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Erectile Dysfunction

What is erectile dysfunction (impotence)?

Unfortunately for men, erectile dysfunction is the most common sexual health condition. Also known as impotence, this condition can affect men of all ages. Statistics state that more than 1 in 10 men will have to deal with ED at some point in their lives. The cause for this can range from anxiety for bad lifestyle choices (food for instance). Also, more and more, young men experience this due to social anxiety pressure and stress. Nevertheless, this does not have to be a permanent issue! Nowadays there are effective treatments such as Viagra, Levitra and Cialis that can really target this condition and put you again on track for a healthy sex life.

Sexual health is an important component of the emotional and physical health of any person. The impossibility of sexual realization for various reasons leads to the development of severe neurosis and violates the social adaptation of the individual in society. In the structure of sexual disorders, erectile dysfunction takes a leading place, both in the frequency of occurrence and in social importance, since it worsens the quality of life of the most socially active and able-bodied men. Erectile dysfunction is defined as the inability to achieve or maintain an erection sufficient to satisfy sexual activity if these disorders are observed for at least 3 months.

According to the World Health Organization (WHO), one in ten men over 21 suffers from erectile dysfunction, and every third man over 60 is generally not able to have sexual intercourse. At the age of 40–50 years, ED is detected in 40% of men, in 50–60 years, in 48–57% of the examined, and in the older age group 70% of men suffer from this disorder, and for 6% of people aged 50 to 75 years erectile dysfunction is a serious life problem. ED is observed in approximately 140–150 million men in the world and it is estimated that over the next 25 years this figure may double. Modern studies have shown that ED, as a rule, has an organic etiology and is more often caused by somatic causes, at least in men older than 50 years.

The erection mechanism is a complex physiological process, which is ensured by the joint activity of smooth muscle elements, the vascular, nervous and endocrine systems. Erection of the penis is caused either by local sensory stimulation of the genital organs or by central stimuli obtained or developed by the brain. At the cellular level, relaxation of smooth muscle cells occurs under the influence of mediators: cAMP and cGMP. An increase in their intracellular concentration leads to the release of calcium into the extracellular space. A change in calcium concentration leads to a change in the potential of the cell membrane, relaxation of smooth muscle trabeculae of cavernous tissue and penile erection. Guanylate cyclase is activated by the action of NO, converting GTP to cGMP.

It should be noted that the source of NO in the cavernous tissue is not only endothelial cells but also non-cholinergic non-adrenergic nerve endings in which this mediator is synthesized as a result of the action of the enzyme neuronal NOC (nNOC). Excreted by the nerve endings as a result of their activation, NO “triggers” an erection, and subsequently, as a result of the mechanical effect of the increased blood flow on the walls of the cavernous arteries and sinuses of the cavernous bodies of the penis, eNOC is activated, which in turn leads to a prolonged synthesis of NO with the development of maximum erections. 

The main risk factors for ED are age, cardiovascular disease, including hypertension, endocrine disorders (diabetes, androgen deficiency), side effects of drugs, spinal cord injuries, depression, bad habits and diseases of the prostate gland. Along with this, smoking, alcohol abuse, physical inactivity and the use of certain drugs contribute to the development of ED: some antihypertensive drugs, antidepressants, tranquilizers, narcotic drugs, H2-blockers, hormonal drugs.

In most men, the main cause of erectile dysfunction is a vascular disease. In almost all epidemiological studies devoted to erectile dysfunction, a connection between its occurrence and arterial hypertension and atherosclerosis has been revealed. Moreover, according to some authors, the detection of erectile dysfunction may indicate the presence and the patient has one of these diseases in a latent form. Some authors even recommend performing stress ECG tests before starting treatment for ED.

It is proved that arterial insufficiency of the penis in about a third of cases develops to systemic manifestations of cardiovascular pathology. Moreover, due to the fact that the diameter of the cavernous arteries is smaller than the diameter of the coronary arteries, ED can be the first clinical manifestation of diseases caused by endothelial dysfunction. Therefore, in the presence of risk factors, first of all, functional and organic damage to smaller arteries occurs.

Due to atherosclerotic lesions of the vessels of the penis (PC), not only mechanical impairment of blood flow occurs, but the production of neurotransmitters is also disrupted, and the elasticity of the vessels decreases. Ultimately, these vessels are unable to supply the organs with the necessary amount of oxygen and nutrients, contributing to increased fibrogenesis of the cavernous tissue of the penis. Due to the fibrous transformation of the cavernous tissue, it becomes impossible to maintain an erection sufficient for full sexual intercourse.

Often, various manifestations of atherosclerosis develop in parallel, since the risk factors for endothelial dysfunction and atherosclerosis affecting the penile blood vessels are the same as the risk factors for coronary heart disease - smoking, diabetes mellitus dyslipoproteinemia. The risk of CHD in patients over the age of 50 years is significantly increased in the presence of erectile dysfunction.

Arterial hypertension also contributes to erectile dysfunction, even in the absence of atherosclerosis: muscle tissue proliferates in the cavernous bodies and blood vessels, fibrosis of the cavernous tissue and an increase in the amount of collagen type III in it. Moreover, the severity of these changes is directly proportional to the degree of increase in systolic blood pressure.

