Understanding Erectile Dysfunction An Overview

1 ) Basic Description and Significance of ED:

" Erectile dysfunction " ( ED ), from time to time called " male / sexual impotence " ( or " impotence " only ), corresponds to the failure to achieve or sustain an erection enough for acceptable sexual intercourse ( coitus / copulation ). ED is distinct from other conditions that harm normal sexual intercourse, such as lack of sexual wish ( libido ) and ejaculation / orgasm disorders. Even so, several associated sexual disorders may happen, causing a significant distress to patients.


ED, being strongly attached to cultural conceptions of strength, triumph and masculinity, can have devastating psychological consequences including feelings of dishonor, loss or inadequacy. ED can be a critical ruin to interpersonal relationships and self - esteem. It affects millions of men worldwide, with implications that go further than sexual activity only. By age 45, most men have undergone ED, at least once in life. Many men also are unwilling to speak about erectile dysfunction with their wives and doctors, and therefore the condition is underrated.
In spite of the fact that ED can occur at any age, usually the older the man is, the higher his risk is.

2 ) Anatomo-Physiology of Penile Erection:

The penis contains two chambers, called the " corpora cavernosa ", which run the length of the upper side of the penis. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa. Filling the corpora cavernosa is a spongy tissue consisting of smooth muscles, fibrous tissues, spaces, veins, and arteries. A membrane, called the " tunica albuginea ", surrounds the corpora cavernosa. Veins placed in the tunica albuginea drive blood out of the penis.
Penile erection can be occasioned by two different processes. The first one is the reflex erection, which is reached by gently, directly and continuously touching and rubbing the penile shaft.
The second is the psychogenic erection, which is obtained by lascivious fantasies, imagination or dreaming.
Thus, the sexual stimulation, which can be tactile ( reflex ) or psychogenic / psychologic, originates electrical impulses along the nerves going to the penis, and causes the nerves to liberate nitric oxide ( NO ), which, in turn, increases the production of cyclic GMP ( cGMP ) in the smooth muscle cells of the corpora cavernosa. The cGMP causes the relaxation of smooth muscles of corpora cavernosa, enabling a quick blood flowing into the penis ( the blood fills the corpora cavernosa, making the penis larger, harder and thicker ). The resulting pressure compresses the veins in the tunica albuginea, helping to entrap the blood in the corpora cavernosa, hence maintaining erection. Erection is reversed when cGMP levels in the corpora cavernosa reduce, allowing the smooth muscles of the corpora cavernosa to contract, breaking off the inflow of blood and opening veins that drain blood away from the penis. The levels of the cGMP in the corpora cavernosa fall because it is destroyed by an enzyme, known as " phosphodiesterase type 5 " ( PDE5 ).

Beyond erection:
" Nucleotides " are organic chemical compounds produced by the combination of three molecular structures: a nitrogenous base, a sugar, and a phosphate group. The commonest nucleotides typically are classified through two groups ( " purines " and " pyrimidines " ), based on the structure of the nitrogenous base. The bonded sugar can be either " ribose " or " deoxyribose ".
Nucleotides are the structural units of RNA and DNA ( the " Nucleic Acids " ). Nucleotides also work as important cofactors in cellular signaling and metabolism.
Guanosine - 5 ' - triphosphate ( GTP ) is a purine nucleotide. One key biologic function of GTP is being substrate for the synthesis of RNA ( during the " transcription " phase / process ). On the other hand, GTP also plays an important role in cellular energetics and / or an activation of substrates in metabolic reactions, similarly to ATP ( " adenosine - 5 ' - triphosphate " - the main molecule which acts as cellular " fuel ", this is, the biologic energy source ). ATP is a " more universal " cellular energy source, but GTP also is important, being preponderantly used as a source of energy for protein synthesis.
Cyclic guanosine monophosphate ( cGMP ) is a cyclic nucleotide derived from guanosine triphosphate ( GTP ). cGMP acts as a " second messenger " likewise cAMP ( cyclic AMP = cyclic adenosine triphosphate ), mostly by activating intracellular protein kinases, in response to the binding of membrane - impermeable peptide hormones to the external cell surface. " Signal transduction pathways " are complex biochemical cascades, where many compounds are intricated, reacting in a sequential / successive order ( like, for instance " A => B => C => D => E " - it is impossible to directly " A => E " ). The cascade begins once a molecule binds to its receptor, and ends in a terminal biochemical reaction responsible for many cellular actions / effects.
cGMP synthesis is mediated by " guanylate cyclase " ( GC ), an enzyme which catalyzes the conversion from GTP to cGMP. " Membrane - bound GC " is activated by peptide hormones such as the atrial natriuretic peptides; while " soluble GC ", in confrontation to " membrane - bound GC ", is typically activated by nitric oxide ( NO ), to stimulate cGMP synthesis. Thus, both, NO and natriuretic peptides, through dissimilar initial molecular ways, result in increased cGMP synthesis.
cGMP ( and also cAMP, similarly ) is a primary and of the highest importance cellular molecule, modulating ion channel ' s conductance ( relative permeability to a lot of ions, correlated with an equilibrium of its electrical forces ), glycogenolysis ( glycogen breakdown to produce ready - to - use glucose molecules ), and apoptosis ( genetically programmed cell death ). It also relaxes smooth muscle cells. In blood vessels, primarily in arteries and arterioles, there is a thick smooth muscular layer. Therefore, the relaxation of vascular smooth muscles leads to vasodilation and augmented blood arise. This effect is crucial when choosing agents to treat ED and Hypertension, for example.
Many cyclic nucleotide phosphodiesterases ( PDE ) can degrade cGMP, by hydrolyzing cGMP into 5 ' - GMP. Phosphodiesterase inhibitors postpone the degradation of cGMP, thus raising and / or sustaining its effects.

