Part 22: Types of Erectile Dysfunction and Western Medical Treatments

◇A Guide to Caring for Your Husband's Health as a Good Wife◇

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Treatment and recuperation of common diseases

Types of erectile dysfunction

For ease of treatment, erectile dysfunction is clinically classified into four types according to age:

Type I: Those under 20 years old who cannot have normal first intercourse or maintain a sufficient erection. The causes include family discord, psychological trauma, devout religious beliefs, and homosexuality. Most of these patients are treated by psychiatrists and are considered to have refractory and intractable erectile dysfunction.

Type II: 20-35 years old, average age 25. Mainly due to excessive mental stress during the honeymoon, unable to complete sexual intercourse. Sometimes there is a history of masturbation. There is abnormal psychogenic erectile function in the morning. There is only excessive sexual desire. This type of patient should be treated with psychotherapy.

Type III: Middle-aged men aged 30-35, whose erectile dysfunction is initially hidden, and who cannot be aroused by sexual desire, emotions, or passion under any circumstances. The cure rate for this group is 12%-26%, and they are in a low androgen level.

Type IV: Individuals aged 50-70 who have experienced significant psychological trauma, such as the death of a spouse, divorce, or reproductive tract surgery leading to erectile dysfunction and decreased libido. Acute episodes are associated with atherosclerosis, diabetes, and alcohol poisoning.

How does Western medicine treat this?

1. Medical treatment:

(1) Treatment of systemic diseases: For example, in patients with early-stage diabetes, proper diet control, use of insulin or oral hypoglycemic drugs can often lead to rapid improvement in sexual function.

(2) Discontinue medications that affect sexual function: Many medications, such as antihypertensive drugs, antipsychotics, diuretics, hormones, anticholinergics, and cardiovascular drugs, can cause impotence. Therefore, discontinuing these medications will help restore sexual function. However, before discontinuing them, the patient’s overall condition must be considered to determine whether to continue treatment of the primary disease, reduce the dosage, switch to other medications, or completely stop medication.

(3) Endocrine therapy:

Sex hormones or gonadotropins: For primary testicular insufficiency, testosterone can be used as replacement therapy; for hypothalamic or pituitary diseases, gonadotropins or luteinizing hormone-releasing hormone can be used. Testosterone propionate has a plasma half-life of 5-7 hours, thus requiring frequent dosing, which is inconvenient. For those intending to use it for a longer period, long-acting testosterone such as testosterone cyclopentylpropionate can be selected.

Adrenocortical hormones or thyroid hormones: Applicable to adrenocortical or thyroid hypofunction.

Dopamine enhancers or dopamine agonists: Suitable for patients with hyperprolactinemia caused by hypothalamic or pituitary disorders. Approximately 5% to 19% of patients with erectile dysfunction have hyperprolactinemia, which can be treated with bromoergot cyclopeptide.

Correcting metabolic disorders, such as diabetic ketoacidosis and metabolic acidosis.

Endocrine gland surgery: Surgical treatment of conditions such as hypothalamic and pituitary tumors, male feminizing hypercortisolism, or hyperthyroidism can help restore sexual function.

Non-hormonal drug treatment: yohimbine, an alpha-adrenergic blocker, can enhance the release of norepinephrine from nerve endings and reduce penile venous return. The usual dose is 6 mg three times a day. If gastric or neurological symptoms occur and the patient cannot tolerate the medication, the dose should be reduced to 2 mg three times a day and gradually increased (doubled weekly) until it reaches 18 mg per day. The medication should be continued for at least 18 weeks.

2. Intracavernosal injection of vasoactive drugs: Papaverine is a potent smooth muscle relaxant. Injection into the corpora cavernosa can dilate arteries and relax the smooth muscle of the trabecular bone, thereby increasing blood flow to the penis and inducing erection. It is suitable for vascular, neurogenic, endocrine, and refractory psychogenic erectile dysfunction, with an effectiveness rate of 70% to 97%.

The method involves stretching the penis along the inner thigh and injecting the medication vertically into the corpora cavernosa at the base of the penis using a 30-gauge needle. The medication and initial dose are determined based on the cause of erectile dysfunction and the patient's penile brachial artery index. For neurogenic and psychogenic erectile dysfunction, only papaverine (30 mg/mL) is used, with an initial injection of 0.25 mL. For other types of erectile dysfunction, a mixture of papaverine (25 mg/mL) and phentolamine (0.83 mg/mL) is used, also with an initial dose of 0.25 mL. For vascular erectile dysfunction with a penile blood pressure index less than 0.85, the initial dose is 0.5 mL. After injection, the penis is gently massaged to ensure even distribution of the medication within the corpora cavernosa. The patient can then go home, be encouraged to engage in sexual activity, and their response and side effects are monitored. If the effect is not significant, the dose can be doubled until functional erection is achieved, with each dose not exceeding 1.5 mL. If neurogenic or psychogenic erectile dysfunction does not respond to papaverine injection alone, combination therapy can be tried. If a functional erection is achieved after the injection, self-injection can be attempted. Follow up on medication use monthly and undergo physical examinations, and have liver function tests every 3 weeks.

3. Vascular surgery: Many cases of erectile dysfunction are caused by vascular lesions, and there are three common causes:

(1) Insufficient blood supply to the arteries: Atherosclerotic lesions of the aorta, common iliac, internal iliac, internal pudendal, dorsal penile or cavernous arteries can cause narrowing or embolism of the vascular lumen; pelvic fractures or perineal surgery can cause insufficient blood supply and lead to impotence.

(2) Venous abnormalities: Fistulas between the corpora cavernosa and the glans penis, and venous malformations of the tunica albuginea can all cause impotence due to excessive venous drainage.

(3) Arteriovenous fistula: Arteriovenous fistula in the pudendal vessels can cause impotence due to the shunting of arterial blood, so treatment should also be targeted at the above-mentioned causes.

For patients with arterial insufficiency, if the lesion is located above the level of the iliac artery, endarterectomy, percutaneous transluminal angioplasty, vascular resection and transplantation, or bypass surgery can be performed.

There are three surgical methods for treating lesions of small arteries:

(1) Vascular reconstruction of the corpus cavernosum.

(2) Microsurgical reconstruction of penile blood vessels.

(3) Venous arterialization.

Erectile dysfunction caused by venous abnormalities can be treated with surgeries such as deep dorsal vein surgery or direct treatment of venous fistulas. For cases caused by arteriovenous fistulas, direct treatment of the fistula is necessary to improve blood supply to the corpora cavernosa. Careful selection of indications is crucial before treatment, considering not only arterial inflow rate but also venous resistance.