Introduction
Erectile dysfunction is defined as the persistent inability to achieve or maintain an erection sufficient for sexual intercourse. According to one of the large-scale studies, up to 52% of men aged 40 to 70 years old have some erection disorder. According to current information, in approximately 50-70% of cases, erectile dysfunction is due to vascular factors, while up to half of all vasculogenic erectile dysfunction is associated with venous insufficiency of the penis.
The main task of the penile vein system is to create a mechanism of veno-occlusion, which is implemented in the erection phase. The essence of this phenomenon lies in the gradual reduction of the venous outflow from the penis due to compression by the increasing cavernous bodies of the circumflex and emissary veins that flow into the deep dorsal vein. The latter, as you know, drains most (proximal 2/3) of the cavernous bodies and always flows into the network of preprostatic venous vessels that are part of the santorini plexus.
The most informative diagnostic tests for venous insufficiency of the penis are dynamic cavernosography in combination with perfusion artificial erection and cavernosotonometry. High invasiveness, which causes a large number of complications of these research methods, has led to their limited use only before the upcoming surgical treatment of venogenic erectile dysfunction.
In connection with the above circumstances, in recent years, the role of penile pharmacoechodopplerography in assessing the state of the veno-occlusive mechanism of erection has been actively studied. However, it was found that this method allows only indirect assessment of the consistency of the venous hemodynamics of the penis by measuring the parameters of its arterial supply.
Thus, today there is no optimal method for minimally invasive diagnosis of venocorporeal erectile dysfunction. This was the reason for conducting our own study on this issue.
Materials and methods
In the clinic of urology of the MMA named after I.M. Sechenov, 18 patients aged 48 to 72 years old were examined in whom, according to complaints and anamnesis, insufficiency of the veno-occlusive mechanism of erection was suspected. The study of blood circulation was carried out on an ultrasound scanner "Acuson XP 128/10" using a multi-plane rectal probe with a frequency of 7.5 MHz. Transrectal ultrasound scanning of the preprostatic plexus was performed, with sequential use of color Doppler mapping and "spectral Doppler" modes. The largest vessel diameters and linear blood flow velocities were measured in the specified venous collector in a calm state, as well as in the phase of maximum erection and during a stress test. The latter was carried out periodically by squeezing the erect penis. For pharmacological modeling of erection, an intracavernous injection of 10-40 μg of prostaglandin E1 was performed. All data were recorded on videotape for subsequent retrospective analysis. In order to determine the degree of differences between the obtained descriptive data, a statistical method of paired T-test was applied.
results
In the study of patients in a state of relaxation of the penis, visualization of the veins of the preprostatic plexus was best achieved with longitudinal scanning. The specified venous collector is located on the anterior surface of the apical zone of the prostate gland. The average initial values of the diameter and maximum blood flow velocity in the vessels of the preprostatic plexus were 1.3±0.27 and 4.7±0.9 cm/sec, respectively (Fig. 1 a,b).
30-60 seconds after the intracavernous injection of a vasoactive agent, a significant increase in these parameters was noted up to 3.2±1.24 mm and 28.4±7.3 cm/sec (p<0,01) (Рис. 2). Описанные допплерографические изменения выявлялись в фазу максимально достигнутой эрекции, которая имела малую (до 10 минут) продолжительность.
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The cavernous bodies are the central link in the erection phenomenon.
From the point of view of hydrodynamics, cavernous bodies are a hydrodynamic system. During an erection, a certain balance of blood flow is created in this system (first, the inflow exceeds the outflow, then it equalizes, and then, with detumescence, the outflow becomes less). Erectile dysfunction is an imbalance of the components of this system, due to the deviation of the values of one or both components above a critical level.
An erection occurs when three structural units of the cavernous bodies interact:
Systems of smooth muscle cells of the cavernous tissue and their ability to adequate relaxation.
- The system of "supporting" elements of the cavernous tissue, when a certain ratio of elastic and connective tissue fibers, creates such an extensibility that allows blocking the infrathecal venous plexus and implementing the veno-occlusive mechanism.
- A system of structures that provide a passive veno-occlusive mechanism - infrathecal venous plexus, perforating veins, albuginea.
All this system during the development of an erection works as a whole, providing blood pressure in the cavernous bodies close to systolic, and before ejaculation 2-4 times higher than it.
Factors causing functional and / or structural disorders in the cavernous bodies can be divided into two groups:
I. Systemic processes affecting the functional ability and structural organization of the cavernous bodies in general.
I. Systemic processes affecting the functional ability and structural organization of the cavernous bodies include:
Endothelial dysfunction
. diabetic microangiopathy
. hypercholesterolemia
. hypoxia of the cavernous bodies
. androgen deficiency
II. Processes affecting individual functional structures of the cavernous bodies.
1. Violations of the smooth muscle apparatus of the cavernous bodies:
. Reversible sympathetic hypertonicity due to vegetative-vascular disorders of various origins
. Organic penile angiospasm. This is an irreversible lesion of vasomotor regulation, which occurs with chronic smoking, diabetes mellitus, vasculitis, angiotrophic syndrome, and chronic intoxication.