3 ) Causes and Mechanisms of ED:

There are many potential causes of ED, which typically can be grouped in 3 big classes:
A ) Main Organic/Somatic;
B ) Main Psychogenic/Psychological;
C ) Mixed/Miscellaneous.

Each one of these classes may have subclasses, as an effective way to organize, classify and study each case. Schematically/pragmatically is important to consider:

A ) Main Organic / Somatic are those which beginning is anywhere in the body, in an organ or tissue; not in psyche. Therefore, there is a lot of diseases able to origin ED:

A. 1 ) Endocrine ( relevant to hormones and glands ):

A. 1. 1 ) Hypogonadism

A. 1. 2 ) Hyperprolactinemia

A. 1. 3 ) Other endocrine disorders ( in which ED tends to go ignored, in the middle of so many other predominant and / or life - threating phenomena )

A. 2 ) Vascular ( akin to arteries and / or veins ):

A. 2. 1 ) Atherosclerosis / Arterial Insufficiency
A. 2. 2 ) Other vascular disorders ( are not common )


A. 3 ) Neurologic ( related to Nervous System, the Central Nervous System ( CNS ) and / or the Peripheral Nervous System ( PNS ) )

A. 4 ) Drug - induced ( many drugs can trigger ED as side effect - some antihypertensives and antidepressants are very frequently associated with ED, but there are many more drugs with ability to cause ED ).

B ) Main Psychogenic / Psychological ( overall, the most common cause of ED )

C ) Mixed / Miscellaneous ( rare or even very rare causes of ED, not grouped elsewhere )

C. 1 ) Other penile disorders associated with ED ( for example: Peyronie ' s disease; Hypospadias / Epispadias; Post - priapism; Penile trauma )

C. 2 ) Hematologic diseases ( blood - related diseases - for example: Sickle cell anemia; Leukemias )

C. 3 ) Liver cirrhosis / Hemochromatosis / Wilson ' s Disease

C. 4 ) Idiopatic systemic diseases ( diseases with unknown cause, engage many body organs / tissues - for example Sarcoidosis )

