“Erectile Dysfunction (ED) is the inability to achieve a satisfactory erection or maintain it throughout sexual intercourse. This problem is a result of various physical, hormonal, and psychological factors. When a man is sexually aroused, the spongy and elastic tissue inside the penis begins to fill with blood, leading to an erection. The nerves surrounding this spongy tissue trigger the expansion of blood vessels during an erection. Testosterone, the male hormone, controls this entire process.

Causes of Erectile Dysfunction and Associated Factors

The inability to achieve a sufficient level of penile rigidity for a satisfying sexual encounter or the inability to maintain the erection throughout intercourse is a common issue. While in younger individuals, this problem is often caused by psychological factors, in middle-aged to older men, there is generally an underlying organic condition involved.

Heart and vascular diseases can lead to erectile dysfunction. Other factors that can cause erectile problems include:

– Diabetes (Diabetes)
– Nerve damage in the penis or pelvic region
– Surgical operations in the pelvic area (prostate and bladder surgeries)
– Radiation therapy to the pelvic region
– Low testosterone levels

Risk factors such as obesity, smoking, high cholesterol, high blood pressure, and lack of exercise can contribute to both erectile dysfunction and cardiovascular diseases. Therefore, it has been suggested that erectile dysfunction could be an early sign of an underlying heart condition, and men experiencing erectile problems should be evaluated for their heart health.

Erectile dysfunction can also coexist with benign prostatic hyperplasia (BPH). In individuals with symptoms such as frequent urination, nighttime awakening to urinate, and a feeling of incomplete bladder emptying, erectile problems are more common. As the severity of these symptoms increases, erectile dysfunction becomes more severe.

It’s important to note that individuals with erectile dysfunction may also experience psychological disorders such as anxiety, depression, feelings of inadequacy, low self-esteem, and stress.

Diagnosis of Erectile Dysfunction

To determine the most appropriate treatment, it is necessary to understand the cause of erectile dysfunction and make an accurate diagnosis. A detailed medical history is taken to understand the individual’s overall health. Information about medication habits, smoking, alcohol use, previous surgeries, cardiovascular diseases, and hormonal disorders is gathered.

Following the general medical history, a sexual history is obtained. These questions may be very specific but are necessary for an accurate diagnosis and treatment. Questions include when the erectile problems started and any previous treatments attempted. Additionally, the quality and duration of spontaneous morning erections and erections with sexual arousal are recorded. It is important to evaluate details about arousal, ejaculation, and orgasm issues that may be associated with erectile dysfunction. Several questionnaires have been developed to systematically evaluate all this information, including the International Index of Erectile Function (IIEF), the Male Sexual Health Questionnaire (SHIM), the International Prostate Symptom Score (IPSS), and depression scales.

A physical examination is performed to investigate diseases that may cause erectile problems. During the physical examination, the penis and testicles are evaluated, and a rectal examination may be performed to detect prostate diseases. Pulse control and blood pressure measurement may be necessary to assess cardiovascular diseases that may cause erectile dysfunction. Some blood tests may also be required to identify potential causes of erectile dysfunction. These tests may include fasting blood sugar, testosterone levels, and lipid profiles.

In some specific cases, additional tests may be required to evaluate erectile dysfunction further. These tests may include nocturnal penile tumescence and rigidity testing, intracavernous injection testing, cavernosometry, and cavernosography. These tests are not commonly used in the initial evaluation.

Treatment of Erectile Dysfunction

Lifestyle Recommendations:

Improving general health can reduce complaints related to erectile dysfunction. Recommendations include quitting smoking, reducing alcohol consumption, and engaging in regular exercise. Additionally, limiting the intake of sugar, salt, and fatty foods can improve both overall health and the quality of sexual intercourse.

Oral Treatments:

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

The main side effects of phosphodiesterase 5 inhibitors include headaches, flushing of the skin, heartburn, nasal congestion, and a feeling of numbness. The use of phosphodiesterase 5 inhibitors can cause a sudden drop in blood pressure in individuals taking nitrate-containing medications.

Topical Treatments:

Topical treatment involves applying a drug to the skin. Alprostadil, in two specific forms, is used for topical treatment. One form is a pellet placed at the tip of the penis (intraurethral), while the other is a cream applied to the outer opening of the urethra at the tip of the penis. Alprostadil is absorbed through the urethra and relaxes the smooth muscles in the penis, increasing blood flow. Side effects may include a decrease in blood pressure with dizziness, but systemic side effects are rare. This treatment is not recommended for individuals with sickle cell anemia, leukemia, bone marrow disorders, or Peyronie’s disease. Condom use may be necessary to prevent the transmission of the medication to the partner.

Vacuum Erectile Devices:

These devices are cylindrical in shape and have a rubber or silicone ring that compresses the penis at its base. Vacuum erectile devices are used in cases where initial treatments have failed. It is recommended to consult a healthcare professional to learn how to use them (see Figure 1).

Intracavernous Injections:

Intracavernous injection involves injecting medication into the spongy tissue inside the penis. It is recommended when lifestyle changes and phosphodiesterase 5 inhibitors do not provide benefit initially. An erection occurs within 10-15 minutes after the injection, even without sexual arousal. The most commonly used agent is PGE1, or alprostadil. In some cases, it may be combined with phentolamine and papaverine. Injection should be administered under the guidance of a physician, and it should be applied to the base of the penis to avoid damaging the urethra, nerves, and blood vessels (see 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 pain in the penis. The most serious side effect is priapism, characterized by a painful erection lasting more than 4 hours, which requires immediate medical attention.

Shockwave Therapy:

Shockwave therapy involves delivering low-intensity, focused shockwaves to the penis in short intervals to improve erections. It is administered in multiple sessions and can be repeated if necessary. This therapy creates minor damage to the penile tissue, leading to the formation of new blood vessels during the healing process. This increases blood flow to the penis, improving the quality of erections.

Penile Prosthesis Implantation:

Penile prostheses are implanted in cases of severe erectile dysfunction when other treatments have failed. During this surgical procedure, prostheses that facilitate erections are placed inside the penis. There are two types of penile prostheses: semi-rigid (non-in flatable) prostheses and inflatable prostheses.

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

Penile prosthesis surgery may be performed under general anesthesia or spinal anesthesia (numbing from the waist down). During the procedure, a small incision is made just above the penis (or between the penis and the scrotum), and the cylinders are inserted into the penis. A pump is placed in the scrotum to allow for inflation of the cylinders. The reservoir for storing the fluid is typically placed behind the abdominal wall. 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. After surgery, patients should avoid heavy lifting, cycling, thermal baths, and saunas for 4-6 weeks. In cases of excessive swelling or non-resolution, or in the presence of discharge or redness at the incision site, prompt medical attention is required.”