Erectile Dysfunctions

Disclaimer 
This is for educational purposes only. It’s healthy to know how you work. If you were having problems, please seek the direct consultation of a qualified, licensed physician. 

Erectile function 

A basic understanding of erectile function is a prerequisite to reviewing erectile function. For this, you must understand the phases of erectile function. 

Oversimplifying of course, you get an erection (or you don’t; or its poor angle prevents penetration); your erection persists (or it doesn’t); and you get a satisfactory ejaculation (or you don’t; the least of your concerns if you haven’t penetrated your partner in years because of injury or illness or just lack of use). 

Different men are trying to achieve different abilities with each of these three phases. So, as long as the physician and the patient work as a team, and as long as I get couples to expect less and enjoy more, well, I have found that I have never produced dissolution for anybody with care I have provided. 

Anyway, back to function. First phase, the formation of an erection, is based on cavernous sinuses of the penis filling with blood. Thus, first phase depends on inflow. The second phase of erection is persistence. Persistence depends on those veins that you see outside of the penis. The more those things are developed, in number, size, and amount in general, the more the tunica albuginea can distort them. The more the tunica albuginea can distort them, more persistent an erection. Thus, second phase depends on outflow. 

The distinction of inflow and outflow, of erection in contrast to persistence, and then in turn the important contrast of erection and ejaculation, are all important distinctions because things that help the two phases of erection may hurt ejaculation. Drugs for example that contribute to erection formation like Viagra actually can make ejaculation less satisfying at higher doses. Hence, everyone’s interest in lowering the doses of drugs in general... Side effects... Is here key. 

This brings up another point. Some people try to promote persistence of erections with drugs like Viagra. That is not a good strategy, as you now understand. Again, just to be clear, Viagra is good for you getting an erection. Not so good for maintaining an erection, and even working against you when it comes to producing satisfying ejaculation. 

Back to nervous system control of male sexual function, the parasympathetic system generally governs erection, the sympathetic nervous system governs ejaculation. P and S. Point and Shoot was the old pneumonic we always used to remember Parasympathetic and Sympathetic for erection and ejaculation, respectively. 


The spectrum of erectile dysfunction 

Even at a day to day level, normal males will experience fluctuations in erectile function that range from sub-par ability to frank dysfunction. Psychogenic and stress factors may also affect the nervous system’s control of erectile function thus also altering parasympathetic and sympathetic function. 

Heck, even eating affects erectile function. If your gut is full of blood digesting your food, less is going to get into your penis. There’s also dilution effect from a belly full of food on erection producing medications like Viagra. Most of these patients are aware of these limitations, and take such medicine on a more empty stomach to have the first phase of erection go better when they are in use. 

Psychogenic causes of erectile dysfunction are famous. Yes, even marriage causes erectile dysfunction according to some studies. But the first step... All organic illness must be entertained and aggressively ruled out. 

Yeah, the frank erectile dysfunction diseases and disorders. The causes of erectile dysfunction are worth keeping in mind, because every man that has had sexual difficulty may begin to wonder at some point or another, maybe this isn’t something normal. Or even psych. 

I think the mindful, intelligent, modern patient or the patient’s partner is really trying to ask, could my male partner have a “real” problem. This has many implications. Do they have a problem, or is this something I’m doing wrong; or the partner might entertain this possibility. If the “I’m doing something wrong“ is the issue, then that may need some attention. ASAP (any degree of her launch just use produces erectile dysfunction!). And these are all thoughts in a spectrum of healthy speculation, as long as expert physicians are kept involved, as long as care Is being attempted simultaneously to get function back to the junction while the work is underway, and the process remains a team effort designed to produce results - - and no one gets hung up on inner conflicts. But... 

If they indeed have a problem, then certainly the problem should be found and fixed. Could be a primary organic problem. Or it could be a secondary symptoms of another primary disorder that MUST be found (Instead of just masking that this order by treating the erectile dysfunction in and of itself). In other words, maybe erectile dysfunction is just a symptom something larger that should be addressed. Yes, one fairly important symptom. But a bigger problem needs to be fixed like diabetes or something. So, segue... And on to the problems that cause it. 

Yes, diabetes is a big cause. There are precursors to diabetes, pre-diabetic states if you will, including “metabolic syndrome” which is the number one cause of erectile dysfunction in this country. 

So if a physician is providing good care, all of the organic possibilities like diabetes and prediabetes including metabolic syndrome must be ruled out as care is entertained with exciting new treatments like shockwave therapy. And PRP. 

Another big cause of erectile dysfunction is something called Peyronie’s disease. It is a plaque or a pebble in the shaft of the penis. It causes the penis to tilt, making penetration complicated and difficult. 

That induration or plaque or pebble is scar tissue developing on the tunica albaginia. See below under question 4 for the significance of the tunica albaginia. 

So, pre-diabetes syndromes, including metabolic syndrome, and of course anatomic problems, including birth defects and Peyronie’s disease - - all leading causes of erectile dysfunction. 

Just about any other of the major chronic diseases can cause erectile dysfunction. 