2. Violations of the structural organization of the cavernous bodies - the causes of cavernous fibrosis:
. priapism, especially lasting more than 72 hours
. intracavernous injections
. penile fracture and rupture of the cavernous bodies
. introduction into the cavernous bodies of various oils and gels
. consequences of the postponed cavernitis
. effects of penetrating radiation
3. Violations of the structures that ensure the implementation of the veno-occlusive mechanism of erection - pathology of the albuginea and venous vessels of the cavernous bodies:
. Congenital insufficient rigidity of the albuginea, which does not provide adequate compression of the infrathecal venous plexus during erection in the presence of sufficient elasticity of the cavernous tissue.
. Peyronie's disease
. Spongiocavernous shunting
. Dilated venous graduates of congenital and acquired genesis
. Congenital and acquired arteriovenous fistulas
There are five types of cavernous erectile dysfunction.
Type 1 is caused by erectile dysfunction due to a too large diameter of the veins through which it flows from the cavernous bodies.
Type 2 is caused by overstretching of the veins due to deformation of the albuginea in Peyronie's disease.
Type 3 is caused by impaired relaxation of the smooth muscle cells of the cavernous bodies due to sclerosis or fibrosis.
Type 4 is caused by a deficiency of mediators of relaxation of smooth muscle cells against the background of systemic processes (endothelial dysfunction, diabetic microangiopathy, etc.) or against the background of neurogenic and psychogenic erectile dysfunction
Type 5 is due to abnormal communication between the cavernous and spongy bodies (spongiocavernous bypass surgery for priapism)
When planning conservative treatment of erectile dysfunction, it is necessary to clearly understand its possibilities:
Firstly. With erectile dysfunction, organic damage to arterial vessels and cavernous bodies is often combined with increased smooth muscle reactivity of varying severity (angiodystonia and functional angiospasm). By eliminating the functional component of the arterial component, it is possible to reduce the deficiency of arterial inflow, and hence improve the quality of erection.
Secondly. The cause of erectile dysfunction is often a combination of arterial and venous insufficiency. In the presence of mild venous insufficiency, but in the absence of insufficiency of arterial inflow, the necessary intracavernous pressure will be achieved and maintained at a satisfactory level if the increasing arterial inflow exceeds the venous "leak". Although the "margin of safety" of the positive balance of blood flow will be low. In the event of arterial insufficiency, the positive balance of blood flow can be easily disturbed and will be insufficient to create the necessary intracavernous pressure, which will provoke the onset of erectile dysfunction. In this case, the restoration and strengthening of arterial inflow will restore the lost balance in the hydrodynamic system "Penis" and will contribute to the restoration of normal erections.
Thirdly. With systemic factors, the emerging sclerosis of the cavernous bodies reduces the elasticity of the cavernous tissue, which leads to incomplete occlusion of the infrathecal venous plexus and the formation of secondary venous insufficiency. Improving the elasticity (extensibility) of the cavernous tissue will contribute to a more complete venous occlusion during the development of an erection and the creation of a positive blood flow balance.
Fourth. Cavernous tissue, like no other muscle structure, needs adequate oxygenation, which is provided by a developed microcirculation system. Even a slight pathology of the microvasculature, leading to a decrease in oxygenation, reduces the activity of biochemical processes for the synthesis of relaxing factors, which can be the cause of erectile dysfunction. Improvement of microcirculation and oxygenation of the cavernous tissue is a necessary condition for the restoration of erectile function in most patients with vasculogenic erectile dysfunction.
The most important for the development of cavernous erectile dysfunction are systemic processes that affect the functional ability and structural organization of the cavernous bodies:
. endothelial dysfunction
. hypoxia of the cavernous bodies
. diabetic myroangiopathy
. hypercholesterolemia
Endothelial dysfunction and cavernous erectile dysfunction.
Erection is initiated by the sacral parasympathetic nerves, whose preganglionic neurotransmitter is acetylcholine. The postganglionic dilating effect of the parasympathetic nervous system is carried out by fibers, the impulse transmission in which is mediated by neurotransmitters that are characteristic only for this type of nerve endings. They are called non-adrenergic non-cholinergic neurotransmitters. They are nitric oxide and vaso-intestinal polypeptide.
The endothelial layer of the lacunae of the cavernous tissue has synapses of the cholinergic nervous system. When stimulated with acetylcholine, endothelial cells produce an endothelial relaxation factor - nitric oxide, which can have a relaxing effect on the underlying smooth muscle layer. Endothelial relaxing factors also include prostaglandins synthesized by endothelial cells. Synthesis of nitric oxide is produced by nitric oxide synthetases (NOS - NO synthase), which affect the amino acid arginine using molecular oxygen. As a result, the amino acid citrulline and nitric oxide are formed. Distinguish between endothelial NO synthetase (eNOS) and nervous tissue (nNOS). Their activity depends on the partial pressure of molecular oxygen.
Diffusion of non-adrenergic non-cholinergic neurotransmitters and endothelial relaxation factor - nitric oxide into the smooth muscle cells of the cavernous tissue activates guanylate cyclase and accumulates cGMP, triggering a cascade of biochemical reactions, the result of which is the relaxation of smooth muscle cells.
