Here are some stories from the clinic about how do the patients approach the doctor?
1-When Suresh walked into my clinic, I knew I was looking at a person who had a “crisis of confidence” writ large on his face. Drooping shoulders and lowered chin didn’t help the matter either.
He pulled his chair near me and whispered in my ears, “Doctor, I have a serious problem. I am supposed to get married after a fortnight. Last night, I wanted to say my girlfriend goodbye. We got emotional and things turned hot. She wanted to give me a parting gift. But doctor, I got so excited that this bloody thing just wouldn’t get hard. What happened afterward is indescribable. But if the same thing happens on my wedding night, I will be a complete goner. Doctor, please help me”.
It was an S.O.S.
Suresh was a victim of performance anxiety. His condition was addressable.
2-Hamid, 26, had lost his job. He was trying to get another. But the jobs were difficult to come by. He lost interest in life, his appetite,and sleep at night. (His mother told me). Parents thought that the marriage could stall his depression. They got him married. But his depression worsened when he did not get an erection on the wedding night.
Hamid was a victim of anxiety and depression.
3-Josef, 35, worked in a corporate sector. He was so stressed up and tired when he came home every day that sex was never on his agenda. One day his wife forced him into having sex. But his penis refused to budge.
Josef was a victim of corporate stress.
4-Pankaj had a troubled childhood. His neighbor, whom he called an uncle, would sexually abuse him every day when he didn’t even know what sexual abuse meant. He carried that trauma in adulthood. Today he gets shit scared when he thinks of sex.
Suresh, Hamid, Josef, and Pankaj- all of them had one thing in common. They all had psychogenic ED.
Once your doctor is convinced that you have a problem then the next step is investigation.
The diagnosis, per se, generally doesn’t require many investigations if the history is perfect. For psychological causes, no investigations are required. Diagnosis is apparent.
One very important thing to remember is-
If one has erectile dysfunction but gets those morning erections, then, in all likelihood, the problem is psychological. But to label someone as psychological without ruling out the physical causes is not acceptable.
Lab investigations-
1-CBC– ( Complete Blood Count)- mainly for anemia.
2-Blood Sugar- Fasting and PP– To rule out Diabetes
3-Hormonal study– Serum Testosterone, Luteinizing hormone (LH), Prolactin, FSH, Thyroid Function Tests (TFT)- To rule out any hormonal imbalance.
4-Lipid profile– To rule out the chances of atherosclerosis
5- Color-flow duplex ultrasound of penis — to find out the penile fibrosis, blood supply to the penis. Doppler studies are also done after giving intra penile injection of the erection-inducing drug. (Papaverine-an alpha receptor blocker that produces vasodilatation)- To find out any aberration in arterial inflow or any diastolic leak.
The techniques that are used to treat psychogenic ED –
1- Oedipus complex-
Individual Freudian therapy.- Oedipus was a5th-century BC, Greek mythological character, who unwittingly killed his father, and married his mother. The positive Oedipus complex refers to a child’s unconscious sexual desire for the opposite-sex parent and hatred for the same-sex parent.
The negative Oedipus complex refers to a child’s unconscious sexual desire for the same-sex parent and hatred for the opposite-sex parent. These infatuations and hatred generated during childhood play a major role in the psycho-social development of a child, as per Sigmund Freud.
2-Individual and couple counseling-
It is based on Masters and Johnson’s concept of performance anxiety. This is generally used for premature ejaculation. But many times these conditions co-exist. The “stop and squeeze” technique was developed by Masters and Johnson in the late 1970s. The partner manually stimulates the patient’s penis until he is close to the point of orgasm and then squeezes the penis just below the glance for 3 or 4 seconds. The partner does this until the patient loses his urge to ejaculate.
Masters and Johnson claimed to have 97%success rate. Present-day studies don’t agree with this.
3- Psychodynamic psychotherapy- It’s the therapy that focuses on unconscious processes as they are manifested in the patient’s present behavior. The goals of psychodynamic therapy are the patient’s self-awareness and understanding of the influence of the past on present behavior. A psychodynamic approach enables the patient to examine unresolved conflicts and symptoms that arise from past dysfunctional relationships and manifest themselves in the need and desire to abuse substances.
4- Cognitive behavioral therapy-(CBT)
Is a talking therapy that can help you managing your problems by changing the way you think and behave. It is most commonly used to treat anxiety and depression but can be useful for performance anxiety in ED
5- Hypnotherapy — in selective cases.
6- Kegel exercises –
One can strengthen the pelvic floor muscles, which support the bladder and bowel and affect sexual function. First, you have to learn to identify the muscles. If you practice stopping and restarting urinary flow during urination, you can easily identify and then practice their contractions and relaxation. This is again basically for PME but many times PME is a part of ED.
7-Local anesthetic gels and condoms are used to numb the sensations. They do not help much.
Organic ED-
Even the patients, undergoing treatment for organic causes should opt for psychological sessions. They may get benefited from opening lines of communication about sex and getting guidance on how best to use their functional capacity. If ED is due to an organic cause then the basic cause has to be treated.
If it’s long-standing it would take a longer time.
Irrespective of the cause following measures can be taken.
1- Vacuum-constriction devices- (VCD)
VCD is an external pump that a man with ED can use to get and maintain an erection. The pump helps the penis to become erect and a band attached to the pump helps to maintain the erection. The overall satisfaction quotient is not great.
2- Medicines-
A) Antidepressant-like Trazodone has been routinely used in ED without much help.
B) The real breakthrough was-PDE5 inhibitors. The advent of this group has changed the whole perspective of erectile dysfunction. They work irrespective of the cause and produce results. The first drug in this class was Sildenafil. Sildenafil has an interesting history. The drug was invented in 1989 for hypertension and angina. It was later realized that the drug would also cause erection of the penis. Its use as hypertensive was discarded and it was ‘repositioned’ for, erectile dysfunction in 1998.
After Sildenafil, the whole chain of PDE5 inhibitors followed- Tadalafil, Vardenafil, Avanafil, etc. We won’t go into the details of its action. Just to make a passing mention of it -Sildenafil acts by blocking PDE5 an enzyme that promotes the breakdown of cyclic GMP that regulates blood flow in the penis.
There are certain very important things about all these PDE5 inhibitors that one should remember-
1. They can be proved dangerous if taken with Nitrates, the drugs taken for hypertension and ischemic heart disease. It can cause a sudden fall in blood pressure resulting in death too. It should not be taken without an expert’s opinion.
2. Sildenafil Should be taken on an empty stomach
3. It takes nearly 30 minutes to 1 hour to show effect.
4. Sexual desire is a must. Without which it’s useless.
Tadalafil scores over sildenafil in some respects-
A) Tadalafil can be taken at any time, with no relation to food, while sildenafil has to be taken on an empty stomach
B) The Half-life of Sildenafil is 4hours. That means after 4 hours half the drug is thrown out of the body. Hence the effect is short-lived. While with Tadalafil the half-life is almost 17 hours. This means that after 17 hours if you take another dose of Tadalafil the active ingredient would remain in your body for a much longer duration and one can keep enjoying sex multiple times.
C) There are people in whom PDE5 inhibitors won’t work. Surgery is always taken as a last resort.
3-Penile prosthesis– There are different types of penile implants. You can get it done by urology experts. “Penile implants” is another topic, and we will not go into details about it.
To summarize-
ED is treatable.
Identify the cause and then draw a plan of action.
Have patience and co-operate with the treating physician.
The outcome might change your life!
Sexual Health and Wellness 