Erectile dysfunction

The inability to sustain an erection is one of the main presentations of erectile dysfunction. However, based on the cause of the impotence (organic or non-organic/psychogenic), other symptoms that a person may experience include:

Symptoms of Psychogenic ED

• Sudden onset of erection issues
• Intermittent dysfunction (variability and situational)
• Loss of sustaining capability
• Nocturnal erection
• Excellent response to phosphodiesterase type 5 (PDE-5) inhibitors

Symptoms of Organic ED

• Gradual onset
• Often progressive
• Consistently poor response to phosphodiesterase type 5 (PDE-5) inhibitors
• Poor nocturnal erection
• Symptoms improve on standing rather than lying down (in cases of venous leak)

In order to understand the causes of erectile dysfunction (ED), it is essential to first know the mechanism of an erection. Here is what happens during an erection:

The penis remains in its flaccid state when the blood vessels in the penis are not fully dilated. This allows only a small amount of arterial blood flow into the penis, which is primarily required for nutritional purposes. When you are sexually stimulated, there is a release of neurotransmitters, namely nitric oxide (NO), from the nerve terminals in the penis. This causes relaxation of the smooth muscles of blood vessels, resulting in increased blood flow into the cavernosa of the penile region. Consequently, the penis becomes erect and rigid.

Erection ends when ejaculation occurs and sexual arousal subsides, allowing the accumulated cavernosa blood to flow out through the penile veins back into circulation.

Sometimes, a combination of various physical and psychological factors can cause a disturbance in the mechanism of erection. These factors are explained in detail in the next section.

• Sedentary lifestyle
• Unhealthy diet
• Certain medications, including some antihypertensives and antidepressants
• Alcohol consumption
• Smoking
• Stress
• Anxiety
• Obesity
• Hypertension
• Diabetes
• Heart disease
• Atherosclerosis
• Hypercholesterolemia
• Depression
• Pelvic surgery
• Penile injuries
• Cancer surgery

The tests recommended for patients seeking medical care for erectile dysfunction include an evaluation of:

• An accurate medical and sexual history
• A careful general and focused genitourinary examination
• Radiological tests like penile Doppler
• Routine lab tests

1. Radiological Tests

Radiological tests, such as penile Doppler, are important for the diagnosis of erectile dysfunction. This advanced imaging technique measures blood flow through the blood vessels in the penis, which is crucial for achieving erections.

2. Routine Lab Tests

Routine lab tests include hormonal and biochemical assessments, such as:

• Total and free testosterone
• Sex hormone-binding globulin
• Prolactin
• Thyroid hormone
• Total and high-density lipoprotein cholesterol
• Triglycerides
• Fasting glucose and glycosylated hemoglobin
• Prostate/testis/penis abnormalities
• Serum estrogen
• Dehydroepiandrosterone sulfate (DHEAS)
• Sex hormone binding globulin

Some of the common ways that can help you prevent ED include:

• Monitor disorders, particularly diabetes and heart problems, as these can increase your risk of ED.
• Limit tobacco consumption, as it can impact your sex life and ability to achieve an erection.
• Address overweight or obesity, which is a common risk factor for ED; losing weight can improve both physical and sexual health.
• If you are taking medications such as antidepressants or antihistamines, consult your doctor about possible alternatives or strategies to minimize their impact on your sexual activity.

There are multiple non-invasive treatments for ED that include lifestyle changes, oral medications (phosphodiesterase type 5 inhibitors), vacuum-assisted devices, and intraurethral suppositories. While lifestyle changes and oral medications are typically first-line treatments for ED, more invasive treatments, including intracavernosal injections and surgically implanted prosthetic devices, may be required for the management of complex cases.

1. Oral medications: These medications inhibit the enzyme phosphodiesterase type 5 (PDE5), which keeps the level of cGMP (cyclic guanosine monophosphate) high and promotes erections. The most well-known PDE5 inhibitor is sildenafil. Other commonly used medications include:
   • Tadalafil
   • Vardenafil
   • Avanafil
2. Intracavernosal injections (ICIs): These are an alternative to oral medications and are injected directly into the penile corpora (at the lateral base of the penis). The most commonly injected medication is prostaglandin E1 (PGE1), which stimulates cyclic adenosine monophosphate (cAMP) to induce smooth muscle relaxation and promote erections. It may be preferred in certain patients for whom oral medications may be contraindicated or in cases where nerves that stimulate erections are damaged.
3. Intraurethral suppositories: These medications are preferred by patients who wish to avoid oral or injectable medications. While intraurethral suppositories improve erectile function, they are known to be less effective than ICIs.
4. Vacuum-assisted erection devices (VED): This device is placed over the penis and pumped to create a vacuum, which pulls blood into the penis to cause engorgement and erection. The device may be challenging to use for patients with a large amount of lower abdominal fat and buried penis.
5. Penile implants (or prosthesis): This is a surgically implanted device that comes in an inflatable form (with two- or three-piece devices) and malleable form (with two rigid cylinders that are implanted within the penile corpora). This device remains rigid and may be simply positioned to allow for intercourse. These are usually recommended for people who fail to respond to less invasive ED treatments, but in some cases, they are also considered to be the first-line therapy.
6. Counselling: This is also a recommended treatment approach for men with psychogenic ED. Most patients have symptoms of depression and anxiety related to sexual performance, which increases focus on the firmness of the erection, leading to self-consciousness and cognitive distractions that interfere with arousal and contribute to poor performance. In such cases, seeking help from a psychiatrist or a sex counsellor can be beneficial.

