(Popularly: impotence; ED)
Erectile dysfunction is defined to achieve or satisfactory for sexual intercourse erection maintain than inability. Most forms of erectile dysfunction are caused by vascular, neurological, psychological, or hormonal imbalances. Similarly, medications may be the cause. The examination typically comprises the search for the underlying disorders and the measurement of plasma testosterone levels. Treatment options are oral phosphodiesterase-5 inhibitors, intracavernous or intraurethral applied prostaglandins, mechanical pumps as a tool or surgical implants.
Erectile dysfunction (ED, formerly called impotence) affects up to 20 million people in the United States. The prevalence of partial or complete ED> 50% in men aged 40-70 years, and the prevalence increases with aging. However, most affected men can be treated successfully.
Erectile dysfunction is defined to achieve or satisfactory for sexual intercourse erection maintain than inability. Most forms of erectile dysfunction are caused by vascular, neurological, psychological, or hormonal imbalances. Similarly, medications may be the cause. The examination typically comprises the search for the underlying disorders and the measurement of plasma testosterone levels. Treatment options are oral phosphodiesterase-5 inhibitors, intracavernous or intraurethral applied prostaglandins, mechanical pumps as a tool or surgical implants. Erectile dysfunction (ED, formerly called impotence) affects up to 20 million people in the United States. The prevalence of partial or complete ED> 50% in men aged 40-70 years, and the prevalence increases with aging. However, most affected men can be treated successfully. Etiology There are two types of ED: A primary ED, the man was never able to achieve or maintain an erection Secondary ED, purchased by a man later in life, who could previously achieve an erection. Primary ED is rare and almost always due to psychological factors or clinically obvious anatomic abnormalities. Secondary ED is more common and more than 90% of the cases of secondary ED have an organic and 40% of a psychogenic etiology. many men with ED secondary develop reactive psychological difficulties that worsen the problem. Psychological causes, whether primary or reactive, must be considered in each case. Psychological causes of ED are primary guilt, fear of intimacy, depression or anxiety. In secondary ED causes can be related to performance anxiety, stress or depression. Psychogenic ED may be situational, u. a. through a special place, a special time or a special partner. The most important organic causes of ED are vascular diseases Neurological diseases These diseases often originate from atherosclerosis or diabetes. The most common vascular cause is atherosclerosis of the cavernous arteries of the penis, usually as a result of smoking or diabetes. Atherosclerosis and aging reduce the ability to dilate the arterial blood vessels and smooth muscle relaxation. Thus, the amount of blood that the penis is reduced (overview of male sexual function: erection) can pass. A vein occlusion dysfunction allows venous leak that causes the inability to erection. Priapism is usually with the use of trazodone, cocaine abuse and sickle cell anemia associated, can cause penile fibrosis and lead to ED by causing fibrosis of the penile veins that impedes drainage. Neurological causes include strokes, complex focal epileptic seizures, multiple sclerosis, peripheral, or autonomic neuropathy, and spinal cord injuries a. Diabetic neuropathy and surgery-related injuries are very common causes. Complications of pelvic surgery (eg. B. radical prostatectomy [even with nerve-sparing techniques], radical cystectomy, transurethral resection of the prostate, rectal cancer surgery) are other common causes. Other causes include hormonal imbalances, medications, radiation of the pelvis or structural disorders of the penis (eg. As Peyronie’s disease / Peyronie [IPP]). A longer perineal pressure load (such as when riding a bicycle) or pelvines or perianal trauma can cause temporary ED. A endocrinopathy or aging in conjunction with a testosterone deficiency (hypogonadism) may decrease the libido and thereby causing ED. However, erectile function only rarely improves with normalization of serum testosterone mirror because most affected men also have neurovascular causes of ED. Other causes include various drugs (see Table: Commonly used drugs that can cause erectile dysfunction). Alcohol can cause temporary ED. Diagnosis Clinical evaluation screening for depression testosterone levels In studying the history with respect to drugs (including prescription and herbal drugs) and alcohol, surgery and trauma of the pelvis as well as smoking, diabetes, hypertension, arteriosclerosis and symptoms should vascular, hormonal, neurological and psychological fault levied. Satisfaction with sexual