All pathological processes leading to hypoxia, hyperglycemia, hypercholesterolemia, hypertension damage the endothelium, resulting in endothelial dysfunction. At the same time, the synthesis of endothelial relaxation factors (nitric oxide and prostaglandins) is sharply inhibited, which leads to the impossibility of smooth muscle relaxation. Deficiency of prostaglandins leads to disinhibition of collagen synthesis, and increased formation of endothelin-1 supports the contraction of smooth muscle elements of the trabeculae of the cavernous tissue, prevents vasodilation and, thereby, exacerbates hypoxia. Against this background, the transformation factor B1 is activated, the synthesis of which is controlled by prostaglandins. Transformation factor B1 induces the synthesis of collagen and its accumulation in the cavernous tissue, which leads to atrophy and fibrous transformation of smooth muscle cells. Thus, impaired relaxation of smooth muscle cells, vasoconstriction and sclerotic changes in cavernous tissue are a key link in the pathogenesis of cavernous erectile dysfunction due to endothelial dysfunction.
Hypoxia and cavernous erectile dysfunction.
A very important role in the regulation of neurophysiological and biochemical processes in the cavernous tissue is played by blood oxygen saturation - the partial pressure of blood oxygen in the cavernous bodies. The value of the partial pressure of oxygen of the blood flowing through the cavernous bodies of the non-erect penis is equal to the partial pressure of oxygen of the venous blood (25-45 mm Hg). During an erection, increased blood flow through the dilated penile arteries rapidly raises the partial pressure of oxygen in the cavernous tissue to the level in the arterial blood (100 mmHg). Studies have shown that changes in intracavernous oxygen partial pressure play an active role in the regulation of penile erection. The low value of oxygen pressure in the non-erect penis leads to inhibition of the synthesis of nitric oxide, which prevents the relaxation of the smooth muscle fibers of the trabeculae of the cavernous tissue. Inhibition of the synthesis of nitric oxide is a necessary condition for finding the penis in a relaxed state. With vasodilation and an increase in the partial pressure of oxygen in the blood, the synthesis of the endothelial relaxation factor, nitric oxide and prostaglandin E, is stimulated, the effect of which causes smooth muscle relaxation.
Hypoxia of endothelial cells leads to an increase in their synthesis of endothelin-1. It is a peptide synthesized by the endothelium of the cavernous tissue and has a strong constrictor effect. It is believed that endothelin provides contraction of smooth muscle fibers to maintain a relaxed state of the penis.
The state of hypoxia with an increased content of endothelin-1 leads to the expression of transformation factor B1, which is a pleiotropic cytokinin that induces collagen synthesis and accumulation, and also stimulates the growth of fibroblasts. These changes lead to phenotypic changes in the cavernous tissue, namely, to increased synthesis and accumulation of collagen with an outcome in cavernous fibrosis.
It has been established that 48 hours after erection, the degree of hypoxia develops in the cavernous tissue, at which the transformation factor B1 is induced. In a man with normal sexual function, even if he is not sexually active, 4-8 episodes of spontaneous erection during nocturnal sleep provide sufficient oxygenation of the cavernous tissue to prevent changes leading to fibrosis of the cavernous tissue. Oxygenation of the cavernous tissue during nocturnal erections regulates the normal ratio of the synthesis of cytokinins, growth factors, nitric oxide and prostaglandins. It is important to note that prostaglandins synthesized by the endothelium of the cavernous tissue are directly involved in the regulation of collagen formation in the cavernous tissue. Prostaglandins inhibit transformation factor B1 and thus block collagen synthesis.
Thus, a quality erection that creates maximum oxygenation of the cavernous tissue reproduces the next erection. The penis for normal functioning just needs regular and long erections.
In this regard, two things must be emphasized.
Firstly, with age, to maintain an adequate readiness for erection of the cavernous tissue, its oxygenation is insufficient only during nocturnal erections. In humans, in the absence of a regular sexual life, poor oxygen supply to the cavernous tissue many times accelerates the "aging" of the penis.
Secondly, any pathological conditions that contribute to the weakening of erectile function, and hence the oxygenation of the cavernous tissue, trigger the pathological process of impaired relaxation of smooth muscle cells, vasoconstriction and collagen synthesis, which leads to the closure of the circle of pathogenesis.
Diabetes mellitus and cavernous erectile dysfunction.
In patients with diabetes mellitus, cavernous erectile dysfunction is often due to local pathological changes in the cavernous bodies, which are similar to the phenomena of diabetic microangiopathy. The accumulation of collagen, as well as the end products of non-enzymatic glycosylation of penile proteins, is shown, which leads to a decrease in the elasticity of the cavernous tissue and the albuginea. An indirect indication of increased collagen accumulation may be the often detected increased number of fibroblasts in the cavernous tissue of patients with diabetes mellitus and erectile dysfunction.
According to other researchers, in diabetes mellitus, there is a decrease in the activity of endothelial NO-synthetase, which is due to the accumulation of end products of non-enzymatic glycosylation of proteins in the cavernous tissue. This leads to an insufficient response of the smooth muscle cells of the cavernous bodies to erectogenic stimuli.
In patients with diabetes mellitus, there is also a decrease in the number of nerve fibers in the cavernous tissue that secrete vasointestinal peptide, and a decrease in the sensitivity of the latter to this neurotransmitter.
Hypercholesterolemia and cavernous erectile dysfunction.
