The article is devoted to sexual dysfunctions, which are currently accepted divided into primary and secondary. Particular attention is paid to erectile dysfunction as a disease that significantly reduces the quality of life. Erectile dysfunction not only deprives a man of sexual pleasure, but also causes a strong decrease in overall life satisfaction, worsens partnerships, although many wives attach less importance to decreased erection than the husbands themselves, lowers mood, even to the point of depression, and affects self-esteem. Most scientists call erection the main manifestation of sexuality in men. The article provides data on the etiology, pathogenesis, physiology and anatomy of erection. Risk factors divided into three groups are considered. Data are provided on the differential diagnosis and treatment of erectile dysfunction using the SISL model (removal of the prohibition, information, advice, treatment), which can be used by doctors of all specialties. Our article also examines the topic of adaptation as a process of maintaining the functional state of the homeostatic systems of the body as a whole, ensuring its preservation, development, performance, and maximum life expectancy in inadequate environmental conditions. The pathophysiological mechanism of the connection between erectile dysfunction and adaptation disorders is given. The article talks about indirect iatrogenics and other reasons that force patients with erectile dysfunction not to seek medical help.
Keywords: adaptation, adjustment disorders, sexual dysfunction, erectile dysfunction, treatment erectile dysfunction.
In the modern world, where the duration of human life and its value are steadily increasing, conditions such as sexual dysfunction, which significantly reduce the quality of life, deserve special attention from doctors and psychologists.
It is known that sexual dysfunction has very diverse causes and is due to both psychological, mental, and somatic reasons. There are primary and secondary sexual dysfunctions; the concept of impotence (Latin impotentia — weakness, impotence) is little used due to its inconsistency with the true essence of the pathological process.
Primary , developing without connection with any other disease, sexual breakdowns with subsequent neurotic fixation are pathoreflex. Dysfunctions due to systematic violations of the physiological program of sexual intercourse (interruption or prolongation) are dysregulatory; due to sexual abstinence — withdrawal symptoms; and finally, due to the constitutional inferiority of the morpho-functional structures responsible for the neuro-humoral regulation of sexual function — constitutional-genetic.
Secondary , or symptomatic, disorders include sexual dysfunction, which is a specific syndrome of various diseases of the nervous, endocrine, genitourinary or other systems. In men, it is customary to identify disorders of the erectile and ejaculatory components of the copulatory cycle, while in women, as a rule, frigidity, anorgasmia, and in both of them, alibidemia.
Modern understanding of the etiopathogenesis of erectile dysfunction
Erectile dysfunction is a common disease. Men on all continents suffer from this disease. According to WHO, 150 million men worldwide have erectile dysfunction. Due to the increase in life expectancy in the coming years, their number should double and amount to approximately 322 million men in 2025 [2]. The greatest increase in the number of cases of erectile dysfunction is expected in developing countries, which is primarily due to a lack of funds and inadequate nutrition, chronic stress, the presence of somatic pathologies and the lack of access to sexological help due to the lack of training of general practitioners and mid-level specialists, as well as low sexual literacy of the population, false shame and ignorance, lack of knowledge about sexual hygiene.
Physiology of erection
Erection is the main manifestation of sexuality in men; it is expressed in increased elasticity of the penis, an increase in its size due to increased arterial blood flow into the corpora cavernosa and difficulty in the outflow of venous blood from them. There are spontaneous and adequate erections. Spontaneous, as a rule, arise without the participation of higher cortical centers of sexuality. In young people they arise during erotic fantasies and perception of erotic information. With age, this property disappears, and spontaneous erections persist only upon awakening, during sleep, with a full bladder, abstinence, congestion in the pelvic organs, as well as with stimulation of the spinal center, irritation of the external genitalia.
Adequate erections occur with the participation of higher cortical centers, in response to sexual stimulation. They are not stable and depend on psycho-emotional factors and external conditions. With experience, this mechanism becomes more stable.
Anatomy
The deep artery of the penis pierces the tunica albuginea and enters the corpus cavernosum, where it divides into many corkscrew-shaped arteries that open into the cavernous spaces. Ebner's pads protrude into the lumen of the arterioles — smooth muscle elements, which, when contracting, change the blood supply to the cavernous bodies. Three groups of veins drain the penis: superficial, intermediate and deep. The veins pierce the tunica albuginea at right and oblique angles, this ensures blocking of the outflow along with the valve apparatus of the veins. Cavernous tissue has a mesh structure of cavernous spaces lined with endothelium and separated by trabeculae. It contains smooth muscle fibers, which also ensures an erection.
During erection, intracavernosal pressure increases due to an increase in blood inflow by 3–4 times and a sharp decrease in blood outflow. The pressure increases in the corpora cavernosa much more than in the corpus spongiosum of the urethra [7].
Mechanism of erection development: sexual stimulation → increase in parasympathetic activity → release of NO → increase in the concentration of intracellular cGMP → relaxation of vascular smooth muscle cells, vasodilation → increased blood flow → compression of venules and blockage of outflow from the penis → erection.
