Male sexual health

Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. It can be an occasional problem or a persistent condition, affecting men of all ages but becoming more common with age.

In Canada, the prevalence of erectile dysfunction (ED) mirrors trends seen in other developed countries. Here are some key points about the incidence of ED in Canada:

• It is estimated that one in four Canadian men suffer from erectile dysfunction , although prevalence may vary by age and other factors.
• In younger men, studies suggest that about 10 to 15% of men under the age of 40 experience some degree of ED.
• Prevalence increases with age. For example, approximately 50% of men aged 50 to 70 have some form of ED, with higher rates among those over 70.

Incidence by severity

• One often-cited study, the 1994 Massachusetts Male Aging Study, found that about 52% of men between the ages of 40 and 70 had some form of ED.
  • Mild ED affected about 17% of men.
  • Moderate ED affected about 25% of men.
  • Full-blown ED affected about 10% of men.

Incidence in young men

• Recent studies show that up to 25% of men under the age of 40 may experience ED, often due to psychological factors such as stress and anxiety, although lifestyle factors (e.g., alcohol consumption, unhealthy diet) may also contribute.

Risk factors

Risk factors for ED include:

• Chronic conditions : Diabetes, cardiovascular disease, and hypertension are important risk factors for ED.
• Lifestyle factors : Smoking, excessive alcohol consumption, and obesity also contribute to the risk of ED.

ED can have a significant impact on quality of life and mental health, leading to decreased sexual satisfaction and relationship problems.

Causes of ED

ED can have a variety of causes, including:

1. Physical causes
   • Cardiovascular Diseases : Conditions like high blood pressure, atherosclerosis, and heart disease can restrict blood flow to the penis.
   • Diabetes : This can damage the blood vessels and nerves that control an erection.
   • Obesity : Being overweight can lead to cardiovascular problems that can cause ED.
   • Hormonal imbalances : Low testosterone levels or thyroid problems can contribute to ED.
   • Neurological conditions : Stroke, Parkinson’s disease, and multiple sclerosis can interfere with nerve signals to the penis.
   • Medications : Some medications for high blood pressure, depression, and other conditions can cause ED as a side effect.
   • Substance use : Alcohol, smoking, and drug use can impair erectile function.
2. Psychological causes
   • Stress and Anxiety : Performance anxiety or other sources of stress can lead to ED.
   • Depression : Mental health issues can affect libido and sexual performance.
   • Relationship problems : Difficulties with intimacy or communication may contribute to ED.
3. Lifestyle factors
   • Lack of exercise : A sedentary lifestyle can increase the risk of ED by contributing to obesity and cardiovascular problems.
   • Unbalanced diet : A diet high in processed foods and unhealthy fats can affect heart health and blood flow.

Diagnosis of erectile dysfunction (ED)

Investigation of erectile dysfunction (ED) involves a thorough evaluation to identify underlying causes, which may be physical, psychological, or a combination of both. The diagnostic process typically includes a combination of medical history, physical examination, laboratory tests, and sometimes specialized tests. Here’s how healthcare professionals typically approach the investigation:

