2023-09-07 13:30:22
Types of erectile dysfunction
Erection is the most important and most “vulnerable” component of male sexuality, which is sensitive to any changes in the body. An erection occurs due to the harmonious interaction of the nervous, vascular and endocrine systems, the failure of any of them can cause erectile dysfunction.
Depending on the pathogenesis of ED subdivided into psychogenic, organic and combined. 40% of cases of impotence are associated with psychogenic factors – mental disorders, high personal anxiety, dependence on psychoactive substances.
The organic form of impotence is a consequence of somatic disorders, it accounts for 29% of all cases. It can be associated with endocrine, cardiovascular, neurological diseases, spinal cord and brain injuries. It also includes smoking and alcoholism.
Despite the variety of causes of organic ED, in most cases it is characteristic the same pathological mechanism is endothelial dysfunction, in which the vascular endothelium produces little nitric oxide, the main mediator of erection.
in response to sexual stimuli is growing synthesis of nitric oxide, which is accompanied by relaxation of smooth muscle cells of the cavernous bodies, vasodilation and acceleration of blood flow in the penis. As a result, the cavernous bodies are filled with blood, and the penis lengthens and increases. With endothelial dysfunction, these processes are disrupted.
Usually organic ED It has vascular origin. This explains its high prevalence among men with diabetes mellitus, arterial hypertension and other pathologies in which blood vessels are affected.
In a quarter of cases, ED is caused by a combination of psychogenic and organic factors; in 6%, its cause cannot be established.
Determinants of impotence
1. Catastrophizing Sexual Failures and Depression
Psychogenic ED is more common develops in men of an anxious and suspicious warehouse, who react painfully to the slightest erectile dysfunction and equate it with a tragedy. Similar hypersensitivity and propensity to catastrophize become fertile ground for the syndrome of anxious expectation of sexual failure. The key manifestation of the syndrome is a wild fear of intimacy, blocking libido and erection. Anxious and suspicious character traits are observed in several personality disorders, including anancaste disorder.
A common cause of erectile dysfunction is depression. Depending on the severity of depression, the risk of ED varies from 25% to 90%.
Often, impotence is a “mask” of hidden depression, in which somatic symptoms come to the fore, and mental problems are hidden. Often, this form of depression goes undiagnosed, making it difficult to treat sexual disorders.
2. Atherosclerosis
With atherosclerosis, plaques form on the inner lining of blood vessels. It is generally accepted that this disease attacks only the elderly, but in fact its subclinical stage is diagnosed in a third of young people. Atherosclerosis affects many organs, including the penis.
In men with systemic atherosclerosis observed narrowing of the lumen of the arteries of the penis, thickening of their walls, a decrease in arterial blood flow.
Atherosclerosis of the penis vessels is a provocateur of cavernous fibrosis, in which healthy erectile tissue is replaced by connective tissue. A penis affected by fibrosis is unable to maintain a normal erection.
3. Arterial hypertension
Arterial hypertension recognized a major trigger for cardiovascular disease, including stroke, heart attack, and heart failure. It also causes erectile dysfunction.
The prevalence of ED is twice as high among patients with arterial hypertension. The risk of impotence increases if hypertension is combined with other cardiovascular pathologies: ED is diagnosed in 64% of patients with coronary artery disease and in 57% of patients who underwent coronary bypass surgery.
Link between hypertension and ED conditioned the fact that a chronic increase in blood pressure provokes the growth of muscle tissue in the cavernous bodies, and also contributes to the development of fibrosis. The intensity of these processes depends on the degree of increase in SBP. In addition, in hypertension observed endothelial dysfunction.
A quarter of cases of ED in hypertensive patients are due to medication. Some groups of antihypertensive drugs (intended to reduce pressure) adversely affect potency. For example, non-selective β-blockers reduce sexual activity and testosterone levels.
The safest antihypertensive drugs for potency are angiotensin receptor blockers (ARBs) and selective β1-blockers.
The recommendations of the European Society of Cardiology present the results of a 5-year study involving 2337 men taking various antihypertensive drugs. The study demonstrated the safety of selective β1-blockers for male sexual health.
