Erectile dysfunction is a common clinical picture observed in about half of men over the age of 50 that affects quality of life. It used to be thought that erectile dysfunction was due to psychological factors (stress, anxiety, etc.). Today, however, it is known that most erectile dysfunction is the result of an underlying disease, or may be a harbinger of serious, potentially life-threatening diseases (cardiovascular disease, stroke, etc.).
How common is erectile dysfunction?
Studies have shown the prevalence of erectile dysfunction to be 19–52%. In the same studies the incidence (the number of new cases per 1,000 men per year) is given as 19.2 to 65.6. The fact that the studies were conducted in different geographical regions with different socio-economic and cultural structures explains this wide range.
According to studies conducted in Turkey, 34% of men over 40 have erectile dysfunction. With these rates, and a male population over 40 reported as approximately 12 million according to 2020 data, it is possible to say that 4.8 million men in Turkey are faced with erectile dysfunction.
Which diseases and risk factors accompany erectile dysfunction?
It is seen more frequently in certain conditions:
- Advanced age
- Obesity (being overweight)
- Smoking
- Excessive alcohol consumption
- High blood pressure (hypertension)
- Diabetes mellitus
- High blood lipids (dyslipidaemia, high cholesterol)
- Cardiovascular diseases
- Depression
- Anxiety, stress
- Use of drugs with a negative effect on erection (some antidepressants, some blood pressure medications, etc.)
- Previous surgical operations (especially prostate, bladder and colon cancer operations)
How is erectile dysfunction diagnosed?
The patient's history is very important in diagnosing erectile dysfunction. Patients are questioned about their complaints, risk factors, previous operations, medication use and accompanying diseases. They are asked whether they have night-time and morning erections. Their psychological state and their relationship with their partner are evaluated. A detailed physical examination is performed (the penis, testicles and prostate are assessed).
Certain laboratory tests (male hormone, LH, FSH, thyroid hormones, fasting blood glucose, blood lipids) may be requested from patients with erectile dysfunction. Where necessary, more advanced tests (penile Doppler ultrasonography, stimulation test with intracavernosal drug injection) can be performed. Imaging methods such as MRI and CT are rarely requested in patients without a history of cancer or surgery.
Does it affect quality of life?
When left untreated, erectile dysfunction can lead to problems such as anxiety, loss of self-confidence, reduced quality of life, a negative impact on social relationships and depression. It can cause deterioration in the relationship between partners.
What are the treatment options?
First, modifiable risk factors must be brought under control through lifestyle changes. Losing weight through daily exercise and diet, close monitoring of fasting blood glucose, cholesterol and triglyceride levels, and receiving appropriate treatment for high blood pressure under medical supervision are approaches aimed at controlling risk factors. In patients whose erectile dysfunction is thought to be due to psychological factors, a psychiatrist's opinion can be sought for psychotherapy. The methods used in the treatment of erectile dysfunction are as follows:
1) Oral medications
This is the most commonly used treatment in patients with erectile dysfunction. Depending on the degree of the condition and the patient's compliance, pharmacological drugs called ‘type 5 phosphodiesterase inhibitors’ are given. These drugs (sildenafil, tadalafil, vardenafil, avanafil) produce an erection by relaxing the smooth muscles in the penis. Their use is divided into on-demand (use only before intercourse) and continuous (taking the drug every day in patients with a regular sex life). Oral medications have been shown to be up to 80% effective. Tolerable side effects such as headache, muscle pain, nasal congestion and, rarely, visual disturbance may occur. Patients taking nitrates for heart disease are advised not to use these drugs.
2) Vacuum device
Based on the principle of drawing blood into the penis by means of a vacuum and then trapping it for a while with a rubber band, this device has an effectiveness and patient satisfaction rate of up to 85%. Because of side effects such as pain, inability to ejaculate and numbness, seen in about 30% of patients, half of patients abandon this treatment after the first 3 months. Not recommended for patients with bleeding or clotting problems, this treatment can be a suitable solution for elderly patients who do not have frequent intercourse and are not suitable for other treatments.
3) Intracavernosal injection
This consists of applying erection-inducing drugs (such as papaverine and alprostadil) into the penis with a fine-tipped syringe, and is defined as ‘self-injection’. Alprostadil (prostaglandin E1) is more effective and has fewer side effects than papaverine. In this treatment model, applications are first made at low doses under the supervision of a healthcare professional; in this way the patient is taught the application and the appropriate dose is determined. Success rates reach 80%. Side effects can include penile pain, fibrosis (scar tissue formation) and a feeling of dizziness.
4) Penile prosthesis
Another treatment method is the surgical placement of a penile prosthesis, also known among patients as the “happiness stick”, in a way that suits the patient's anatomy. This treatment is the definitive solution to erectile dysfunction. Penile prostheses come in three-piece types consisting of a pump, a reservoir and two cylinders, or two-piece types. The three-piece prosthesis, which provides the best rigidity and flexibility and is considered closest to the natural form, is preferred. Patient satisfaction is between 90–100%, while partner satisfaction reaches 95%. Prosthesis infection, one of the most important complications, has been reduced to 1–2% with the emergence of new techniques and antibiotic-coated prostheses.
5) Shockwave therapy (Li-ESWT)
Shockwave therapy is one of the new treatments that has come to the fore in the treatment of erectile dysfunction in the last decade. This treatment uses shockwaves directed at the penis from outside the body. There are several devices used for this purpose. The treatment emits acoustic pressure waves that regenerate the vascular, nerve and smooth muscle tissues in the area where it is applied.
6) Stem cell therapy
Stem cells are cells with unlimited capacity for proliferation that can transform into more than one cell type and renew themselves and the surrounding tissues through the factors they secrete. Stem cell therapies have emerged in the last 20 years as an innovative method in the treatment of many diseases. When used for the treatment of erectile dysfunction, the stem cells are usually of mesenchymal origin and are obtained from fat tissue. Through the factors they secrete at the site of injection, stem cells lead to certain changes in the surrounding tissues. Many studies have observed cell growth, proliferation and prolonged cell survival with stem cell therapy. New vessel formation, nerve regeneration, re-formation of epithelial tissue and immune-regulating effects have also been reported at the injection site. Because the stem cells are obtained from the patient, they do not cause a reaction in the body and no side effects are observed.
7) Platelet-rich plasma (PRP) therapy
Plasma and platelets are separated from the other components of the blood by centrifuging the blood sample taken. The remaining plasma- and platelet-rich fluid contains abundant growth factors. These biological molecules are thought to have a restorative effect by increasing cell regeneration in the muscle, nerve and vascular tissue of the penis. The plasma obtained by centrifugation is injected into the tissues of the penis that fill with blood to produce an erection (corpora cavernosa). Vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), epidermal growth factor (EGF), insulin-like growth factor (IGF) and fibroblast growth factor (FGF) have been identified in PRP. Many animal and human studies have shown that these factors have a positive effect on erectile function. VEGF in particular has been reported to increase the production of nitric oxide, the main step in penile erection, and to have a restorative effect on the main nerves of the penis. No serious side effects have been reported in studies.
“Stem cell and PRP treatments, referred to as the restorative treatment group, are regarded as ‘experimental’ in the light of the current literature. Current applications of such treatments are considered possible only within well-designed scientific study protocols and for research purposes.”
