Erectile dysfunction!

Erectile dysfunction (ED) seen in varying degrees in more than half of the middle-advanced age group is defined as penile erection, which is required for sexual intercourse, does not reach a sufficient level for satisfactory sexual performance or cannot be sustained. The erection process consists of loose, filling phase, tumescence, full erection, rigid erection and detumescence phases.

Relaxation of penile smooth muscle due to the release of neurotransmitters leads to arterial and arteriolar vasodilation and widening of the sinusoids to accept most of the increased blood flow. The compression of blood in the penile tissue allows the penis to lengthen and enlarge. Meanwhile, pressure expansion of the sinusoids towards the tunica albuginea causes compression of the venous plexus. This compresses the emissary veins, effectively reducing venous flow. The flaccid penis becomes erect with the intracavernous pressure and PO2 rise to 100 mmHg. In addition, contraction of the ischiocavernous muscles increases the pressure, leading to a rigid erection phase. Any disorder in this process leads to erectile dysfunction. It can be organic, psychogenic or mixed (both). Psychological conditions such as performance anxiety, lack of sexual stimulation, depression, and schizophrenia cause erectile dysfunction. Approximately 20% of ED cases are of neurogenic origin and are known to result from peripheral or central pathologies. Spinal cord trauma, dementia, Parkinson’s disease, tumors, stroke, diabetes mellitus, chronic alcohol consumption and vitamin deficiency are the main ones. At the same time, ED is observed quite frequently in patients who have undergone radical surgery (radical prostatectomy, rectal operations). Despite nerve-sparing surgeries, regaining an erection takes up to 2 years, which can be treated with penile rehabilitation.

The most common hormonal disorders are hypogonadism, Cushing’s syndrome, Addison’s disease, hypo/hyperthyroidism, a history of orchiectomy with estrogen or antiandrogen therapy. Arterial insufficiency and venous insufficiency are the most common vascular causes. Those with systemic vascular disease, coronary artery disease, atherosclerosis, diabetics and men with risk factors (smoking, cholesterolemia,…) leading to vascular disease are candidates for ED. Also, many drugs are known to cause ED. SSRI group drugs, antipsychotics, antidepressants, antihypertensives, antiandrogens, … are some of these drugs. Detailed history and physical examination are very important in the diagnosis of erectile dysfunction.

In addition to laboratory examinations such as glucose level, lipid profile, testosterone, and TSH, self-assessment questionnaire (IIEF) tests that can measure the severity of the disease are very helpful in diagnosis. With advanced tests such as duplex ultrasonography, combined intracavernosal injection and stimulation (CIS), cavernosometry, and angiography, the cause of the disease is learned and treatment is planned accordingly. The nocturnal penile tumescence (NPT) test is a test that measures the quality and duration of an erection during night sleep. In the treatment, step therapy method is applied. Lifestyle changes and changing medications, if any, psychosexual therapy, hormonal therapy are the first-line treatments for patients who need it. Phosphodiesterase inhibitors have been a breakthrough in the treatment of ED since the beginning of their use and have been a salvage treatment for the majority of patients. Sildenafil, vardenafil, tadalafil are molecules being used today and knowledge of which drug to use safely and effectively in which patients has become very important. Intracavernosal injection treatments (papaverine, phentolamine, alprostadil) and intraurethral alprostadil treatments are highly effective in selected patients. Penile prostheses are the method we consider as the last resort in treatment. They are bendable, mechanical and inflatable devices. generally flexible bendable ones last longer than inflatable ones.

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