Here are a few lifestyle changes that can help you deal with erectile dysfunction and improve your sexual life.

• Exercise regularly: It is essential to stay physically active. It helps maintain regulated blood flow to the pelvic regions. Erectile dysfunction is more commonly reported in men who are not physically active. Try different forms of physical workouts such as running, swimming, or brisk walking. Regular exercise helps prevent lifestyle problems such as cardiovascular diseases, obesity, high cholesterol, and stress, which also decreases the risk of erectile dysfunction.
• Foods to eat and avoid: A healthy, balanced diet plays a crucial role in maintaining blood flow to the sexual organs. Nutritious eating habits reduce the risk of lifestyle problems such as obesity, vascular diseases, and diabetes. Include fruits, vegetables, and whole grains in your daily diet. Reduce or avoid the intake of red meat and refined grains, as they may increase the risk of erectile dysfunction.
• Limit intake of medications: Several forms of antidepressants, sedatives, and antihistamines can affect male sexual response. The vascular network that produces an erection is often controlled by the nervous system. These medications can interfere with critical nerve signals and impair sexual response.
• Get enough sleep: Fatigue and stress can severely affect sexual health. Psychological stress leads to increased adrenaline, which causes the contraction of blood vessels. This contraction inhibits blood supply to the pelvic region and adversely affects sexual health.
• Get rid of your vices: Drink in moderation. Excessive alcohol consumption is detrimental to overall health. Chronic heavy drinking can affect organ systems and cause fluctuations in sex hormones, which are major triggers for conditions such as erectile dysfunction. If you smoke, quit smoking. Nicotine narrows blood vessels and hampers blood flow to the pelvic region, including the penis.

If left untreated, ED can lead to various health complications that can impact your sexual and mental well-being. Some common complications that can result from ED include:

• An unsatisfactory sex life
• Stress or depression
• Embarrassment or low self-esteem
• Problems in the relationship with your partner
• Inability to conceive with your partner

Acupuncture for ED

Studies suggest that acupuncture has been found to successfully reverse erectile dysfunction. It helps in improving the ability to maintain an erection, sustainable hardness during erection, and improved sexual satisfaction.

Ayurvedic medicine for ED

• Ginseng: Ginseng root has been used as an important constituent in Chinese medicine. It is known for many beneficial properties and has been recognized as an effective remedy for ED. However, certain precautions need to be exercised since it can cause side effects like insomnia and interactions with some medications. The recommended dosage is 600 mg-1000 mg a day. It is available in powdered and capsule form.
• Tribulus herb: This plant (Tribulus terrestris), also known as puncture vine, has been used in traditional Chinese medicine and Ayurveda since ancient times. It is known to increase sexual drive in both men and women and is considered a remedy for ED in men. Extracts of the roots and flowers are used in available tablets.
• Maca root: This root is known to improve hormonal balance, especially of the thyroid gland. It helps enhance stamina, energy, and overall sexual performance.
• Horny goat weed: Chinese medicine has traditionally used horny goat weed for treating ED. It has shown positive results in animal studies but has not been tested in humans yet. Experts recommend horny goat weed primarily for boosting overall energy, which may enhance performance. Extracts from the plant can be taken in capsule or tablet form.
• Yohimbe: The bark of the African Yohimbe tree contains yohimbine, which has shown positive results in treating ED in humans. However, it may cause serious side effects like lowered blood pressure, anxiety, and irregular heartbeat. Never take Yohimbe without a doctor’s supervision. It is available in capsule form, containing the bark extract.

Home remedies for ED

• Garlic: Garlic acts as an aphrodisiac and serves as a tonic for those suffering from loss of libido or those who are unable to maintain an erection. Crush two or three cloves of garlic and eat them every morning.
• Onion: Onion, known for its several health benefits, is recognized for strengthening reproductive organs and aiding those suffering from erectile dysfunction. Usually, white onions are recommended for such conditions.
• Dark chocolate: More often known as a herb, it contains close to 70% cocoa, which helps to increase dopamine levels in the brain. It uplifts mood, relaxes the body, and improves the body’s response to stimulation. Consume it regularly without needing a special occasion.
• Lady finger: According to Ayurvedic literature, lady finger helps regain sexual vigor. It treats sexual disorders and improves overall health. Grind the lady finger and add it to a glass of milk. Add sugar to taste. Drink this daily for significant results.
• Drumstick (Sahjan): According to Ayurveda, this spindly vegetable may help relieve symptoms of functional sterility in both males and females. The dried bark of the tree has been found beneficial for conditions such as impotence, premature ejaculation, and lack of sperm motility. Grind the bark, add the powder to milk, boil the mixture, and drink it daily for health benefits.