1. Medical history
   • Sexual history : The doctor will ask about the frequency and quality of erections, difficulty achieving or maintaining an erection, and other aspects of sexual function (eg, libido, ejaculation, orgasm).
   • Duration of DE : When did the problem start and is it an occasional or persistent problem?
   • Psychological factors : Questions about stress, anxiety, depression, or relationship problems that might contribute to ED.
   • Lifestyle factors : Smoking, alcohol consumption, physical activity, and diet.
   • Medications : Review of prescription drugs, over-the-counter medications, and supplements, as some may contribute to ED.
   • Chronic conditions : Inquiry into conditions such as diabetes, cardiovascular disease, hypertension, or hormonal disorders that may affect erectile function.
2. Physical examination
   • Genital exam : The doctor will inspect the penis and testicles for any anatomical abnormalities (eg, Peyronie’s disease, testicular atrophy).
   • Cardiovascular health : Blood pressure measurement and heart exam to detect signs of cardiovascular disease, often linked to ED.
   • Neurological exam : Testing of reflexes and nerve function in the genital area to check for nerve damage that could interfere with erections.
   • Prostate exam : In older men, a prostate exam may be done to check for prostate problems.
3. Laboratory tests Blood tests are crucial to check for possible underlying health problems:
   • Hormone levels : Testosterone, luteinizing hormone (LH), and prolactin to check for hormonal imbalances.
   • Blood sugar : To screen for diabetes, a common cause of ED.
   • Lipid profile : To assess cholesterol levels and risk of cardiovascular disease.
   • Kidney and liver function : Abnormalities in these organs can contribute to ED.
   • Thyroid function : Hypothyroidism or hyperthyroidism can affect erectile function.
4. Psychological assessment
   • Counseling or questionnaire : If psychological factors (eg, stress, depression, anxiety) are suspected, a psychological evaluation may be performed, often involving structured questionnaires such as the International Index of Erectile Function (IIEF).
   • Partner involvement : Discussing relationship dynamics with both partners can help identify issues contributing to ED.
5. Specialized Testing at Select Centers in North America If the initial evaluation does not identify the cause or additional information is needed, the following specialized tests may be performed:
   • Nocturnal penile tumescence test (NPT) : This test measures whether spontaneous erections occur during sleep. Healthy men typically have multiple erections during the night, and the absence of nocturnal erections may suggest a physical cause.
   • Penile Doppler ultrasound : This test assesses blood flow to the penis, identifying problems such as blocked arteries or venous leakage. It is performed after injection of a vasodilator (e.g., alprostadil) to induce an erection.
   • Cavernosometry and cavernosography : These tests are more invasive and measure pressure and blood flow in the penile arteries and veins.
   • Intracavernosal injection test : An injection of a vasodilator (eg, prostaglandin) into the penis can help assess the ability to achieve and maintain an erection.
   • Dynamic Infusion Cavernosometry : This test measures the pressure inside the penis during an erection to diagnose venous leaks.
   • Arteriography : If a vascular problem is suspected, this imaging test can help identify blocked arteries.
6. Diagnosis of psychological ED
   • If physical assessment and testing are normal but ED persists, a diagnosis of psychological ED may be made. Psychological ED tends to occur in younger men or those experiencing situational stress, and treatment may focus on therapy or counseling.
7. Cardiovascular Evaluation Because ED can be an early sign of cardiovascular disease, especially in older men, doctors may recommend a more comprehensive cardiovascular evaluation, such as an electrocardiogram (ECG), stress testing, or even cardiac imaging. Early detection of ED can help reveal serious underlying conditions like heart disease, making prompt investigation essential.
8. Drug Trial In some cases, a doctor may prescribe an ED medication (e.g., sildenafil, tadalafil) to see if it improves erectile function. A positive response could indicate that the problem is related to blood flow or a vascular problem.
9. Endocrinological Investigation If low testosterone or other hormonal imbalances are suspected, additional tests (eg, pituitary hormone levels) may be done to rule out endocrine disorders such as hypogonadism or pituitary problems.

Medical management of erectile dysfunction (ED) and treatments

Medical management of erectile dysfunction (ED) involves several treatment options that depend on the underlying cause of the condition, patient preferences, and comorbidities. Treatment typically begins with lifestyle modifications and oral medications, but may also include other interventions such as hormone therapy, devices, injections, or surgery. Here is an overview of common approaches:

