More common from the age of 50, erectile dysfunction may be linked to physical and/or psychological health. Also called erectile disorders or erectile dysfunction or even “sexual impotence” in everyday language, these disorders are defined as “an inability to obtain or maintain an erection sufficient to have a satisfactory sexual relationship”, according to the site of health insurancewhich specifies, however, that “even in the event of erection problems, it remains possible to feel desire, to have an orgasm and to ejaculate”
In addition, we are talking about erection problems only:
- when they last more than three months;
- when they repeat themselves every time they have sex.
Erection: how does it work?
Anatomically, four elements are important for there to be an erection:
- Good vascularization, to allow blood to be returned to the penis;
- Good innervation;
- A solid structure, without anomaly, with two corpora cavernosa (two cylinders present in the penis which fill with blood during erection) surrounded by albuginea, which is an envelope which gives a hard texture to the penis during erection ;
- A stimulation which will provoke a desire, and therefore sending a message from the brain allowing the mechanisms of erection to be initiated.
“In the presence of excitement, the brain sends a message and the nerves will release a neurotransmitter (NO). A molecular cascade follows which will cause vasodilation, that is to say a dilation of the veins in the penis. Without NO, there cannot be an erection”, explains the urologist. “When ejaculation has occurred, there is the production of an enzyme called phosphodiesterase type 5 (PDE5) which will lead to another molecular cascade allowing a return to a flaccid state.”, he adds.
What are the main causes of erectile dysfunction?
Erectile problems can have varied origins. “Diabetes weakens the arteries, the vessels function less well, the disease also affects the nerves. It is therefore a common cause of erection problems”, observes Dr. Pinar. Artery diseases, high blood pressure and smoking can also be causes. Any surgery which can damage the nerves or arteries of the penis, in particular pelvic surgeries (prostate or rectal surgery) can also be the cause of erectile problems. A final cause may be age-related androgen deficiency or andropause. Finally, sometimes we cannot find a precise cause.
What are the different treatments for erectile dysfunction?
There is a fairly wide range of treatments, depending on the cause of the problems. As first intention, so-called non-invasive treatments will be used such as oral medications (phosphodiesterase type 5 inhibitors) or vacuum. Secondly, local treatments (intracavernous or intraurethral injection) can be prescribed by the urologist. If all these treatments fail, surgery consisting of the placement of a penile implant will be offered to the patient.
Phosphodiesterase type 5 inhibitors
“Phosphodiesterase type 5 inhibitors (such as viagra or Cialis for example) improve the concentration of certain mediators allowing erection and its maintenance”, explains Dr. Pinar. But the treatment does not work on all patients, for example those who have nerve damage following an operation. “There must be a release of NO, otherwise it cannot work, but without nerves, there is no NO”, adds the doctor.
Prostaglandins
Prostaglandins are an interesting treatment because, unlike phosphodiesterase type 5 inhibitors requiring NO production to function, they use another signaling pathway without NO. “Locally acting prostaglandins are used to achieve an erection. The molecule can therefore be delivered either with a gel which is applied in the urethra, or by an injection carried out directly into the corpus cavernosum of the penis by the patient.”, explains Dr. Pinar.
The vacuum
It is a pump that is placed around the penis and which allows you to obtain an erection by creating a vacuum thanks to the pump, which will bring blood into the penis.
The penile implant
Finally, as a last intention and if non-invasive treatments do not work, it is possible to place a penile implant. “These are two cylinders placed in the corpora cavernosa of the penis. They are connected to a balloon filled with serum and located in the patient’s stomach, and to a pump placed in the scrotum. To obtain an erection, the patient uses the pump located in the scrotum to fill the cylinders”, explains the urologist. This method is still little used in France, with around 800 poses per year.
Thanks to Dr Ugo Pinar, urological surgeon at the Pitié-Salpêtrière university hospital center, Paris.