Erectile dysfunction, Sexual Health and Therapy

Is sexuality important?

Sexual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health is part of overall health and impacts on you and your relationship.

This includes having pleasurable and safe sexual experiences, free of coercion, discrimination and violence within a consenting, mutually  respected and safe couple context .

Research has demonstrated that for many men and their partners, sexuality remains an important and intrinsic  aspect of their lives irrespective of age or general health.

Due to its sensitive nature, sexual health, even in  ‘high-risk’ populations, is rarely addressed by health care professionals. Studies have shown that when it has been addressed only approximately 16% are treated. Sexual dysfunction can be experienced by both men and women. More than 40% of women and 30% of men report some level of sexual dysfunction.

Erectile dysfunction  (ED) has been a concern  for men  since the beginning of documented history, affecting all men irrespective of class, race or social structure. ED If left untreated, can lead to significant and serious problems for you, your partner and your relationship. Individual distress, decreased self esteem, frustration ,anger guilt and hopelessness follow.

Erectile Dysfunction

Erectile dysfunction (ED) or Impotentia coeundi is defined as a man’s consistent or recurrent inability to attain and/or maintain penile erection, sufficient for satisfactory sexual activity. Symptoms include a marked difficulty in obtaining an erection during sexual activity and/or maintaining an erection until the completion of sexual activity, and marked decrease in erectile rigidity. The diagnosis is made if the problem has existed for a minimum of 6 months, and if at least 75% of attempts to carry out sexual intercourse have been unsuccessful.

Impact of ED on the man

  • Depression and anxiety
  • Decreases self esteem and self worth
  • Denial or avoidance behaviour
  • Decreased masculinity
  • Anger
  • Guilt
  • Embarrassment

Impact of ED on the partner

  • Feeling unwanted and undesirable
  • Loss of self-esteem
  • Experiencing feelings of rejection and abandonment
  • Leaves a partner feeling confused and anxious
  • Creates suspicion of infidelity

The Penis is a health barometer and therefore ED can actually save your life

Why?

Normal erectile function requires the involvement and coordination of multiple regulatory systems and, is thus, subject to the influence of psychological, hormonal, neurological, vascular, and social factors. An alteration in any of these factors may be sufficient to cause erectile dysfunction (ED), but in many cases a combination of several factors is involved.

Please take the 1 minute – 3 question test

  1. Do you have a chronic illness and /or ED or loss of early morning erections?
  2. Are you aware if these diseases are related to ED/loss of EME?
  3. Consult your doctor to find out if there is a relationship between your chronic illness and your ED/loss of EME .

ED is uncommon without associated diseases/conditions; either psychological or physical. ED can be the first symptom of many underlying diseases or difficulties

Is there a link between ED and cardiovascular and other diseases?

Erectile dysfunction and cardio vascular disease share major risk factors including age, inactivity, smoking, obesity, dyslipidaemia, depression, hypertension and diabetes mellitus and obstructive sleep apnoea. Other conditions that occur with ED are HIV; hypogonadism; metabolic syndrome and benign prostatic hyperplasia with lower urinary tract symptoms. In fact, erectile dysfunction has been shown to be a sentinel risk factor for cardio-vascular disease.  As a result, sexual dysfunctions like erectile dysfunction provides the family practitioner with an ideal opportunity to screen you for concomitant (associated) co-morbidities.

Is ED common?

ED is a common disease with prevalence ranging from 2% in men in their twenties, to over 80% in men older than 75. Globally, research such as the Massachusetts Male aging study in 1994 showed a high prevalence and estimated a prevalence of 150 million worldwide. By the year 2025 this number is predicted to rise to 322 million men. Within Africa there are approximately 11½ million men affected, while in  South Africa,  exploratory studies in primary care  in KwaZulu-Natal has demonstrated an overall prevalence of 64.9%  in a sample of men aged 18 and older. Of these men, 14.6%  reported mild, 19.9%  moderate and 30.4% severe erectile dysfunction. Erectile dysfunction increased with age, and showed a strong correlation with economic status and co-morbidities. In men attending primary care clinics in Western Cape, greater than 70% had experienced some degree of ED, with 45% experiencing moderate or complete ED. Complete inability to attain and/or maintain an erection occurs in 1 in 20 men aged 40 versus 1 in 7 in men aged 70.

What is the significance of early morning erections (EME) ?

Morning erections are scientifically defined as involuntary sleep-related erections (SREs) or nocturnal penile tumescence (NPT) and are a healthy and normal physiological response that most men experience . If a lack of morning erections is accompanied by a lack of overall erections, a physical cause is suggested rather than a psychological cause.  Oddly enough, the erections have generally been considered as mere epiphenomena of Rapid Eye Movement sleep-related physiologic changes . The erections are not related to erotic content of dreams, previous sexual activity, or a full or empty bladder

That is, morning erections have been connected to some hormones and neurotransmitters

Loss of early morning erections may imply underlying diseases ,metabolic illnesses , forthcoming erectile dysfunction , etc.

What about testosterone deficiency?

You may present with the following symptoms:

  • Erectile dysfunction
  • Loss of Libido

Other

  • Fatigue
  • Reduced feeling of well-being
  • Loss of concentration
  • Sweats/hot flushes
  • Anaemia
  • Reduced muscle mass
  • Reduced body Hair

Many men and couples have the misconception that:

  • Matters relating to sexual dysfunction are taboo
  • Clinicians do not treat sexual health
  • Loss of erection is uncommon, and their problem is unique
  • ED is a normal part of aging
  • ED is primarily a psychological problem, not a physical problem

82% of men would like their doctor to initiate the conversation, while 75% never seek help and most do not initiate the conversation due to embarrassment.

