Erectile dysfunction

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Nocturnal sacrifice to Priapus ; a man sacrifices a pig (bottom left) in order to be cured of his impotence (fresco from the Mystery Villa in Pompeii ).

An erectile dysfunction - abbreviation ED , including erectile dysfunction , erectile dysfunction , Impotentia coeundi (from Latin coire go together ',' mate ', see. Coitus ), popularly known as impotence - is a sexual disorder in which there a man over a longer period the majority of attempts fail to achieve or maintain an erection of the penis sufficient for a satisfactory sex life . However, short-term erectile dysfunction are not considered ED.

meaning

ED is a serious condition. Thanks to modern examination methods, it is now known that organic diseases play a role in the vast majority of cases. However, if nocturnal erections occur at the same time, psychological causes are to be assumed.

ED is often also a harbinger of other, more serious diseases and should therefore always be examined by a doctor. Scientific studies show that ED is often an indicator of coronary heart disease , as ED can also be caused by damage to the endothelium . An internist or cardiologist should therefore always be consulted after a diagnosed ED .

Many sufferers do not initially go to the andrologist because of a false sense of shame . Often, however, a quick examination - immediate in the case of injuries - is necessary in order to avoid long-term damage and to restore the ability to erect.

frequency

The frequency of erectile dysfunction depends heavily on age. In terms of prevalence , erectile dysfunction increases from 2.3% in the third decade of life to 53.4% ​​in the seventh decade of life. Erectile dysfunction is particularly common in old age. Around half of 60-year-olds and around two-thirds of 70-year-olds are affected.

causes

For a long time, erectile dysfunction was divided into two categories: organic and psychological. Today it is agreed that only a small percentage is caused purely psychogenic or somatogenic. The majority of erectile dysfunction has several causes. Biological, psychological, interpersonal and cultural factors usually play together. While psychological causes are more common in young and middle ages, organic factors play an increasingly important role with increasing age. It is estimated that from the age of 50, about 80% physical causes are predominant. Overall, regardless of age, about half of erectile dysfunction is assumed to have a purely organic cause, about a third to be a purely psychogenic disorder, and in 20% of cases a mixed organic and psychogenic cause. Diabetes mellitus, arteriosclerosis and vascular anomalies make up the main causes of erectile dysfunction among the physical diseases with around 45%.

Mental causes

The fear of sexual failure plays a central role in the development of erectile dysfunction. Typically, this fear is related to relationship conflicts, separation, self-blame, and professional failure or role conflicts as a man.

“The more we make pleasure our goal, the more we miss it. We see this as one of the most common causes of sexual neuroses. After all, potency and orgasm are disturbed to the extent that they either become the object of our attention or the object of our intention. "

Organic causes

Warning notice on cigarette packs

Organic causes of erectile dysfunction are often diabetes , high blood pressure , operations , injuries to the erectile tissue, but also the consequences of long-term use of addictive substances or drugs such as smoking or excessive alcohol consumption . This results in damage to blood vessels or cavernous bodies .

Erection problems can u. a. due to:

  • Atherosclerosis of the afferent blood vessels
  • Leaks in the erectile tissue to the drainage veins (not uncommon, difficult to see)
  • connective tissue remodeling of the erectile tissue, e.g. B. after permanent erection ( priapism )
  • Damage to the nerves supplying the smooth muscles (Nn. Erigentes) in the pelvis, e.g. B. through major operations on the prostate and rectum , radiation, injury, but also through diabetes mellitus , alcohol abuse and other metabolic diseases with neuropathy
  • That affect spinal damage the erection center, some paraplegia (not all)
  • Blockages in the lumbar spine area
  • Drugs that contain neuro-blockers (e.g. anti-epileptic drugs, antidepressants)
  • Beta blockers
  • Antiandrogens (drugs such as Androcur , Dutasteride, or Finasteride )
  • psychological causes such as stress
  • very rare: lack of male sex hormone. With testosterone levels below 15 nmol / l a loss of libido is more likely, with levels below 10 nmol / l the likelihood of depression and sleep disorders increases, hot flashes and erectile dysfunction are usually only observed at below 8 nmol / l.

diagnosis

The diagnosis of erectile dysfunction is now primarily in the hands of urologists. The neurologist or psychotherapist is consulted if necessary. In many cases, interdisciplinary collaboration is required. The urologist will first clarify in an anamnesis interview what the sexual problems look like and how long they have existed. This shows the first signs of whether there are psychological factors that lead to a loss of potency. This is followed by a risk and medication history to find out whether the patient has previous illnesses that could lead to ED, whether he is taking medication with such an effect.

