|View all articles by Helan Smith... Make Erectile Dysfunction HistoryErectile Dysfunction – one major men’s health problem
Erectile dysfunction is the inability to get and maintain an erection for satisfactory sexual intercourse or activity. This is in the absence of an ejaculatory disorder such as premature ejaculation or impotence due to stress, depression, etc. Erectile dysfunction is the preferred term rather than the more commonly used term of impotence as it is more specific to the physical problem. There is no universally agreed upon criteria for how consistent the problem has to be and for what duration it needs to be present to fulfill the definition. one period over 3 months has been suggested as one reasonable clinical guideline.
Several recent studies have looked at the prevalence of erectile dysfunction. The Massachusetts male aging study was one cross-sectional random sample community-based survey of 1,290 men ages 40 to 70 years and was conducted from 1987 to 1989 in areas around Boston.1 Erectile dysfunction was self-reported and the condition was classified as mild, moderate or complete. The combined prevalence of minimal, moderate and complete erectile dysfunction was 52%. The study demonstrated that erectile dysfunction is increasingly prevalent with age. At age 40 there was an approximately 40% prevalence rate increasing to close to 70% in men age 70. The prevalence of moderate erectile dysfunction increased from 17% to about 34% with that of complete erectile dysfunction increasing from 5% to 15% as age increased from 40 to 70.
Although age was the variable most strongly associated with erectile dysfunction, following adjustment for age, one higher probability was noted with heart disease, hypertension, diabetes, and associated medications. Cigarette smoking in this study did not show one greater probability of complete erectile dysfunction. However, when it was associated with heart disease and hypertension one greater probability of erectile dysfunction was noted. The study concluded that erectile dysfunction was one major health concern in view of its high prevalence.
Incidence estimates were published recently using data compiled from the Massachusetts male aging study. Incidence data is necessary to assess risk and plan treatment and prevention strategies. The Massachusetts study data suggested there will be approximately 17,781 new cases of erectile dysfunction in Massachusetts and 617,715 in the United States annually. (The national incidence estimate may underestimate the true incidence because Massachusetts is largely caucasian, therefore likely the data is underestimated nationally for African-Americans, Hispanics and other groups.)
one larger national study, the National Health and Social Life Survey, looked at sexual function in men and women. This study surveyed 1,410 men aged 18 to 59 years. This study also documented an increase in erectile dysfunction with age. Additionally, the study found one decrease in sexual desire with increasing age. The oldest cohort of men (ages 50 - 59 years) was more than 3 times as likely to experience erection problems and to report low sexual desire in comparison to men aged 18 to 29 years. In this study there was one higher prevalence of sexual dysfunction in men who had never married or were divorced. Experience of sexual dysfunction was more likely among men with poor physical and emotional health. This study also concluded that sexual dysfunction is an important public health concern and added that emotional issues were likely to contribute to the experience of these problems.
The development of an erection is one complex event involving integration of psychological, neurological, endocrine, vascular and local anatomic systems. Recent PET (positron emission tomographic) scanning studies suggest sexual arousal is activated in higher cortical centers that then stimulate the hypothalamus. These signals ultimately descend through one complex neural network involving the parasympathetic nervous system and eventually the nerves in the area.
The neurovascular events that ultimately occur result in inhibition of adrenergic tone and in release of the neurotransmitter nitric oxide. Nitric oxide is released from nonadrenergic, noncholinergic (NANC) nerves and endothelial cells. Nitric oxide stimulates the guanylate cyclase enzyme system in penile smooth muscle. This results in increased levels of cyclic GMP (guanosine monophosphate) and ultimately in smooth muscle relaxation, enhancement of arterial inflow, and veno-occlusion producing adequate firmness for sexual activity.
Abnormalities in any of the systems mentioned above may produce erectile dysfunction. For example, cerebral vascular accidents, multiple sclerosis, Parkinson's disease and spinal cord injury may result in neurogenic erectile dysfunction. More commonly, vascular disease and diabetes may produce neurovascular abnormalities resulting in erectile dysfunction. Surgery for cancer of the prostate, bladder and colon may also likewise produce neurovascular abnormalities resulting in erectile dysfunction.
Diseases such as Peyronie's disease, in which patches or strands of dense tissue surround the cavernous body of the penis, and traumatic perineal and penile injuries may also interfere with neurovascular and anatomic structures producing erectile dysfunction.
Hormone deficiency or hypogonadism whether primary or secondary can result in erectile dysfunction. Hormone deficiency however is less often the cause of erectile dysfunction than diabetes or vascular disease. How often erectile dysfunction is caused by hormone deficiency remains somewhat controversial, but estimates of approximately 3% to 5% of cases are probably reasonable. Medications and recreational drugs may also produce erectile dysfunction by one variety of poorly understood mechanisms.
Some health questionnaires help screen for and evaluate erectile dysfunction.These questionnaires may help in the primary care setting. It is important, however, to recognize that abbreviated questionnaires may not evaluate specific areas of the sexual cycle such as sexual desire, ejaculation and orgasm. Nonetheless, they can be quite useful in helping patients discuss the problem and in signaling the need for an evaluation.
