Erectile dysfunction can have a devastating effect on men and their relationships, but increasing awareness and better treatments provide hope
Erectile dysfunction (ED) is a complex symptom that may have a number of underlying causes. Most men occasionally have a problem achieving or maintaining an erection, and this is often caused by stress, fatigue or drinking too much alcohol, or a combination of these. If medical causes have been ruled out, these patients can be reassured in a pharmacy consultation that it is nothing to worry about. However, if these symptoms are persistent, they may have a physiological basis.
ED happens when there is insufficient blood flow to the penis. This can potentially be due to a number of physical causes, including heart disease, hardened arteries, smoking, or even diabetes, which can cause small vessel disease or nerve damage to the penis. Maintaining enough blood in the penis enables a man to maintain an erection, but in cases of ED, this may not be possible.
Nerve damage
Certain injuries or diseases can also cause ED, including surgery to or injury to the pelvis that damages the nerves in that area. Cancer treatment to the pelvic area can also affect sexual functionality, including surgery and/or radiation for cancers in the lower abdomen or pelvis. Bladder, colorectal or prostate cancers often mean that men will develop ED, and as part of their cancer treatment plan, these patients should be under the care of a urologist and may also benefit from psychosexual counselling.
As pharmacists are well aware, certain prescription medications also carry with them side-effects that can impact sexual function.
Emotional issues
The physiological causes of ED are complex and can be compounded by emotional issues. ED can itself be caused solely by psychological distress. According to the HSE, if a man only has erection problems some of the time — for example if he gets erections in the morning but not during sexual activity — this may be a sign of a psychological cause.
The Urology Care Foundation, under the umbrella of the American Urological Association, points out that the emotional causes of ED can include:
- Depression.
- Anxiety.
- Relationship conflicts.
- Stress at home or work.
- Stress from social, cultural or religious conflicts.
- Worry about sex performance.
Many of these issues can be treat with counselling or cognitive behavioural therapy.
Treatments
Oral pharmacological ED treatments work by enhancing the effects of nitric oxide naturally produced in the body and which boosts blood flow. Each oral medication for ED has a slightly different chemical composition that affects its characteristics, such as how quickly it wears off. These differences may also vary in terms of side-effects, although generally, side-effects from oral ED medications are minimal and the treatments are usually well tolerated.
The most commonly-used ED treatments are classified as phosphodiesterase type 5 (PDE5) inhibitors. PDE5 is an enzyme in the walls of blood vessels that affects blood flow and also influences how cells signal within the body.
These inhibitors work by blocking the PDE5 enzyme to prevent it from working, which in turn relaxes the blood vessels and increases blood flow. This mechanism of action is also useful in treating pulmonary hypertension, as it controls blood flow to the arteries in the lungs and increases blood flow to the lungs. Research has also suggested that PDE5 inhibitors may be useful tools in treating heart disease, diabetes, and some cancers.
According to the American College of Cardiology, people who should not take PDE5 inhibitors include those who are taking nitrates or nitroglycerin, as concomitant use of PDE5 inhibitors leads to excessive preload reduction. This effect is common in patients using long-acting nitrates such as isosorbide mononitrate, isosorbide dinitrate, and transdermal nitroglycerin patches as prophylaxis for chronic angina. The College recommends patients taking PDE5 inhibitors to wait for at least one-to-two days after the last PDE5 inhibitor dose before taking nitrates.
Increasing prevalence
The incidence of ED increases with age, so with Ireland’s increasingly ageing population, treating the condition will be a growing challenge demographically. However, ED is not confined only to older men.
A study published in 1999 estimated the likely worldwide increase in ED prevalence between 1995 and 2025. The authors wrote that in 1995, there were over 152 million men worldwide who experienced ED. The projections for 2025 show a prevalence of approximately 322 million with ED, representing an increase of nearly 170 million men.
“Already under-funded national health systems will be confronted with unanticipated resource requests and challenges to existing government funding priorities,” the authors wrote. “The projected trends represent a serious challenge for healthcare policy makers to develop and implement policies to prevent or alleviate ED.”
This points to an increasing role for pharmacists and GPs in helping to establish the causes of ED, treating the symptoms of the condition, and improving outcomes for these distressed patients.
References on request
