Erectile Dysfunction

Erectile dysfunction (ED), sometimes also called impotence, is the inability to achieve or maintain an erection for sexual intercourse. ED can be a source of negative self image in a lot of men, and can also be a factor in relationship strain between couples.

What is erectile dysfunction?

Erectile dysfunction (ED) is a disorder of the penis characterised by the inability to achieve or keep an erection long enough for sexual intercourse. Sometimes, not being able to maintain an erection due to stress, fatigue, or due to taking certain medications is normal and not a cause for concern. Persistent ED that occurs frequently or consistently may warrant a visit to the doctor.

What causes erectile dysfunction?

A penis erection is a neurovascular event controlled by hormonal, vascular and neuronal events of the body [1]. During sexual arousal, the brain sends signals through the spinal cord to the nerve terminals of the corpora cavernosa, the muscular structure that causes the penis to become erect and firm. The neurotransmitters cause the release of nitric oxide to the tissues, leading to muscle relaxation and blood vessel dilation. The dilated blood vessels allow more blood to enter the corpora cavernosa and the corpus spongiosum, the spongy tissues around the urethra. Additionally, the compression of the subtunical venular plexuses, a network of veins around the penis, reduces blood outflow from the penis, which maintains the erection [2].

Causes of erectile dysfunction can be due to dysfunction of the systems that control the events of an erection, as well as other underlying conditions [3]:

Neurogenic ED

Neurogenic ED is caused by a dysfunctional nervous system, this can be due to peripheral nerve, spinal nerve, or central nerve disturbances which impair the transmission of signals to achieve an erection. Risk factors that can cause a neurogenic ED include spinal cord injuries, multiple sclerosis, syringomyelia , and radical pelvic injuries.

Vascular ED

Scientists have reported that vascular ED and cardiovascular diseases have similar risk factors, such as diabetes, hypertension, and high cholesterol levels. Disruption of the blood flow leading to the penis, such as atherosclerosis, may cause difficulty in achieving an erection.

Hormonal ED

Endocrine disorders can cause ED due to a lack of androgens, which leads to low sexual drive or libido. Low levels of testosterone also can reduce smooth muscle relaxation capabilities of the corpora cavernosa [4]. Elevated levels of estradiol, due to hypogonadism, can reduce nitric oxide-mediated cavernosal relaxation, which may contribute to ED [5].

Primary ED

Primary ED refers to ED which may be caused by anatomical deformities, such as to the blood or nerve supply. Additionally, vascular or neurological injuries, or hormonal issues from childhood can be a risk factor in primary ED.

Drug-induced ED

Use of certain medications can lead to ED, common medications with ED as a side effect include diuretics, antipsychotics, antidepressants, and antiandrogens.

Diabetes

Studies have shown that diabetic patients are more likely to suffer from ED. This can be due to a number of factors such as disturbances to the central nervous system, androgen secretion, peripheral nerve function, and smooth muscle contractility.

Chronic kidney disease

Chronic kidney diseases can lead to a buildup of waste products in the blood, also called uremia. Uremia can lead to lower levels of nitric oxide in the blood, which is important in achieving an erection.

What are the signs and symptoms of erectile dysfunction?

The signs and symptoms of ED include:

Inconsistency in achieving erection
Being able to achieve an erection before sex, but not being able to maintain it
Complete inability to achieve an erection
Requiring a lot of stimulation just to maintain an erection

As mentioned, occasional episodes of not achieving erection, or not being able to maintain an erection can be normal. These can be due to temporary causes such as stress or fatigue. However, persistently having difficulties with achieving or maintaining an erection may require medical attention and treatment.

Who is at risk of erectile dysfunction in singapore?

As men age, getting and maintaining an erection might take longer than usual, this is normal. Other risk factors that can contribute to ED include [6]:

Identifying risk factors can be helpful for physicians to diagnose the cause of your ED. Knowing the cause or factors that contribute to ED can allow your doctor to treat the root cause.

Alcohol and smoking

Research suggests that excessive alcohol intake and smoking shows a dose-dependent effect on erectile dysfunction. This means that the more you drink or smoke, the higher the risk of ED. Scientists suggested that both excessive alcohol intake and smoking leads to damage to the blood vessels, which may contribute to impaired blood flow into the vessels of the corpora cavernosa.

Lack of physical activity

Studies reported that moderate and frequent exercise was linked to a lower risk of ED.

Obesity

Obesity and other metabolic syndromes increase the risk of ED likely from comorbidities and complications such as hypogonadism and inflammation.

Diabetes

Diabetes can increase the risk of ED through complications such as peripheral neuropathy, atherosclerosis, and associated hypogonadism.

