Impotence and Erectile Dysfunction

DEFINITION:

The erectile dysfunction affects one third of the population over 60 years. social disability and relationship, it also represents a precursor marker of cardiovascular disease she should cause the balance sheet. The search for an etiology is by examination and clinical examination. There is very little room for additional investigations outside the hormonal balance. The development of inhibitors of phosphodiesterase type V enabled a revolution in the treatment of this pathology.

The term impotence has to be abandoned in favor of “erectile dysfunction” or “erectile dysfunction” or better yet “erectile dysfunction”. Indeed, the term impotence carries a heavy negative connotation and may result in feelings of guilt. The virile impotence is actually experienced by humans suffering from this dysfunction as a social and relational disabilities.

In practice, erectile dysfunction is defined as inadequate penile rigidity to allow to obtain a satisfactory sexual intercourse.

It can be mild, manifested by a decrease in stiffness, size or duration of erection, or more severe, up to the total lack of rigidity and rebel flaccidity.

EPIDEMIOLOGY:

It can occur at any age: often the beginning of sexual activity in connection with performance anxiety of the first reports, or opposite appear with age. In fact, its incidence increases with the sixth decade.

The Kinsey report in 1948 had raised the problem of erectile dysfunction depending on the age by observing a gradual decline in male sexual activity from 40 years.

This study concluded that 70% of couples were sexually active at age 70, the average frequency of intercourse at this age being 0.3 report per week. Since many studies have provided a better study human sexuality in particular the work of Masters and Johnson in the 1960s and in the 1990s, a study of male population cohort showed that the prevalence of erectile dysfunction was around 10% in the general population (18 to 59 years), 20% in the oldest age group (50 to 59) and highlighted a clear link between sexual dysfunction and aging but also a correlation with General health problems. In 1994, Feldman was used to study 1290 men aged 40-70 years and defined the cumulative prevalence of erectile dysfunction in 52% divided into three degrees of helplessness: minimal (17.2%), moderate (25, 2%) and complete (9.6%). In France, the SPIRA study (1993) on nearly 9,000 male subjects revealed 19% of erectile dysfunction in a general population.

Schematically, we will retain at least a third of the French population aged 60 to 80 years has a total or partial erectile insufficiency.

The management of erectile dysfunction should not be considered as a treatment comfort. Sexual complaint is genuine, anxiety, pain, personal injury, and affects the integrity of the men and therefore leads to dysfunction of the couple.

It must be considered a real medical problem which we have to realize and integrate it into the overall care of sexual health. This concept has been defined by the World Health Organization (WHO) in 1972 as to comprise three basic elements:

– Respect the capacity to enjoy and control sexual and reproductive behavior in relation to personal and social ethics;

– Assist in the deliverance from fear, shame and guilt of false beliefs and other psychological factors that can inhibit sexual response and interfere with sexual intercourse;

– Allow the absence of organ dysfunction disorders of disease or deficiency interfering with their sexual and reproductive function.

It is important to always remember that erectile dysfunction remains a relational symptom and must take charge in view of the relationship partner.

Anatomy and Physiology:

The modern concept of erection is based on the principle of active sponge. Anatomically, the corpora cavernosa are filled vascular spaces (areola) that are included in a mass of smooth muscles inserting on an abundant connective skeleton. When muscle relaxation of smooth muscle fibers, blood penetrates actively in the areola, the areola form a real blood reservoir which allows varying the volume and rigidity of the penis.

When the areola is engorged, the cavernous body stiffens the penis causing erection. The outer envelope of the corpora cavernosa also called tunica is rich in collagen. These collagen fibers are not very extensible, they nevertheless allow the rod of double volume erect, and its strength makes the stiffening high pressure cavernosa.

Erection phenomena are directly dependent vascularization by internal shameful arteries (or pudendal arteries) that provide for intracavernous cavernosa arteries and dorsal arteries of the penis. Intracavernous arteries give arterioles which will be distributed to the areolas.