Hypercholesterolemia leads to structural changes in the cavernous tissue. In patients with elevated cholesterol levels, increased collagen synthesis and reduced elasticity of the trabeculae of the cavernous bodies.
erectile dysfunction (outdated - impotence)- the inability of a man to achieve or maintain an erection sufficient for sexual intercourse and the satisfaction of sexual activity. At the same time, erectile dysfunction is considered a condition in which these problems exist for at least three months. From term: "impotence"- recently they began to refuse, since this diagnosis implies an extreme degree of sexual dysfunction, and the unlikely success of conservative treatment.
Causes of impotence:
Based on the causes and mechanisms of development, ED is divided into several types:
1) Psychogenic erectile dysfunction- based on: overwork, depression, various phobias and deviations, associative psychotraumatic factors. As a result of these factors, the cerebral cortex causes a number of negative effects on the mechanism of normal erection:
- Direct inhibitory action.
- Inhibitory action mediated through the spinal centers responsible for the mechanism of erection.
- Increased levels of adrenaline and noradrenaline.
2) Arteriogenic impotence occurs due to vascular damage: atherosclerosis, congenital anomalies of the vessels of the penis, smoking, diabetes mellitus, hypertension. Often, with this form, in addition to worsening erection, dystrophic changes occur in the cavernous tissue, due to insufficient blood supply. In this case, a vicious circle is formed, and in the absence of timely treatment, irreversible changes in the cavernous bodies develop.
3) Venogenic erectile dysfunction develops due to a violation of the veno-occlusive mechanism (this mechanism is described in detail on the page):
- Ectopic drainage (abnormal discharge of blood): through the great saphenous veins, dorsal veins, through enlarged cavernous or pedunculate veins.
- Cavernous spongy shunt (shunt of blood from the cavernous bodies to the spongiform).
- Insufficiency of the albuginea (traumatic rupture, primary or secondary thinning).
- Functional insufficiency of cavernous erectile tissue (lack of nephrotransmitters, psychogenic inhibition, smoking, ultrastructural changes).
4) Dysfunction of the cavernous tissue (cavernous insufficiency). The causes of cavernous insufficiency are different. They lead to intra- and extracellular changes in the cavernous bodies, their vessels and nerve endings, which interfere with the normal functioning of the erector mechanism.
6) Anatomical (structural) impotence associated with violation. This is primarily (Peyronie's disease, penis, congenital curvature). Fibrosis of the corpora cavernosa is often associated with trauma, insertion, surgical interventions, etc.
Treatment of ED of anatomic origin most often requires surgical intervention. And, as experience has shown, often in such cases, the optimal choice is penile prosthetics.
7) Hormonal erectile dysfunction. The enzyme responsible for the synthesis of nitric oxide (which, in turn, causes vasodilation) is androgen-dependent, that is, with a decrease in the level of the male sex hormone (testosterone), the activity of this enzyme decreases and, accordingly, erection worsens. That is why, with the hormonal form of the disease, treatment with drugs that inhibit type 5 phosphodiesterase (Viagra, Cialis, Levitra) is not effective.
It is also known that a decrease in testosterone concentration leads to increased deposition of fat cells in the cavernous bodies, degeneration of smooth muscle cells, which ultimately leads to a violation of the veno-occlusive mechanism.
Well, it must be said that it largely depends on the normal level of testosterone.
8) Age impotence. Age, in itself, has an impact on the usefulness and duration of an erection. In older people, the blood flow rate, testosterone levels, the sensitivity of the nervous system and the elasticity of the vascular walls decrease, which accordingly affects the erection. However, it is necessary to distinguish the natural age-related decline in erectile function from impotence caused by somatic diseases, the likelihood of which increases significantly with age. It is known that people who do not suffer from various chronic diseases live a full-fledged (taking into account age norms) sexual life even at the age of 80.
Some andrologies also distinguish a separate species: drug-induced (drug) ED.
Diagnosis of ED
Based on anamnesis, examination, instrumental and laboratory examination.
The collection of information facilitates the use of customized questionnaires. The use of such forms allows not only to smooth out the feeling of awkwardness in a conversation with a shy patient, but also save the doctor's time.
International index of erectile function
How do you rate |
Very low |
Low |
Medium |
high |
Very high |
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When you had an erection during sexual stimulation, how often was it sufficient for insertion of the penis into the vagina? |
There was no sexual activity |
Almost never or never |
|
|
|
Almost always or always |
During intercourse, how often did you manage to maintain an erection after insertion of the penis into the vagina? |
|
Almost never or never |
Rare (much less than half the time) |
Sometimes (about half the time) |
Often (much more than half the time) |
Almost always or always |
During intercourse, did you find it difficult to maintain an erection until the end of intercourse? |
Didn't try to have sex |
Extremely difficult |
Very hard |
Difficult |
A bit difficult |
Not difficult |
When you tried to have sexual intercourse, were you often satisfied? |
Didn't try to have sex |
Almost never or never |
Rare (much less than half the time) |
Sometimes (about half the time) |
Often (much more than half the time) |
Almost always or always |
Interpretation of the received data:
- 5–7 points - severe degree of ED - impotence,
- 8–11 points - moderate severity,
- 12–16 points - easy-medium degree,
- 17–21 points - mild degree,
- 22–25 points - the patient is healthy.
