Erectile dysfunction or impotence is one of the most common yet most untreated sexual problems in India.

 

 

 

 

 

 

 

 

Erectile dysfunction(ED)  commonly co-exists with a host of other clinical conditions such as urological problems (BPH, LUTS, etc.), psychological issues or endocrinological disturbances, diabetes, being one of the major concern. 

However, the link between ED prevalence and cardiovascular disease is very strong.  It is well known that cardiovascular disorders and ED share some common risk factors like atherosclerosis, obesity, hypertension, impaired glucose tolerance, etc.

There is evidence that rather than being a disease of the penile vasculature, ED may be a manifestation of a systemic vascular disease.Well designed clinical studies have indicated that symptoms related to ED often predate symptomatic angina by two to three years and other major adverse CV events by three to five years.

Increased awareness, as well as significant media interest, is prompting more and more patients to seek help from general practitioners for sexual dysfunction or ED. With varied data from clinical studies, ED clearly constitutes a significant number of patient population that is likely to present regularly to a General practitioner(GP). GP, thus, plays an eminent role in assessing, counselling and treating ED.

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Diagnosis of erectile dysfunction

Diagnosis of ED requires thorough history including sexual, medical and psychosocial history. Sexual history must include details like onset, duration and severity of the erectile dysfunction, and details of the sexual response. Medical history of relevant risk factors for erectile dysfunction like diabetes, hypertension, smoking, obesity, CVD and dyslipidemia should be taken. A psychosocial history of anger, depression, guilt, addictions, financial insecurities, extramarital affairs, body image issues, etc. needs to be assessed as well. A detailed physical examination of the reproductive organs and rectal examination may prove worthy to find varicocele hernia, hydrocele, phimosis, paraphimosis, herpes, peyronies disease, micropenis or other pathologies. A questionnaire like IEF (International Index of Erectile Function) or Sexual Health Inventory for Men (SHIM) or Brief Male Sexual Functioning Inventory (BMSFI) may also form a part of the diagnosis. This would be followed by rectal examination and evaluation of hormonal status or other tests as required. 

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First-line treatments that can be easily prescribed and recommended by primary care clinicians include psycho-social counselling, lifestyle changes, medication changes, PDE5 inhibitors doses and vacuum-constriction devices.

Management of erectile dysfunction

Psychotherapy is a powerful tool in the management of erectile dysfunction as various psychological co-morbidities are often seen in ED patients. Counseling is extremely effective in treating such cases and forms major treatment part of ED. Counselling and educating the patient about the strong link between unhealthy lifestyle such as obesity, lack of exercise, smoking, and alcohol and recreational drug abuse and ED is helpful.Strong recommendations for behaviour modifications can often help improve the condition. Addressing psychosocial issues about relationships, anxiety, lifestyle change or stress is also important. 

First line therapy for erectile dysfunction

Apart from counselling, oral Phosphodiesterase 5 Inhibitors (PDE5 inhibitors) drugs like Sildenafil Citrate, Tadalafil and Udenafil form the first line of treatment for ED. The most commonly prescribed PDE-5 inhibitor drug is Tadalafil, and the least commonly prescribed is Udenafil. The choice depends upon the pharmacokinetic properties and cost as per patient’s individual needs and acceptance. 

Second and third line of therapy 

When first-line therapy for ED fails, second and third line therapy can be considered in secondary care,  whereas penile prosthesis or implants are the last resort invasive intervention when everything else fails.Such patients are further referred to urologists.

The second line therapy includes intracavernous injection of papaverine and largactil and prostaglandin, vacuum assisted erection therapy and intraurethral drugs like prostaglandin.

 

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New approach to management of erectile dysfunction 

The new approach for erectile dysfunction management focuses on regenerative therapies to achieve both vasorelaxation and inhibition of platelet aggregation. These include:

• Recombinant vascular endothelial growth factor (VEGF): Transfection of VEGF is being tried into the rat penis to reverse vasculogenic erectile dysfunction by increasing the levels of eNOS and inducible nitric oxide synthase (iNOS).
• Endothelial microparticles, myeloperoxidase and haem oxygenase -1: These emerging molecular targets are under research to treat vasculogenic erectile dysfunction.
• Rho- Kinase Inhibitors: It works by inhibition of the calcium sensitization pathway.
• Sonic Hedgehog: There is clinical evidence that suggests the reduced levels of Shh in the penis of rats and human with diabetes. Moreover, it has also been found that exogenous administration of Shh increased vascular endothelial growth factor and Nitric Oxide Synthase.
• Gene Therapy: An adenoviral vector constructed to introduce a gene coding for a protein has been useful for improving erectile dysfunction.
• Mesenchymal Stem Cell Therapy: The evidence suggesting the possibility of regeneration due to the presence of penile endogenous Stem Cells offer new perceptions for management of erectile dysfunction.
• Nano technology: This includes topical administration of drugs to get erectile functioning, or injection of gels into the penis for prevention of morphological changes, or injection of hydrogels for CN regeneration/neuroprotection and drug encapsulation (PDE5i) to increase erectile function. 

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ED, a distressing condition, needs thorough investigation and can be managed in primary care setting in most cases.