A physical exam and ultrasound can reveal evidence of injury; hormonal disorders can be concluded from a blood sample. If the findings are not serious, the patient is treated with PDE-5 inhibitors . If the therapy does not work or there are signs of organic damage (e.g. to blood vessels), more invasive methods are chosen to find the cause. Which includes:

The NPTR measurement records nocturnal erections. A healthy person does this three to six times a night for at least ten minutes. If they occur in the patient, an organic disorder is excluded, there must be psychological reasons for the ED. In SKIT , which is also used as a cavernous body injection therapy, drugs (papaverine, phentolamine and prostaglandin) induce an erection. If this lasts for more than 15 minutes, a disruption of the vessels can be ruled out with a high degree of probability. A duplex sonography made while the blood is being flooded provides objective data on the blood flow during this. CC-EMG and PSH measure nerve and muscle activity. With them, nervous and muscular ailments can be excluded. If the SKIT produces a suspicious result, arterial causes can be sought using PPAG and venous causes using PKMG. With PPAG, the arteries of the erectile tissue are visualized with a contrast medium and an X-ray machine. With PKMG, the pressure in the penis is measured while it is kept stiff by medication or saline infusion. If this only works with a high flow of table salt or not at all, a venous outflow disorder is assumed.

treatment

An evidence-based S1 guideline for the treatment of erectile dysfunction has been available since September 2012 .

psychotherapy

If psychological causes play a role, counseling sex therapy or psychotherapy , possibly with the involvement of the partner, can be helpful. In the event of a diagnosed illness, the health insurance company will cover the costs.

In the context of treatments within the official health system , so-called surrogate partners , who take on the role of the desired partner and enable an expectation-free encounter with one's own sexuality, are not used. Masters and Johnson found in the 1970s that homosexuals were easiest to treat because they were not under "pressure" to have sex like heterosexuals.

Pharmacotherapy

In many cases, drugs that increase potency can alleviate the symptoms. We strongly advise against self-medication, especially with drugs ordered on the Internet, as these are often not approved . Certain contraindications must also be ruled out before taking .

The prescription PDE-5 inhibitors sildenafil (Viagra) , vardenafil (Levitra) , tadalafil (Cialis) and avanafil ( Spedra ; available since April 2014) are currently approved in Germany and examined in scientific studies . For all of these drugs there is currently no cost assumption by the statutory health insurers. PDE-5 inhibitors do not work if the nerves responsible for erection are completely damaged. Apomorphine and yohimbine are rarely prescribed.

An important alternative is topically applied alprostadil , which has to be injected or placed in the urethra. There are three different forms of application available for this: In the erectile tissue autoinjection therapy (SKAT), the active substance is injected into the corpus cavernosum using a syringe close to the base of the penis . In the long term, this can lead to further deterioration of the situation and irreversible damage to the erectile tissue. In the drug-based urethral system for erection (MUSE), a rod is inserted into the urethra and the active ingredient is released as a small pellet , where it is absorbed through the mucous membrane. There is a risk of injuring the urethra. Alprostadil cream drops (Vitaros) that are instilled into the urethral opening are less invasive . Mechanical injury to the erectile tissue and urethra can thus be ruled out. However, transmission to the sexual partner is possible with MUSE and Alprostadil cream drops. A condom must be used when intercourse with women of childbearing age .

Operational procedures

Sometimes ED can be corrected surgically, for example with certain vascular injuries or with part of the hernias.