C. 5 ) Idiopatic ED ( isolated ED, of unknown cause; not accompanied by other known disorders )

=> A. 1 ) Endocrine

=> => Hypogonadism
The gonads are the organs of sexual distinction: in the female, they are ovaries; in the male, the testes. Along with producing eggs and sperm ( gametes ), they produce sex hormones that generate all the differences between men and women. The gonads are not independent in their function, even so. They are tightly commanded by the pituitary gland ( hypophysis ) and hypothalamus ( " hypothalamic - pituitary axis " ). The hypothalamic - pituitary hormones are the same for males and females, but the gonadal hormones are different: men mostly generate androgens ( primarily testosterone ), and women mostly generate estrogens and progesterone. Androgens modulate the development of the embryo, determining whether it is a male or a female ( male in the presence of androgens and female in the absence of androgens ). They also guide the adolescent maturation of reproductive organs into their mature form. In addition, they support other sexual functions throughout the reproductive years. Estrogens and testosterone aid to keep bone mass; furthermore, estrogens also seem to protect the cardiovascular system from atherosclerotic disease.
Lack of sex hormones can result in faulty primary or secondary sexual development, or back down consequences ( for instance premature menopause ) in adults. Abnormal egg or sperm production may conduct to infertility. The term " hypogonadism " is typically employed to permanent, instead of temporary or reversible defects, and generally implies deficiency of sex hormones, with or without fertility faults. The term " hypogonadism " is less commonly used for infertility without sex hormone deficiency.

There are several types of hypogonadism and, therefore, many classifications:

#] " Primary " ( due to intrinsic gonadal pathology - examples: Klinefelter and Turner syndromes ) versus " Secondary " ( due to intrinsic hypothalamic - pituitary axis pathology - examples: Kallmann syndrome, hypopituitarism );

#] " Predominantly Hormonal " ( hormone production is more affected than fertility - examples: Kallmann syndrome, hypopituitarism ) versus " Predominantly Reproductive " ( fertility is more affected than hormone production - examples: Klinefelter and Kartagener syndromes );

#] " Congenital " ( present at / since birth, as a consequence of heredity or environmental factors - for example: Turner syndrome ) versus " Acquired " ( not present at birth; appears later, elsewhere through life span - for example: castration ).

=> => Hyperprolactinemia
Hyperprolactinemia corresponds to the presence of abnormally elevated levels of prolactin in the blood. Prolactin is a hormone released by the anterior lobe of the pituitary gland. Its primary function is to promote the secretion of milk after childbirth ( lactogenesis ), however, it also is responsible by many more functions / actions, in both men and women.
The major effect of increased prolactin is a decrease in normal levels of sex hormones ( estrogens in women; testosterone in men ). Prolactin is downregulated by dopamine and upregulated by estrogens. On the other hand, it represses the effects of dopamine, which is responsible for sexual arousal.
Use of prescription medicines is the most common cause of hyperprolactinemia. Drugs that antagonize the effects of dopamine at the pituitary or consume dopamine stock in the brain, may stimulate the pituitary to release prolactin.
Prolactinomas are prolactin - secreting tumors, thus they can be a cause of hyperprolactinemia. Then again, tumors destroying dopamine - secreting neurons located in or around the hypothalamic - pituitary axis, also can be a cause of hyperprolactinemia, since dopamine downregulates prolactin.
In men, the most usual symptoms of hyperprolactinemia are ED, decreased libido, and infertility.

=> A. 2 ) Vascular

=> => A. 2. 1 ) Atherosclerosis / Arterial Insufficiency
Atherosclerosis is the most frequent organic / somatic cause of ED, corresponding to the cause of ED in about 70 % of all non - psychogenic cases ( 70 % of patients with non - psychogenic ED ).
Atherosclerosis is a chronic, very long standing disease, characterized by pathological thickening of the walls of the arteries and / or arterioles, due to fatty deposits of cholesterol ( atheromas ) across the vascular wall. The atheromas ( fatty deposits of cholesterol ) are progressively surrounded by inflammatory cells, fibrous tissue, and calcium deposits, becoming organized as stiff plaques that narrow the vessel lumen, hence decreasing its diameter, with subsequent decrease in blood flow. These pathological processes ( scarring / fibrosis and calcification ) make the arterial / arteriolar walls less elastic, raising blood pressure even more.
Sometimes, since these plaques become big and very stiff, they may " break " spontaneously, spilling chemical compounds which will promptly stimulate the local formation of a blood clot ( thrombus ); leading to total vascular obstruction and total absence of blood flow. All cells may die if the absence of blood flow persists during long enough time.