In some cases, apply monitoring of nocturnal spontaneous erections. This method allows for differential diagnosis of organic and psychogenic forms. So, with psychogenic ED, in contrast to organic, spontaneous nocturnal erections are preserved.
Doppler ultrasound (USDG) of the arteries of the penis allows you to evaluate microcirculation, identify structural changes in cavernous fibrosis and Peyronie's disease. UZDG of the arteries of the penis is more informative if it is performed at rest and erection, followed by a comparison of the results.
Test with intracavernous administration of vasoactive drugs(usually alprostadil, a prostaglandin E analogue) reveals vasculogenic ED. With normal arterial and veno-occlusive hemodynamics, 10 minutes after the injection, a pronounced erection occurs, which persists for 30 minutes or more.
According to the indications, other studies are also performed:
- cavernosometry (determination of the volumetric velocity of the physiological solution injected into the cavernous bodies, which is necessary for the onset of an erection) - the main test that directly assesses the degree of violation of the elasticity of the sinusoidal system and its closing ability;
- cavernosography (demonstrates venous vessels, through which blood is mainly discharged from the cavernous bodies);
- radioisotope phalloscintigraphy (allows to assess the qualitative and quantitative indicators of regional hemodynamics in the cavernous bodies of the penis);
- neurophysiological studies, in particular the determination of the bulbocavernosal reflex in patients with diabetes mellitus, with spinal cord injury.
Treatment of erectile dysfunction and impotence
Conservative treatment the choice of methods is determined by the doctor
1) Prescription of phosphodiesterase type 5 inhibitors(Viagra, Levitra, Cialis). A contraindication for prescribing drugs of this group is the use of nitric oxide or nitrate donators in any dosage form (nitrosorbitol, nitroglycerin, nitrong, sustak, etc.) by the patient.
2) Hormone replacement therapy. If the disease is caused by hormonal disorders, it is necessary to restore the normal hormonal status. To date, there are convenient dosage forms that allow you to adjust the level of testosterone (male sex hormone): Androgel, Nebido.
3) Another treatment method is vacuum therapy using a penis pump. The vacuum device is quite simple - it consists of a tube that is connected to a pump. You put your penis into the tube and pump the air out of the tube. The result is a vacuum that stimulates blood flow to the penis.
4) If erectile dysfunction treatment is not successful, or if the patient is unable for some reason to take PDE5 inhibitors or use a vacuum device, a drug called alprostadil may be prescribed. Alprostadil helps improve blood flow to the penis. Alprostadil may be injected directly into the penis, or a small tablet (urethral tube) may be placed into the urethra.
5) Psychotherapy (sex therapy). If the cause of ED lies in the field of psychology, the help of a psychotherapist is needed. Sex therapy is a form of psychotherapy where you and your partner can discuss any issues related to sex life, emotional problems that may contribute to the development of the disease. A therapist can also give you practical advice on issues such as pre-sexual stimulation and other effective treatments that can be used to improve your sex life.
6) Cognitive behavioral therapy is another type of psychological counseling that can be useful in this disease. This method is based on the following principle: what we feel depends largely on how we think about it. Consequently, harmful thoughts and unrealistic ideas can seriously affect your self-esteem, sexuality, and your relationships with loved ones and contribute to the development of erectile dysfunction. In this situation, a psychotherapist who practices cognitive behavioral therapy will help you get rid of such thoughts and ideas and develop a correct and realistic attitude towards yourself and your sexuality.
Impotence is a violation of potency, sexual impotence, manifested in the inability of a man to have sexual intercourse. It often serves as a manifestation of the underlying disease and is eliminated by its cure (endocrine, nervous, cardiovascular disorders, diseases of the urogenital area). Erectile dysfunction can cause deep psychological depression, disharmony of sexual and family relationships. Erectile dysfunction or impotence is manifested by the inability to achieve an erection sufficient for a full-fledged sexual intercourse while maintaining psychological comfort during it.
General information
- violation of potency, sexual impotence, manifested in the inability of a man to have sexual intercourse. It often serves as a manifestation of the underlying disease and is eliminated by its cure (endocrine, nervous, cardiovascular disorders, diseases of the urogenital area). Erectile dysfunction can cause deep psychogenic depression, disharmony of sexual and family relationships.
Erectile dysfunction or impotence is manifested by the inability to achieve an erection sufficient for a full-fledged sexual intercourse while maintaining psychological comfort during it. Recently, the pathogenesis and causes of erectile dysfunction have been sufficiently studied in order to restore a normal sexual life, and today the problem of impotence is not difficult to solve.
Physiology of erection and detumescence
The smooth muscles of the cavernous bodies and the walls of the arteries and arterioles perform the main function in the process of erection and in the process of detumescence - a decline in erection after ejaculation or due to reasons that prevented the natural end of sexual intercourse. In a calm state, the smooth muscles of the penis are under the influence of sympathetic nerve endings. At the moment of sexual arousal or stimulation of the penis, impulses transmitted through parasympathetic nerve fibers cause the release of erection neurotransmitters, blood filling of the cavernous bodies occurs. This complex chemical process takes place with the mandatory participation of nitric oxide. First, there is relaxation and relaxation of smooth muscles, which in turn contributes to unimpeded blood filling. Increasing in size from the incoming arterial blood, the cavernous bodies partially block the outflow of venous blood. Due to the difference in the volume of inflow and outflow of blood, intracavernous pressure increases, which contributes to the development of a rigid erection.