Erectile disfunction
Erectile dysfunction is a persistent inability to achieve or maintain an erection sufficient for sexual intercourse [6].
Despite the apparent indifference of this disease to health, this disease has a great impact on the general condition of a person, significantly worsening the quality of life and health in general. Erectile dysfunction not only deprives men of sexual pleasure, but also causes a strong decrease in overall life satisfaction, worsens partner relationships (although many wives attach less importance to decreased erection than their husbands do), lowers mood, even to the point of depression, and affects self- esteem [11, 15]. All this leads to a deterioration in the quality of life of patients and reduces performance. Contrary to the above, 85 % of patients do not seek treatment, while the rest do so with great delay [6]. This behavior is explained by a reluctance to see a doctor and increased sexual shyness of men [14]. Meanwhile, according to I. S. Kohn, 95 % of all cases of erectile dysfunction are curable [6]. Patients suffering from this disease do not go to doctors because many doctors lack the skills to communicate confidentially and trustingly with patients, as well as due to the lack of sexologists. They often turn to psychologists who, although they have communication skills, try not to pay attention to this topic, even when the client states it as the main one. Another problem is indirect iatrogeny — the doctor’s (or psychologist’s) conviction that problems of sexual desire can be considered separately from the entire complex of a person’s psychophysical life, as if in isolation from this complex [3].
Classification .
1. Organic erectile dysfunction (30 %-80 %) Causes:
– Vascular
– Neurogenic
– Hormonal
– Medication
– Injuries and diseases of the penis
– Kidney failure and hemodialysis
2. Psychogenic erectile dysfunction — occurs due to central inhibition of erection mechanisms without structural changes (20 % — 70 %)
Causes:
– Depression and anxiety
– Loss of partner and withdrawal Lack
– of sexual literacy Other
3. Mixed erectile dysfunction — a combination of organic and psychogenic factors [2].
Differential diagnosis.
Psychogenic erectile dysfunction
- Sudden onset of the disorder
- Sudden and complete loss of function
- Nocturnal erections are preserved
4. Dependence on partner and environment (selective disorder)
5. May appear during masturbation
Organic erectile dysfunction
- Gradual start
- Gradual progression of the disorder
- Nocturnal erections are impaired or absent
- Erection is always impaired
- Does not occur during masturbation.
Risk factors for erectile dysfunction:
1. Chronic diseases:
– Systemic diseases (atherosclerosis, diabetes mellitus, cardiovascular diseases, renal and liver failure)
– Neurological diseases (Alzheimer’s disease, multiple sclerosis, spinal cord lesions, etc.)
– Pathology of the penis (Peyronie's disease, etc.)
– Mental illnesses
– Endocrine diseases (hyperthyroidism, hypothyroidism, hypogonadism, hyperprolactinemia)
2. Surgical interventions and injuries, as well as radiation injuries to the pelvic area. At the same time, chronic prostatitis is not the cause of erectile dysfunction, but removal of the prostate can lead to this [13].
3Pharmacotherapy and use of substances that alter metabolism (alcohol, smoking, drugs). Medications:
– antihypertensives (thiazide diuretics, β-blockers)
– antidepressants
– hormonal drugs
– tranquilizers
– others (digitalis, antihistamines).
This side effect is always indicated in the annotation, but it is necessary to explain to patients that during the treatment of a somatic or mental illness, sexual disorders may occur.
Pathophysiological relationship between adaptation disorders and erectile dysfunction.
Adaptation is the process of supporting the functional state of the homeostatic systems of the body as a whole, ensuring its preservation, development, performance, and maximum life expectancy in inadequate environmental conditions [5]. Or, as defined by F. Z. Meyerson, adaptation is the process of gaining resistance to certain environmental factors and gaining the opportunity to live in conditions previously incompatible with life, to solve problems that were previously unsolvable [9].
Adaptation disorders from a pathophysiological perspective are a violation of the adaptation process or adaptation (syndrome) process. ICD-10 defines adjustment disorder as a state of distress and emotional disturbance that interferes with social functioning and productivity that occurs during adjustment to a significant life change or stressful life event.
It has been revealed that testosterone levels in people who have experienced stressful situations are below the average statistical norm for the male population of the central regions of the European part of Russia, while the values of follicle-stimulating and luteinizing hormones remain within normal limits [12, 1]. A clinical study of men who experienced a stressful situation in seismically active zones of Armenia (Leninakan, Kirovakan, Spitak, etc.) revealed sexological disorders in the form of erectile dysfunction, decreased libido, and orgasm disorders. Hormonal studies revealed a sharp decrease in the concentration of testosterone in the blood and an increase in the level of corticotropin [10].
Results of the 1986–1988 study. Veterans of the Vietnam War reveal a significant increase in sexual disharmony among American military personnel who experienced combat stress: 40 % of men who participated in combat operations divorced their wives once, 10 % — two or more times, 14.1 % reported serious marital problems. Problems [1].