These are the main mechanisms underlying angina pectoris / heart attack, stroke, and intermittent claudication of legs. They also can be responsible for ED and other " arterial insufficiency " disorders, like " intestinal angina " ( abdominal pain due to intestinal atherosclerosis ), for example. Since all organs need to be irrigated by abundant blood flow, atherosclerosis may damage any organ; although heart, brain and legs use to be the most frequently damaged.
The main risk factors to promote and accelerate Atherosclerosis are: Hypertension ( Systemic Arterial Hypertension ); Dyslipidemia / Hyperlipidemia; Diabetes Mellitus; Metabolic Syndrome; cigarette smoking. All these conditions have something of the highest importance in common - they all lead to severe endothelial damage. The endothelium is the thin layer of flat epithelial cells that covers the inner surface of blood vessels. These cells ( endothelial cells ) produce and release chemical compounds needed to normal ( healthy ) vascular functions. Severe endothelial damage is really a catastrophic vascular phenomena!...

" Pelvic / external iliac steal " syndrome is a vascular disorder which can cause ED, although it is not very frequent. It is characterized by the ability to reach erection but inability to conserve it when coitus begins. Patients complain of loss of erection immediately following the initiation of coitus. It is also played along gluteal pain. Changing coital position, from a prone to lateral or supine position, which decreases muscle activity of the hip extensors, partly rectifies the situation. It occurs when there is significant narrowing of the common iliac artery lumen. Blood flowing through the internal iliac artery, hence, is decreased. Blood to the lower extremity ( foot and leg ) is supplied by collateral arteries. Blood flow may be enough, in a resting state, to allow a normal erection, however, dilation of the arteries in the legs and gluteal muscles occur with movement and blood flow to the pelvic area, including the penis, ceases; implying erection reversal. Likewise, the occlusion of the distal aorta can cause ED.
Leriche, a French surgeon, in the 1940 ' s, reported the occurrence of ED in men with arterial thrombosis and occlusion of the aortic bifurcation, hence the name Leriche syndrome is used to describe aortic occlusion.

=> => A. 2. 2 ) Other vascular disorders ( non - atherosclerotic ) causing ED are relatively rare.
For instance, arterial occlusions may occur after pelvic fractures; arterio - venous anastomosis ( abnormal communication between an arteria and a vein, bypassing the normal capillary circulation ) in the pelvic area; dysplasia of the arteries and reconstructive surgery of the arteries in the legs.

In some men, adequate arterial blood flow into the penis occurs, but may be defeated by excessive venous leakage, due to defective veno - occlusive mechanisms. Thus, excessive efflux through local venules may happen, contributing to erection loss or dysfunction. Sometimes men with venous leakage may be able to have a normal erection if influx can compensate the exaggerated efflux. Conversely, a man with a low influx may be able to have a normal erection if complete venous occlusion occurs.
Veno - occlusive dysfunction is secondary to inadequate relaxation of trabecular smooth muscle or structural alterations in the fibroelastic components of the trabecula. Conditions that cause inadequate relaxation of the cavernosal muscle include excessive adrenergic constrictor tone ( for example, as occurs during anxiety ) or damage to the parasympathetic dilator nerves. Structural alterations in the fibroelastic components of the trabecula may result from: altered synthesis of collagen, surgery, or trauma. These may be attributable age or systemic disease. The fibroelastic framework loses compliance with the consequent inability to dilate the trabecula against the tunica albuginea, so much it fails to compress the subtunical venules.

=> A. 3 ) Neurologic
Many neurologic disorders cause ED. The most common are: spinal cord injury, neuropathies, Parkinson ' s disease, Alzheimer ' s disease, multiple sclerosis, stroke.

Neurologic ED can occur from any disorder affecting either the parasympathetic sacral spinal cord or the peripheral efferent autonomic fibers, since these nerves cause relaxation of smooth muscle in both the corpora cavernosa itself and the arteries supplying the corpora cavernosa.

Spinal cord injuries above T12 - L1, cause ED secondary to deficiency of control from higher centers, even whilst the reflexogenic erectile mechanism is unimpaired. However, this may be defeated by constant tactile stimulation even though sensation may not be present. If the cord lesion is below the thoracic center ( T12 - L1 ) but above the sacral center ( S2 - S4 ), psychogenic erections are adequate through impulses from higher centers leaving the cord at T12 - L1. Patients with partial injury of the upper cord can have better erectile capabilities.

