Erectile Dysfunction - Conditions

Introduction

Conditions of Erectile Dysfunction vary over a wide variety of health complications. Principally, ED occurs frequently in those that suffer from:

• Obesity
• Diabetes
• Heart Attacks
• Radical Prostatectomy

Of course ED is not limited to these health conditions and can result from a variety of medical and non-medical related concerns.

Diabetes

How often do men with diabetes experience ED?

Erectile dysfunction is a common issue in diabetic men -- in fact, research indicates that men with diabetes are four times more likely to experience erectile dysfunction as men without diabetes.

Erectile dysfunction occurs 10-to-15 years earlier in men with diabetes than in men without diabetes and diabetic men with ED may also suffer more severe ED than men without diabetes. The severity of their ED also increases with age, length of time and poor diabetes control. ED may also worsen with the presence of cardiovascular complications and therapy.

Understand that, with proper treatment of diabetes, the chances of diabetic men being affected by ED are reduced, but not eliminated.

Why does diabetes cause ED?

Diabetes has to do with the body's metabolism. Most of the food we eat is broken down into glucose, a type of sugar in the blood. After digestion, glucose moves into the blood stream to help cell growth and energy. A hormone, called insulin, changes glucose into the energy the body needs for daily life. In people with diabetes, though, the body produces either too little or no insulin. People with diabetes may experience frequent changes of high and low blood sugar levels.

Very high levels of blood sugar associated with diabetes can affect the penis in a variety of ways, and lead to ED. The effects include blood vessel damage, nerve damage and damage to erection tissue itself. This nerve and blood vessel damage can disrupt normal sexual function.

Diabetes can cause neuropathy, or damage to nerves, throughout the body, including the penis. These damaged nerves cannot communicate properly, meaning that the proper information is not being relayed from the brain to the penis making it difficult to have an erection firm enough for intercourse.

Additionally, poor blood sugar control in diabetic men can slow the creation of certain chemicals in the penis that enable erections, such as nitric oxide. Nitric oxide is the major neurotransmitter involved in the development and maintenance of an erection. A lack of nitric oxide can prevent the pressure of blood from rising enough to close off the valve mechanism which allows blood to flow out of the penis, preventing the man from keeping his erection.

In diabetes, chemicals known as advanced glycation end-products (AGE) are associated with stiffening of certain tissues including erectile tissue. Stiffening of these tissues can lead to a defective valve mechanism inside the corpora cavernosa. Such a defect, known as 'venous leak,' can result in severe ED and poor response to erection drugs, in particular drugs like Viagra®, Levitra® and Cialis®.

Diabetes is associated with accelerated atherosclerosis, the hardening and narrowing of blood vessels. If the blood vessels become too narrow or hard, it can result in poor circulation of blood and oxygen into the penis. This, too, can affect pressure inside the penis and lead to ED.

What diabetes factors are predictors of ED?

Prolonged high levels of glucose in the blood of men with diabetes may be a predictor of ED. Control of blood glucose levels is an important risk factor for developing ED. Neuropathy, or damage to nerves in the body, including the penis, can also lead to ED.

Symptoms of coronary atherosclerosis (narrowing of the coronary arteries) or symptomatic coronary artery disease can be predictors of ED. Getting older, damaged nerves, retinopathy and long duration of diabetes can also be factors.

Also, many diabetic patients have asymptomatic (silent) coronary artery disease (CAD), which puts them unknowingly at risk for ED. In the case of CAD, high blood pressure and problems with cholesterol can also be predictors of ED.

Do men with diabetes and ED differ from the general population with ED?

Many oral ED medications may not work as well for men with diabetes. These men may need penile injections or penile implant surgery. ED can also indicate undetected cardiovascular disease in diabetic men.

Can ED in men with diabetes indicate other underlying conditions?

Erectile dysfunction with diabetes can indicate the presence of chronic diabetes complications, such as endothelial dysfunction. A healthy endothelium (a layer of cells that lines blood vessels) is important for cardiovascular health. Endothelial dysfunction is closely related to atherosclerosis and cardiovascular disease. This can be a signifier of silent or early cardiovascular disease such as coronary heart disease, stroke and peripheral vascular disease.

Radical Prostatectomy

What is the prostate?

The prostate is a donut shaped gland found only in men. It is roughly the size of a walnut. It is located just below the bladder. The prostate surrounds the urethra, which is the tube that carries urine from the bladder to the outside during urination or semen during ejaculation. The prostate produces about a quarter of the semen, the milky substance that comes out during ejaculation.

What is prostate disease?

