Erectile dysfunction (impotence) is the inability to achieve and/or maintain a sufficient erection for satisfactory sexual intercourse. It can occur in all decades of life, from puberty to old age; for some men this can be an occasional problem while for others a frequent one. It is important to note that having an erectile dysfunction does not mean not being able to have an orgasm or ejaculation or not being fertile.

The pathogenic mechanisms responsible for erectile dysfunction (impotence) are numerous, but before taking them into consideration, a brief reflection should be made on the anatomical and physiological bases responsible for erection. The penis is essentially made up of three columns of erectile tissue: two corpora cavernosa and a corpus spongiosum, the latter located lower down, between the corpora cavernosa. The structural basis of the erectile system  is constituted by a complex sinusoidal vascular network supported by a fibrillar elastic fabric which, in erection, can be stretched up to four times compared to the baseline condition. The corpora cavernosa are surrounded by a fibrous membrane, called the tunica albuginea, whose inextensibility is fundamental to achieving penile rigidity. During sexual arousal, the sinusoidal vascular system, which constitutes the corpora cavernosa and spongiosum, is filled with blood due to a hyperflow of arterial blood and venous outflow block, resulting from a complex interplay of vascular microsphincters. In this way the arterial blood which has reached the corpora cavernosa and spongiosum is “trapped” inside, determining penile erection. Subsequently, relaxation of the venous sphincters determines the outflow of blood from the erectile structures, thus their detumescence and the return of the penis to the flaccid state. It is important to emphasize that at the basis of the erectile mechanism there is a strong synergy between the central nervous system (where desire is stimulated through visual, tactile, olfactory and psychogenic sensations) and the vascular system, subject to its integrity  and that of the peripheral nerve pathways and to an appropriate hormonal environment .

Any perturbing factor ( neurological , vascular , hormonal, metabolic , psychogenic ), acting on one or more of the mechanisms involved, can cause erectile problems (impotence). It is inevitable that aging results in a progressive loss of effectiveness of the sophisticated systems that induce erection and therefore some degree of erectile dysfunction (impotence) is a paraphysiological phenomenon in old age. However, there are a number of risk factors which, regardless of age, are associated with erectile dysfunction (impotence). The following are  the most common:

– Vascular and cardiovascular disease (eg ischemic heart disease ) and correlated risk factors  such as hypertension and dyslipidemia

– Diabetes mellitus (the prevalence of erectile dysfunction in the diabetic population is about three times higher than in the non-diabetic population and occurs earlier, up to 10-15 years earlier)

– obesity

– sedentary lifestyle (on the contrary, moderate daily physical activity appears protect against the development of erectile dysfunction) ;

– Smoking, mainly cigarettes (important studies have shown that smoking doubles the risk of developing moderate/severe erectile dysfunction )

– Chronic abuse of alcohol and drugs

– Certain classes of commonly used psychiatric or general medical drugs (can cause and/or exacerbate erectile dysfunction )

– Neurological (in particular multiple sclerosis and spinal cord injury of various types) and psychiatric diseases

– Pelvic surgery and radiotherapy  (e.g., radical prostatectomy is the most common cause of erectile dysfunction)

– Renal and hepatic insufficiency

Among the psychogenic factors, the most common ones include situations of anxiety and/or depression (intrapsychic) besides couple relationship issues (relational component). It should be noted that a particular condition, called performance anxiety, can determine erection inhibition often as a result of one or more previous episodes of failure.  It must therefore be taken into account that a negative psychogenic component will be established in the male with erectile dysfunction (impotence), regardless of whether the initial cause is organic.

It is clear at this point that a correct diagnosis of the patient with erectile dysfunction should  consider both the organic component, and the patient’s intrapsychic component and relational component with his partner. The diagnostic process will be based on these situations. The first visit to the clinical andrologist ( Endocrinologist – Andrologist ) will include:

– A thorough general medical history, in order to obtain a range of useful information to contextualize the origin of the disorder

– Specific sexological anamnesis to contextualize the emotional and sexual relationships of the patient, and the emotional component involved in dealing with the situation, (tensions and anxieties, performance and/or relational )

– The administration of questionnaires for interviewing or  self-report (our clinic prefers to use the  SIED, a structured interview that makes it possible to identify and quantify the three fundamental pathogenetic moments of erectile dysfunction: organic,  intrapsychic and relational )

– A general physical examination (including peripheral pulses) and one of the genital tract, in particular regarding testicular, penile and prostate volume and morphology, and other anatomical abnormalities.

– First level laboratory analysis to assess the main metabolic and hormone parameters (basal and possibly postprandial glycemia, lipid profiles, possible hepatic and renal function, total and free testosterone, LH, FSH, prolactin, TSH)

– Ultrasonography of the genital region

If first level findings identify organic causes ( eg, diabetes, hypertension, vascular disease, or endocrine disorders ), the patient will undergo both a specific etiologic therapy (aimed at correcting the risk factors) and, if necessary, a  second level in-depth diagnostic analysis for erectile dysfunction (impotence) such as penile vascular evaluation with eco-color Doppler before and after intracavernous injection of vasoactive substances (PGE1) and possibly a specific therapy for erectile dysfunction (impotence). If  diagnostic tests of the I level show a predominant primitive psychogenic component, sex therapy for the individual and/or couple should be considered.

The most commonly used drug therapy consists of PDE-5 inhibitors (phosphodiesterase -5). This is a category of drugs whose mechanism of action involves the inhibition of the enzyme that degrades cyclic GMP, maintaining relaxation over time of the smooth muscle of the corpora cavernosa and therefore erection. In less technical terms, it is a pharmacological principle which contrasts the loss of erection, thus facilitating it. This statement implies that, for completion of sexual activity, all the normal procedures which trigger an erection (sexual desire, foreplay, etc.) are put into action, maintaining the normal sequence that characterizes human sexual activity. These drugs respect  proprioceptivity and other characteristics of our sexuality. This clarification is necessary as sometimes patients or their partners refuse the pharmacological approach because it is considered unnatural. Actually this is not so; if there is no desire,  no attraction towards the partner, in short no sexual “play”, the drug does not work.

If the patient is in a situation of overt hypogonadism (with total testosterone levels below 8 nmol/l), this situation must be corrected by administering testosterone with slow-release preparations (intramuscularly or transdermally). In the absence of a suitable androgenic environment, libido decreases, and some mechanisms involved in erection are defective, with a high risk of failure when administering PDE5 inhibitors.

In the case of oral therapy ineffectiveness or impossibility of using it,  an alternative therapeutic option is intracavernosal administration of a drug (ProstaglandinaE1) that causes an erection by activating cyclic AMP. Its use requires specific training of the patient regarding the methods of injection and personal dose optimization, otherwise it can have an inefficient or excessive response, which can lead to complications such as prolonged and painful erections (priapism) .

It should be emphasized that the pharmacological approach should not be fostered beyond what is strictly necessary, given the potential risk of triggering some kind of psychogenic drug-addiction in the patient. In fact it is not uncommon, especially in primitive psychogenic erectile dysfunction (impotence), that a correct diagnostic evaluation is in itself a therapeutic act by redefining  the problem .

In conclusion, the best solution for erectile dysfunction treatment is the one that derives from a global diagnostic classification of the disorder made ​​by a specialized andrologist (a careful analysis of the patient, his life-style, his marital relationship, general state of health and an appropriate diagnostic procedure). Also the therapeutic strategy must be decided on by the andrologist, based on clinical, laboratory and instrumental data obtained after an appropriate diagnostic procedure.

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Giancarlo Balercia

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