Erectile dysfunction is the inability to achieve and maintain an erection sufficient to allow satisfactory sexual performance. Dr. Josep Torremadé explains that, although it is a benign disorder, it affects the physical and psychosocial health of the patient and has a significant impact on the quality of life of those who suffer from it, as well as their partners and families.
Recent epidemiological data indicate a high prevalence and incidence of erectile dysfunction worldwide. The large community-based MMAS (Massachusetts Male Aging Study) reported an overall prevalence of erectile dysfunction of 52% in men aged 40-70 years.
What is the main cause of erectile dysfunction?
Erectile dysfunction is usually caused by several factors. In addition, it is common to find several of these factors in the same patient and that at the same time they end up causing erectile dysfunction. The factors can be divided into the following groups:
- Vascular causes: hypertension, diabetes, cholesterol, smoking, sedentary lifestyle, obesity, prostate surgery and vasculpatias.
- Neurogenic causes: stroke, multiple sclerosis, parkisnon or spinal cord pathology.
- Anatomical causes: Peyronie’s disease, congenital incurvation of the penis, micropenis, hypospadias, etc.
- Hormonal causes: testosterone deficiency syndrome, hyperprolactinemia or hypo/hyperthyroidism.
- Psychogenic causes: stress, relationship problems, fear of failure.
- Pharmacological causes: antihypertensives, antidepressants, antipsychotics, drugs.
Can it be prevented?
Erectile dysfunction can be associated with modifiable or reversible factors, including factors related to lifestyle habits or medications. By influencing them, the probability of presenting erectile dysfunction can be reduced or the pathology can be improved as long as it is mild. Some of the recommendations in this context are:
- Blood pressure control
- Balanced diet
- Doing sports
- Avoid toxic substances (alcohol, tobacco and other drugs).
Can it occur for psychological reasons?
The correct approach to erectile dysfunction usually requires a multidisciplinary approach shared and in collaboration with different professionals, physicians and psychosexologists.
In many cases, the trigger is the psychogenic component, so assessment, counseling and psychological treatment are essential. The demand to “function” does not allow or disables the enjoyment of the sexual act, which generates in the patient an attitude of alertness that causes him to be more concerned with obtaining and maintaining an erection than with relaxing and giving and receiving pleasure.
What is the most effective treatment?
As a general rule, dysfunction can be successfully treated with current therapeutic options, but there is no cure. The only exceptions are basically pure psychogenic erectile dysfunction and hormonal causes.
Generally, treatment for erectile dysfunction has to be multidisciplinary, addressing the psychosexual and medical spheres together. Medical treatment can be divided into 3 therapeutic steps, from less to more invasive:
- Oral treatment, such as phosphodiesterase-5 inhibitors.There are different presentations and active ingredients (sildenafil, vardenafil, tadalafil and avanafil). Depending on the demands of the patient, the drug that best suits the patient’s needs due to its pharmacokinetics is used.
- Treatment with vasoactive agents (alprostadil): they can be administered intracavernously and intraurethrally.
- Penile prosthesis: Surgical implantation of a penile prosthesis may be considered in patients who do not respond to drug therapy or who prefer a permanent solution to their problem. There are two types of prostheses: malleable (semi-rigid) and inflatable (two- or three-component). Most patients prefer the three-piece inflatable devices because of the more ‘natural’ erections. The entire prosthesis is implanted through a small incision of just 2 centimeters in the scrotum, virtually unnoticeable. With the current models, erection and detumescence (return to the flaccid state) are practically identical to the physiological ones. Prosthesis implantation has one of the highest satisfaction rates (70-87%) among the treatment options for erectile dysfunction.
In psychosexual and couple therapy, the initial objective is to express, detect and modify the immediate and concrete causes in order to reduce the level of anxiety. It is the anticipatory anxiety (fear of failure) about sexual performance and the demand “to function” that plays an essential role in both the origin and the maintenance of this erectile dysfunction of psychogenic origin.
Based on cognitive-behavioral techniques, we propose objectives such as:
- Identify and combat anticipatory thoughts related to sexual intercourse, replacing them with more adaptive ones.
- To diminish cognitive distortions related to the demand, perfectionism, guilt and fear of abandonment.
- Attenuate and control physiological responses.
- To reduce the levels of tension associated with the sexual act and to make satisfactory successive approaches.