ED: The bigger picture

In recent years, anti-impotency drugs such as Viagra and Cialis have become sexual life savers for many couples.

But men who suffer from impotency, or erectile dysfunction (ED), shouldn't just order these drugs and leave it at that. Erectile problems could be the first sign of something far more serious.

Men hesitant to discuss ED
Unfortunately, there are many obstacles on the way to better health for the ED patient. One of the major issues is that men tend to be hesitant to discuss erectile problems with their doctors.

According to research, only 30-50% of men with ED consult a doctor about their condition. Men are either too embarrassed to discuss the problem, feel that the problem is only temporary, or don't think ED is a medical problem at all. "Culture and religion can also create hurdles," says Dr Prithy Ramlachan, a Durban-based sexologist.

Ramlachan also reckons that doctors' lack of training, respect for patients' privacy, and the perception that ED is a psychological problem, stand in the way of ED problems being picked up.

However, experts and physicians worldwide agree that flagging potency can be a red flag that something else – something far more serious – may be wrong. But most patients who muster the courage to speak to their doctors don't even realise this, according to Ramlachan.

A bigger threat
Until the early 1990s, most cases of ED were thought to be of psychological origin, but research now shows that the causes are physiological in 85% to 90% of cases.

In fact, the most common causes of ED are damage to arteries, smooth muscles and fibrous tissues. Problems with the blood vessels (vascular problems) are responsible for 48% of erection problems.

Other possible physiological causes include neurological problems (in 14% of cases) and problems with the structure of the penis or surrounding tissues (3%).

However, psychological problems, such as stress, anxiety and depression, could also interfere with the erection process by distracting the man from things that would normally arouse him. These problems are responsible for between 10% and 40% of ED cases.

ED tied to heart disease
Several studies have shown a correlation between ED and heart disease.

Researchers have found that 64% of men who were hospitalised for a heart attack had ED prior to the incident. It also showed that 40% of men with ED had significant atherosclerosis, while a study conducted by the St Paul Heart Clinic in Minnesota showed that the arteries of men with ED expanded less efficiently than those of men without erectile difficulties.

To explain this, ED is sometimes likened to a common plumbing problem.

"If you turn on your kitchen faucet and you don't get any flow, either the faucet's broken or the pipes are clogged," Dr Andrew McCullough, director of male sexual health, fertility and microsurgery at New York University School of Medicine, told HealthDay.

For men with advanced heart disease, the clogged-pipe explanation makes sense, since the build-up of cholesterol in the arteries can greatly reduce blood flow – also to the penis.

To find and treat patients with "silent" heart disease is very important, since early diagnosis means earlier treatment and reduced risk of heart attack.

Hypertension and diabetes considered
Many studies have also confirmed the link between hypertension, diabetes and ED.

In research conducted among men with hypertension, 46% to 68% had ED and in a patient population of men with diabetes, 62% suffered erectile difficulties. In a study that included men with both diseases, 67% had ED, while 12% of these men had severe erectile problems.

Experts now believe that ED patients should keep a close eye on their blood pressure and blood sugar levels, because of the higher likelihood that diabetes or hypertension may present itself at a later stage. ED should be seen as an early warning sign of these conditions.

ED screening essential
"Patients with ED suffer from a multitude of problems, ranging from depression, loss of self-esteem, worthlessness, workplace inattention and concentration loss, once they experience a failure to erect," according to Ramlachan.

"The partner is also faced with the dilemma of not knowing whether she is loved anymore, whether her partner is having an affair, and whether he still finds her attractive, or not.

"This series of events, that can take up to two to three years to present, leads to increased emotional detachment, which drives the couple further and further apart," Ramlachan says.

However, despite these important relationship issues, ED screenings may also uncover underlying disease.

The International Index of Erectile Function (IIEF) questionnaire is an important screening tool used by doctors in this regard. The questionnaire consists of five questions concerning erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction.

"If the patient scores in the 'severe category' (on the IIEF questionnaire), the possibility of severe arteriosclerosis is high and the risks of complications of coronary artery disease is higher," Ramlachan says.

The questionnaire's results can also point to the underlying presence of hypertension and diabetes, as discussed in previous paragraphs.

Ramlachan believes that patients should be routinely screened for ED in order to point out these problems.

A note to doctors
Many experts believe that doctors should do a proper cardiovascular evaluation before starting drug therapy for ED. Underlying psychological causes and relationship issues should also be addressed, if necessary.

"The key to therapy is to remember that restoring the erection is actually the smallest problem and that looking at 'the man behind the penis' and the partner is the new focus," Ramlachan says.

As a final note to doctors, Ramlachan says, "Practitioners who are in the phase of quick-fix therapy will soon realise that the relationships (between ED patients and their partners) need more than a tablet". – (Carine van Rooyen, Health24, updated April 2008)

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