Multiple sclerosis ( MS ) is a chronic, inflammatory and demyelinating disease of the CNS. The hallmark of this disease stands for to the injury of the myelin sheath ( the fatty covering of the axons ), the oligodendrocytes ( the cells that produce myelin in CNS ) and, in a lesser extent, the axons and neurons themselves. Myelin is the fatty isolating layer which surrounds many axons ( nerve fibres ). On the axons, myelin sheaths are disposed in segments that are separated by narrow regions of naked axolemma ( the cell membrane of the axon ); known as " nodes of Ranvier ". These are the sites where action potential is generated in myelinated axons. The myelin represents a layer of high electrical resistance and low capacitance, what eases and speeds up the so rapid saltatory ( jumping ) conduction of electrical impulses, from node to node, for long distances, along axons. The loss of myelin, seen in patients with MS, induces the axonal electrical conductivity blockage that lies under the incapacitating clinical symptoms of the disease. The symptoms of MS diverge, depending, in part, on the localization of plaques ( areas of thick scar tissue ) inside the CNS. Frequent symptoms include: weakness and fatigue; sensory disturbances in the limbs; bladder and / or bowel dysfunction; problems with sexual function ( including not only ED but also other sexual disorders, mainly alterations in ejaculation ); ataxia ( loss of coordination ); and visual alterations.

Parkinson ' s disease ( PD ) is a " neuro - degenerative " disorder ( there is gradual deterioration of structure and function of some neurons ), and usually is idiopathic ( unknown cause ). The symptoms of PD come from the loss of pigmented dopamine - secreting ( " dopaminergic " ) cells in the " pars compacta " region of the " substantia nigra " ( literally stands for " black substance " ). The loss of these cells breaks up the brain ' s normal control of movement, making the patient to undergo retarded movements, stiffness or rigidity, and tremor.
PD is one of the most common neuro - degenerative diseases, second only to Alzheimer ' s disease ( AD ) in the number of patients affected. It involves older people much more than younger, and so, old age is the single greatest risk factor for PD. The average age at diagnosis is 62. Onset before age 40 is highly infrequent. Men are somewhat more likely to be affected than women.
The earliest symptoms of PD, and the most widely acknowledged, are tremor, slowed movements ( bradykinesia ), and stiffness or rigidity. Symptoms often begin on one side of the body, and progress across the time to affect both sides. The tremor of PD is a " rest tremor ", this is, the shaking occurs when the patient is not trying to use the limb, and decreases when the limb is being used. Bradykinesia and stiffness, along with loss of some balance reflexes, can be aggregate to cause postural instability, and increase the likelihood of falling down.
Other symptoms of PD include:
#] orthostatic hypotension, ( decrease in blood pressure on standing up, which can cause dizziness, vertigo and fainting );
#] painful foot cramps;
#] micro - graphia, ( diminished size of handwriting );
#] decreased voice loudness;
#] reduced facial gesture;
#] excessive sweating;
#] constipation;
#] decreased capacity to smell ( hyposmia / anosmia );
#] erectile dysfunction;
#] excessive salivating;
#] sleep disruption;
#] depression;
#] anxiety;
#] panic attacks;
#] late - stage dementia.

Alzheimer ' s disease ( AD ) is the most frequent form of " dementia ", a neurologic syndrome characterized by gradual, progressive failure of cognitive functions.
The majority of AD cases appear in people older than 60 years. The precise cause of this late - onset AD is not well known. It is known that the APOE * E4 allele, is a risk factor for AD ( as well as for vascular and Lewy body dementia ). Beyond age and family history, other risk factors are female gender, lower academic level, and a history of head injury with loss of consciousness. Existence of atherosclerosis is a risk factor for AD as well as vascular dementia.
Histopathologic markers of Alzheimer ' s disease involve senile plaques ( aggregations of abnormal amyloid protein ), neurofibrillary tangles ( hyperphosphorylation of tau protein ), and brain cell death. Neurofibillary tangles are preferentially distributed in the medial temporal lobe, hippocampus, and amygdala, while senile plaques are broadly scattered in every the cerebral cortex.
Many neurotransmitters including norepinephrine, serotonin, somatostatin, and diverse neuropeptides show important abnormalities in AD. The most plentiful neuro - chemical defect seems to be a deficiency in the enzyme choline O - acetyltransferase, resulting in a deficit of acetylcholine. Changes in neuro - chemistry possibly contribute to the associated psychiatric symptoms of AD such as depression, anxiety, agitation, and psychoses. AD can also be a trigger of ED and / or other sexual disorders.