Prosthetic restoration using implants is associated with a high level of acceptance and satisfaction if the indication is correct and the patient and partner have been informed. The primary satisfaction is around 80% with suitable patient selection. Semirigid and hydraulic implants are basically available, whereby the significantly better cosmetic result of the hydraulic models is accompanied by an error rate of around five percent.

The therapy is part of the operational standard in urology. In Germany, the cost of such an operation is borne by the health insurance company, in Austria this measure can only be carried out as a private medical service.

Shock wave therapy

Focused piezo shock wave with a linear effective area

The current guidelines of the EAU (European Association of Urology) mention this form of treatment among the first-line treatments, but do not make a recommendation due to the weak data situation. The active principle of this therapy is to promote local blood flow to the erectile tissue. A systematic review from 2018 reported that the efficacy results were inconsistent and that further comparable studies were needed.

Tools

In addition to this or instead of drug therapy, a so-called penis pump can be used (the health insurance company will assume the costs if prescribed by a doctor). It is positive here: if used properly, no side effects are to be expected. In addition, penis pumps or vacuum pumps can be used for all types of ED, including psychological causes. Studies have shown that the use of vacuum systems enables over 80% of men to achieve a degree of penis swelling sufficient for them to have sexual intercourse.

Erectile dysfunction in social life

In the public, the impairments of those affected by their illness, especially the psychological side effects, are often not sufficiently perceived. In Germany , private and statutory health insurances are not obliged to cover the costs of potency drugs.

In the media, “impotence” is often equated with the inability to conceive, although one has nothing to do with the other. As a result, it is little known that despite ED, many sufferers are able to ejaculate, experience orgasms and have children naturally.

Celebrities such as former Brazilian football player and sports minister Pele support campaigns in order to ED taboos .

Canon Law

The impotentia coeundi is also a term used in Catholic canon law . A persistent impotentia coeundi is seen as an obstacle to marriage . In this context, it is generally understood to mean the impossibility of sexual intercourse between spouses , regardless of whether the cause lies with the man or the woman.

See also

literature

  • Richard Hautmann, Hartwig Huland: Urology . 3. Edition. Springer Medicine, Heidelberg 2006, ISBN 3-540-29923-8 , p. 349 ff .
  • Volkmar Sigusch (ed.): Sexual disorders and their treatment. 4th edition. Thieme, Stuttgart a. a. 2007, ISBN 978-3-13-103944-6 .
  • Ursula Gresser , Christoph Gleiter: Erectile dysfunction: comparison of efficacy and side effects of the PDE-5 inhibitors sildenafil, vardenafil and tadalafil - review of the literature. In: European Journal of Medical Research. (Eur J Med Res) October 2002, Volume 7, No. 10, pp. 435-446, PMID 12435622 , (review of the three most important drugs for the treatment of erectile dysfunction) ( PDF file full text).
  • Bernie Zilbergled: The new sexuality of men. 4th edition, Dgvt-Verlag, Tübingen 2000, ISBN 3-87159-099-1 .
  • Peter Gehrig: erectile dysfunction - erectile dysfunction - ED. Sex therapy and counseling. In P. Gehrig; K. Bischof (Ed.): Guide to sexual counseling for medical practice. Pfizer AG, Zurich 2010 ( PDF file full text).
  • S1 guideline erectile dysfunction. Diagnostics and therapy of the German Society for Neurology (DGN). In: AWMF online (as of 2012)
  • Yoram Vardi, Boaz Appel, Amichai Kilchevsky †, Ilan Gruenwald: Does Low Intensity Extracorporeal Shock Wave Therapy Have a Physiological Effect on Erectile Function? Short-Term Results of a Randomized, Double-Blind, Sham Controlled Study. In: The Journal of urology. (J Urol.) Volume 187, No. 5, May 2012, pp. 1769–1775, doi: 10.1016 / j.juro.2011.12.117 ( full text ).