Yer another entire class of dysfunction is vascular-genic dysfunction; 80% of all erectile dysfunction has a component of this in some estimates. That is, calcium deposits in the blood vessels can lead to vascular obstruction and reduced function. Hence, the response to medications like verapamil (see below). 

Radiation therapy destroys cells releasing platelet activating calcium, calcifying blood vessels harmfully as well. This produces erectile dysfunction quickly, and care should be started as early as possible in this setting for best treatment response. Many start the safest form of erectile dysfunction care, shockwave therapy (see below), right away in this setting knowing that such vasoactive erectile function is likely coming soon. 

Prostatectomy. An obvious cause of erectile dysfunction. 

Neurogenic lesions in the spine like in multiple sclerosis affect the parasympathetic and sympathetic nervous function of erectile function (recall the “Point and Shoot” pneumonic, parasympathetic P governs Point, erection - - Sympathetic governs Shoot, ejaculation). 

Endocrine including low testosterone levels produces 10% Of the population of reduced function males. Hence, there’s not much to be gained by supplements. Plus the ever looming threat of suppressing your own body’s testosterone production by supplementing testosterone... Making testosterone supplements likely to produce yet another cause of erectile dysfunction when that notorious feedback loop goes awry. 

Pharmacologic destruction of erectile function, another obvious cause. NSAIDS are a big problem. Daily Advil or Aleve users or any of the cousins these drugs. Stop! It’s hurting your erectile function. 

Any of the CNS depressants... So, benzodiazepines, of course... But the depressant list goes on and on. SSRI’s (used for premature ejaculation and depression) and beta blockers can adversely affect erectile function (Although one interesting beta blocker, Bystolic, actually contributes to nitric oxide formation, improving erection formation - - so, a nice choice with a patient that wants to control blood pressure risks while improving erectile function.) 

And in the Venn diagram of things, there’s a great overlap amongst the different types of disorders that contribute to erectile dysfunction. 


Treatment 

In as much as the normal male can thus experience suboptimal erectile function, the normal male can strive to optimize erectile ability with different safe lifestyle practices and therapies. 

I like to think beyond hormone replacement therapy (HRT), which can be safe. There’s so, so much more! 

Lifestyle optimizations include maintaining a healthy weight, eating correctly, working out regularly, not participating in any regular substance abuse including alcohol, smoking, and marijuana. 

Penile injections, implants, pumps, PDI inhibitors - - all of these address erection formation. They produce little improvement in erection persistence. For that, we turn to anatomy boosting therapies, many of which do not even require drugs. 

Such therapies include shockwave, acoustic therapy (like GainsWave). The regimen involves a start up 6-12 sessions, followed by a yearly maintenance session. No drugs involved here. Just angiogenesis that is actually stimulated - - a revascularization of the veins of the shaft of the penis to maximize the persistence of erection. So much is written and spoken about returning function to the junction. Just regular sexual activity promotes lift off as well as persistence. And I am a big advocate of that. But what really is effective is getting the maximum anatomy back to the junction. That in turn leads in and of itself to ideal function in the junction today, and preserves it for decades of fullest function use. 

Since many causes of erectile disfunction stem from vasoactive dysfunction secondary to calcium deposition and secondary vascular dysfunction, calcium channel blockers like verapamil can work nicely. Atropine is another pharmacologic agent that can promote erection formation, thereby someone palliate erectile dysfunction. 

Continuing on the vascular campaign to remediate erectile dysfunction… One of the many procedures that help with vascular problems that wreck erectile dysfunction, clever surgery exists where a branch of the epigastric artery is brought down to the dorsal artery of the penis, allowing for better cavernous sinus filling, and hence improved erection formation. 

There are even ligaments that can be safely ligated, even in the B minus player, to prolong the penis, and thereby improve performance that way. 

For clinical situations where there is more extensive pathology to overcome, other surgery exists where a flexible filler rod is implanted into the cavernous sinuses. 9 out of 10 men get great satisfaction and response from this. 1 of 10 - - a very bad situation. Not only is it not effective in this unfortunate small group, but once the cavernous sinuses have been destroyed in this manner, sexual function may be very much adversely affected, to say the least. Bottom line, you need to know the risks. 


Conclusion 

There are many treatment options to shockwave for erectile dysfunction. 

Fixing the underlying problem like diabetes or metabolic disorder or anatomical disturbances or psychological problems is the most important first step in the treatment plan when there’s actual erectile dysfunction disease or disorder. 

Since a large portion of these pathological processes have a vasoactive underlying dysfunction, it stands to reason that vascular stabilizing medications like the calcium channel blocker‘s including forever no would help. And this is indeed the case. 

But living healthy is your best bet for maintaining optimal erectile function. 

Keeping sexually active is also key. 

And for therapies, avoid drugs, avoid surgeries... When you can, of course. The side effects are worth knowing and are in general strongly prohibitive. Move along... 

And strongly consider shockwave therapy - - super effective, and above all, safe. 

Stay good. And... Stay well. 

David Allingham, MD, MS

Author
Dr. David Allingham, MD, MS

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