Healthy Corner

By: Dr. Heru H. Oentoeng, MRepro, SpAnd-K, FECSM

Many men worry and even fear the experience of erectile dysfunction. A proper understanding will help men comprehend the existing problems so they can resolve their issues and avoid falling prey to unscientific treatments widely advertised in mass media, or becoming victims of myths about treatments as well as misleading advertisements about erectile dysfunction.What is Erectile Dysfunction? Erectile Dysfunction (ED) is the inability to achieve or maintain adequate penile erection hardness for satisfactory sexual intercourse¹. Why is ED important? Because ED is one of the early symptoms of vascular disease and can be an indication of a serious ailment in the body that may result in a fatal condition^2,3 This condition is also related to psychological conditions as well as interpersonal relationship disorders⁴.Globally, ED affects about 13-28% of men aged 40-80 years⁵, and in America alone, the prevalence is estimated at around 22% in men over 40 years old⁶. The prevalence of ED is expected to continue increasing to exceed 300 million men by 2025⁷. The latest prevalence of ED in Indonesia in 2019 is 35.6% (22.3% mild, 13.7% mild to moderate, 3.1% moderate, and 0.8% severe). The prevalence of ED ranges from 6.5% in the 20-29 age group to as high as 88% in groups aged 60 years and above⁸. ED does not only occur in men over 40 years old as shown in the statistics above; ED may also occur in younger men.The causes of ED can be due to organic factors, psychogenic factors, and also a combination of both. The causes from organic factors include: damage or dysfunction of blood vessel endothelial linings (which may be caused by hypertension and high blood cholesterol levels), diabetes mellitus, damage to nerves involved in the erection process (including those caused by surgical procedures in certain cases), consumption of certain medications, and also hormonal disorders. Examples of psychogenic factors include: anxiety, depression, relationship conflicts, workplace stress, home stress, and concerns about poor sexual performance. Several of the issues mentioned above can increase the likelihood of ED compared to those who don't experience them at the same age^9,10,11.An easy way to assess erectile ability is with the Erection Hardness Score (EHS) in addition to the slightly more complex International Index of Erectile Function - 5 (IIEF-5). In daily sexual life, we can assess erection hardness with EHS, as follows: EHS 1 = penis enlarges but is not hard, EHS 2 = penis becomes hard but not hard enough for penetration, EHS 3 = penis is hard enough for penetration but not completely hard, and EHS 4 = penis is completely hard and fully rigid¹².The Asia Pacific Sexual Health & Overall Wellness Survey found survey results regarding the satisfaction with erection hardness relates to sexual satisfaction, romance, life priorities, and overall health¹³. Men with suboptimal erections, such as in EHS 3, are commonly less satisfied with their sexual relationships and experiences¹⁴. Based on study results, changes in erection hardness from EHS 3 to EHS 4 show increased satisfaction in sexual performance, personal relationships, and emotional health¹².ED can also negatively impact a man's quality of life. This quality of life includes both physical and psychological health. A man experiencing ED may respond to this condition differently¹⁵. Investigation of causative factors, both organic and psychogenic, must be carried out immediately by doctors competent in sexuality, and comprehensive and scientific treatment must be performed to help men with ED issues.Men with suboptimal erections naturally desire the return of fully hard, rigid, and long-lasting erections to satisfy their partners, so they can also gain satisfaction whilst restoring their own confidence. However, based on facts obtained from a study, 96% of Indonesians with sexual problems do not seek any medical help¹⁶. Yet ED is a condition that can be treated medically.If a man experiences mild, moderate to severe ED in his sexual life, he should immediately discuss it openly with a competent doctor to receive a comprehensive scientific evaluation. An earlier evaluation is certainly better, considering that ED is a 'window' to investigate whether there are risks of more serious disorders or issues that may occur, so a prevention of future possible fatal risks along with present quality of life does not deteriorate due to these issues. Partners should be involved in these discussions, because a man's ED problem will certainly affect their partner too, and their partner's support in the treatment process will also accelerate the recovery.There are numerous problems faced when seeking solutions for ED. These include the lack of scientific information regarding ED to healthcare workers, articles without scientific basis including myths circulating within society, misleading advertising, inappropriate drug selection due to misunderstandings about drug efficacy, counterfeit drugs, questionable herbal medicines, and many other problems that may lead men experiencing ED into even bigger problems. Of course, proper scientific medical treatment and appropriate drug selection are projected to resolve the ED concerns that are being experienced.ED management must be done comprehensively, where proper sexual education, lifestyle changes, and handling of causative factors become the basis of ED treatment¹⁰. Providing first-line ED treatment, namely Phosphodiesterase-5 Inhibitor (PDE-5I) drugs, will be very helpful and should be done together with counseling and sexual therapy; the use of penis vacuum pumps can also be attempted to help. The selection of PDE5-I drugs must certainly be adjusted to the patient's condition, including certain physical conditions that affect it, their sexual rhythm, and especially the patient's hopes for recovery of a healthy sexual life in their marriage. If the first line of treatments do not resolve the problem, then a second line is given, namely drugs that are inserted into the urethra or injected directly into the penis to stimulate penile blood flow. If the first and second lines fail and the disease conditions that become causative factors cannot be corrected, then a third line is considered, namely the installation of penile prosthesis^10,11.Several new findings such as Low Intensity Shock Wave Treatment (LiSWT)¹⁷, and stem-cell for penile rejuvenation¹⁸ are still in the research phase, with both pros and cons regarding the effectiveness of these therapy modalities, so they have not been used as guidelines for regular clinical treatment. Certainly, these new therapy modalities cannot replace first-line oral PDE5-I drug treatment in ED management, but they can become additional treatments performed together to achieve the goal of recovery for men with ED problems.

 

References:

National Institutes of Health Consensus Conference. Impotence: NIH Consensus Development Panel on Impotence. JAMA. 1993;270(1):83-90. Levine LA, Kloner RA. Am J Cardiol. 2000;86(11):1210-3. Jackson G. Int J Clin Pract. 1999;53(5):363-8. Swindle RW, et al. Arch Sex Behav. 2004;33(1):19-30. Launmann EO, et al. Int J Impot Res. 2005;17(1):39-57. Launmann EO, et al. J Sex Med. 2007;4(1):57-65. Aytac IA, et al. BJU Int. 1999;84:50-6. Birowo P, Deswanto IA, Rasyid N. F1000Res. 2019;8(817):1-11. Dick B, et al. Int J Med Rev. 2017;4(4):102-11. Urology Care Foundation. What is Erectile Dysfunction? Available at: https://urologyhealth.org/urology-a-z/e/erectile-dysfunction-(ed). [Accessed on 28 June 2024] Hatzimouratidis K, et al. EAU Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and Priapism. Europe: European Association of Urology; 2017. Goldstein I, et al. J Sex Med. 2008;5(10):2374–80. King R, et al. Int J Impot Res. 2011;23(4):135-41. The Star. The harder, the better. Available at: https://www.thestar.com.my/lifestyle/health/2011/06/19/the-harder-the-better. [Accessed on 28 June 2024]. EAU Patient Information. Living with erectile dysfunction. Available at: https://patients.uroweb.org/wp-content/uploads/2018/12/PI_Erectile-Dysfunction-EN-Q1-2020-1.pdf. [Accessed on 28 June 2024]. Nicolosi A, et al. BJU Int. 2005;95(4):609-14. Kalyvianakis D, et al. Int J Impot Res. 2020;32(3):329-37. Matz EL, et al. Sex Med Rev. 2019;7(2):321-8.

 

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