Immediately after ejaculation, the cessation of sexual stimulation, or for other reasons, the reverse process begins - detumescence. After the activation of synaptic structures, such neurotransmitters as norepinephrine and neuropeptide are released into the blood.
Both of these processes are controlled by the middle preoptic zone of the cerebral cortex; in general, the sexual activity and sexual behavior of a man depends on the concentration of dopamine-like substances that have a stimulating effect, and seratonin-like substances that have an inhibitory effect. Violations in any link of the whole process can lead to impotence.
Symptoms of impotence
Depending on the pathogenesis of erectile dysfunction, there are several types of impotence.
Psychogenic impotence can be both permanent and temporary, this type of impotence can occur in men who are subject to frequent mental and physical overwork, having certain psychological difficulties or problems finding a partner. Temporary psychogenic impotence disappears after the normalization of lifestyle.
Psychogenic impotence, in the pathogenesis of which lies a decrease in the sensitivity of the cavernous tissue to neurotransmitters due to the inhibitory effect of the cerebral cortex or due to indirect influence through the spinal centers, can occur against the background of sexual phobias and deviations, associative psychotraumas and religious prejudices. Today, thanks to the development of diagnostics between true and psychogenic erectile dysfunction, psychogenic impotence in its purest form, as, for example, happens with serious sexual deviations (pedophilia, bestiality) is diagnosed less often.
Neurogenic impotence occurs against the background of injuries and diseases of the central nervous system and peripheral nerves. The pathogenetic link is the difficulty or complete absence of the passage of nerve impulses into the cavernous bodies. In 75% of cases, the cause of neurogenic impotence is spinal cord injury. The remaining 25% account for neoplasms, cerebrovascular pathologies, herniated discs, multiple sclerosis, syringomyelia and other neurogenic diseases.
Arteriogenic impotence is an age-related pathology, since atherosclerotic changes in the coronary and penile vessels are identical. At an early age, arteriogenic impotence can occur due to congenital vascular anomalies, smoking, hypertension, diabetes mellitus, or due to trauma. Insufficient arterial blood flow is not able to fully nourish the cavernous tissues and vascular endothelium, local metabolism is disturbed, which can lead to irreversible dysfunctional disorders of the cavernous tissue.
Pathogenesis venogenic impotence not studied enough, but its development is facilitated by disturbances in the venous bloodstream, in which the lumen of the veins increases. This happens with ectopic drainage of the cavernous bodies through the venous vessels of the penis, with traumatic ruptures of the albuginea, resulting in its insufficiency. Venogenic impotence often accompanies Peyronie's disease and functional insufficiency of the cavernous erectile tissue. Smoking and alcohol abuse exacerbate the symptoms of venogenic impotence.
Hormonal impotence most often develops against the background of diabetes mellitus, since in diabetes mellitus changes in penile vessels and cavernous tissue are quite serious. But at the same time, the cause of hormonal impotence is not so much a decrease in testosterone levels, but a violation of its absorption, because in persons with hypogonadism, erection problems were not observed when stimulating. But with hypogonadism and male menopause, hormone replacement therapy is carried out as the main treatment for erectile dysfunction.
Cavernous insufficiency or dysfunction of the cavernous tissue can also lead to impotence. In the pathogenesis of this type of impotence are changes in the cavernous bodies, blood vessels and nerve endings that disrupt the erection mechanism.
Kidney diseases in which patients are indicated for extracorporeal dialysis in half of the cases are combined with erectile dysfunction, while after kidney transplantation, two-thirds of patients restore erectile abilities. Prostatitis can cause impotence both due to insufficient serum testosterone levels and due to circulatory psychogenic disorders: pain during ejaculation, premature ejaculation and iatrogenic conditions in which failure syndrome is formed.
In patients with bronchial asthma, in a post-infarction state, impotence is due to the fear of an exacerbation of the disease during intercourse.
Prostatitis is not the main cause of impotence, it can only aggravate its course, this should be borne in mind, since most men believe that only prostatitis can cause erectile dysfunction.
Diagnosis of impotence
All diagnostic procedures are aimed at establishing the cause of impotence, which means the possibility of restoring erectile function and eliminating emotional experiences. To do this, first of all, it is necessary to differentiate psychogenic and organic impotence. A simple and reliable method is to monitor nocturnal erections and intracavernous injection test (coverject test). If, according to these methods, the organic nature of impotence is confirmed, then a number of additional examinations are carried out to identify the underlying cause.
impotence treatment
Modern andrology has a fairly wide choice of schemes and methods for the treatment of erectile dysfunction. The choice of treatment method is based on the decision of the andrologist and on the acceptability of the use for the given patient. Drug therapy for impotence is a traditional method of treatment, usually they resort to testosterone replacement therapy and drugs from the group of adrenergic blockers. Against the background of the main treatment, courses of such drugs as trazodone, trimipramine, nitroglycerin, metachlorphenylpiperazine are periodically carried out - they are used in the form of ointment applications. The effectiveness of drug therapy does not exceed 30%, so drugs are not indicated for all patients.