Venous level, the veins of the penis are a rétrobalanique plexus draining into the superficial and deep dorsal veins of the penis. The veins of the cavernous bodies are represented by emissary veins from the venous plexus under albuginéal highly developed. This plexus plays a very important role in locking the cavernous drainage.

These veins then drain into the plexus of Santorini, then in the internal pudendal veins.

The normal physiological state of smooth muscle of the corpus cavernosum is being contracted 20 hours over 24 hours putting the penis when flaccid and rest. The erection usually lasts 4 to 6 hours per day in men between 20 and 40 is a transient phenomenon and reflex corresponding to a state of muscle relaxation of the smooth muscle fiber.

This control involves the central nervous system, spinal cord and a set of perineal nerves. All neurological structures allow to individualize three types of erection:

– Psychogenic erection defined by supraspinal localization of neural structures originally information enabling erection (audiovisual stimulation or fantasy);

– Nocturnal erections occurring during REM sleep lasting between 2 and 3 hours. They provide, among other erectile tissue oxygenation;

– Reflex erections answering genital stimulation via a loop reflexes at the spinal level.

This distinction helps to better understand the erectile dysfunction of neurological origin that may affect one or more of three types of erections that just described. For example, in men castrated, nocturnal erections are significantly altered when the erections caused by erotic visual stimuli are kept. In case of spinal injuries, there may be reflex erections while psychogenic erections have completely disappeared.

ETIOLOGY:

Schematically the penile erections require a favorable climate hormone (androgen), integrity of the nervous control (cortex to elastic fibers), an operational vasculature of normal cavernosa and especially a mild psychological state.

While all of these are very closely linked, it is possible for each of them to seek an anomaly either primary or acquired, or induced (iatrogenic). The artificial separation between organic and psychogenic etiology is increasingly obsolete.

Indeed, the origin of erectile dysfunction is usually multifactorial and even in the high organic component patient, there is always a psychogenic factor due to the feeling of impotence virile.

Hormonal:

Androgens secreted mainly by the testes stimulate libido and cause erection (increasing the concentration of nitrogen monoxide [NO] to the bulbocavernosus muscles).

Reached HPA:

The hypogonadotropic hypogonadism by reaching the hypothalamic-pituitary-testicular axis can be congenital or acquired (tumor, brain trauma, degeneration).

Hypogonadism hypergonadotropic may in turn be the result of various bilateral testicular damage (inguinal or scrotal surgery, cryptorchidism, Klinefelter, perineal trauma).

By decreasing testosterone levels, hyperprolactinemia by pituitary adenoma causes not only of erectile dysfunction and a drop in libido but also gynecomastia or galactorrhea.

Thyroid dysfunction:

Hypothyroidism can also cause a decrease in the secretion of testosterone and therefore of erectile dysfunction.

More rarely, hyperthyroidism and hyperchromatose may be involved by circulating estrogens.

Andropause:

generally grouped under the term DALA (andropause) the effect of the reduction of androgens with age.

This is a device whose primary hypogonadism cause seems to be a disorder of testicular vasculature with scarcity of Leydig cells associated enzymatic modification in target cells. The DALA usually occurs after 60 years and combines a clinically decreased libido, erectile disorders, reduced ejaculation volume, an increase in the refractory time between erections, fatigue and sometimes depression syndrome. Biologically, then there is a decrease in testosterone levels (bioavailable testosterone in particular) and an increase in LH.

Iatrogenic etiologies:

The anti-androgenic therapy (treatment of prostate cancers) are responsible for erectile impotence reversible upon discontinuation of treatment.

Neurogenic:

Any infringement of the cerebral cortex to the spinal cord, pudendal and shameful cavernous nerves can cause erectile dysfunction.

