituitary hormones, in order to identify possible triggering and potentially treatable causes of ED.
TREATMENT
ESWT Technology
Unlike the current classical pharmacological therapy, used by the majority of the urological community in the treatment of ED, based on substances like sildenafil (Viagra) that are effective in only 50% of men, electromagnetic shock wave therapy for erectile dysfunction is an innovative medical treatment that addresses the cause of ED, not just its symptoms. Erectile dysfunction (ED) results from poor blood flow to the penis and affects over 40% of men over the age of 40.
Shock wave therapy is the only non-invasive therapy offered to restore the normal erectile function of the penis. Multiple studies have shown that the majority of men will experience a significant improvement in sexual performance after treatment, with no risk of side effects. Being the only clinic exclusively dedicated to male sexual health and one of the few clinics in Europe offering this procedure, we have been performing shock wave therapy for over 4 years. The procedure is confirmed by the E.A.U. (European Association of Urology) as the only effective non-drug therapy for treating erectile dysfunction, being mentioned as such in the European urological medical practice guidelines and validated by the experience of several European medical clinics. It has been scientifically proven that low-intensity shock waves stimulate the formation of new blood vessels in the corpora cavernosa of the penis, resulting in improved arterial blood flow and better erection parameters.
How does ESWT therapy treat erectile dysfunction?
Shock wave therapy for erectile dysfunction is delivered by a medical device produced by Storz – Switzerland, which emits low-intensity shock waves (Li-ESWT). These electromagnetic waves stimulate the formation of new arterial blood vessels by mobilizing pluripotent stem cells at the sites where they are applied (the corpora cavernosa of the penis), leading to the regeneration of the pre-existing vascular tree. This process is also stimulated by the local, physiological secretion of vascular growth factor as a tissue response to the action of the shock waves. There is no discomfort during or after the procedure.
The successful use of extracorporeal shock waves is well documented in many areas of medicine, including cardiology, physiotherapy, urology, and pain management.
BENEFITS
- Shock wave therapy offers new possibilities for the direct treatment of the organic causes of erectile dysfunction.
- The treatment offers more than just symptom management. It is a restoration of natural, spontaneous sexual health.
- The treatment has a high level of safety, effectiveness (with over an 80% success rate), and confidentiality.
- There are no risks for men with concurrent medical health conditions.
- Effectiveness varies from patient to patient, depending on how the body individually responds to the treatment.
- An important benefit of this therapy is the scientifically proven fact that patients who undergo ESWT therapy become responsive to sildenafil-type medication (Viagra), even if these medications were previously ineffective for them.