=> B ) Main Psychogenic / Psychological

Psychogenic / Psychological causes of ED are, overall, the most frequent; and young men can be affected - the sexually inexperienced young man, without any disease, may have ED during the first sexual activities with his partner, because he may get " fear to fail / disappoint his partner ". The conviction that an erection will not develop when required, therefore, becomes a self - fulfilling prophesy.
And, on the other hand, for any age, men who live under psychological stress ( excessive work; lack of sleep; personal conflicts ) can get depressed, anxious, impotent and feel lack of libido ( sexual desire ). Then, ED may emerge and aggravate the existent anxiety, and so a " vicious cycle " could be established and become very difficult to deal with.
Sexual dysfunction founded on earlier / deeper factors builds up in reaction to misconceptions bearing on human sexual expression. Our culture admonishes sexual curiosity and exploration. The seek for sexual pleasure is condemned. Children and adolescents are frequently educated that sex is immoral, evil, shameful... They are punished if they touch their genitals or exhibit sexual interest. This indoctrination during development drives many people, as adults, to feel sexual conflict and guilt. Moreover, society infuses the ideals of strength and independence in males, leaving some men incapable to allow their own needs for affection to be met. Immediate causes of sexual dysfunction include life stressors such as divorce / break up of a relationship, illness, death of a spouse / significant other, loss of a job, change in social position or family troubles.
The loss of erectile capability or decay in energy brings on conflict affecting sexual activity. Among the most frequent immediate causes of sexual failure is " spectatoring " ( means " being spectator " ). This is the routine of critically observing one ' s own performance while engaged in sexual activity. Anxiety referring the ability to reach and keep erection, achieve orgasm, in addition to the worry with partner satisfaction, are queried during sexual act. In a lot of cases " spectatoring " is associated with a fear of repeating previous sexual failure. Such over concern forecloses one from spontaneously enjoying sex. Another immediate cause for sexual dysfunction is an anti - erotic environment created by the inability to do things the individual feels arousing. Fear of failure plays a role in developing a repressive anxiety conjugated with fear of rejection and an exaggerated feel of pressure to perform.
Additional causes of sexual dysfunction are related to interactions between couples. Successful sex needs reciprocal trust and abandonment on the moment to go directly to pleasure. Naturally, infidelity, martial dissatisfaction, and rejection can induce psychological trauma. Couples must establish compromises and communicate openly with one another. Deficiency of either can cause frustration and disappointment which can conduce to anger or rebellion which may be expressed primarily as sexual dysfunction. Another factor that can lead to sexual difficulty is a conflict for power. The necessity to control people in one ' s environment is generally unconscious. It is frequently attached to the fear of losing control and implicit anger. If each partner fights for domination, a destructive battle occurs which is often evidenced by sexual dysfunction.
Increased sympathetic vasoconstrictor tone, with raised blood circulating norepinephrine / epinephrine levels, seems to play a key role in psychogenic ED. The sympathetic branch of the autonomic nervous system is typically activated under stress situations, preparing the body for a " fight or flight " reaction, by releasing 2 main catecholamines ( norepinephrine = noradrenalin is directly released by sympathetic nerves; and epinephrine = adrenalin is released from adrenal = supra - renal glands, after stimulation by sympathetic nerves ). These catecholamines induce vasoconstriction ( constriction of arteries ), what makes erection more difficult to occur.
Although not so frequently, ED can be associated with a more serious psychiatric disorder, such as schizophrenia, substance abuse, panic disorder, generalized anxiety disorder, personality disorders. ED, presented to a doctor, as main complain, can be " the tip of the iceberg "; therefore, being " the iceberg ", a very serious psychiatric disorder...
Depression ( mild, moderate or severe / major ) is frequently companied by loss of sexual seek and ability to execute sexual activities. It is crucial to consider this possibility whenever a sexual complaint is made. Other symptoms of depression such as sleep / appetite disturbances, social detachment, and loss of ability to feel pleasure ( " anhedonia " - not being able to feel any kind of pleasure, even during activities that previously used to be very pleasurable ) must, thereby, be suspected and investigated. In some contexts, ED will begin as a singular expression of depression. Depression may later ameliorate, but ED may persist. The original stress, then, will become superseded by the stress of the having ED, hence relapsing the loss of self - worth and the fear of lower performance sex. Moreover, men who have been sexually inactive for some time, due to loss of a partner or illness, may get erectile troubles on recommencement of sexual activity.

