MASTER MINI KADATE

CDK 174/vol.37 no.1/Januari - Februari 2010

TINJAUAN PUSTAKA

Management of Erectile Dysfunction

Wimpie Pangkahila

Department of Andrology and Sexology, Center for Study of Anti-Aging Medicine,

Medical Faculty, Udayana University, Denpasar, Indonesia

Erectile dysfunction (ED) is one of the sexual dysfunctions that

disturbs many men and their partners all over the world. It is

estimated that more than 152 million men worldwide experienced

ED in 1995, and that this number will rise by 170 million, to

approximately 322 million by the year 20251. ED is the persistent

or recurrent inability to achieve or maintain penile erection

sufficient for sexual intercourse.

The incidence of ED increases with age. The Massachusetts Male

Ageing Study (MMAS) showed that 52 percent of respondents

aged 40-70 years reported some degree of ED

. If the MMAS

data is extrapolated, it is estimated 18-30 million American men

have ED. Unfortunately there is no data of the number of ED

patient in Indonesia. However, based on the patient records in

the clinic it is no doubt that there are many ED people in this

country. It is estimated not less than 10 percents of the Indone-

sian married men have ED

CAUSES AND PATHOPYHSIOLOGY

Basically the causes of ED are divided into two groups, those are

physical factors and psychogenic factors. There are 4 groups of

physical factors as the causes of ED, i.e. endocrine, neurogenic,

arterial, venous, and iatrogenic factors

. Some endocrine abnor-

malities associated with ED are hypogonadism, hyperprolactine-

mia, hyperthyroidism, and hypothyroidism. ED due to hypogo-

nadism is associated with the dysfunction of tunica albuginea

and corpus cavernosum

. However, hypogonadism also causes

decreased sexual desire that further results in failure of erection.

The neurogenic causes of ED include any disease or injury affec-

ting central nervous system, spinal cord, and peripheral nervous

system. The arterial factors are diseases or disturbances of artery

restricting the blood inflow into the corpus cavernosum. The

most common of the arterial factor is atherosclerosis. The others

are traumatic injury of the penile arteries due to pelvic fracture,

and a number of surgical procedures that reduce arterial supply

to the penis.

The venous factors as the causes of ED based on the veno-

occlusive mechanism in the erectile process. Failure of the veno-

occlusive mechanism causes blood outflow from the penis, and

erection does not occur. The venous factors include the abnor-

mality of venous vessels and veno-occlusive dysfunction. The

veno-occlusive dysfunction is primarily caused by abnormal

smooth muscle function and impaired function of tunica albug-

inea. The severity of the veno-occlusive dysfunction is related to

reduced amount of smooth muscle cells in the corpus caver-

nosum

. Decreased testosterone may cause dysfunction of

tunica albuginea and reduced amount of smooth muscle cells of

the corpus cavernosum.

ED is an important sign of vascular disease including coronary

artery disease (CAD), stroke, and diabetes. Epidemiologic study

also showed close correlation between ED and vascular disease.

The same etiologic factor is endothel dysfunction

7,8

Some operation procedures, drugs, and radiotherapy can result

in ED. Damages of nerves or arteries associated with erectile

function that may occur during the operation procedure can

cause ED. Some drugs can cause ED like psychotropic agents,

antidepressants, antihypertensives, hormonal drugs, anticholi-

nergic agents, and recreational drugs

4,9

. Radical radiotherapy to

pelvic organs like prostate or rectum is assumed to cause vasculi-

tis. This may cause ED due to ischaemic damage of cavernosal

nerves

. Some prominent diseases that could cause ED are diabe-

tes, hypertension, peripheral vascular diseases, coronary heart

diseases, dislipidemia, heavy smoking, and depression

The psychogenic factors include all psychological factors that can

inhibit the mechanism of erection. The psychogenic factors can

be divided into three groups, those are predisposing, precipitating,

and maintaining factors

. Predisposing factors include restricted

upbringing (e.g.guilty feeling), traumatic sexual experience, poor

sexual education, disturbed family relationship, lifestyle problems,

and personality type. Factors included in precipitating factors are

organic disease, ageing, infidelity, unreasonable expectation,

depression, anxiety, and loss of partner. Maintaining factors are

performance anxiety, diminished attraction, poor communica-

tion, fear of intimacy, poor sexual education, and poor general

relationship.