The three most common problems that can develop in the prostate gland are:

• Inflammation, also known as prostatitis - this can be due to infectious or non-infectious causes. Infections can be treated with with antibiotics. Non-infectious inflammation is more difficult to treat.
• Prostate enlargement or benign prostatic hyperplasia (BPH) - BPH frequently occurs in men over the age of 50. It is a natural part of the aging process. BPH can result in a gradual squeezing of the urethra, sometimes making it hard to urinate. The symptoms associated with BPH are called lower urinary tract symptoms (lurts).
• Prostate cancer -This is the most common cancer in older men and the second leading cause of cancer deaths in the US. Researchers estimate that about 225,000 men are diagnosed with prostate cancer and about 30,000 die of prostate cancer in the United States each year.

How does prostate disease cause ED?

Men with lower urinary tract symptoms (LUTS) are more likely to have ED. The more severe the LUTS, the more severe the ED. These difficulties may include getting up to urinate at night, having to urinate often and urgently and trouble urinating. Such symptoms can be due to BPH, studies have shown a strong and consistent link between LUTS, BPH and ED.

Surgical removal of the entire prostate gland for the treatment of benign prostate enlargement or prostate cancer, or surgical removal of the bladder and prostate for the treatment of bladder cancer often injure the nerves and arteries leading to the penis. This usually causes at least temporary ED. ED can also result from the various forms of radiation therapy that are used to treat prostate cancer. Also, hormone treatment for advanced prostate cancer, which occurs when prostate cancer has spread outside of the prostate to other organs, reduces a man's sexual desire and erection function.

Why is prostate surgery (radical prostatectomy) associated with ED?

In 2003, about 225,000 men were diagnosed with prostate cancer in the United States. 45% of these men received treatment by surgical removal of the prostate gland (radical prostatectomy.) The majority of those men who have had this surgery will experience temporary or permanent ED.

Radical prostatectomy is an operation that completely removes the prostate and the surrounding tissue. Prostate surgery can be:

• Nerve-sparing (keeping intact the nerves which lead to the erection chambers and provide the stimulation for erection)
• Non nerve-sparing (not preserving these nerves)

Even if the majority of the nerves are preserved in the surgery, temporary ED is common.

When the nerve-sparing technique is used, particularly bilateral nerve-sparing, permanent ED is less common than with non-nerve sparing surgery and recovery often occurs within the first year or two following the procedure.

ED from a non-nerve-sparing procedure is common and recovery of erectile function after a non-nerve-sparing technique is unlikely though not impossible.

Erectile function following surgery depends on an individual patient's age, anatomy, extent of cancer and preoperative sexual function.5 Most studies report that 50-80% of men who have a radical prostatectomy have some degree of ED for the first year after surgery even if the surgeon is able to spare all or part of the nerves.6 Even in bilateral nerve-sparing surgery, return of erectile function may take up to 12-24 months. Eventually though, erections adequate for vaginal penetration return in 40-80% of men. Unilateral nerve sparing technique produces results that are intermediate between bilateral and non-nerve sparing surgery. Also, duration of time from the surgery to treatment for ED can play a role in the effectiveness of different therapeutic options.

Other sexual complications following radical prostatectomy include the absence of ejaculation or dry orgasm (orgasm without discharge of semen) in all cases, and loss of penile length in some men.

Do men respond to PDE5 inhibitors after having prostate surgery?

The first line of treatment for ED following prostate surgery is oral medications, such as phosphodiesterase-5 inhibitors (PDE5i) - sildenafil (Viagra®), vardenafil (Levitra®) and tadalafil (Cialis®). About 70% of men respond in some fashion to oral drug therapy in the post-operative setting.

Since these drugs are designed to increase blood flow to the penis upon sexual stimulation, they require intact nerves and arteries. Men receiving the nerve-sparing prostatectomy generally have a better response.

(will have a link here to our section on PDE5i that provides readers with basic information about these oral medications)

Does self-injection therapy used after prostate surgery help erectile function?

Penile self-injections provide very effective treatment of ED after prostate cancer surgery. Some studies report that penile self-injections can achieve a 95% success rate. Self-injection therapy is usually used after trying oral medications because of the convenience of oral therapy.

The role of oral, self-injection, intraurethral and vacuum therapies after treatment for prostate cancer:

For men who have had surgical or radiation treatment for prostate cancer, evidence suggests that oral, self-injection treatments started soon after treatment may improve the chances for later recovery of natural spontaneous erections. Oral therapy can be used with any of the three PDE5 inhibitor drugs. There are three vasodilator drugs used for self-injection therapy:

• papaverine,
• phentolamine and
• Alprostadil, a type of prostaglandin E 1.

Injection of Alprostadil may cause penile pain. If this occurs, lowering the dose of Alprostadil and/or mixing Alprostadil with papaverine and phentolamine may reduce or eliminate the pain. The prescription drug called MUSE is used in intraurethral therapy.

Penile implants are a third line therapy, with a success rate of about 80-90%. They are the single most reliable form of treatment for erectile dysfunction, and they provide an excellent solution to the problem of erectile dysfunction.