Psychotherapy can be the main treatment for psychogenic and neurogenic impotence, but on condition that psychotherapeutic procedures are carried out professionally. Vacuum-erectile therapy, which was developed in 1970 by Dr. D. Osbon, if carried out correctly, gives an efficiency of up to 83%; complications in the form of petechial hemorrhages, painful intercourse occur in isolated cases.
Intracavernous drug therapy is a relatively new treatment for impotence. For the first time, papaverine was administered intracavernously to improve erectile function (1982), then phentolamine, prostaglandin E1 and other drugs began to be used. Minimal side effects, high efficiency and ease of use gives the drug prostaglandin E1; the use of this technique in 80% of cases allows you to have a quality sex life without any restrictions.
When using papaverine and phentolamine for intracavernous drug therapy of impotence, priapism and cavernous fibrosis sometimes occurred as complications, which is extremely rare when using prostaglandin E1. The only disadvantage of this method of impotence therapy is the pain of injections, therefore, after injections of prostaglandin E1, an injection of 7.5% sodium bicarbonate is made to relieve pain. Since this method of treating impotence with minimal intervention gives good results, non-injection methods of intracavernous administration of drugs are being developed.
Intracavernous phalloprosthesis was first successfully carried out in 1936 by the Soviet professor Bogoraz, rib cartilage was used as a prosthesis. And already in the mid-70s, intracavernous penile prosthesis began to be widely used for the treatment of impotence. To date, prostheses have different principles of action and give complete freedom to lead a normal sexual life. The reliability of the systems used for prosthetics and the quality of the technique made it possible to reduce the number of complications to 3.5-5%, and among patients using penile prostheses to correct impotence, more than 80% give good recommendations to this technique.
Moreover, if impotence is of an organic nature, patients should be advised to immediately undergo phaloprosthetics. Because according to statistics, most of the men who use penile prostheses first used drug therapy, vacuum therapy and intracavernous self-injections. The main reason why intracavernous penile prosthesis is preferred by most patients who are faced with the problem of impotence is the natural erection, the absence of the need for painful injections and constant medication, and the minimum number of complications.
Under erectile dysfunction (impotence) refers to the inability of a man for at least three months to achieve and maintain an erection to satisfy sexual activity and sexual intercourse.
The term "impotence" according to modern concepts is untenable, since this diagnosis assumes an extreme degree of such a problem as sexual dysfunction with the ineffectiveness of conservative therapy.
Causes of decreased erectile function
ED (erectile dysfunction) can be of several types depending on the mechanisms of its development and causes:
- psychogenic;
- arteriogenic;
- venogenic;
- cavernous insufficiency;
- neurogenic;
- anatomical;
- hormonal;
- age;
- medical.
Psychogenic ED is caused by:
- depression
- overwork;
- associative psychotraumatic factors;
- various deviations and phobias.
The influence of these factors determines the fact that a number of processes are triggered in the cerebral cortex that negatively affect the mechanism of the normal development of erection processes:
- direct inhibitory effect;
- indirect inhibitory effect (through the spinal centers responsible for the erection mechanism);
- increased levels of norepinephrine and adrenaline.
At the core arteriogenic ED vascular lesions lie:
- congenital anomalies of the vessels of the penis;
- hypertonic disease;
- penis injury;
- atherosclerosis;
- diabetes;
- smoking.
This form of the disease is often accompanied by degenerative changes in the cavernous tissue due to insufficient blood supply. As a result, a vicious circle arises, which, in the absence of timely therapy, leads to changes in the cavernous bodies of an irreversible nature.
Cause venogenic ED is a violation of the veno-occlusive mechanism:
- abnormal bleeding(ectopic drainage) through dorsal, great saphenous, enlarged pedunculate or cavernous veins;
- shunting of blood into the spongy body from cavernous (cavernous-spongy shunt);
- insufficiency of the albuginea(Peyronie's disease, traumatic rupture, thinning (primary or secondary));
- functional insufficiency of erectile cavernous tissue(psychogenic inhibition, lack of nephrotransmitters, ultrastructural changes, smoking).
Cavernous insufficiency(a form of ED, which is a dysfunction of the cavernous tissue). The causes of this pathology are very diverse and cause extra- and intracellular changes in the cavernous bodies, as well as their nerve endings and blood vessels, preventing the normal function of the erector mechanism.
Neurogenic ED caused by various injuries and diseases of the spinal cord and brain, pathologies of the peripheral nerves of the small pelvis (as a result, for example, of open surgery for cancer or prostate adenoma).
Structural (anatomical) ED It is caused by violations of the anatomy, as a rule, by a pronounced curvature of the penis, such as:
- fibrosis of the cavernous bodies, usually associated with surgical interventions, the introduction of foreign bodies into the urethra, injuries, etc .;
- Peyronie's disease;
- congenital curvature.
Anatomical ED is treated surgically, the best option of which is penile prosthesis.
The mechanism of development of hormonal ED is due to a number of processes. Vasodilation is caused by the action of nitric oxide, synthesized in the body with the participation of an androgen-dependent enzyme. A decrease in the level of testosterone (male sex hormone) leads to a decrease in the activity of this enzyme and, accordingly, to a deterioration in erection. That is why an attempt to treat the described form of ED with phosphodiesterase type 5 inhibitory drugs (Cialis, Viagra, Levitra) is ineffective.