In addition, the development of erectile dysfunction is often associated with inadequate antihypertensive therapy. It is believed that 25% of cases of erectile dysfunction in one way or another are caused by medication. Clinical signs of drug-induced erectile dysfunction are considered to be a relatively quick start, a temporary connection with taking a drug that adversely affects various parts of sexual intercourse, and a decrease in the severity of the disorder or its complete disappearance after drug withdrawal. Very often, the occurrence of erectile dysfunction is associated with the use of antihypertensive drugs, especially thiazide diuretics and beta-blockers. The occurrence of erectile dysfunction, of course, reduces the patient's adherence to treatment, and, ultimately, worsens the prognosis.

It is assumed that erectile dysfunction may occur due to a decrease in blood flow to the penis, but it is unclear whether this decrease is a consequence of a decrease in systemic blood pressure during effective antihypertensive therapy, a result of vascular disease, or any other unknown effects of the drug.

Changing the regimen of drugs can help the patient overcome the negative changes in the sexual sphere that are observed with some types of treatment. For example, with the development of erectile dysfunction in patients with arterial hypertension, thiazide diuretics, and non-selective beta-blockers are canceled. In this situation, preference is given to calcium antagonists, ACE inhibitors and alpha-blockers or angiotensin receptor inhibitors. If necessary, the appointment of beta-blockers as the drugs of choice in patients with erectile dysfunction become modern highly selective drugs, such as bisoprolol.

There is a widespread belief among patients that there is a high risk of sudden death in patients with cardiovascular disease during intercourse, however, these fears are greatly exaggerated. Firstly, physical activity during sexual activity is not so great - on average it is similar to walking 1 mile (1.6 km) in 20 minutes or climbing 2 flights of stairs (20 steps) in 10 seconds. Secondly, the results of epidemiological studies show that in the absence of a history of myocardial infarction, the absolute risk of myocardial infarction during sexual activity is only 2 cases per 1 million men. The relative risk of myocardial infarction within 2 hours after sexual contact was 2.5% and did not increase after this period.

There are quite interesting data regarding the relationship of signs of erectile dysfunction in patients with coronary artery disease with the localization of myocardial infarction, which is difficult to give a scientific explanation. So, the resulting apical and anterior myocardial infarction affect the achievement of an erection, posterior - on the satisfaction of sexual intercourse, septum - on satisfaction with sexual relations. Such features may be due to different changes in lipid and carbohydrate metabolism, production of eicosanoids, C-reactive protein, fibrinogen, vascular endothelial function and synthesis of a cell adhesion molecule, since the severity of ED is associated with these parameters in patients with coronary artery disease. Thus, it can be argued that sexual life should be and is an important component of the quality of life for patients with cardiovascular diseases. Treatment. Active endothelial agents - type 5 phosphodiesterase inhibitors (PDEs) are modulators of natural erections. Currently, 4 drugs of the group of type 5 FDA inhibitors are registered in Russia: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) and udenafil (Ziden). They do not have a direct relaxing effect on the corpora cavernosa, but enhance the relaxing effect of NO by inhibiting PDE-5 and increasing the concentration of cGMP during sexual arousal, thereby increasing blood flow to the cavernous body and contributing to the emergence and maintenance of physiological erections.

In patients with cardiovascular diseases, two features of the action of PDE-5 inhibitors should be considered: they lower blood pressure and interact with nitrates. The first drug in this group, sildenafil, lowers systolic blood pressure by about 8 mmHg. Art., however, against the background of antihypertensive therapy, the frequency of its side effects associated with a decrease in blood pressure (dizziness, fainting) does not increase. Tadalafil (Cialis) has more selective properties for PDE-5 compared to PDE-6 (PDE isoforms found in the retina), which ensures a minimum of side effects, including from the side of vision. Cialis begins to act after 16 minutes and persists for 36 hours after administration. In addition, the advantages of the drug include the lack of interaction with food and alcohol. The effectiveness of the drug was similar in young patients and in people over 65 and did not depend on the etiology of erectile dysfunction. In healthy individuals, taking Cialis at a dose of 10 and 20 mg did not cause a statistically significant decrease in blood pressure in a standing position, and in general, the effect of the drug did not affect hemodynamics. Tadalafil has been shown to be effective in men with multiple sclerosis, suggesting the possibility of its use even in severe somatic pathology. which indicates the possibility of its use even in severe somatic pathology. which indicates the possibility of its use even in severe somatic pathology.

Contraindication to the use of PDE-5 inhibitors is the simultaneous administration of nitrates. With the development of an attack of angina pectoris during therapy with PDE-5 inhibitors, the administration of nitroglycerin is strictly contraindicated. With caution, drugs of this group are used for unstable cardiovascular conditions, in which sexual activity itself is a risk factor for complications, in the presence of anatomical deformities of the penis, diseases that contribute to the occurrence of priapism.

Conclusion. Erectile dysfunction is a common condition in men of various age groups, especially with existing cardiac pathology, including arterial hypertension. The presence of ED in people without diseases of the cardiovascular system leads to an increased risk of their occurrence in the future, especially in young men. The existing ED in patients with cardiac pathology and arterial hypertension is one of the predictors of an unfavorable prognosis - an increased risk of cardiovascular and general mortality. Antihypertensive therapy has an ambiguous effect on the occurrence and progression of erectile dysfunction. The negative effect is more associated with the use of thiazide diuretics and some beta-blockers.