1. Lifestyle changes
   • Exercise : Regular physical activity, especially aerobic exercise, can improve cardiovascular health, increase blood flow, and reduce the severity of ED.
   • Weight loss : Reducing excess weight, especially in obese men, may improve erectile function.
   • Dietary changes : A heart-healthy diet, such as the Mediterranean diet, may promote better blood flow and reduce the risk of ED.
   • Quitting Smoking : Smoking damages blood vessels and restricts blood flow to the penis, so quitting smoking can significantly improve ED.
   • Limiting alcohol : Reducing alcohol consumption may improve sexual performance, as excessive consumption can affect erectile function.
   • Stress management : Reducing stress and anxiety through mindfulness, therapy, or relaxation techniques may help with ED, especially if psychological factors are involved.
2. Oral Medications First-line treatment for ED usually involves phosphodiesterase type 5 (PDE5) inhibitors. These medications improve blood flow to the penis by relaxing blood vessels.
   • Sildenafil (Viagra) : Taken 60 to 90 minutes before sexual activity; effective for 4 to 5 hours.
   • Tadalafil (Cialis) : Can be taken as needed or daily; effective for up to 36 hours, providing more spontaneity.
   • Vardenafil (Levitra) : Similar to sildenafil, with a shorter duration of action (4 to 5 hours).
   • Avanafil (Stendra) : A newer PDE5 inhibitor with a faster onset of action, effective within 15 minutes.
   • Important considerations :
     • These drugs work for many men, but not all.
     • They require sexual stimulation to work and will not cause an erection without it.
     • They are contraindicated in men taking nitrates ( for heart disease), as this combination can cause a dangerous drop in blood pressure.
     • Side effects may include headache, facial flushing, nasal congestion, and dizziness.
3. Hormone therapy
   • Testosterone replacement therapy (TRT) : In men with ED due to low testosterone levels (hypogonadism), hormone replacement can restore normal testosterone levels and improve sexual function. TRT can be given by:
     • Injections
     • Topical gels/creams
     • Patches
     • Implants
   • TRT is only indicated if blood tests confirm low testosterone levels and other causes of ED have been ruled out. It may not be suitable for men with certain conditions, such as prostate cancer.
4. Intraurethral or intracavernous therapy If oral medications are ineffective or contraindicated, other options include:
   • Alprostadil (Caverject, Muse) : This medication can be administered directly into the penis by two methods:
     • Intraurethral suppository (Muse): A small amount of alprostadil is inserted into the urethra using a special applicator.
     • Intracavernous injection (Caverject, Edex): Alprostadil is injected into the side of the penis, producing an erection within 5 to 20 minutes.
   • These methods are often more effective for men who do not respond to oral medications, although they may cause pain, priapism (prolonged erection), or penile fibrosis (scarring).
5. Erectile Stimulation Devices (VED)
   • A vacuum pump is a mechanical device that helps draw blood into the penis by creating a vacuum around it.
   • A constriction ring is placed at the base of the penis to maintain the erection.
   • VEDs are effective for many men and are a non-invasive option. However, they can cause bruising, discomfort, or numbness in some cases.
6. Penile Implants (Surgery) For men who do not respond to less invasive treatments, penile implants may be an option. There are two main types:
   • Inflatable implants : These consist of two cylinders placed in the penis, a pump in the scrotum, and a reservoir in the abdomen. The man can control when to inflate and deflate the implant to produce an erection.
   • Malleable (semi-rigid) implants : These are rods inserted into the penis that allow manual adjustment for an erection. This type is simpler but less natural in appearance than inflatable implants.
   • Surgery is usually reserved for men who have exhausted other treatment options. Penile implants have a good satisfaction rate, but carry risks, including infection or mechanical failure.
7. Psychotherapy and counseling For men whose ED is due to psychological factors (e.g., anxiety, depression, relationship problems), therapy may be beneficial, either alone or in combination with medical treatments. Options include:
   • Cognitive Behavioral Therapy (CBT) : Helps address negative thought patterns related to sexual performance.
   • Sex therapy : Focuses on improving communication and intimacy between partners.
   • Couples counseling : Can help address relationship issues that may be contributing to ED.
   • Performance anxiety, stress, and depression are common psychological causes of ED, and treating them can significantly improve sexual function.
8. Emerging and experimental treatments
   • Low-intensity extracorporeal shockwave therapy (LI-ESWT) : A noninvasive procedure that uses shockwaves to stimulate blood flow and tissue regeneration in the penis. Early studies show promise, but it is still considered experimental.
   • Stem cell therapy and platelet-rich plasma (PRP) : These are experimental therapies being studied for their potential to regenerate erectile tissue, but they are not yet widely available for the treatment of ED.
9. Managing Underlying Conditions If ED is caused by another condition, such as diabetes, heart disease, or high blood pressure, it is crucial to manage that condition. Good control of blood sugar, cholesterol, and blood pressure can reduce the severity of ED and improve treatment outcomes.

Emerging Therapies: Extracorporeal Shockwave Therapy (LI-ESWT)

Low-intensity extracorporeal shockwave therapy (LI-ESWT) is emerging as a treatment option for erectile dysfunction (ED), particularly in cases related to vascular problems. It may improve erectile function by promoting better blood flow to the penis and potentially regenerating erectile tissue.

1. What is LI-ESWT?

LI-ESWT involves applying low-energy shock waves to the tissues of the penis. These waves, which are sound waves, stimulate biological processes such as the formation of new blood vessels and improve blood flow in the penis.