relationships should be examined, including the interaction with the partner and the partner’s sexual dysfunction (eg. B atrophic vaginitis, dyspareunia, depression). It is important to look for a depression, which is not always apparent. The Beck Depression Scale or the Geriatric Depression Scale (GDS) for older men (see table: Geriatric Depression Scale (short form)) to Yesavage is easy to use and can be helpful. The investigation focuses on the genitals and extragenital findings of a hormonal, neurological or vascular disorder. The genitalia (Peyronie’s disease / IPP) examined for abnormalities and signs of hypogonadism fibrous strands or plaques. A low rectal tone, decreased perineal discomfort or bulbocavernosus reflex abnormalities may indicate a neurological dysfunction. Decreased peripheral pulses suggest vascular dysfunction. A psychological cause should be suspected in young men with abrupt onset of ED, especially when the onset is or with a specific emotional event in the context if the dysfunction occurs only under certain conditions. A history of spontaneous improvement in ED also suggests a psychological cause close (psychogenic ED). Men with psychogenic ED usually have normal nocturnal erections and erections upon awakening, while this is in men with organic ED often not the case. Commonly used drugs that can cause erectile dysfunction category drugs antihypertensives ?-blockers, clonidine, loop diuretics (probably), spironolactone, thiazide diuretics, CNS drugs alcohol, anxiolytics, cocaine, monoamine oxidase inhibitors, opioids, SSRIs, tricyclic antidepressants Other amphetamines, 5?-reductase inhibitors, anti-androgens, chemotherapeutic agents, anticholinergics, cimetidine, estrogens, luteinizing ” hormone-releasing hormone agonists and antagonists “Testing Laboratory tests should include the measurement of the morning testosterone levels. If the levels are low or low-normal, prolactin, and luteinizing hormone (LH) should be determined. In case of clinical suspicion should be investigated on a hidden diabetes, dyslipidemia, hyperprolactinemia, thyroid disease and Cushing’s syndrome. Currently, a duplex sonography after intracavernous injection of a vasoactive drug is usually carried out as prostaglandin E1, to evaluate the penile vasculature. Normal values ??comprise a maximum systolic flow rate of> 20 cm / s and a resistance index> 0.8. Under the resistive index is defined as the difference between peak systolic velocity and end-diastolic velocity divided by peak systolic velocity. Rarely are revascularization in selected patients, for a penile Revaskularisierungschirurgie is considered by trauma of the pelvis, a “dynamic infusion cavernosography” and cavernosometry performed. Treatment Treatment depends on the underlying causes of drug, generally oral phosphodiesterase inhibitors vacuum erection pump or intrakavernöses or intraurethral prostaglandin E1 (Treatment of 2nd choice) when other treatments fail, surgical implantation of a penile prosthesis underlying organic disorders (eg. B . diabetes, hypogonadism, Peyronie’s disease) require adequate treatment. Drugs that are temporarily associated with the development of ED should be discontinued or changed. Depression needs to be treated in certain circumstances. Strengthening of self-confidence and sex education are (if possible also the partner) is very important for all patients. For further therapy, an oral phosphodiesterase inhibitor is prescribed first. If necessary, as eingeestzt a vacuum pump or erection intrakavernöses or intraurethral prostaglandin E1 Next, other non-invasive methods. Invasive treatments are used only when noninvasive methods fail. All drugs and devices should be ? tried five times before they are considered invalid. Drugs for erectile dysfunction, the first-line treatment of ED is usually in the oral administration of a phosphodiesterase. To the other drugs that are used include intrakavernöses or intraurethral prostaglandin E1. However, since almost all patients prefer oral drug therapy, oral medications are used unless they are contraindicated or incompatible. Orally administered phosphodiesterase inhibitors selectively inhibit cyclic guanosine monophosphate (cGMP) -specific phosphodiesterase type 5 (PDE5) which is the main isoform of the phosphodiesterase in the penis. These drugs include sildenafil, vardenafil, and tadalafil avanafil (see table: Oral administered phosphodiesterase-5 inhibitors for erectile dysfunction). By preventing the hydrolysis of cGMP, these drugs promote the cGMP-dependent relaxation of smooth muscle, which is important for normal erection. Although vardenafil and tadalafil are selective for the penile vasculature than sildenafil (n. D. Talk .: probably the PDE-5 receptors), are the response to therapy and the side effects of these drugs similar. In comparative clinical trials, these drugs show similar