Why is it important for doctors to ask about ED?

Men with ED could experience/correlate with any or all of the following:

  • Social stigma
  • Feeling of emasculation
  • Reduced self-esteem
  • Depression
  • Anxiety
  • Significant impact on partner
  • Predictor of CV events
  • Relation to risk of diabetes
  • Reduced quality of life
  • Business Life Problems (Reduced productivity)

Why Should We Diagnose ED?

ED is associated with other serious treatable disorders.

The risk of heart disease was 50 times higher in men 40-49 years of age with Ed compared to those without ED.

  • 60% of men with ED have dyslipidemia
  • 56% of men with ED have a positive cardiovascular stress test
  • 42% of men with ED have hypertension
  • 40% of men with ED have significant coronary occlusions
  • 20% of men with ED have diabetes mellitus
  • 11% of men with ED have depression

Are there benefits in restoring sexual activity for patients with ED?

Treating erectile problems may help to improve the patient’s overall health status.

Proactive management of ED in the cardiovascular patient provides an ideal and effective opportunity to address other cardiovascular risk factors and improve treatment outcomes.

Treating erectile difficulty may have a positive impact on Quality of Life and partner relationships:

  • Lowered depression
  • Improved well-being
  • Improved self-control and mental health
  • Improved social contacts, leisure, and vocational situation
  • Improved partner relationship

Management of your ED

The treatment of erectile dysfunction has advanced greatly over the past 40 years. Men battling with ED today are able to benefit from viable options resulting in more satisfying sexual lives and experiences. It is imperative that you consult your family practitioner and have a complete  assessment. At the very least your blood glucose ,lipids and testosterone levels should be done preferably in a fasting state Prostate specific antigen as indicated if over 50 or at 45 if there is a family history of prostate cancer or vulnerable race groups. An ECG (electrocardiogram) is indicated to assist with stratifying cardiovascular risk .

It is important that you involve your partner in the shared decision making.

The journey in treating erectile dysfunction, regardless of age. is comprehensive and may include:

  • Counselling and/or life style modification
  • Psychological (cognitive/behavioural/ sex therapy) management
  • Medical (pharmacotherapy, devices) therapies
  • Surgery
  • Cardiovascular risk assessment,
  • Hormone levels,
  • Relationship and partner issues

Suggested recommendations on lifestyle changes

Lifestyle interventions and limiting cardiovascular risk factors, such as smoking, hypertension, dyslipidaemia and obesity, should be advocated with the promotion of healthy living habits such as moderation in the consumption of alcohol and getting physical exercise appropriate for age.

Physical activity

  • Moderate to vigorous intensity 4 times per week for 40 minutes overall
  • Weekly exercise dose of 160 minutes for 6 months.
  • Combining physical activity and caloric restriction improves ED, but only under very strict supervision
  • Exercise tolerance should be established prior to initiation of ED therapy.

Weight loss

  • 5 to 10 % weight loss has been shown to be beneficial

Improvement of diet quality

  • Simple caloric restriction may improve ED
  • Mediterranean diet may prevent and improve ED
  • Alcohol intake 1 to 2 drinks maximum per day

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Smoking cessation is an important strategy and has shown improvement in erectile function upon stopping.

ED treatments include

  • Pharmacological management (PDE-5 inhibitors, testosterone replacement therapy and invasive prostaglandin administration)
  • Mechanical devices (vacuum pumps and constriction rings),
  • Surgical interventions (prosthetic penile implants, arterial reconstruction and venous blocking procedures

These include the use of:

  • Oral therapy by way of tablets called PDE5 inhibitors which have excellent efficacy and safety
  • The use of vacuum pumps,
  • Injections into the penis called intracavernous injections which you can self administer after prior training and education .
  • Psychosexual therapy if indicated . Psychotherapy alone, or in combination with psychoactive drugs and PDE-5 inhibitors, should be prescribed when depression or anxiety is the primary cause.
  • Hormonal therapy if indicated for hormonal deficiency
  • Extracorporeal shockwave therapy
  • Penile implant

Evaluation of sexual well-being is assessed by

  • Treatment outcome (as regards sexual function and adherence to therapy)
  • You and your partner’s relationship satisfaction
  • Life satisfaction and improved Quality of life

Conclusion

ED is a global health problem, which has received substantial attention because of its association with poor cardiovascular health. It is an early sign of heart disease, and sexual dysfunction often precedes onset of CAD by as much as 3 years. Patients with ED should be considered at increased risk of CVD, as the two share the underlying causative factor of endothelial dysfunction along with many common and mutual risk factors.

The enormously negative impact of chronic ED on psyche, self-esteem, and family – private and professional life and especially on the partnership itself implies the need for a timely and professional aid. A supportive partner and increased sexual communication devoid of ridicule and blame will boost self esteem and confidence thereby promoting an effective therapeutic alliance. This journey will allow both you and your partner to arrive at the destination together.

DR P RAMLACHAN
Director of, and practices at the Newkwa Health and Wellness Centre
Part-time lecturer and examiner for under and post graduate students at the Department of Family Medicine at the Nelson Mandela School of Medicine in Kwa-Zulu Natal
MBChB from the University of Natal, Durban, South Africa in 1985
Master’s degree in Health Sciences (Sexual Health) from the University of Sydney in 2007
The Fellow of the European Committee of Sexual Medicine Specialist (FECSM) from the European Union of Medical Specialist In 2012
Affiliations: International Society for Sexual Medicine, African Society for Sexual Medicine , Southern African Sexual Health Association
Interest lies in research, sexual medicine, diabetes ,hypertension and metabolic syndrome/disease
This contribution was submitted by a key opinion leader and is not the intellectual property of Pharma Dynamics

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