4. Obesity and diabetes
25% of men in Russia are obese. Obesity provokes impotence through several mechanisms:
contributes to the development of endothelial dysfunction; lowers testosterone levels. With obesity, aromatase activity increases, which enhances the transformation of androgens into estrogens; increases blood pressure. With obesity, the likelihood of manifestation of hypertension for three years or more 5 times higherthan at normal weight; leads to the development of type 2 diabetes mellitus, which also refers to provocateurs of ED.
In patients with type 2 diabetes aged 40–60 years, erectile dysfunction occurs 4–6 times more often than in the general population. Most often, it occurs in decompensated diabetes: a chronic increase in blood glucose levels leads to the development of diabetic neuropathy and atherosclerosis of the vessels of the penis.
5. Smoking
Smoking is a determinant of premature death, serious illness and impotence. smokers live on average, 10.5 years less than non-smokers, they are twice as likely to have cardiovascular diseases and liver pathologies, 1.5 times more likely to have impaired potency.
Nicotine and other harmful substances in tobacco smoke suppress the production of gonadotropin, a pituitary hormone that affects testosterone synthesis in the testicles. In addition, nicotine directly affects the testes, reducing their hormonal function.
Smoking constricts blood vessels and impairs blood circulation in the penis, which also affects potency. Smoking 20-40 cigarettes a day twice reduces the rate of blood flow in the arteries of the penis. Smokers are much more likely to develop atherosclerosis of the vessels of the penis at a young age.
Diagnostic methods
To assess sexual activity and detect ED developed special questionnaires: ICEF, which includes 15 questions, and its abbreviated version ICEF-5. These questionnaires can be used not only by andrologists and urologists, but also by doctors of other specialties. A number of symptoms allow a doctor to distinguish organic from psychogenic ED.
Organic erectile dysfunction is characterized by slow progression and an unstable profile of morning erections, psychogenic – an acute onset and normal morning erections.
The main method of instrumental diagnostics is ultrasound dopplerography arteries of the penis. For accurate diagnosis, it should be carried out twice: at rest of the penis and following the introduction of alprostadil, a drug with vasodilating properties, into it.
Since ED is often caused by cardiovascular and endocrine diseases, laboratory diagnostics should include a lipid profile, a study of the concentration of testosterone and glucose in the blood.
Special criteria have been developed for determining cardiovascular risk (CVR) in patients. With a low CVR, the treatment of erectile dysfunction is considered safe, with an average and high one, a preliminary consultation with a cardiologist is required.
Treatment of erectile dysfunction
1. Eliminate disease triggers
The key condition for successful treatment of ED is the elimination of provocateurs of the disease. Sometimes lifestyle modification capable significantly improve potency. For example, in almost every third obese patient, a 10% weight loss contributes to the normalization of an erection.
If ED is associated with mental problems, the help of a psychiatrist is required. The main role in the treatment of psychogenic sexual disorders is given to cognitive behavioral therapy.
2. Drug therapy
For medical treatment of ED apply PDE-5 inhibitors, which promote relaxation of the smooth muscles of the penis in response to sexual stimuli. The drugs are indicated for ED of any etiology. Depending on the duration of the effect, they subdivided for short-acting and long-acting drugs.
The standard mode of taking medications is “on demand”, but not more than once a day. In addition to it, a more effective treatment regimen can be used: daily intake of prolonged drugs in reduced dosages.
20-40% of men with impotence do not achieve a normal erection when taking PDE-5 inhibitors on demand. Often this scheme does not work with ED associated with vascular pathologies, endocrine diseases, and surgical treatment.
Approximately one third of men who have not reached potency when using the drug on demand, achieve it following switching to a daily low-dose intake of drugs.
Long-term suppression of PDE-5 activity increases blood flow in the penis and normalizes IIEF parameters.
In addition to high efficiency, daily use has other advantages:
long lasting effect. Normalization of IIEF parameters achieved with the help of a daily regimen persists even following discontinuation of drugs; low risk of side effects; opportunity to have spontaneous sex. The “on demand” mode eliminates spontaneous intimacy, since an erection does not occur immediately following taking the pill. With a daily regimen, this disadvantage is absent.
If PDE-5 inhibitors fail, intracavernous injections of alprostadil are recommended. This treatment works in 85% of cases.
3. Surgical treatment
When medications fail, the best treatment is penile prosthesis. The most advanced solutions are three-piece inflatable implants that allow you to achieve a more natural erection. After their installation, more than 90% of those operated on and their partners are satisfied with their intimate life.
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