What is it?
The term “erectile dysfunction” (ED) or “impotence” refers to a persistent or recurrent inability to obtain and/or maintain a penile erection adequate for the chronological and satisfactory completion of sexual activity. Although ED is a benign condition, it impairs physical and psychosocial health status and has a significant impact on the quality of life of both the individual who suffers from it and his partner. ED is a widespread disease throughout the world, with incidence varying from about 20% to peaks of 50% and more depending on the countries considered. The risk factors of ED are partly common to cardiovascular diseases (sedentariness, obesity, smoking, hypercholesterolemia, diabetes, metabolic syndrome, hypertension, alcohol abuse, age). ED can therefore be psychogenic (e.g. anxiety, stress, depression, common especially in young patients), organic (hormonal alterations, alterations of the central/peripheral nervous system, penile arteries and/or veins, iatrogenic causes, i.e. medical causes such as certain drugs, such as SSRI antidepressants, or certain surgeries, such as pelvic surgeries) or mixed. ED is now considered an alarm bell in the cardiovascular field, since it has been demonstrated in the literature that it can anticipate even by many years a subsequent major vascular event, such as myocardial infarction.
Causes and risk factors
Which are the symptoms?
With regard to the diagnosis of ED, the first step is the urological examination during which the specialist collects detailed information about the medical, psychological and sexual history of the patient. In this context, the completion of questionnaires provided by the specialist and validated in the scientific literature (e.g. International Index of Erectile Dysfunction questionnaire - IIEF) by the patient provides a simple and rapid way to get an objective idea of the severity of ED, if present (4). During the examination, the urological examination can also highlight any changes in the external genitalia and prostate. Another important diagnostic aspect is represented by laboratory tests which is decided on a case by case basis by the specialist and basically includes the evaluation of glycemic values, lipid profile and hormonal picture (e.g. testosterone). For some patients, further diagnostic investigations may be necessary, such as the evaluation of nocturnal penile tumescence and rigidity with rigidometry (to verify the presence of spontaneous nocturnal erections that would then exclude an organic origin of ED in cases of suspected psychogenic ED), the penile echocolordoppler (performed after obtaining an erection by intracavernous injection of prostaglandin E1, with the intent to assess the penile arterial and venous flow and consequent values of turgidity and rigidity obtained and the penile anatomy) and any psychosexual counseling.
How is it diagnosed?
How is it treated?
The first line of treatment for ED is elimination of the cause, when possible, and any modifiable risk factors (eg, smoking, weight loss, diabetes, dysplipidemia) (1). Except for cases that can be effectively cured with specific treatment, ED is not cured but treated. Non-cause-specific treatments are of three levels:
- first level: drugs for oral use of type 5 phosphodiesterase inhibitors family, such as Sildenafil, Tadalafil, Avanafil and Vardenafil, which can be used in varying dosages and modalities depending on the characteristics and needs of the patient.
- second level: local intracavernous injections of drugs designed to increase blood flow in the penis and the consequent achievement of rigidity, such as Alprostadil
- third level: surgical implantation of penile prostheses, rigid or semi-rigid.
It is generally proposed to start the therapy from the first level, less invasive (i.e. oral drugs), then moving to higher levels when the previous ones are not effective in solving the problem.
Where do we treat it?
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