Erectile Dysfunction

What Is an Erection?

An erection is a process that occurs through the influence of physical, hormonal and psychological factors. The spongy, elastic tissue inside the penis begins to fill with blood as a result of sexual arousal, and the erection of the penis takes place. The nerves surrounding this spongy tissue cause the blood vessels to dilate during an erection. This entire process is controlled by testosterone, known as the male hormone.

Erectile Dysfunction and Its Causes

The penis failing to reach sufficient rigidity for satisfying sexual intercourse, or the rigidity not being maintained throughout intercourse, is a common problem. In younger men this problem usually arises from certain psychological issues, whereas in middle-aged and older men there is usually an underlying organic condition.

Cardiovascular diseases can lead to erectile dysfunction. Other causes that may lead to erection problems include:

• Diabetes mellitus

• Nerve damage in the penis or the pelvic region

• Previous surgery in the pelvic region (prostate and bladder operations)

• Radiation therapy to the pelvic region

• Low testosterone levels

A number of risk factors such as obesity, smoking, high cholesterol, high blood pressure and lack of exercise can lead to both erectile dysfunction and cardiovascular disease. For this reason, it has been suggested that erectile dysfunction may be an early sign of hidden heart disease, and that men experiencing erection problems should be evaluated with regard to their cardiovascular health.

Erectile dysfunction can also occur together with benign prostatic hyperplasia (BPH). Erection problems are more common in individuals with complaints such as frequent urination, getting up at night to urinate and a sudden urge to urinate. As the severity of these complaints increases, the erectile dysfunction also worsens.

It should not be forgotten that the following psychological conditions may develop in men with erectile dysfunction:

• Anxiety

• Depression

• Feelings of inadequacy

• Low self-esteem

• Stress

Diagnosis of Erectile Dysfunction

In order to provide the most appropriate treatment, the cause of the erectile dysfunction must be understood and the correct diagnosis established. A detailed medical history is taken to assess your general health. Medication use, smoking and/or alcohol consumption, previous surgical operations, cardiovascular diseases and hormonal disorders are reviewed.

After the general medical history, a sexual history is taken. These questions can be very personal, but they are necessary for a correct diagnosis and treatment. You will be asked when your erectile dysfunction began and which treatments have been tried before. The quality and duration of spontaneous morning erections and of erections occurring with sexual stimulation are also recorded. Details are asked about arousal, ejaculation and orgasm problems that may accompany erectile dysfunction. Several questionnaires have been developed that allow all this information about sexuality to be evaluated systematically. These include the International Index of Erectile Function (IIEF), the Sexual Health Inventory for Men (SHIM), the International Prostate Symptom Score (IPSS) and depression scales.

After the medical history, a physical examination is performed to investigate conditions that may cause erection problems. During the physical examination, the penis and testicles are assessed, and a digital rectal examination is performed to detect prostate diseases. Pulse checks and blood pressure measurement may be needed to evaluate cardiovascular diseases that can lead to erectile dysfunction. Some blood tests may also be necessary to clarify the cause of the erectile dysfunction. Tests performed for this purpose include fasting blood glucose, testosterone level and blood lipid profile.

In certain special situations, other tests may also be required to evaluate erectile dysfunction. These include the nocturnal penile tumescence and rigidity test, the intracavernosal injection test, cavernosometry and cavernosography. These tests are not commonly used in the initial evaluation.

Treatment of Erectile Dysfunction

Lifestyle Recommendations:

Improving general health problems can help reduce complaints related to erectile dysfunction. Quitting smoking, drinking less alcohol and exercising regularly are among the main recommendations. In addition, limiting sugar, salt and fatty foods improves both overall quality of life and the quality of sexual intercourse.

Oral Treatments:

The first-line treatment recommended for erectile dysfunction is phosphodiesterase type 5 inhibitors. These medications cause the vessels in the penis to dilate and increase blood flow. In our country, sildenafil, tadalafil and vardenafil are available from this drug group. Due to their possible side effects, these medications should be used under the supervision of a physician.