2. Operation of LI-ESWT for DE

LI-ESWT uses acoustic waves to trigger angiogenesis (formation of new blood vessels) and improve blood flow in penile tissue. The main mechanisms include:

• Increased blood vessel formation : Shock waves promote the release of growth factors, such as vascular endothelial growth factor (VEGF).
• Improved blood circulation : By increasing the formation of new microvascular networks, blood circulation to erectile tissues improves.
• Tissue regeneration : Evidence suggests that LI-ESWT may help repair erectile tissue by stimulating stem cells and activating cellular repair mechanisms.

3. Indications for LI-ESWT in ED

LI-ESWT is primarily considered for men with vascular ED, particularly those who:

• Have not responded well to oral medications (eg, PDE5 inhibitors).
• Wish to avoid or delay more invasive treatments, such as penile injections or surgery.
• Experience ED due to poor penile blood circulation, often associated with aging, diabetes, or cardiovascular disease.

4. Procedure

• Non-invasive and painless : LI-ESWT does not require anesthesia and is generally painless.
• Duration and frequency : A typical treatment protocol includes 6 to 12 sessions of 15 to 20 minutes, usually spread over several weeks.
• No downtime : Patients can return to normal activities immediately after the procedure.

5. Effectiveness and results

• Positive results : Clinical studies show that LI-ESWT can improve erectile function in men with mild to moderate ED.
• Long-lasting effects : The effects of LI-ESWT can last for a year or more, providing long-term advantages over medication.
• Variable response : Not all men will respond the same way, and effectiveness is generally greater in men with mild to moderate ED.

6. Safety and side effects

• Safe and well tolerated : LI-ESWT is considered safe, with few reported side effects.
• Minimal side effects : Temporary redness or bruising may occur, but serious effects are rare.
• No systemic effects : Unlike oral medications, LI-ESWT does not cause systemic side effects.

7. Comparison with other ED treatments

• Oral medications : LI-ESWT aims to improve underlying vascular health, unlike medications which offer a temporary solution.
• Injections or implants : LI-ESWT is a less invasive alternative to these treatments.
• Complementary treatment : It can be used in addition to other treatments for better results.

8. Current research and limitations

• Promising but evolving : Although the results are encouraging, LI-ESWT is still considered experimental.
• Non-universal protocol : There are variations in application protocols, which may affect results.
• Cost and availability : LI-ESWT is not yet widely available and may not be covered by insurance.

9. Who should consider LI-ESWT?

• Men with mild to moderate ED who have not responded well to medications or wish to avoid medications long-term.
• Men with vascular ED, such as those with cardiovascular disease or diabetes.
• Men looking for a non-invasive and long-lasting treatment option.

Summary

LI-ESWT is an emerging treatment for ED that uses low-energy shockwaves to improve blood flow and promote tissue regeneration. Although it shows promise, further research is needed to validate its long-term effectiveness and establish standardized protocols.

Platelet Rich Plasma (PRP) or P-Shot

Platelet-rich plasma (PRP) therapy is an emerging and experimental treatment for erectile dysfunction (ED). PRP involves injecting a concentrated dose of a patient’s platelets into the erectile tissues. The theory behind this treatment is that platelets contain growth factors that can promote tissue healing and regeneration, thereby improving blood flow and erectile function. Here’s an overview of PRP therapy for ED:

1. What is PRP?
   • Platelet-rich plasma is a component of blood that contains a higher concentration of platelets than are normally found in the blood. Platelets are rich in growth factors and proteins that are essential for healing damaged tissues and regenerating cells.
   • To create PRP, blood is drawn from the patient, processed in a centrifuge to concentrate the platelets, then injected into targeted areas, such as the penis in the case of ED.
2. How does PRP work for ED?
   • PRP is thought to help treat ED by promoting the repair and regeneration of erectile tissues, which include:
     • Blood vessels: PRP can stimulate the formation of new blood vessels (angiogenesis), improving blood flow to the penis.
     • Smooth Muscle Cells and Nerve Cells: PRP can also promote the regeneration of damaged nerves and smooth muscle cells, which are essential for achieving and maintaining erections.
     • Collagen and Elastin: Growth factors in PRP can enhance the production of collagen and elastin, enhancing tissue elasticity and overall penile health.
3. Indications for PRP in ED
   • PRP therapy is typically considered for men with ED who:
     • Have mild to moderate ED that may not respond well to medications such as PDE5 inhibitors (eg, sildenafil, tadalafil).
     • Prefer a more natural treatment option using their own biological material.
     • Have ED related to vascular problems or nerve damage (for example, due to diabetes or after prostate surgery).
     • Are looking for non-invasive treatment without the potential side effects of medications or surgery.