In psychogenic erectile dysfunction, there is increased norepi-

nephrine level in the penis and systemic blood. The norepinephrine

increase results in constriction of the blood vessels in the corpus

CDK 174/vol.37 no.1/Januari - Februari 2010

TINJAUAN PUSTAKA

Goal of treatment

The goal of ED treatment is to achieve optimal erection. A

recent retrospective data analysis from 26 randomized

controlled trials demonstrated that improved erection hardness

correlated with significant improvements in sexual intercourse

enjoyment, sexual relationship satisfaction, and confidence in

erections for satisfactory sexual activity

In studies and surveys of men with erectile dysfunction (ED),

improvement in a man's erectile function enhances the emo-

tional well-being and quality of life for both partners

15-19

After eleven years in worldwide market and ten years in

Indonesia, the role of sildenafil citrate (Viagra) is still dominant.

After ten years experience in prescribing Viagra, the following

conclusions have been noted. 1. Most ED patients satisfied

with 50 mg Viagra to achieve optimal erection. 2. Partners of

ED patients also satisfied with the quality of erection after

taking Viagra. 3. Only very few patients have adverse effects :

headache, flushing, nasal congestion. No drop out because of

adverse effects. 4. Many ED patients recover their erectile

function and do not have to take Viagra anymore, at least for a

period of time

Hormonal replacement therapy

Many signs, symptoms, and complaints in aging males are

caused by decreased hormone levels. Sexual problems are

common in aging males which disturb the quality of life.

The hormonal replacement therapy is a need to maintain and

reverse the sexual function and other functions of the whole body

system. Testosterone replacement therapy is common in aging.

It results in the recovery of functions related to testosterone

including sexual dysfunction, wellbeing, and body composition.

The combination of PDE5 inhibitors with testosterone is emerg-

ing as a new treatment in ED, especially in aging. Testosterone

has profound effect on penis tissues involved in the mechanism

of erection. Testosterone deficiency impairs the anatomical and

physiological substrate of erection capacity, reversible upon

androgen replacement. The synthesis of PDE5 is upregulated

by androgen and the arterial inflow into the penis is improved

by androgen

. Thus testosterone improves the response to

PDE5 inhibitors. This combination is hoped to overcome the

problem.

References

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between 1995 and 2025 and some possible policy consequences. Br J Urol Int. 1999;

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Medical and Psychological Correlates: Results of the Massachusetts Male Ageing

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London, Mosby-Wolfe Medical Communication, 1998.

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physiological substrate of penile erection. Asian J Androl. 2006; 8[1]:3-9.

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Clinicopathological Correlation of Corporeal Function and Structure. J Urol.1996;

156:1320-1329.

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Dy sfunction and Cardiac Risk: New Guidelines for Sexual Medicine. J Sex Med. 2006;

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Medical Association. Jakarta. 2006.

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that results in erection in the psychogenic erectile dysfunction patients. Dissertation.

Airlangga University. 1996.

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Erection Hardness Score and Its Relationship to Successful Sexual Intercourse. J Sex

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on tadalafil. Urology. 2006; 68: 631-5.

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treatment satisfaction in couples affected by erectile dysfunction (ED): a randomized,

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partners. J Sex Med. 2006; 3: 1028-36.b

17. Fisher WA, Rosen RC, Eardley I, Sand M, Goldstein I. Sexual experience of female

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19. Heiman JR, Talley DR, Bailen JL et al. Sexual function and satisfaction in heterosexual

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Viagra in Indonesia. Presented at the 2nd National Congress of Indonesian Androlo-

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physiological substrate of penile erection. Asian J Androl 8:1, 2006.

cavernosum, and inhibits erection

. Even though the underly-

ing cause of ED is physical factor, the psychogenic factor almost

always contribute to and coexist with it.