The main side effects of phosphodiesterase type 5 inhibitors are headache, skin flushing, heartburn, nasal congestion and a feeling of drowsiness. In patients taking nitrate-containing medications, the use of phosphodiesterase type 5 inhibitors can cause a sudden drop in blood pressure.

Topical Treatments:

Topical treatment means applying medication to the skin. Two special forms of the drug alprostadil are used for topical treatment. The first is a pellet form placed into the tip of the penis (intraurethral), while the second is a cream applied to the external opening of the urethra at the tip of the penis. Alprostadil is absorbed through the urethra and increases blood flow by relaxing the smooth muscles of the penile vessels. Its side effects are a feeling of light-headedness together with low blood pressure. Systemic side effects are rare. This treatment is not recommended in the presence of sickle cell anemia, leukemia, bone marrow diseases or Peyronie's disease. While using this medication, condom use may be required to prevent the drug from being transferred to the partner.

Vacuum Erection Devices:

These devices are cylinder-shaped and include a rubber or silicone ring that fits tightly around the penis. They, too, are used when first-line treatments have failed. It is recommended that you consult your physician to learn how to use them (Figure 1).

Intracavernosal Injections:

This is a treatment option in which medication is injected into the spongy tissue inside the penis. It is recommended when the lifestyle changes and phosphodiesterase type 5 inhibitors used in the first stage have not been effective. An erection occurs 10-15 minutes after the injection, even without sexual stimulation. The most commonly used agent is PGE1, that is, alprostadil. In some cases it can be combined with phentolamine and papaverine. The patient must receive the necessary training from the physician on how to perform the injection. The injection is applied to the base of the penis to avoid damaging the urethra, the nerves and the blood vessels of the penis (Figure 2). After the injection, pressure should be applied to the injection site for 2-5 minutes to prevent bruising. The most common side effect of this treatment is penile pain. Its most serious side effect is priapism, characterized by an erection that lasts longer than 4 hours and is painful. Therefore, if an erection lasts more than 4 hours following an intracavernosal injection, a physician should be consulted immediately.

Shock Wave Therapy (ESWT):

This is a form of treatment in which low-intensity, focused shock waves are delivered to the penis in short intervals to improve erections. It is applied in multiple sessions and can be repeated if necessary. This treatment creates minor micro-damage in the penile tissue and, during the healing process, leads to the formation of new blood vessels. In this way, blood flow to the penis increases, which improves the quality of erections.

Penile Prosthesis Implantation:

This is a surgical procedure performed in patients with severe erectile dysfunction when other treatments have failed. During this procedure, prostheses that will provide rigidity are placed inside the penis. There are two types of penile prostheses: semi-rigid (non-inflatable) prostheses and inflatable prostheses.

Semi-rigid prostheses consist of two bendable rods placed into the erectile chambers of the penis. They can be bent into a suitable position during sexual activity. Inflatable prostheses, on the other hand, are fluid-filled devices. They consist of two inflatable cylinders placed inside the penis, a pump placed into the scrotal sac (known as the scrotum) and a reservoir that stores the fluid. Inflatable prostheses are used more frequently because they provide a more natural erection (Figure 3).

Penile prosthesis surgery can be performed under general anesthesia or spinal anesthesia (numbing from the waist down). Under anesthesia, an incision is made just above the penis (or between the penis and the scrotum) and the cylinders are placed inside the penis. Following this step, the reservoir storing the inflation fluid is placed behind the abdominal wall, and the pump that inflates the cylinders is placed in the scrotum. Finally, all components are connected and the incision is sutured. The wound is cleaned and a pressure dressing is applied. Patients can usually be discharged one day after surgery. Penile pain and scrotal swelling may be observed for a few days after the operation.

For 4-6 weeks after the operation, heavy lifting, cycling, thermal baths and saunas should be avoided. If the swelling is severe or does not subside, if there is discharge from the wound, or if redness develops around the incision, a physician should be consulted without delay.