Web links

Commons : Erectile dysfunction  - collection of images, videos and audio files
Wiktionary: erectile dysfunction  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. Erectile dysfunction heralds danger to the heart . In: Doctors newspaper . dated September 7, 2011, accessed July 31, 2014.
  2. ^ M. Braun, G. Wassmer, T. Klotz et al .: Epidemiology of erectile dysfunction: results of the "Cologne male Survey". In: International journal of impotence research. (Int J Imp Res) 2000, Vol. 12, No. 6, pp. 305-311, PMID 11416833 .
  3. ^ HA Feldman, I. Goldstein et al .: Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. In: The Journal of Urology . 1994, Vol. 151, No. 1, pp. 54-61, PMID 8254833 .
  4. a b Stephen B. Levine: Erectile dysfunction: Why drug therapy isn't always enough. In: Cleveland Clinic Journal of Medicine. (Cleve Clin J Med) March 2003, Volume 70, No. 3, pp. 241-246, PMID 12678215 ( PDF file full text).
  5. Professional Association of German Internists V .: Erectile dysfunction, causes . On: Internisten-im-Netz.de ; accessed on September 8, 2016.
  6. ^ Viktor Frankl : Medical pastoral care. Basics of logotherapy and existential analysis. Last edition. Status: 2005. In: Viktor Frankl : Gesammelte Werke. Volume 4. Böhlau, Vienna / Cologne / Weimar 2011, ISBN 978-3-205-78619-1 , p. 311 (545).
  7. Thomas Meißner: If you stay slim, you keep your testosterone level in old age. Testosterone levels in men do not necessarily decrease with age. But: Many comorbidities are associated with a testosterone deficiency . In: Ärzte Zeitung of April 27, 2010.
  8. a b AWMF S1 guideline erectile dysfunction ( Memento from September 23, 2015 in the Internet Archive ) (PDF; 1 MB)
  9. European Health Authority (EMA): European public assessment report (EPAR) for Spedra - avanafil . Accessed on 11 February 2014 at: ema.europa.eu .
  10. Deutsche Apotheker Zeitung (DAZ): Erectile Dysfunction - New PDE5 Inhibitor Avanafil On: deutsche-apotheker-zeitung.de accessed on February 11, 2014.
  11. V. Hanchanale, I. Eardley: alprostadil for the treatment of impotence . In: Expert Opinion on Pharmacotherapy . tape 15 , no. 3 , 2014, p. 421-428 , doi : 10.1517 / 14656566.2014.873789 .
  12. ^ B. Cuzin: Alprostadil cream in the treatment of erectile dysfunction: clinical evidence and experience. In: Therapeutic Advances in Urology . tape 8 , no. 4 , 2016, p. 249-256 , doi : 10.1177 / 1756287216644116 .
  13. Jürgen Zieren, Charalambos Menenakos, Marco Paul, Jochen M. Müller: Sexual function before and after mesh repair of inguinal hernia. In: International Journal of Urology. Volume 12, No. 1, January 2005, pp. 35-38, doi: 10.1111 / j.1442-2042.2004.00983.x ( full text as PDF file ).
  14. KE Hatzimouratidis, E. Wespe et al .: Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. In: European Urology . 2010, Volume 57, No. 5, pp. 804–814, PMID 20189712 , doi : 10.1016 / j.eururo.2010.02.020 ( PDF file, complete version of the guidelines ( Memento from April 13, 2014 in the Internet Archive )) .
  15. ^ Shockwave therapy. EAU-Guidelines (2016), 3rd Male sexual dysfunction, Chapter 3.1.4.2.3
  16. PJ Rizk, JR Krieger, TP Kohn, AW Pastuszak: Low-Intensity Shockwave Therapy for Erectile Dysfunction. In: Sexual medicine reviews. [electronic publication before printing] March 2018, doi : 10.1016 / j.sxmr.2018.01.002 , PMID 29576441 (review).
  17. European Association of Urology (EAU): Guidelines: Male Sexual Dysfunction. Chapter 3.1.4.2.2. Vacuum erection devices. On: uroweb.org ; last accessed on March 4, 2017.
  18. ^ Wilhelm Kursawa: Impotentia coeundi as a reason for nullity of marriage: a canonical study on the interpretation and application of Canon 1084 of the Codex Iuris Canonici 1983 . Echter, Würzburg 1995, ISBN 3-429-01681-9 (Zugl .: Bonn, Univ., Diss., 1994).