   However, PRP therapy is experimental , and its effectiveness is still being studied. It may not be effective for all men with ED, especially those with severe erectile dysfunction or significant underlying medical problems.

4. Procedure
   • Blood collection : The procedure begins with a standard blood draw from the patient.
   • Centrifugation : Blood is centrifuged to separate platelet-rich plasma from other components.
   • Injection : PRP is then injected into specific areas of the penis. The number of injections and targeted areas may vary depending on the clinician’s protocol.
   • Outpatient and minimal discomfort : PRP therapy is an outpatient procedure, and discomfort is usually minimal. A local anesthetic or numbing cream is usually applied to the injection site to minimize pain.
   • Duration and frequency : A single session typically lasts about 30 to 60 minutes. Multiple sessions (often 2 to 3, spaced over several weeks) are often recommended to maximize results, although protocols may vary.
5. Effectiveness and results
   • Limited evidence : Although there are anecdotal reports and limited studies suggesting that PRP may improve erectile function, large-scale, high-quality clinical trials are still lacking. The available studies have shown mixed results.
   • Potential benefits : Some men report improvements in:
     • The quality of erections (e.g., firmer and longer lasting erections).
     • Penile sensitivity (which can improve sexual satisfaction).
     • Overall sexual performance.
   • Varied response : The effectiveness of PRP appears to vary widely, with some men seeing significant improvements while others notice little or no change. Results may take several weeks to show and may last for several months, but repeat treatments may be necessary.
6. Safety and side effects
   • Generally Regarded as Safe : Because PRP uses the patient’s own blood, the risk of allergic reactions or adverse effects is low.
   • Minimal side effects : Potential side effects are generally mild and may include temporary pain or swelling at the injection site, bruising, or infection, although serious complications are rare.
   • No systemic effects : Unlike oral ED medications, PRP does not affect other parts of the body, avoiding problems such as headaches, dizziness, or digestive issues.
7. Comparison with other ED treatments
   • Oral medications (PDE5 inhibitors) : Medications like sildenafil or tadalafil offer temporary relief by improving blood flow to the penis but must be taken before each sexual encounter. PRP, on the other hand, is believed to provide longer-term benefits by regenerating erectile tissue.
   • LI-ESWT (Shockwave Therapy) : Both PRP and LI-ESWT aim to regenerate tissue and improve blood flow, but shockwave therapy uses acoustic waves, while PRP uses growth factors from the patient’s blood. These treatments can be complementary and are sometimes used together.
   • Injections (e.g., alprostadil) : Alprostadil injections produce immediate erections but do not treat the underlying cause of ED. PRP seeks to improve the health of erectile tissues, potentially offering a more lasting solution.
   • Penile implants : For men with severe ED, penile implants may be the most effective solution, but they involve surgery. PRP is much less invasive but may not be as effective for advanced cases of ED.
8. Current research and limitations
   • Small studies : Some small studies and clinical trials have shown promising results for PRP in treating ED, but larger, more rigorous trials are needed to determine its long-term effectiveness and establish standardized treatment protocols.
   • Not FDA Approved for ED : PRP therapy for ED is considered investigational, and the U.S. Food and Drug Administration (FDA) has not yet approved it specifically for this use. When it is used, it is off-label.
   • Protocol Variability : Different clinics may use different PRP concentrations, injection techniques, and treatment schedules, leading to inconsistent results.
   • Cost and availability : PRP therapy is typically not covered by insurance, and the cost can be high, ranging from several hundred to several thousand dollars per treatment. The treatment is available at specialty clinics that offer regenerative medicine services.
9. Who can consider PRP for ED?
   • Men with mild to moderate ED who are looking for alternative or complementary treatments to oral medications.
   • Men with ED due to vascular problems or nerve damage who may not have responded well to other treatments.
   • Men looking for non-invasive options that may improve erectile function over time.
   • Those who prefer autologous treatments (using their own biological material) with minimal risk of adverse effects.

Medical Management Summary:

1. Lifestyle changes are essential and often the first step.
2. PDE5 inhibitors (eg, sildenafil) are the first-line drug treatment for most men.
3. Hormone therapy may be necessary for men with low testosterone levels.

Understanding Erectile Dysfunction: Resources and Information

Explore detailed guides and PDF resources to learn more about erectile dysfunction and its treatment options.