Pathologies in question:

Degenerative diseases of the nervous system (Parkinson’s disease, multiple sclerosis, Alzheimer’s disease) as well as head trauma and central tumors can cause the erectile dysfunction. In spinal cord damage, dysfunction depends on the nature and level of injury. A reflex erection is preserved in almost 95% of full high section. Chronic alcoholism and vitamin deficiencies can also cause peripheral neuropathy with achieving erection.

Diabetes is responsible for sexual problems. Erectile dysfunction can have neurogenic mixed origin (peripheral neuropathy), vascular (distal arterial disease), tissue (brake on NO release) or psychogenic (anxiety by learning about the disease and its consequences). In fact, it is usually a multifactorial etiology embracing all such factors.

Iatrogenic etiologies:

Pelvic Surgery is the main cause of damage to peripheral nerves genital destiny. Whether during a radical prostatectomy, with a total cystoprostatectomy, a colorectal resection or pelvectomy, preservation of the nerves is difficult and often impossible to achieve without breaking the oncologic prognosis. Radiotherapy is also generating erectile dysfunction (neurogenic, vascular and tissue).

Vascular:

the vascular erectile dysfunction is defined by insufficient blood perfusion at the cavernous tissue. It can be either an arterial disease, most often by arteriosclerosis or arteritis, or venous insufficiency. This perfusion failure prevents the filling space of the sinusoids and the tensioning of the tunica albuginea, then the compression of venous drainage system sub-albuginea.

These disorders result in a delay in obtaining erection, an imperfect stiffness and a holding gap.

Pathologies in question:

The arterial insufficiency may be due to arteriosclerosis, to a distal arteritis (smoking, diabetes, autoimmune arteritis, etc.), hypertension but also a pelvic trauma with arterial injury. The veno-occlusive dysfunction (incorrectly called venous leakage) can come from several pathophysiological processes. It may be an excessive proliferation of drainage or degenerative pathologies veins (Peyronie, aging, diabetes or trauma of the tunica albuginea).

Iatrogenic etiologies:

The aortoiliac surgery is iatrogenic etiology of erectile dysfunction. The reduction in flow is common iliac effect after bypass surgery or angioplasty (ligation, shunt, theft, etc.)

Among the hypotensive, two classes are particularly concerned, diuretics and beta blockers.

Tissue:

Abnormal tissue of the corpora cavernosa may be the cause of erectile dysfunction.

It may be a structural damage of the cavernous sinusoids, smooth muscle or vascular endothelium.

Pathologies in question:

Loss compliance cavernous sinusoids comes mostly an aging tissue by collagen deposition. It may be also after penile trauma or priapism impairmentsin fibroélastiques structures.

In some diseases, such as diabetes, high cholesterol or nicotine poisoning, the endothelium can be damaged and as a result the NO concentration becomes lower.

Iatrogenic etiologies:

The drugs used for intracavernous injections can cause fibrosis of the corpora cavernosa. Radiation therapy also causes damage to the endothelium and smooth muscle cavernous partly explains the irreversible erectile dysfunction that can occur up to several months after irradiation.

Psychogenic:

erectile disorders have too long been considered a symptom from a psychological dysfunction or a psychotic event. In fact if the psychological aspect should always be considered in the search for the etiology, patient care should not overestimate it. In case of psychological disorders, erection can be disrupted either by direct inhibition of higher functions, or by peripheral elevated catecholamine levels. These increase the smooth muscle tone and prevent relaxation of muscle fibers required for erection.

Pathologies in question:

Many diseases can cause psychogenic erectile dysfunction. We note mainly five types according to Tom Lue:

– Type 1: predominantly anxiety, performance anxiety;

– Type 2: endogenous depression or secondary;

– Type 3: marital conflict, disagreement with a partner;

– Type 4: ignorance of sexuality, religious constraints;

– Type 5: psychotic obsession, deviant or perverse.

Iatrogenic etiologies:

All antipsychotics can affect sexuality. More often, they reduce libido but can also affect erectile function. Most tranquilizers have side effects on sexuality. These effects are explained either by their sedative properties, either by their anticholinergic action, and finally by their central antidopaminergic action on the pituitary and hypothalamus.