(will have a link here to our section on each of these treatments that provides readers with their basic information)

Is prostate surgery associated with penile shortening?

Decreased penile length is commonly experienced following radical prostatectomy. In one study, loss of penile length ranging from 0.5 to 4 cm (about 1/4 to 1½ inches) was experienced in 71% of men, although only 48% of men reported a loss over 1cm (about ½ inch). Some experts believe that penile shortening can be reduced by starting oral, self-injection, intraurethral and/or vacuum therapy a few weeks after surgery.

Is it normal for men to leak urine during an orgasm?

Some men may leak urine during sexual activity and/or orgasm following prostate surgery, but the amount and frequency of leakage usually decrease over time. One way to help avoid leaking is to empty the bladder completely before sexual intimacy. Strategies used to minimize this problem have included wearing condoms, certain medications (the antidepressant imipramine, for example) and the use of a constriction band after the achievement of an erection (like the ACTIS tension band).

Radiation Therapy

How does radiation therapy cause ED?

Radiation therapy is a well-known cause of ED. Radiation therapy uses high levels of radiation to damage cancer cells's DNA in an effort to destroy them or keep them from growing and dividing, while minimizing damage to the surrounding healthy cells. Both pelvic external beam radiotherapy and seed implants (brachytherapy) are used to treat prostate cancer.

Radiation therapy in the pelvis area of men can cause ED in 3 possible ways:

• Arterial damage may block blood flow and/or damage the lining of the blood vessels that carry blood to the penis
• Nerves in the pelvic area may become permanently damaged
• Erectile tissue may be damaged, reducing blood flow to the penis and/or causing leakage of blood from erectile tissue (venous leak) during an erection

Some of the sexual side effects after radiation therapy are:

• Inability to achieve or maintain an erection (erectile dysfunction)
• Weaker, less satisfying orgasms
• Pain during ejaculation (although this usually goes away within several weeks)
• Dry orgasm or retrograde ejaculation (orgasm without the discharge of semen)
• Less semen ejaculated

There are three main factors that determine the extent of vascular damage that occurs following radiation exposure:

• Dose of radiation
• The higher the dose the greater the degree of vascular damage
• The amount of area exposed to radiation; the wider the area exposed, the more significant the damage
• The existence of vascular risk factors1

How common is it for men to experience ED following radiation therapy?

Radiation therapy is a well-known cause of ED. Although ED may begin about six months after treatment, and progress gradually, it is the most common long-term complication of radiation therapy.

There is a 20 - 80% chance of ED from radiation therapy. There seems to be an increase in sexual dysfunction rates as time goes by following radiation therapy. One study revealed that two years after radiation therapy, 61.5% of men reported they had ED.

Other predictors of ED can include patient age, pre-treatment erectile function, method and dose of radiation delivery, the use of neoadjuvant (pre-surgery) hormone deprivation and the duration following radiation at which the patient is assessed by a physician. Also, men who smoke or who have a history of heart disease, high blood pressure or diabetes also may be at a higher risk of ED. These conditions may have already caused some artery damage which becomes further damaged by the radiation, Older men (especially those over 60) may find that treatment accelerates the sexual side effects associated with normal aging.

Radiation specialists have developed new techniques that target just the prostate and avoid surrounding tissue, nerves and blood vessels essential in erectile function.

How soon after having radiation therapy are men likely to have ED?

Even with the most precise radiation therapy, men may experience some ED for the first few months after treatment. Many of the sexual side effects of radiation are slow and gradual, and may take as long as six months to several years to appear. Unfortunately, radiation-induced ED is usually permanent.

There are a number of treatments available. These include early post-treatment evaluation and early institution of a trial of drug treatment as soon as the patient experiences any trouble with his erectile function. Men are encouraged to develop regular erections with or without sexual relations and they are followed up on a regular basis to ensure appropriate early treatment.

First line therapy includes management of related medical conditions and psychological support combined with oral therapy. Second line includes vacuum erection device therapy, penile injection therapy, and transurethral prostaglandin suppository administration. Third line therapy is penile implant surgery.

Does anti-androgen therapy make ED either better or worse?

Hormone treatment (also called androgen deprivation therapy or androgen suppression therapy) for prostate cancer attempts to stop, block or remove the production of testosterone and all androgens to slow down or stop the progression of cancer. When hormone therapy is used, it is common for sexual problems to occur within the month following the beginning of therapy.10 In addition to causing ED, hormone therapy can also reduce a man’s sex drive.

Other common sexual side effects with hormone treatment include4:

• Inability to get or keep an erection (ED)
• Difficulty climaxing
• Orgasm without discharge of semen (dry orgasm)
• Weaker, less satisfying orgasms

Younger men tend to have fewer side effects from hormone therapy.