=> C. 1 ) Other penile disorders associated with ED

Peyronie ' s Disease ( PeyD ) is also formally called " penile induration " or " Induratio Penis Plastica ( IPP ) " and informally as " bent nail syndrome ". A French surgeon, François de la Peyronie, first reported the disease in 1743.
PeyD is a non - malignant ( non - cancerous ) idiopathic ( unknown cause ) disorder, characterized by formation of inelastic scars or plagues, located within the tunica albuginea of the corpora cavernosa. This disease causes variable degrees of penile curvature, decreased penile rigidity, and painful erections. ED, in variable degrees, frequently comes up with these symptoms in the later stages of the disease process. PeyD may also make painful and / or difficult coitus, although many men describe acceptable coitus notwithstanding the disease.
Whilst the exact etiopathogenesis is badly understood, it tends to have a genetic predisposition generally affecting men of Northern European ( Caucasian ) arriving in the fifth and sixth decades of life. The natural progression of the disease is uncertain. The active phase endures between six to eighteen months. Thenceforth, about 10 % will undergo total remission with disease regression and resolution of symptoms, 50 % will continue with little or no change, and the left 40 % will have active and advancing disease with greater plague formations and additional deformity. About 30 % of men with PeyD develop fibrosis in other elastic tissues of the body, such as on the hand or foot, including Dupuytren ' s contracture of the hand.

Priapism is an involuntary, persistent, painful penile erection, not associated with sexual excitation and not decreasing after ejaculation. Contrary to a normal erection ( which breaks up after sexual practice stops ), the persistent erection caused by priapism is kept up since the blood in the penile shaft is not drained through local venous system. The shaft persists hard, although the tip of the penis is soft. If it is not quickly treated, priapism can result in permanent scarring of the penis and inability to have a normal erection. In fact, an important number of patients will suffer from ED coming after priapism due to destruction and fibrosis of the corpora cavernosa ( " Post - priapism ED " ).
The etiologic mechanisms of priapism are unwell understood but involve complex neurological and vascular elements. Priapism may be associated with hematological disorders ( especially sickle - cell disease, thalassemias, and leukemias ), and neurologic disorders such as spinal cord injuries. Sometimes, priapism is drug - induced ( caused by medications ).

Penile trauma can lead to ED. Traumatic rupture of the urethra associated with pelvic fracture can cause urethral stricture ( narrowing ) formation and erectile troubles. Any disruption in the vascular or neural tissue supplying the erectile tissue can cause erectile failure, including traumatic or iatrogenic ( inadvertently / accidentally caused by medical treatment or procedures ). Moreover, cancer radiation therapy applied to the pelvis can cause late arterial influx limitation which successively induces venous outflow.

Hypospadias and Epispadias are relatively uncommon congenital abnormalities, possible to occur in both sexes, but much more frequent in the males. In epispadias, the urethra locates and opens on the upper surface ( dorsum ) of the penis ( instead of at the tip of the penis ). By opposition, in hypospadias, the urethra locates and opens on the underside ( ventrum ) of the penis ( rather than at the tip of the penis ). Hypospadias is significantly more common than epispadias.
Treatment is surgical ( surgical reconstruction of normal anatomy ). Usually, babies undergo surgical treatment, which is " perfect ", this is, urinary and sexual functions will be 100 % normal during the rest of life ( adolescence, adulthood ). However, sometimes, exceptions to this rule may occur, what can bring urinary and / or sexual troubles to the patients, although this is very, very rare; happily!

All causes of ED will converge to a common effect - the dilatation of penile arteries fails and consequently no local blood trapping occurs.

Diagnosis of ED usually begins by patient report, and next, the study of nocturnal penile tumescence ( NPT ) is the subsequent requested diagnostic test to confirm the suspected diagnosis. NPT corresponds to the spontaneous penile erections during sleep. All men without ED go through this phenomenon, typically many times while sleeping. Therefore, the NPT test is crucial to establish the ED diagnosis, since it can indicate a psychological cause ( most common ), or an organic cause - patients with psychogenic ED have nocturnal erections, what means that there is no organic / somatic basis for their ED.