Antidepressants, widely prescribed in France, are often the cause of erectile dysfunction. In fact, whether or tricyclic inhibitors of monoamine oxidase, these antidepressants have a central and peripheral actions on the erection. The newer antidepressants (the serotonin reuptake inhibitors and IRSRNA [reuptake inhibitor of serotonin and norepinephrine]) have less effect on erectile dysfunction but can participate by changing the mood they lead to sexual mode changes. Lithium and anxiolytics may also be implicated in erectile dysfunction.

SUPPORTED:

Several objectives must be defined at the first consultation:

– Confirm erectile dysfunction;

– Study the sexuality of the patient;

– Evaluate organic and psychogenic hand;

– Assess the need for an organic balance sheet;

– Assess the possibility of supporting this or that patient to use expert advice;

– Establish a quality relationship from the first consultation;

– Provide a therapeutic orientation plan with the patient.

Cardiovascular risk:

Cardiovascular involvement is not a cons-indication to sexual intercourse or the use of inhibitors of phosphodiesterase type V.

If the presence of erectile failure imposes a cardiovascular evaluation, it is because it is now established that it is a disease precursor of the endothelium. Patients who suffer from erectile dysfunction and are more at risk for myocardial myocar of and at an earlier stage than the general population.

In the Princeton Consensus Conference patients with more than three cardiovascular risk factors, history of myocardial infarction, clinical signs of arterial or NYHA class II heart failure are part of a group at intermediate risk for which a balance sheet cardiovascular necessary.

Examination:

Sexual symptoms:

It is important to clarify the sexual symptoms.

Is it really an erectile dysfunction or other pathology malformed or denied? If agitil an ejaculation disorder, a personality disorder or an isolated conjugopathie? We can individualize frequent simple sexual failures in the subject young and severe erectile dysfunction installed either psychogenic origin or of organic origin.

The characteristics of sexual dysfunction enable diagnostic orientation: the installation mode of erectile dysfunction, retention or not of night and morning erections and the search for libido disorders are essential to guide the etiology.

The type of erectile dysfunction should be also investigated. Is it a problem of frequency (how many attempts reports, how much success, what results by masturbation?). You should also know if it is a disorder of initiation or of a disorder of maintaining erection. In the latter case, the patient can enter but in the report the penis becomes soft denying it a satisfactory report. This sign often directs towards a psychogenic origin with erectile dysfunction due to performance anxiety.

Quality of erections:

It is important to encode the quality of erections:

– 0: lack of erection;

– 1: small increase in volume without induration;

– 2: Increase volume without stiffness;

– 3: insuffi cient rigidity for penetration;

– 4: possible relationship but pliable penis;

– 5: normal erection.

Patient history:

The patient’s sexual experience (number of partners, hetero- or homosexuality, promiscuity, image of women, introduction to sexuality, motivation and that of the partner) provides the fundamentals for treatment adherence and taking the patient.

The patient’s age, finally, is an essential factor that must not be too put forward during the interview. In fact, erectile dysfunction is often seen as a sign of premature aging, the therapist must avoid reinforcing with his patient that idea.

Patient history:

The search for a tobacco intoxication is essential. We know the direct harmful effect of nicotine on the erectile tissue but also the impact of chronic tobacco abuse on erectile function through blood reached. The alcohol abuse must be investigated. Chronic poisoning is responsible for erectile dysfunction by neuropathy or decline in circulating testosterone. It is the same for marijuana.

Drug treatments should be carefully noted. Many medications can interfere with erectile function which must not however be overestimated responsibility.

It is often difficult to distinguish between harmful causal disease of erectile function (hypertension, hypercholesterolemia), the psychological impact of a chronic disease or the age of the patient and the prescribed treatment.

Surgical history, especially, pelvic surgery or vascular moving towards an organic origin, neurological or vascular.Medical history, especially diabetes, is one of the first causes of impotence.