Cardiovascular diseases

Cardiovascular diseases and ED have common causes due to underlying vascular disorders.

Benign prostate hyperplasia (BPH) and lower urinary tract symptoms (LUTS)

Researchers reported an increased association between patients with BPH/LUTS and ED.

Psychological disorders

Psychological disorders such as depression and anxiety, as well as the use of psychotropic drugs to treat these conditions are known to increase the risk of ED.

When should I be worried about erectile dysfunction?

Occasional difficulty achieving or staying erect is a common experience and often not a cause for concern. However, if it becomes frequent, persists over time, or affects your quality of life, it may indicate an underlying condition that warrants a visit to your urologist. Some points to take note of include:

It occurs frequently
You are unable to achieve or maintain an erection at all, even with adequate stimulation
It is negatively impacting your relationship and confidence
You are experiencing accompanying symptoms, such as difficulty urinating
You have risk factors, such as cardiovascular diseases or suffer from chronic stress

Erectile Dysfunction

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How is erectile dysfunction diagnosed?

Assessment and diagnosis of patients with ED require investigation into risk factors and causes that may contribute to ED. The common process of diagnosing ED includes:

The first evaluation the doctor will perform is to take your medical history, this includes questions about your symptoms, when it first started, and whether you have any underlying conditions that can contribute to your ED such as diabetes, or a history of injuries or surgery to the pelvic area.

Physical examination may include checking your heart rate, breathing, penis, and prostate. These can help the doctor identify possible causes such as risk of cardiovascular diseases, neurological issues, penis, prostate or testes abnormalities, or Peyronie disease.

The doctor will perform blood tests to further investigate the suspected cause of ED from the physical examinations. This may include tests to look for sex hormone levels, thyroid function, lipid profile, and blood sugar levels.

A Doppler ultrasound allows the doctor to observe blood circulation in the arteries and veins. This can identify possible blockages that may cause ED.

Psychological evaluation is done to identify possible psychological disorders that may contribute to ED, such as depression, anxiety, stress, or issues with self-esteem.

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How is erectile dysfunction treated?

Treatment of ED can depend on the presence of an underlying cause. In the absence of these underlying causes, your doctor can give you the following treatments for ED [6]:

Lifestyle changes such as reducing alcohol intake and tobacco use, and doing more frequent exercises can reduce occurrences of ED, especially in younger patients.

PDE5 inhibitors such as sildenafil, vardenafil, and tadalafil promote smooth muscle relaxation necessary for an erection. PDE5 inhibitors need to be taken several hours before sexual intercourse for the medication to work.

Vacuum erection devices are pumps placed on the penis to draw blood into the penis, allowing for an erection. This is often used in combination with a band placed at the base of the penis to maintain the erection.

Intraurethral suppositories involve inserting a pellet with prostaglandin E1 into the urethra and massaging it to disperse the medication. The medication is absorbed through the urethra to the corpora cavernosa, which allows for smooth muscle relaxation for an erection.

Intracavernosal injections involve injecting vasoactive substances that allow the blood vessels to dilate, allowing more blood to flow into the penis. Among the common vasoactive substances used are prostaglandin E1, papaverine, phentolamine, and atropine. Intracavernosal injections are only prescribed if PDE5 inhibitors are not effective.

Surgery for penile implants are only indicated if other treatments are not effective. Different types of implants include malleable implants and inflatable implants.

Penile revascularisation surgery is similar to a bypass surgery for coronary heart diseases.

Many patients feel embarrassed about their ED, which may deter them from seeking medical help. However, visiting a doctor for a proper diagnosis can allow you to receive the proper treatment necessary to improve your condition. Reach out to us to book an appointment with our doctors to know how to treat ED.

Frequently Asked Questions (FAQs)

01. Will erectile dysfunction worsen as I age?

Ageing can reduce the ability to get and maintain an erection, but it is not the only contributor to ED. Many elderly men are still able to get and maintain an erection.

02. Can erectile dysfunction go away on its own?

Some cases of ED may go away on their own. Temporary causes such as stress and fatigue can lead to difficulties getting or maintaining an erection. Medical attention may only be necessary with consistent or frequent ED.

03. Do men with erectile dysfunction still feel desire?

Sex drive (libido) and the ability to get an erection are separate. Men with ED may be aroused but unable to achieve an erection. However, ED can also lead to a low sex drive or desire.

04. Is erectile dysfunction permanent?

Most cases of ED are treatable. Visiting a healthcare professional can help diagnose and identify the sources and causes of ED.

05. Which doctor should I see for erectile dysfunction?

A urologist is your first-line specialist for erectile dysfunction. They deal with matters related to male reproductive health and urinary issues. This includes poor blood flow, nerve damage, or testosterone imbalances.