Tag: erectile-dysfunction

What was going on in the mind of the creator when he was gifting a man his sex organ?
Was it only for procreation?
Was it also meant to be for fun?
In some animals, the ejaculatory time is even less than 10 seconds.
Imagine you are passing through a jungle and see a lion. The lion notices you, but he also sees a lioness that appears to be in a wild mood. The lion would not give any thought to who he would prefer.
Before you could blink twice, he’d run for the lioness, deposit his sperms in the receptacle, and then rush toward you to devour his delectable food.
But this example is not enough to give you an idea that sex is only for procreation; because a lioness generally has sex, almost twenty times a day with different partners.
Now, that should tell you that sex is not meant only for procreation!
Erectile dysfunction(ED) has its space in clinical medicine.
ED can be defined as the inability of the man to attain and then sustain the penile erection sufficient enough to achieve satisfactory sexual intercourse.
A workable definition for a treating physician to decide whether a person qualifies for a working diagnosis is-“persistent inability for at least 3 months to attain or maintain an erection sufficient for satisfactory performance”.
In humans, procreation is a coincidence, if not an accident. The main purpose is recreation.
There is no way to know the prevalence of erectile dysfunction, for it still being a social stigma; people are not vocal with symptom. In my private practice, I see 2 to 3 cases every day. So if I see10 male patients per day the incidence should be at least 30% in the general population.
Talking about erectile dysfunction is still a taboo in India.
Incidentally, even those three patients who come to a clinic generally present themselves with some different problem. They just mention ED as a passing reference in a course of medical examination and try to portray it as just another symptom, though that’s a leading concern on their minds.
ED is very common in either the young population or those who are more than 60 years of age. Age-related erectile dysfunction is easier to explain. By the time men reach that stage most of them have diabetes, hypertension, metabolic syndrome, or some form of debilitating disease, which gives them a platform for ED.
The most common reason for teenagers is the pornographic material that is available on digital media, at the click of a button. In most of these instances, the sex is depicted in the most exotic possible way. So the teenagers grow up with weird ideas about sex. And when they get to experience their first encounter with sex, they learn it a hard way, that it is nowhere close to whatever is projected on the tube.
And then- what’s the natural outcome?
Abysmal failure!
This failure haunts them in the future whenever they have their sexual encounters. This forms a chain of failures from which it becomes difficult to emerge victoriously.
• Longer the better!
• Sturdier, the better!
• Longer lasting, the better!
These are the ideas they grow up with. Ironically this is the race where no man wants to come first. A man, who always tries his hardest to touch the finishing line first, wants to do the exact opposite when it comes to sex. But his brain is not conditioned for the situation.
And then performance anxiety takes over.
This is psychogenic erectile dysfunction.
The causes for psychogenic ED are —
• Relationship conflicts
• Sexual inhibitions
• Sexual abuse as a child
• Sexual preference conflicts
• Fear of pregnancy
• Fear of Sexually transmitted diseases
There is an intriguing story about what must have been going on in the mind of the creator when he made the penis.
First, he wanted to make it only for the sake of procreation. He changed his mind later. Why not create a level playing field where Adam can have a little fun!
He thought of several options.
First, he considered making a bony penis, but then that would constantly be in an erectile phase.
No way!
Men would have to move in three-legged trousers. There would be no way a woman could find out whether the man was excited after seeing her.
The second choice was to make it out of skeletal muscles. But the skeletal muscles would again require the help of bone for a support.
The skeletal muscles mean voluntary control. Men would move around the streets, flashing their erect organs all the time.
The creator must have thought it a vulgar concept!
No wonder; the idea was dropped!
Then he came out with this gem of a creation! There was no way this could have been any better. He created a special tissue called corpus spongiosum and corpus cavernosum. Once a man gets excited, blood enters in corpus spongiosum and corpus cavernosum, increasing both the length and the width of a penis. The function of the corpus spongiosum is to prevent compression of the urethra during erection.
Here is something interesting-
During physical activity, the blood supply to the heart increases 5 times its normal blood supply, but during sexual stimulation, the blood supply to the penis gets increased to phenomenal 100 times its normal!
What an idea!
Penis has autonomous control. No one can erect the penis at any given time at his will.
The other type of ED is “organic”, where you can pinpoint the cause of ED.
The list is long.
There were times when even experts would say that psychogenic causes account for 70% of all the causes of ED.
Now the opinion is exactly the opposite.
The causes of organic erectile dysfunction are-
1-Vascular causes are- Pre-existing cardiovascular disease, atherosclerosis, hyperlipidemia, hypertension, diabetes, and smoking.
One very important point to remember is- erectile dysfunction at a younger age could be a starting point for your cardiovascular event in the future. If atherosclerosis can start in penile arteries it can always start in your coronaries.
Diabetes Mellitus (DM) by far remains the most important organic cause of ED. Never forget the fact that DM is a disease of nerves and blood vessels
2- Anatomical- Penile fibrosis, Peyronie’s disease, Micropenis
3-Hormonal- Central hypogonadism, Thyroid disease, Cushing’s syndrome, Hyperprolactinemia, Metabolic syndrome, Obesity
4-Neurological- (Central)- traumatic brain injury, Parkinson’s, Multiple sclerosis (MS), brain tumors, spinal cord injury
5-Neurological-(Peripheral) — peripheral neuropathy, alcoholism,
6-Drugs- Beta-blockers, LHRH analogs (Luteinizing Hormone-Releasing Factors Agonists), antidepressants, recreational drugs (MDMA, LSD, oxycodone, amphetamine)
Psychological factors usually co-exist with organic ones. Even a bare minimal organic derangement causes performance anxiety.
What a physician needs to know is the answers to three basic questions-
1-Whether the disorder is of sufficient duration to warrant intervention?
2-Whether ED is the primary complaint or associated with other sexual dysfunction like PME (premature ejaculation) or low desire
3- Is the problem secondary to medication use, hormonal imbalance, a neurovascular disorder like DM, hypertension, metabolic syndrome, obesity, or psychogenic?
If it’s organic treat the basic cause.
If it’s psychogenic he will require psychological counseling.
No easy answers!
But it’s treatable.

(Global incidence of ED will increase from 152 million men in 1995 to 322 million men by the year 2025. This exponential rise is alarming.
In 2019–2020- 18 million American males suffered from ED.)

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!