Erection Hardness Score

The quality of erection depends on how optimal the reaction of

penis to sexual stimulation. In 2004, the 2

International

Consultation on Erectile and Sexual Dysfunction addressed the

issue of erection hardness. It also recommended the use of

hardness score to assess erectile function as a part of diagnostic

evaluation for men with complaint of erectile disorder. This

scoring system provides the physicians with a subjective quanti-

tative evaluation of the degree of erection hardness. It is called

Erection Hardness Score (EHS) which has been validated to

assess the hardness of penile erection

The score or grade is as follows:

· Score 1 : Penis is larger but not hard

· Score 2 : Penis is hard but not hard enough for penetration

· Score 3 : Penis is hard enough for penetration but not

completely hard

· Score 4 : Penis is completely hard and fully rigid

The erection hardness of score 3 is sufficient for sexual inter-

course. However it does not mean sexual satisfaction is also

reached, because the quality of erection is not optimal.

Improvement in erection hardness from EHS 3 to EHS 4 is

followed by improvements in sexual intercourse satisfaction,

treatment satisfaction, sexual relationship satisfaction, self-

esteem, and confidence.

The EHS scores show strong correlation with ED severity (no

ED, mild ED, moderate ED, and severe ED) as determined by

the International Index of Erectile Function (IIEF), the gold

standard for evaluating the efficacy of ED treatment. Accord-

ing to IIEF-5 the score 1 is equivalent to Severe Erectile

Dysfunction (IIEF 6 10), score 2 is equivalent to Moderate

Erectile Dysfunction (IIEF 11-15), score 3 is equivalent to Mild

Erectile Dysfunction (IIEF 16-20), and score 4 is equivalent to

normal erectile function (21-25).

ED severity can also be assessed by IIEF-domain score as

follows. Severe ED (6-10), moderate ED (11-16), mild ED

(17-25), no ED (26-30). In correlation with EHS, score 1= severe

ED, score 2= moderate ED, score 3= mild ED, and score 4 = no

ED or normal erectile function.

DIAGNOSIS

The diagnosis of ED is established according to:

1. Sexual history.

Including the following assessment:

· Erectile insufficiency, altered sexual desire

· Nocturnal and morning erection

· Ejaculation, orgasm, genital pain

Partner

sexual

function

The use of International Index of Erectile Function-5 (IIEF-5) can

establish the diagnosis of ED.

2. Medical history

Lifestyle

factors,

smoking

· Chronic medical illness

· Pelvic/perineal/penile trauma and surgery, pelvic radiotherapy

· Medications/recreational drug use

· Neurological disease, endocrine disease

· Psychological state, psychiatric problem

3. Clinical examination

General

examination:

· Body configuration: fat distribution, gynaecomastia

· Degree of virilization: hair distribution, muscle, skin

· Blood pressure, cardiovascular

Neurological

b. Penis examination: secondary sexual characteristics,

hypospadia, epispadia, phimosis, scars, other pathological

conditions.

c. Testis examination: position, volume, consistency. Testis

position, consistency, are examined by palpation. Testis

volume can be measured by orchidometer.

4. Laboratory tests: LFT, Lipid tests, Glucose. Testosterone assay

should be performed in case of low sexual desire and of

diminished size testes.

5. Additional testing: erectiometer, Doppler stethoscope,

Rigiscan

MANAGEMENT

The principle of management of ED is as follows:

1. Diagnose ED, differentiate with other sexual dysfunctions

2. Evaluation to find the etiology

3. Treatment toward the etiology

4. Treatment to recover the erectile function:

· Sexual counseling and sex therapy

· Oral erectogenic: PDE-5 inhibitor- sildenafil citrate is the

first, followed by vardenafil and tadalafil

· Local therapy: intracavernosal injection, transurethral

application, vacuum constriction device

Surgery

TINJAUAN PUSTAKA

CDK 174/vol.37 no.1/Januari - Februari 2010