Erectile dysfunction (ED)
Disorders of erection (stiffening member) often have a mental or physical (physical) cause, including the treatment of prostate cancer. But there are many treatment options.
Erectile dysfunction means literally dysfunction erection (stiffening member) to German erectile dysfunction. It refers to the permanent inability to achieve an erection or to maintain sufficient for satisfactory sexual activity. From this definition it is clear, among other things, that the diagnosis is also dependent on the subjective judgment of the party and that an occasional lack of erection still does not have ED.
Erectile dysfunction is colloquially referred to as erectile dysfunction or impotence (from the Latin potentia = wealth, force, power). However, this is not medically correct, because both terms also include the inability to normal ejaculation (ejaculation), the infertility (sterility) and the lack of desire for sexual activity (lack of libido = "Lust").
An erection is the result of a complicated process, which eventually reach orgasm (climax of sexual arousal) and to ejaculation leads: In undisturbed libido and normal hormonal status constitution of man be in erotic situations under the influence of mental (psychological) excites certain areas of his brain, for example, by visual impressions, touch, odors or representations (the "prelude").
About special centers in the spinal cord and nerve fiber plexuses around the urinary bladder and prostate then the pulses reach the penis. There they let the muscles of the corpora cavernosa and the afferent blood vessels limp. Thus, the blood flow increases in the cavities of the corpora cavernosa, so that these expand, which also restricts the flow of blood. The corpora cavernosa have a stable connective tissue, which limits their expansion (tumescent) and with the balance of inflow and outflow of blood, the hardness (rigidity) determines the erection.
The emptying of the corpora cavernosa is also done under the control of the brain via nerve impulses that lead to contraction of the muscles of the afferent blood vessels and the cavernous body: The blood supply decreases, the flow of blood increases and the cavernous pull himself together.
Frequency
Many men are affected by a more or less pronounced erectile dysfunction, in Germany alone up to 6 million. The frequency increases with the age, according to studies on more than 50%.However, only 10-25% of them seek treatment, although up to two thirds of men are sexually active, even in older age.
The real figure is so high. Presumably shame prevents many sufferers on going to the doctor (or the fear of not being a real man), so that multiple partnerships are loaded, which only exacerbated the problem because of the psychological effects.
Causes
From the above-described process of erection is to be appreciated that this can be disrupted in various ways. Thus we find, according to estimates in half of the cases of erectile dysfunction a physical cause, in 30% a psychological (eg, fear of failure, stress at work, partnership conflicts) and in 20% a mixture of both.
On physical causes come into consideration, for example:
- Supply of enjoyment poisons (eg alcohol, nicotine) or drugs.
- Cardiovascular diseases such as coronary heart disease, high blood pressure, atherosclerosis ("hardening of the arteries").
- Metabolic diseases such as diabetes mellitus (sugar diabetes), metabolic disorders, thyroid diseases.
- Taking medications such as blood pressure and lipid-lowering drugs, heart medications, anti-inflammatories, psychotropic drugs, sedatives and strong analgesics, appetite suppressants, hormonal preparations (including antiandrogens and LH-RH analogues in the treatment of prostate cancer, see hormone therapy ).
- Benign prostatic syndrome (benign prostate enlargement, see BPS ).
- Diseases of the brain or spinal cord, such as multiple sclerosis, stroke.
- Nerve damage, eg by poisons or in prostate cancer by radical prostatectomy or radiation therapy .
- Changes in hormone levels by diseases of the pituitary gland (pituitary gland), testicles or adrenal glands.
- Malformations, injuries or diseases of the penis.
The main risk factors for ED are the same as for cardiovascular disease: lack of exercise, obesity, smoking, hypercholesterolemia (elevated blood lipids) and the metabolic syndrome (combined metabolic disorder in diabetes mellitus).
Investigation
The basis is the collection of detailed medical history (anamnesis) to narrow the number of possible causes. These include issues after taking drugs, the psychological situation and the sexual life. When sexual history, the partners should be involved, and it can also questionnaire used (eg the IIEF, International Index for Erectile Function).
Then follows the physical examination, including measurement of blood pressure and pulse and a DRU (see digital rectal examination ). Laboratory tests are based on the results to date and include the determination of blood glucose, blood fats and sex hormones (see also sex hormones ), optionally also as the PSA level (see PSA test ).
