Update erectile dysfunction: the little friend who won’t grow

4. February 2014
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Even among men well below 40 years of age a 'limp limb' is an often prevailing presence in the bedroom – erectile dysfunction is not limited to elderly patients. Alongside previously unknown risk factors, doctors have found new ways to treat the condition.

Erectile dysfunction (ED): Only relevant to elderly men? Not at all, reports Andrea Salonia of the Vita-Salute San Raffaele University, Italy. In one study, he examined 790 patients who had presented at an outpatient clinic with sexual dysfunction.

Young and limp

After going through a thorough medical history Salonia found 55.6 percent to have ED. About 26 percent of patients were no more than 40 years old. With these patients fewer comorbidities were able to be established, and testosterone levels were expectedly higher than that of fellow sufferers over 40. Nevertheless, younger patients consumed more illegal drugs and smoked more frequently. A severe form of ED occurred with 49 percent of all younger and 40 percent of all older men. It is indeed true that Salonia’s sample group is too small to make causal conclusions. Some years earlier however the Massachusetts Male Aging Study delivered similar results: four out of ten men around 40 suffer from ED. In later life, the risk increases by ten percent per decade. Andrea Salonia evaluated lifestyle to be a critical factor for younger people – in other words, nicotine and illegal substances. He urges colleagues in the practice not to limit putting together sexual histories for men only older than 40 years of age.

Search in the blood vessel

Jacob Rajfer from the Harbor-UCLA Medical Center in Torrance, California, wondered whether there might perhaps still be other explanations. His team pursued the question of what role inflow or outflow disorders play in younger men with ED. Together with colleagues Rajfer evaluated Doppler sonographies of 23 patients. Only in one case was there evidence of an arterial vascular disease. Also, with almost all study participants erectile tissue was able to be enlarged by 50 percent or more. Nine men underwent dynamic infusion cavernosometry for diagnostic purposes. It was found that the veins were more conducive than desired – a new aspect to consider. Rajfer criticised the fact that in the past many studies were carried out with men older than 50 years of age, for whom endothelial dysfunction had come about due to diabetes or hypertension. These explanations hardly fit the bill though when considering patients under 40. Here, the function of smooth muscle in the corpus cavernosum penis should be more thoroughly investigated. Without there being vascular ED present, new therapeutic concepts such as shockwave therapy make little sense. Relevant studies are currently running at Frankfurt University Hospital.

Free to travel on all tracks

For Patients with ED of atherosclerotic genesis there are yet other possible approaches. Jason H. Rogers from Sacramento, USA, treated affected people with a stent. He was able to show that sclerotic deposits in the arteria pudenda interna – this supplies the corpora cavernosa and the genitals – and in the iliac artery go hand in hand. For the purpose of attempting revascularisation Rogers chose 30 men for whom phosphodiesterase-5 inhibitors did not really work. He defined an improvement in the ED in relation to at least four items as listed in the International Index of Erectile Function (IIEF) for 50 percent of all participants as a primary endpoint. He unilaterally implanted a total of 27 stents in 19 subjects. Another eleven men were given a total of 29 stents on both sides. Cobalt chrome alloys were employed here. They contained the antiproliferative drug Zotarolimus embedded in BioLinx™ polymers. Thanks to this technology, there were no major complications such as stent thrombosis or arterial emboli. After six months 59.3 percent of all subjects achieved the primary endpoint. In addition, the peak systolic flow velocity improved in penile arteries. Jason H. Rogers writes in a comment that a critical success factor for stents is the selection of appropriate patients. Without there being randomised trials, these implants are not suitable for universal coverage.

Risks very restless

In addition to vascular triggers, researchers at the Harvard Medical School working under Xiang Gao identified another risk factor: patients with restless-legs syndrome (RLS) suffer significantly more often from ED. Gao’s prospective study included more than 10,000 men who were examined initially for RLS symptoms. With 331 subjects the doctors derived a positive diagnosis without there being evidence of sexual dysfunctions. By the time of the six-year follow-up 23.4 percent of this group had developed ED. In the comparison group, only 15.4 percent were affected. Men with five to 14 RLS episodes per month had a 34 percent higher risk; among patients with 15 or more RLS episodes this was as much as 49 percent. Xiang Gao writes that restless-legs syndrome is a risk factor of similar significance to diabetes mellitus, obesity, smoking and depression. Which processes essentially underlie this phenomenon is something researchers hope to find out. They have by a long way yet still not deciphered all pathomechanisms involved in erectile dysfunction.

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