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Erectile dysfunction


What is an erection?
An erection is a complex phenomenon that requires a delicate and well-orchestrated balance between neurological, vascular and hormonal processes with the final result being the pressurized concentration of blood in the corpora cavernosa of the penis and the achievement of sufficient hardness to penetrate the vagina. It is the miraculous result of a lightning-fast process involving the external genitalia, heart, blood vessels, hormones, nerve axons, emotions, sensations, imagination and memory.

What is Erectile Dysfunction?
Erectile dysfunction is defined as the inability to achieve or maintain an erection capable of penetrating the female vagina. It is a very common disorder, with significant effects on a man's quality of life. It seems that about half of men will experience some form of sexual dysfunction at some point in their lives. It is not a disease, but a symptom that appears in the context of some other situation, while it is an important indicator of the overall health of the man.


What are the causes of Erectile Dysfunction?

Erectile dysfunction can be due to psychogenic or organic causes, but more often to their combination, thus creating a vicious circle

Organic causes are:

Arterial hypertension, smoking atherosclerosis of the vessels, diabetic vasculopathy, post-traumatic damage to the vessels supplying the penis and cardiac problems. It is even considered that erectile dysfunction is a precursor symptom - that is, it appears earlier - of coronary heart disease and myocardial infarction. Erection is the barometer of heart health. The erection. should not only be treated as a quality of life problem for patients, but also as a risk factor for cardiovascular disease

Penile function is controlled by the autonomic nervous system. Any cause, disease or medication that compromises the functioning of this system is likely to lead to erectile dysfunction. Such causes can be multiple sclerosis, Parkinson's disease, Alzheimer's, diabetic neuropathy, spinal injuries e.g. from traffic accidents and the use of neuroleptic drugs – anxiolytics, tranquilizers, hypnotics.


The entire sexual cycle - desire, arousal, erection, ejaculation, orgasm - are under the absolute control of sex hormones. Testosterone and prolactin, directly and indirectly thyroid hormones, play an important role in erectile function. Whether they are due to a malfunction of the corresponding organs, i.e. the testicles and the thyroid gland, or to a central disturbance in their production - at the level of the pituitary gland - or to the gradual decrease in testosterone levels with increasing age (andropause), the decrease in testosterone is very likely to lead to disorders of erection, desire (libido), ejaculation, orgasm, fertility and systemic metabolic disorders.

Metabolic syndrome:
This specific systemic disorder of the body is characterized by disorders of cholesterol, lipids and glucose metabolism (diabetes mellitus, hypertension and abdominal obesity). The metabolic syndrome is one of the most important risk factors for the occurrence of erectile dysfunction in the modern man, as it is disease of the western lifestyle e.g. sedentary life and lack of exercise. Studies prove that a central role in the development of metabolic syndrome is played by the lack of testosterone.

• Antihypertensives (thiazide diuretics, β-blockers, etc.)
• Antidepressants
• Antipsychotics
• Antiandrogens (GnRH agonists and antagonists)
• Drugs (alcohol, heroin, cocaine, marijuana, methadone)
• Anabolic steroids

Surgical procedures:

Many surgeries - several of them are very common - are likely to lead to erectile dysfunction, often irreversible, without taking even preventative therapeutic protocols. Radical prostatectomy – the removal of the prostate for cancer – pelvic surgeries – for colon cancer – have a strong chance of erectile dysfunction.

Special mention should be made of the relationship between erectile dysfunction and diabetes mellitus. It should be clear, however, that it is not necessary for a man with diabetes to also experience erectile dysfunction. This depends on the level of diabetes control, the presence of other health problems, the type of drugs he uses and the presence of sexual desire. It is true that diabetes mellitus can potentially cause damage to the vessels and nerves of the penis, testosterone disorders, disorders in the anatomy of the penis (peyronie's disease) but also intense psychological burden due to chronic illness.

Psychogenic causes are more common in young men and are due to performance anxiety, a romantic disappointment or the loss of a loved one, but also as a secondary consequence of organic erectile dysfunction at older ages. There are many psychological mechanisms that worsen erectile function, such as the reduction of sexual desire, stress (work, social, failure in the sexual act), phobias, obsessions or even specific psychiatric diseases, such as depression and personality disorders.

How is the cause diagnosed?
The causal relationship of erectile dysfunction with the early diagnosis of diseases such as coronary heart disease and diabetes, as well as the multitude of factors to which it may be due, makes a diagnostic test necessary to clearly identify the cause and the severity of erectile dysfunction.

Basic diagnostic testing includes:

- General medical and sexual history. Timing of the onset of the problem, exact determination of the extent, psychosocial history, presence of morning erections.
- Clinical examination especially of external genitalia, breasts and prostate and gross neurological examination.
- Laboratory tests: The basic laboratory test consists of a general blood test and biochemical tests that measure sugar and lipids (cholesterol, triglycerides), as well as a hormonal test that measures testosterone (in a morning sample).
- Pressure measurement
- Cardiological examination, heart echo
- Special endocrinological testing based on indications

What are the current treatments?
The treatment of erectile dysfunction is a matter for the specialist. And when we refer to the term treatment, we mean the improvement of his erection as much as possible with proper information about the treatment and respect for the man's expectations and wishes. There are many therapeutic solutions and the choice should always be made in collaboration with the andrologist and the man, so that he knows what to expect from each treatment and no additional stress is added in relation to the result.