Physical examination:

It is relatively brief. It focuses on secondary sexual characteristics (hair, voice, size, gynecomastia, testicular size).Palpation of the corpora cavernosa and the analysis of the elasticity of the rod will be realized.

Good elasticity of the penis indicates a proper oxygenation of the cavernous tissues and therefore a nocturnal erection of a good quality. The feel of the penis also looks to seek plates or Peyronie’s disease fibrosis. DRE examines the prostate (adenocarcinoma-cons indicates a possible hormone treatment). Finally, taking blood pressure and pulse are different facts in search of a blood disorder.

Additional tests:

Very few additional tests are required in the treatment of erectile dysfunction.

Suspected DALA has existed for patients over 65 years with associated decreased libido and quality of erections. In these patients, it is desirable to have a complete hormonal balance sheet including: the free and bioavailable testosterone, an assay of LH and FSH and prolactin and prostate specific antigen. This exam is routinely asked for if there is a need for androgen supplementation when DALA be confirmed biologically, a prostate adenocarcinoma research should be done to not add androgen in a patient with cancer prostate.

The other reviews are for specialists.

We distinguish the penile pharmaco-Doppler, night plétismographie of recording nocturnal erections one or more nights (RigiScan®). The cavernometry can measure flow rates of initiation and maintenance of an erection facilitated by the injection of a vasoactive substance and maintained by intracavernous saline infusion.

The neurophysiological: latency of bulbocavernosus reflex conduction velocity of sensory dorsal nerve of the penis, somatosensory evoked potentials have no interest in current practice but can be used in specific cases of peripheral neuropathies.

TREATMENT:

The therapeutic management of erectile dysfunction always two parts: firstly a support psychosexologique and also pharmacological treatment.

Indeed, sexuality can not be reduced solely to psychological and physiological theories.

The etiology of erectile dysfunction is always mixed and incomplete support does not make for a satisfactory result.

Psychological care:

It is essential at the beginning of the treatment to have a reinsurance policy facing the patient. It is important also that the consultation of men with erectile dysfunction refers to the doctor preconceptions in his value system and his own sexuality.

A good support sexology starts with finding a temporal relationship in the beginning of erectile dysfunction and a significant life event. The management also assesses the patient’s personality.

Mark depressive symptoms is also necessary. Finally, an evaluation of the couple and the relationship between man and woman is necessary. Many erectile dysfunction also come from a lack of time for sex. It is important to give simple advice for the couple resexualiser, réérotiser relations with the woman.

Medical treatment:

Currently, the therapeutic arms are numerous and the arrival of phosphodiesterase inhibitors led to a real revolution in the management of erectile dysfunction. If erectile dysfunction is primarily a symptom, its origin is multifactorial and even if the understanding of erectile dysfunction has made tremendous progress, therapeutically, in most cases, only the symptoms are treated pharmacologically.

There are two types of drugs: drugs that induce an erection and drugs that facilitate the erection. In the first case (oraltreatment), active stimulation is required in the other (injection of prostaglandin), erection reflex is no sexual stimulation. Medical treatment is associated with diet and lifestyle advice: stop smoking, diabetes control, reduction of harmful drugs, lifestyle.

Treatments per os:

Vasodilators, proérectiles drugs (yohimbine), the veinotonic or anxiolytics treatments can be used to reduce anxiety and to have a driving patient reinsurance.

The discovery of phosphodiesterase inhibitors has significantly changed the management of patients with erectile dysfunction.

In response to sexual stimulation, NO is released from parasynaptiques proérectiles endings and endothelial cells. NO leads to an increase of cyclic GMP stimulates a protein kinase which reduces the free calcium concentration in a loss of contraction. The type V phosphodiesterase is an enzyme that degrades cyclic GMP.

Three drugs are currently available: sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis). The effect of this treatment is rapid after 30 minutes to 1 hour.

