Prevention of Erectile Dysfunction (ED)

Prevention of Erectile Dysfunction

Vascular disease: atherosclerosis, hypertension,  small vessel and arterial-medial disease: 

A.    Control hypertension, diabetes, hypercholesterolemia.
B.    Avoid rather specific trauma-ride bicycles with a wide atraumatic seat (to avoid chronic trauma to the pudendal arteries.)   Planning for pelvic surgery, radiation or cryosurgery should take into account predictable insult to pelvic arterial circulation.
C.    DO NOT SMOKE !!!
D.    There is some evidence that alchoholic liver disease is associated with small vessel disease, so excessive drinking is to be avoided. However, there is also some evidence that moderate ethanol use, possibly red wine, is good for vascular maintenance.
E.    Hormone replacement therapy in women and men is beneficial to maintain vascular tone.

Corporal fibrosis

Penile arterial insufficiency leads to corporal hypoxia and thus to corporal fibrosis.  Therefore, the measures described above also should tend to prevent corporal fibrosis.  True absence of erectile activity (including nocturnal erections) can lead to corporal fibrosis, because of   decreased corporal oxygenation, eg after radical prostatectomy. To prevent this, urologists have used vacuum erection therapy and pharmacologic-injection to maintain erections and oxygenation during the revascularization period. “Use it or lose it” is more than an addage.

Untreated or recurrent priapism results in corporal fibrosis and impaired erections.  The two leading causes for this are use of psychotropic medications (especially SSRI’s) and sickle cell disease. Such medications should be used with care, and all black patients should be screened for sickle cell disease.  Recreational drugs (Heroine and cocaine) have been reported to lead to priapism; patients at risk for using these substances should be so advised.

Peyronie’s disease is not known to be preventable. However, as the pathogenesis is considered to be an individual fibrotic reaction to microtears and microhematomas  in the septal portion of the t.albuginea of the penis, and, if Peyronie’s patients have a distinguishing biochemical feature accounting for the fibrotic reaction, then this should be subject to genetic manipulation once illucidated. Work for the future!.

Penile trauma, especially when there is a possible corporal tear, should be attended to promptly and repaired, to prevent corporeal insufficiency then and later.

Taking antioxidants to prevent corporal fibrosis and maintain corporal muscle mass has been suggested and often used. There is experimental evidence to support its use, but there is no good clinical data to show that they work.

Neurologic disease

Nerve-sparing surgery (during radical prostatectomy, cystectomy, hysterectomy, and during retroperitoneal and rectal surgery)  should be done when possible.  Avoidance of  trauma and other intercurrent disease is obvious, but  hard to plan.  

Certain vitamin deficiencies (B6 and B12, Vit D) can lead to neuropathies which interfere with erections. Avoiding these deficiencies would therefore have preventive value.

Careful of bike riding – chronic compression of pudendal nerves and arteries has been shown to interefere with erectile ability. Use a padded and wide seat.

Control diabetes to prevent diabetic neuropathy. Avoid excess alchohol to avoid alchoholic neuropathy, both short-term(reversible) and long-term(not reversible). 

Occult disc disease should be kept in mind. Cases of voiding dysfunction presenting as the only symptom of lumbar disc have been documented. Similarly, we have all seen ED patients with a history of disc disease, currently without pain, who demonstrate classic denervation hypersensitivity to pharmacologic injection during penodynamics.

Neurosensory disorders, such as multiple sclerosis, are often associated with sexual dysfunction. Pending development of genetic profiling and therapy for these, a seasoned degree of diagnostic acuity is the best preventive factor.

Hormone deficiencies

Actual surveillance of serum testosterone  in older men has been suggested by enthusiasts, but has not been accepted by most geriatricians.  If there are libido changes, then measurement and replacement is indicated.

Hormone Replacement Therapy  is accepted for women, not routine in men.  If testosterone replacement is considered in men, be sure PSA is ok and is monitored closely.

Hormone supplements taken for other reasons must be watched -testosterone  will turn off endogenous production and lead to testicular atrophy; DHEA can lead to estrogen excess and give gynecomastia and decreased erections.

Chronic ethanol abuse can lead to testicular toxicity, which can lead to low testosterone levels.  Alchoholic liver dysfunction, when severe, can also lead to decreased hepatic metabolism of adrenal estrogen, increased serum estrogen, with additional testosterone suppression.

Drug interactions

There are many drugs, particularly  antihypertensives, certain anti-peptic,  cholesterol-lowering , and antipsychotic drugs (and SSRI’s), antihistamines, and a-adrenergic drugs which have been reported to interfere with libido and erections, but a much smaller number which  have been shown in controlled experiments to interfere with erection. Rather than developing a “drug black list” it is more practical  just to monitor the  effect of any newly-started medication on erection, and to change the drug, if an obvious negative effect occurs.

Pelvic muscle tone

During erection and ejaculation, the bulb of the penis is compressed by the surrounding musculature, increasing intracavernous pressure and adding to rigidity. Maintenance of pelvic muscle tone , many believe, aids and abets this process. Therefore, regular exercise which maintains pelvic tone (real exercise, not Kegel and not sitting on a magnet) may be helpful, and certainly can’t hurt.  

Libido and depression

A.     Regular exercise keeps up endorphans which do maintain sexual drive.
B.     Signs of depression, which secondarily reduces  libido, eg anorexia, insomnia, should be recognized and treated promptly.
C.     Marital discord should be addressed promptly.  When relationships sag and/or turn sour, the concomitant estrangement makes subsequent sexual rehabilitation less successful.

Acute Prostatitis

Can make erections and ejaculation painful, and thus be inhibiting. Those men who have had recurrent prostatitis, should avoid the common prostatic irritants (caffeine, pepper and alcohol), and maintain good hydration and regular ejaculation.

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