efficacy (60-75%). be taken orally administered phosphodiesterase-5 inhibitors for erectile dysfunction drug dose * onset comments Avanafil 50, 100 or 200 mg 30 min Can 30 minutes before intercourse Sildenafil Initial: 50 mg maintenance: 25-100 mg (most men respond best to 100 mg) for 60 min duration: ? ??4h Tadalafil 10-20 mg 60 minutes duration of the operation: 24-48 h tadalafil, low doses of 2.5-5 mg 60 minutes for daily use. Taking performed every day around the same time, regardless of when sexual activity for daily use in patients who also require treatment of benign prostatic hyperplasia Vardenafil 10-20 mg 60 minutes duration of the action: ? ??4 h vardenafil, mouth dissolving be taken before intercourse mold 10 mg 30 min 30 min * Can PDE5 inhibitors should on empty stomach at least 1 hour before intercourse be taken unless otherwise stated. The maximum intake is once / day unless otherwise noted. PDE5 = phosphodiesterase type fifth All PDE-5 inhibitors cause coronary vasodilation, and may enhance the hypotensive effect of other nitrates, including those used to treat coronary heart disease, but also as a recreational drug ( “poppers” = amyl nitrite). Therefore, the concomitant use of nitrates and PED-5 inhibitors can be dangerous and should be avoided. Patients who only occasionally use nitrates (eg. As for rare bouts of angina) should talk about the risks, the selection and timing of the application of possible PDE5 inhibitor with a cardiologist. Side effects of PDE-5 inhibitors are redness, blurred vision, hearing loss, dyspepsia and headache. Sildenafil and vardenafil may cause abnormal color vision (blue haze). The use of tadalafil has been associated with myalgia. Rarely has a nichtarteriitische ischemic optic neuropathy (NAION) has been associated with the use of PDE5 inhibitors, but a causal relationship has not been established. All PDE5 inhibitor should be used with caution and with low initial doses to patients, the ?-blockers (for. Example, prazosin, terazosin, doxazosin, tamsulosin) obtained because of the risk of hypotension. Patients taking an ?-blocker should wait at least 4 hours before taking a PDE5 inhibitor. Rarely cause PDE5 inhibitor priapism. Alprostadil (prostaglandin E1), administered via intracavernosal injection or intraurethral insertion itself can cause erections with a mean duration of 30-60 min. Intrakavernöses alprostadil can be assembled with papaverine and phentolamine for increased effectiveness when needed. An excessive dosage may cause priapism at ? 1% of patients and pain in the genital or pelvic in approximately 10% of patients. An information and monitoring by the doctor helps to achieve optimum and safe use, including minimizing the risk of a prolonged erection. An intraurethral therapy is less effective in order to achieve a satisfactory erection (up to 60% of men) as intracavernous injection (to 90%). The combination of PDE-5 inhibitors with intraurethralem alprostadil can be successful in patients who are not on a PDE-5 monotherapy ansprechen.Mechanische aid in erectile dysfunction men who indeed develop an erection, but these can not be maintained, can have a Konstriktionsring use to maintain the erection. An elastic ring is placed around the base of the erect penis and prevents premature loss of erection. Men who can not achieve an erection, can first use a vacuum erection pump that transported through a tube of blood to the penis, then an elastic ring is placed around the base of the penis to maintain the erection. The disadvantages of this measure include bruising of the penis, cold at the tip of the penis and lack of spontaneity. These tools can also werden.Operation, if necessary, combined with drug therapy for erectile dysfunction If medications and vacuum devices fail, the surgical implantation of a penile prosthesis may be considered. Among the prostheses are semi-rigid silicone rods and saline inflatable multi-component devices. Both risks of general anesthesia, of infection and prosthetic malfunction exist. For experienced surgeons, the long-term rate of infection or malfunction significantly below 5% and the rate of satisfied patients and partners at> 95%. Conclusion Vascular, neurological, psychological and hormonal disorders, and sometimes drugs consumption can adversely affect the achievement of satisfactory erections. All men with ED should be tested for hormonal, neurological and vascular disorders as well as depression. Testosterone levels should be assessed and other Untersuchngen be drawn based on the clinical findings into account. Underlying disease must be treated and if necessary, an orally administered PDE5 inhibitors are used. If these measures are ineffective, intrakavernöses or intraurethral prostaglandin E1 or the use of a vacuum device should be considered. Surgical implantation of a penile prosthesis is the final step of the therapy.