The active drug allows an increase of NO in the cavernous tissue thus facilitating erection. Before the introduction of this treatment, make sure that there are no incompatible drug intake (nitrates, NO donor drugs). phosphodiesterase inhibitors may potentiate the vasodilatory effects of nitrates and have serious consequences to the cardiovascular level, up to the patient’s death.

Although the rare side effects are also to know (headache, nausea, flushing, myalgia, changes in color perception).

Androgen:

It can give either by injection (Androtardyl®) or percutaneously (daily skin gel, Androgel®). This androgen therapy should be performed only after verifying that there is no suspicion of prostate cancer. DRE and PSA testing and an evaluation of urinary functional signs is essential before starting this androgen therapy.

Local treatments:

Administration of an intra-urethral gel prostaglandin (MUSE system):

It is reserved for patients resistant to oral treatments and do not wish to resort to intracavernous injections. This easy little use of treatment is less effective than intracavernosal injections. It is marketed recently in France and its success is relative (Fig. 1).

Intracavernous injections:

Direct injection of a drug erectogenic in the corpora cavernosa is a very effective treatment but requires learning.

These injections are used before every report.

Self-administration must be in the side face of the rod between the pubis and the glans of one side or another without the urethra and the glans.

Papaverine was the first drug used.

She has no marketing authorization but the large number of publications describing its use cavernous currently allows many therapists use. Its low price is an obvious advantage over other drugs. Induction of cavernous fibrosis and significant risk of priapism make its less frequent use.

Currently these are less prescribed alpha given the lack of efficacy compared to prostaglandins.

The prostaglandin E1 (PGE1) are erectogenic substances frequently used in intracavernous injection. The first injections should be given in a specialized environment to enable proper learning by the patient and especially to avoid side effects: hypotension and priapism. The Edex® or Caverject® are marketed under several dosages: 5, 10 or 20 micrograms.

Support system erection:

These are devices that have a cylinder connected to a pump for by mechanical pressure with blood flow in the penis causing an erection. This will be maintained after the withdrawal of the apparatus by a snap ring at the root of the penis.

After learning a bit tedious, this simple and harmless way, provides a satisfactory erection without complication.

This treatment can be offered on failure intracavernous injections or when the patient and his partner are hostile to it.

Surgical treatment:

Vascular surgery:

Surgical arterial revascularization indications are limited and usually relate that young patients. It must be proposed if pelvis trauma or when there is arterial malformations requiring vascular reconstruction.

Surgery of venous leakage:

It is practically abandoned due to a better understanding of pathophysiology, the concept of venous leakage disappeared, giving way to that of a cavernoveineuse incompetence for which the indication for surgery is very low.

Prosthetic surgery:

In case of failure of all these treatments, implantation of a penile prosthesis may be justified as a last resort. The prostheses can be either adjustable semi-rigid to cast the rod out reports or inflatable. Erection prostheses work very simply by transferring liquid from a reservoir to a hollow tube with flexible walls. The pump placed in the scrotum enables the prosthesis. The rod then began to erect a satisfactory report.

At the end of the report, the deactivation of the prosthesis is made with the same pump to find a flaccid state.Complications can be infectious because it is a prosthetic or mechanical equipment requiring revision surgical equipment. If this prosthetic surgery is not very established in the Latin countries, it nevertheless provides an important satisfaction.

CONCLUSION:

Erectile dysfunction is a much more common condition than he previously thought even a few years. Its treatment is often multidisciplinary. The first doctor who speaks the patient has a very important role.

He must avoid to deny, minimize or evade the patient’s complaint. First, we must fight against performance anxiety that develops in patients with erectile dysfunction. The search for a cause often avoids worsening the situation (stopping smoking, reducing unnecessary treatments, improved marital relations, domination of anxiety, etc.) and to better tailor treatment ( hormone therapy for example).

The arrival of new effective oral treatment has revolutionized the care of these patients, however, we must never forget that whatever the pharmacological efficacy, it is essential to associate it with a psychosexologique supported.