From a physiological point of view, the occurrence of sexual dysfunction in adaptation disorders looks completely natural, since it is parasympathetic activation that causes an erection, passing through the cavernous nerves from the branches of the pelvic plexus, and the excitation of sympathetic structures, characteristic of stress, on the contrary, through stimulation of the hypogastric plexus and ganglia borderline sympathetic trunk, leads to detumenescence. The main neurotransmitter that causes detumenescence is norepinephrine — by stimulating adrenergic alpha receptors in the cavernous trabeculae and cavernous arteries, it spasms the arterial vessels of the penis [7].
This indicates a physiological connection between sexual dysfunctions, in particular erectile dysfunction, and adaptation disorders.
Other mechanisms for the formation of sexual dysfunctions in adaptation disorders are also described [4, 6].
The influence of psychological and social factors on pathogenesis and the connection between the risk of developing sexual dysfunctions and the patient’s personal characteristics require further study.
Treatment of erectile dysfunction
To carry out quality treatment, it is necessary to remember that the doctor is obliged to “treat the patient, not the disease,” based on this, the treatment of erectile dysfunction should be approached systematically, not considering only the pathology of the genital organs, but paying attention to all the patient’s problems. For the treatment of sexual disorders, especially functional ones, the SISL model is used (S — lifting the prohibition, I — information, S — advice, L — treatment) [4].
C — the doctor seeks a frank conversation about the patient’s sex life;
And — provides the necessary information (limited), fighting ignorance and distorted ideas about sexuality;
C — stimulates self-confidence, the patient often finds himself able to overcome his difficulties;
L — treatment refers to various methods (they are resorted to when SIS is ineffective):
– Pharmacotherapy
– Psychotherapy
– Surgical treatment
– Vacuum therapy.
Pharmacotherapy .
Various groups of drugs are used: 1
- Phosphodiesterase-5 inhibitors (Cialis, Viagra, Livitra)
- Adrenergic blockers (yohimbine, phentolamine)
- Dopamine receptor antagonists (apomorphine)
- Serotonin uptake blockers (trazodone)
- Neuroleptics (sonapax) Androgens (testosterone, andriol)
- Prolactin inhibitors (bromcreptin, parlodel)
- Adaptogens(pantocrine,eleutherococcus)
- Peripheral vasoactive drugs (nitro ointment)
- Intracavernous injections (alprostadil, papaverine)
- Biogenic stimulants (aloe, vitreous) Vitamins and amino acids (aevit, glycine)
- Vasoactive drugs with systemic action (xanthinol nicotinate)
- Herbal medicines (Tentex-forte)
The most popular and one of the most effective are phosphodiesterase-5 inhibitors [2, 15, 16, 17, 20]. But when prescribing them, it must be remembered that they are contraindicated when using any forms of nitrates. It is interesting that after the advent of Viagra, doctors decided that it would also help women, since a partial female analogue of erectile dysfunction is dryness or insufficient hydration of the vagina; this phenomenon, just like in men, can be psychogenic or organic (due to an infectious disease, estrogen deficiency, etc.). Studies have shown that Viagra actually improves muscle tone and vaginal hydration, however, unlike men, for whom penile erection itself, even in the absence of expressed desire, stimulates sexual activity, women’s experiences are associated with more subtle psychological — chemical conditions that neither Viagra, nor Levitra, nor Cialis, of course, affect.
Therefore, further studies were stopped [15, 16].
Psychotherapy
Used in the absence of organic lesions. This treatment is carried out by a psychologist or psychiatrist.
There are various options for psychotherapeutic treatment:
– relieving anxiety and fear
– temporary prohibition of sexual intercourse
– Masters-Johnson exercise “Sensual focus” (The essence of the exercise is to switch your sensory-erotic perceptions and sensations from the genitals to other parts of the body) [8, 18, 19].
– trainings and more
Vacuum therapy .
This treatment option is used for psychogenic and some organic erectile dysfunctions. Special vacuum devices are used — erectors. In some cases, they can make it difficult to ejaculate, which is a side effect.
Surgical treatment.
Indicated for subcompensated and decompensated erectile dysfunction. Surgeries are used aimed at creating additional arterial inflow to the corpora cavernosa (revascularization of the penis). The most common revascularization operations using the Virag and Hauri techniques are various types of anastomoses between the inferior epigastric artery and the dorsal vein of the penis.
Prosthetics
The ineffectiveness of drug therapy and revascularization of the penis is an indication for penile endoprosthetics. Penile prostheses are silicone rods or balloons in shape and size corresponding to the cavernous bodies. During the operation, the corpora cavernosa are bougiered along their entire length, and penile prostheses are implanted into the formed canals. Modern plastic and hydraulic models of prostheses make it possible to simulate the penis, simulating a natural erection in accordance with functional needs. The high efficiency of prostheses has made this method a priority among surgical ones. However, many men feel uncomfortable with dildoendoprostheses and subsequently refuse them.
Conclusion
Considering the widespread prevalence of erectile dysfunction and the potential increase in this pathology, it is necessary to attract more attention to it from doctors, not only those involved in the treatment of the genital area, but also general somatic specialists, psychotherapists and psychologists.
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