 Oral medications

Oral medications, in particular phosphodiesterase type 5 inhibitors, have changed the therapeutic management of erectile dysfunction and contributed strongly to the treatment of the problem. Until now, 4 different substances are available in Greece for the treatment of erectile dysfunction: vardenafil, sildenafil, tadalafil and avanafil. All four of these drugs have the same mechanism of action. They act on the vessels of the penis causing vasodilation resulting in increased blood flow to the penis and therefore an improvement in the hardness and duration of an erection. It is worth noting that the drugs do not create an erection by themselves, but only after sexual stimulation. All the above forms have an indication to be taken upon request by the patient, i.e. before sexual intercourse. The way of taking each substance, the time "window" of action and the possible side effects and contraindications to their administration should be discussed with the man. Erectile dysfunction medications have proven to be among the safest when used as directed by your doctor.





Intravenous injections

By the term "intrapenile" we refer to intracavernous (i.e. inside the cavernous bodies of the penis) injections with vasodilator substances.
With a small syringe and a fine needle, various drugs are injected from the sides, inside the 2 cylinders present in the penis (corpora cavernosa), which cause dilation of the blood vessels and therefore an increase in blood flow to the penis.
The administration of the drug is done by the patient himself, after the proper training by his urologist and the correct and individualized dose has been found. After 10-15 minutes, an erection is achieved regardless of the existence of sexual desire, since the drug acts locally. The procedure is practically painless and complications are rare. The effectiveness of the injections to achieve a satisfactory erection is greater than 80%. Among the drugs that have been used, the most common are papaverine, phentolamine and alprostadil. They can be used either alone or in combination. Intravenous injections are mainly used as a second-line treatment when oral medications fail.





Intraurethral gel
In 2017, the medicinal substance alprostadil was released for intraurethral administration in gel form. Its application consists of placing a small amount of gel from a special device at the mouth of the urethra from where it is absorbed and diffuses into the body of the penis. It seems to be very effective and without the need to prick the penis with a needle. The most common complication seems to involve discomfort or mild pain at the opening of the urethra. The urologist who will recommend the specific treatment will also explain how to use it to the man, so as to avoid important mistakes that may deprive the effectiveness or create complications.




Vacuum pump
It is a good and safe solution when the above remedies have failed. The device is a non-invasive, specially designed pump that works according to the principle of negative pressure. It creates an air gap resulting in the pumping of blood in order to fill the corpora cavernosa, harden the penis and achieve an erection. The erection is then maintained for up to 30 minutes with the help of an elastic ring at the base of the penis. The elastic ring slows the escape of blood to maintain an erection. The method is safe, and has excellent results in more than 80% of patients who have applied it.





Shock waves
The method of applying low-intensity shock waves to the penis is a new and promising therapeutic approach for the treatment of erectile dysfunction. It is a completely painless method and concerns erectile dysfunction due exclusively to vascular causes. The shock waves aim to improve the function of the endothelium and induce neo-angiogenesis, achieving better blood supply to the penis and improved erectile function. That is, new vessels are created in the penis, which replace the damaged ones and this results in an increase in blood flow to the penis.



Pedic intentions

A penile prosthesis is a device that is placed inside the penis, helping the man achieve an erection for successful sexual intercourse. It is a therapeutic option for patients in whom other forms of treatment (drugs, intraperitoneal injections) have failed.
The prostheses consist of two cylinders placed inside the corpora cavernosa and a pump and a reservoir. Whenever the patient wishes to have an erection, he presses the pump and the liquid contained in the reservoir inflates the cylinders located inside the corpora cavernosa. When the contact is over, he presses the pump again and the fluid returns to the reservoir, causing the erection to subside. Ejaculation and orgasm are not affected by the operation.


Whatever treatment is applied, the goal remains the same: the man's satisfaction with his sexual life, always respecting his expectations, his desires, without adding additional stress. The choice must always be personalized and only concern the man and the partner he has chosen. The best solution is to discuss all options with your doctor. The decision you will make, regarding the treatment you will follow, must be based on your own needs and be the result of a detailed discussion with your urologist.

What is the prevention of Erectile Dysfunction?

Maintaining a normal weight or losing weight if you are obese.
Physical exercise at least 2 to 3 times a week.
Mediterranean diet. It has been shown to help not only the heart but also the erection.
Stopping smoking. Smoking damages the vessels of the penis and is responsible for erectile dysfunction. Stopping smoking gradually restores the health of the vascular endothelium.
Maintaining low cholesterol and triglyceride levels.
If you suffer from diabetes, you must take care to keep your sugar levels within an acceptable range determined by your doctor.
Regulation of arterial hypertension. Some antihypertensive drugs, such as diuretics, have a negative effect on erection. Discuss the problem with your doctor, and he will suggest a solution.
Avoiding the consumption of alcohol and drugs.
Dealing with dysthymia and especially depression. Both problems aggravate or cause erectile dysfunction. Also, many antidepressants cause erectile dysfunction and delayed ejaculation.