Because the cardiovascular risk associated with sexual activity, is increased among ED patients and in the treatment of ED, the diagnosis also aims to map those affected corresponding risk class, possibly with the involvement of a cardiologist or internist. Thus at high risk (eg, unstable angina = "chest tightness") until improvement is strongly recommended abstinence and reduce the intake of PDE5 inhibitors (see below) generally prohibited. In contrast, a low-risk experiment with these drugs can be considered without further investigation.
The special diagnostics includes the Schwellkörperinjektionstest (SKIT) and sonography (ultrasound) of the penis vessels, rarely required, for example the measurement of nocturnal erections (NPTR, nocturnal penile tumescence and rigidity), the activity measurement of the muscles of the corpora cavernosa (CC-EMG, Corpuscavernosum electromyography), the X-ray contrast imaging of spongy tissue or blood vessels, and functional testing of nervous or hormonal control circuits.
Treatment
The primary focus is the elimination of risk factors (eg, physical training, weight loss, smoke-stop) and the treatment of the causes (eg adjustment of blood pressure and blood sugar, switching to other medications, hormone replacement, surgery of malformations, psychotherapy).
At the same time - or if this is not sufficient or should not be possible - can be used symptomatic (against the signs of disease, so the ED-directed) actions. It should be noted that these are only in exceptional cases, services of the statutory health insurance (or recoverable and eligible) usually only when a disease requiring treatment underlies (eg diabetes mellitus, in prostate cancer after radical prostatectomy ). There is this, numerous court decisions, and it is recommended to clarify the payment of costs of treatment.
The choice depends on the cause of the ED, the findings and the individual needs and expectations of the couple concerned. Success, satisfaction and adverse effects should be checked regularly and the therapy to be adjusted, for example by a change or a combination of methods. The options are:
PDE-5 inhibitors: These drugs inhibit an enzyme (ferment), the phosphodiesterase type 5 (PDE 5). It builds in the corpora cavernosa from a substance (cGMP), which is necessary for the formation and maintenance of erection, so ensures the decay of the erection. PDE-5 inhibitors are taken in tablet form and run at about 80% of men get an erection. They are now standard, but are only effective during sexual stimulation and intact nerve supply to the penis.Also, the list of absolute and relative contraindications long (contraindications, such as severe diseases of the heart, circulation, liver, gastrointestinal tract and eyes, ingestion of nitrate-containing drugs and nitrite sexual stimulants). There are three different agents (sildenafil, tadalafil, vardenafil). They differ in their profile of action and adverse effects, so that may be an exchange of advantage.
Other medications: Available more active stand with different mechanism of action (eg, yohimbine), others are currently being developed and tested. Must be cautioned against uncritical taking-the-counter drugs and stimulants (aphrodisiacs). Some preparations contain PDE-5 inhibitors or other highly effective substances, so they can be dangerous, while others are completely ineffective or prohibited (eg conservation reasons). At best, you can be previously discussed in detail.
SKAT (Schwellkörperautoinjektionstherapie): When SKAT the person concerned, a solution sharpened yourself (or another person) in both corpora cavernosa, of course, only after detailed instructions. Is mostly used to alprostadil (prostaglandin E1 =) at individual doses, sometimes also discusses other drugs or a combination. Advantage is a high response of up to more than 90%, regardless of the cause of ED. Of undesirable effects especially of priapism is to say, a painful priapism, although rarely occurs, but requires because of possible permanent damage at the latest after four hours of medical intervention.
Intraurethral prostaglandin E1: Here, the person takes the drug alprostadil in the form of a rod with an applicator into the urethra (intraurethral). The method is an alternative to SKAT, if the person refuses this, the response rate, however, is significantly lower.
Vacuum erection systems (vacuum): they produce a passive erection by vacuum in a tube inverted over the penis. A current applied to the penis base ring restricts blood outflow and maintains the erection, he should be taken off again after 30 minutes. The response rate is at least 90% to side effects occur very rarely. Such systems are particularly advantageous when the previously mentioned methods prohibit or have failed.
Penile (penile prosthesis): Planting of rigid, flexible or inflatable rods into the erectile tissue is rarely performed. Disadvantages are in the final change in the corpus cavernosum by means of the operation in general operation, a risk in the risk of a subsequent infection and in the high cost. Advantage, however, is the permanent remedy for erectile dysfunction, which is also evident in one of the highest acceptance rates of all methods.
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