In addition, a decrease in testosterone concentration provokes an increased deposition of fat cells in the cavernous bodies and dystrophy of smooth muscle cells, leading, as a result, to the fact that the veno-occlusive mechanism is disturbed.
Also, the normal level of testosterone determines the sexual desire (libido).
Age-related impotence is caused by changes in the body that occur in older people, namely a decrease in:
- blood flow speed;
- sensitivity of the nervous system;
- testosterone levels;
- elasticity of the vessel walls.
This age-related natural decline in erectile function should be differentiated from a decline caused by somatic pathologies, for which the likelihood of developing with age also increases. The absence of chronic diseases allows you to have a full sexual life (according to age norms) even at the age of 80.
In addition to the described forms of ED, a number of andrologists also distinguish medicinal (medicated) ED.
Diagnostics
- Anamnesis.
- inspection data.
- Laboratory research.
- Instrumental research.
It is optimal to collect information through adapted questionnaires.
Data interpretation (according to the scoring system):
- norm(22–25 b.);
- mild degree(17–21 b.);
- easy-medium degree(12–16 b.);
- average degree(8–11 b.);
- severe ED, impotence(5–7 b.).
Laboratory diagnostics involves determining the hormonal status of the patient. If there are indications, to identify somatic diseases, general blood and urine tests are performed, as well as the definition of:
- lipid spectrum;
- HDL and LDL;
- total cholesterol;
- PSA (PSA);
- blood glucose, etc.
Instrumental diagnostics:
- Monitoring of spontaneous nocturnal erections for differentiation of psychogenic, with preservation of nocturnal erections, and organic forms.
- UZDG (ultrasound dopplerography) penile arteries to assess microcirculation, identify structural changes in Peyronie's disease and cavernous fibrosis. For greater information content, ultrasound of the arteries of the penis should be carried out in a state of erection and rest, and then compare the results.
- Intracavernous administration of vasoactive agents(usually the prostaglandin E analogue alprostadil) to detect vasculogenic ED. The result of the test for normal veno-occlusive and arterial hemodynamics is the occurrence after injection after 10 minutes of a pronounced erection, which persists for half an hour or longer.
It is possible to conduct other studies if there are indications:
- the main test for direct assessment of the degree of violation of elasticity and the closing ability of the sinusoidal system - cavernosometry (determination of the volumetric velocity of saline pumped into the cavernous bodies, which is necessary for the development of an erection);
- cavernosography, which displays the venous vessels through which the predominant discharge of blood from the cavernous bodies occurs;
- radioisotope phalloscintigraphy, which makes it possible to assess quantitative and qualitative indicators of regional hemodynamics in the cavernous bodies of the penis;
- neurophysiological studies, such as the determination of the bulbocavernosus reflex in patients with spinal cord pathology, with diabetes mellitus.
impotence treatment
Conservative treatment
When deciding how to treat ED conservatively, the doctor can choose from the following options:
- Appointment of drugs containing phosphodiesterase type 5 inhibitors (Cialis, Levitra, Viagra). Such funds are contraindicated when patients take nitric oxide donators or any nitrates (nitrong, nitroglycerin, nitrosorbitol, sustac, etc.).
- Implementation of hormone replacement therapy. In the case when the cause of the disease is a violation of the hormonal background, its restoration is required. Convenient dosage forms used to adjust the male sex hormone - testosterone are Nebido, Androgel.
- Using vacuum therapy with a penis pump. The device has a relatively simple structure, representing a tube connected to the pump. The penis is inserted into the tube and air is pumped out of the latter by a pump. The vacuum created in the tube stimulates blood flow to the penis.
- If therapy with these methods is unsuccessful, or the patient cannot use a vacuum device, or take phosphodiesterase type 5 inhibitors, an increase in erectile function can be achieved with a drug called alprostadil. Alprostadil improves blood flow to the penis. The injection of the drug can be carried out directly into the penis, in addition, a urethral tube (small tablet) can be placed in the urethra.
- Conducting sessions of sex therapy (psychotherapy). If weak erectile function is due to psychological reasons, then the help of a psychotherapist may be required. A form of psychotherapy in which it is possible for partners to discuss all sorts of issues related to sexual life and emotional problems that contribute to the development of pathology is sex therapy. A psychotherapist can recommend effective methods to improve sexual life, including methods of erotic stimulation performed before sexual intercourse.
- Conducting a type of psychological counseling such as cognitive behavioral therapy. This method is based on the principle that our feelings are largely determined by how we think. Unrealistic ideas and harmful thoughts can negatively affect sexuality, self-esteem, relationships with loved ones, contributing to the development of erectile dysfunction. The task of a psychotherapist, a specialist in the field of cognitive behavioral therapy, is to help the patient get rid of such ideas and thoughts, to develop an adequate and realistic attitude towards his sexuality and himself.
Surgery
The use of surgical methods for the treatment of impotence is recommended in the presence of convincing evidence of a violation of the blood supply to the penis, as well as in the absence of a result in the application of any other therapeutic measures. In case of arterial or venous insufficiency, it is possible to carry out surgical treatment with the subsequent restoration of normal blood circulation. An alternative method of surgical treatment is penile prosthesis - implantation of a penis prosthesis.
