The erection is a physiological process of both vascular and nervous origin and which is controlled hormonally. It consists of the dilation of the corpora cavernosa.

Erectile dysfunction is called the persistent inability to achieve and maintain an erection that allows adequate sexual satisfaction. Erectile dysfunction despite being an organic disease has many repercussions on quality of life and mental health.

According to the literature that is consulted, the incidence of erectile dysfunction is between 20 and 50% in people over 40 years of age.

Risk factor's

Since vascular phenomena are so involved in erection, it is logical that the risk factors for cardiovascular disease are the same as in erectile dysfunction. Sedentary lifestyle, obesity, smoking and hypercholesterolemia.

After open prostatectomies the risk is high.

Causes of Erectile Dysfunction

The main causes of Erectile Dysfunction are:

. Vascular origin:

  • Heart disease
  • Arterial hypertension
  • Mellitus diabetes
  • Dyslipidemia
  • Cigarette

. Major surgeries:

  • Prostatectomy (total or radical)
  • After radiotherapy on the pelvic region

. Neurological:

  • Parkinson's disease
  • Multiple sclerosis
  • Brain tumors
  • Stroke
  • Spinal cord disorders
  • Herniated discs
  • Polyneuropathies
  • Peripheral neuropathy due to alcoholism
  • Peripheral Diabetes Neuropathy

. Anatomical causes:

  • Peyronie's disease.
  • Penis fracture
  • Congenital curvature of the penis.
  • Hypospadias, epispadias.

. Hormonal causes:

  • Hypogonadism
  • Hyperprolactinemia
  • Hyper and hypothyroidism
  • Cushing's disease

. Pharmacological:

  • Antihypertensives (diuretics and beta-blockers)
  • Antidepressants
  • Antipsychotics
  • Antiandrogens
  • Antihistamines
  • Drugs (heroin, cocaine, methadone)

. Psychological causes:

  • Anxiety
  • Depression
  • Relationship-related problems.
  • Lack of sexual stimulation

Possible treatments

In erectile dysfunction, the basic principle is to find the cause, identify the risk factors that can be modified, to initiate a preventive and curative intervention.

After correcting modifiable factors or life habits, it is necessary to eliminate easily modifiable causes, such as medications or control of some diseases such as high blood pressure or diabetes. Then it goes to a second phase in which medical treatment begins.

Few causes of erectile dysfunction can be cured with specific treatment. Among them we have:

  • Post-traumatic in young patients, after repairing arterial ruptures and improving pelvic blood flow.
  • Hormonal due to hypogonadism or hyperprolactinemia, which are completely corrected when the appropriate hormonal treatment is established.

However, most of the causes require general medical treatment, which must be adapted to each particular case. We can differentiate three lines of treatment, which are chosen progressively when the previous line fails.

First line of treatment:

Medications that inhibit the enzyme PDE5, have as a mechanism of action the vasodilation that causes erection. It takes sexual stimulation. The most common are:

  • Sildenafil
  • Tadalafil
  • Vardenafil
  • Avanafil
  • Mirodenafil

Second line of treatment:

Intracavernous injections

  • Alprostadil, at a dose of 5 to 40 micrograms, achieves an erection in 5 to 15 minutes and the response may depend on the dose. It has an efficiency greater than 70%.
  • Intraurethral alprotadil

Third line of treatment

  • Penile prostheses or implants.

There are other less frequently used drugs with less scientific evidence for the case of erectile dysfunction. They can work in some specific cases:

  • Yohimbine: It is a vasodilator, which has been used as an aphrodisiac for many decades, but it has many side effects.
  • Delecuamin: it is an adrenergic antagonist, more specific than Yohimbine.
  • Trazodone: is an antidepressant drug that has been associated with prolonged erections due to its effect on the lytic muscle in the corpora cavernosa.
  • L ‐ arginine: acts as an antagonist of opioid receptors.
  • Ginseng: It has been commonly used as a vasodilator, although its mechanism of action is unknown.
  • Limaprost: for oral use, it is a derivative of alprostadil.

Treatment summary

The principles of treatment and options are summarized in:

  • Changes in lifestyle habits and risk factors should be established in all cases and try to maintain them throughout the medical treatment.
  • Erection-enhancing medications should be given early in total or radical prostatectomies.
  • In principle, any cause that is previously diagnosed at the beginning of pro-erectile treatment should be treated.
  • Sildenafil and its derivatives constitute the accepted first-line treatment in all cases.
  • In most patients, constant administration of sildenafil or derivatives can restore erectile function to normal.
  • The failure of medical treatment is based on two main causes: the incorrect indication of medication and the lack of education in the use of pro-erectile drugs.
  • Testosterone can be used, but only in cases of hypogonadism, where the decrease of this hormone in the blood is detected or measured. They are mandatory tests before starting a treatment for erectile dysfunction. There are many cases of treatment failure with sildenafil or taladafil due to undiagnosed underlying hypogonadism.
  • In patients with contraindications to the use of sildenafil or derivatives, apomorphine can be used.
  • The use of vacuum constriction devices are a valid option, in some cases of stable and well-disposed couples. However, these devices tend to be discontinued after the first 3 months. Initially, penetration can be achieved in 90% of cases, with satisfaction in sexual intercourse varying from 25 to 95%. They can cause ecchymosis or minor injuries to the penis due to its shape and action. These devices do not cure any type of erectile dysfunction, they are only used as a temporary alternative.
  • Topical treatments with vasodilator creams can be used at the level of the penis, some commercial preparations may include an absorption enhancer.
  • Nitroglycerin 2%
  • 15% or 20% papaverine
  • 2% minoxidil

There is also the sublingual apomorphine alternative, which is used on demand and is fast acting. It is effective between 28 and 50% of the cases.

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