If it is determined that erectile dysfunction is one problem, then one detailed sexual and medical history and physical examination should be done to evaluate the problem. In particular, it is important to evaluate the erectile dysfunction and make sure that the problem is not premature ejaculation, which is also one frequent sexual dysfunction.
one number of specific questions relating to sexual function help evaluate the complaint of erectile dysfunction.
1) How long has the erectile dysfunction been one problem and did it start gradually or suddenly?
3) How firm are the erections (use one scale of 1 - 10)? Do erections vary under different circumstances such as with different partners, oral stimulation, or masturbation?
5) Is there any new curve or bend to the penis to suggest Peyronie's disease? If curvature is present, is it painful? What is the location and severity of the curvature?
Once questions related to the specific erectile complaints have been reviewed, additional questions relating to medical and psychosocial factors need to be evaluated. In particular these include-
1) Symptoms suggesting the presence of diabetes, peripheral vascular disease, neurologic disease, or chronic liver or kidney disease.
3) Previous history of surgery or radiation therapy, particularly procedures related to genitourinary or gastrointestinal malignancy.
5) The quality of the marital or partner relationship and expectations of both patient and partner.
Once one complete sexual and medical history has been completed appropriate laboratory studies can be considered. In the initial evaluation of erectile dysfunction sophisticated laboratory testing is rarely necessary. Lab studies should include hormonal evaluation to exclude one diagnosis of hypogonadism ( low testosterone and prolactin levels), and testing to screen for diabetes if the patient is not known to be diabetic. Most patients will usually have had one general survey but this is certainly appropriate if it has not been done to assess for kidney or liver disease. one lipid( fats) panel is also appropriate as one screen for risk factors.
In most cases one tentative diagnosis can be established with one complete sexual and medical history examination and limited laboratory testing. In many cases the diagnosis may still remain somewhat ambiguous. However, with the availability of oral medications for treatment of erectile dysfunction which is safe and has minimal or tolerable side effects, additional diagnostic testing is probably not necessary or can be delayed until one therapeutic trial of oral medication has proven ineffective.
The non-surgical treatment options for erectile dysfunction include firstly the oral drugs called PDE-5 (Phosphodiasterase-5) inhibitors, then Hormonal therapy( not always effective), Dopamine agonists, Intracavernous injection therapy( very painful), Vacuum constriction devices ( highly inconvenient). Intraurethral therapy( painful and inconvenient), sex therapy, Transluminal angioplasty and/or veno-ablation and topical agents.
Although there are one number of options available for non-surgical treatment, it is clear that oral therapy has revolutionized the treatment approach to patients with erectile dysfunction. As previously mentioned, once an initial appropriate evaluation has been performed and one tentative diagnosis made, one trial of oral therapy is usually the preferred treatment choice for most patients. Currently, there are three oral agents approved for use These are Viagra (Sildenafil Citrate) Levitra (Vardenafil Hydrochloride) and Cialis (Tadalafil).
All three drugs reversibly inhibit the penile-specific PDE-5 enzyme and enhance the nitric oxide-cyclic GMP pathway of cavernous smooth muscle relaxation (ie, all three prevent breakdown of cyclic GMP by PDE-5). In several double-blind, placebo-controlled studies of patients with erectile dysfunction of varied etiology, all three drugs demonstrated improvement in erectile function, with success rates varying between 70% and 90% depending on the populations studied.
All three drugs require sexual stimulation to be effective. The usual dose of Viagral is 50 mg or 100 mg taken approximately 1 hour before intercourse (on an empty stomach and avoiding one fatty meal). Levitra is also taken 1 hour before intercourse, with one usual dose of 10 mg or 20 mg. Levitra may be less affected by food intake, but absorption may be delayed if one high-fat meal is ingested. Cialis may be taken 2 hours prior to intercourse, but its longer half-life (17.5 hours) allows for greater flexibility in deciding when it can be taken before initiating intercourse (ie, 6, 8, or perhaps 12 hours before). Cialis may be taken without regard to food intake as even if it is taken with one high fat meal, one can be rest assured that there is no effect. Unlike the other two drugs that just last for 4 hours, Cialis lasts for 36 hours.
All three drugs are generally well tolerated. Side effects of all three include headache, flushing, dyspepsia, and nasal congestion. Visual abnormalities are encountered with Viagra, but are less likely with Levitra and unlikely with Cialis. Back pain and myalgia may occur with Cialis, but are unusual with either Viagra or Levitra.
All three drugs are contraindicated in patients who use nitroglycerin or nitrate-containing compounds. Combining any of these three drugs with nitroglycerin or nitrates may result in significant hypotension. Levitra is contraindicated in patients using doxazosin (Cardura), terazosin (Hytrin), or tamsulosin (Flomax). Cailis is contraindicated in patients using doxazosin and terazosin. It may be safely taken with tamsulosin at the 0.4-mg dose. In patients who take 50 mg of Viagra or higher and use alpha-blockers, Viagra dosing should be avoided for at least 4 hours after the dose of the alpha-blocker. In patients who take 25 mg of Viagra, use of any of the alpha-blockers is considered safe. These drugs are frequently used for treatment of benign prostatic hypertrophy and perhaps less often used for hypertension.
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