Men's Health: In-depth Analysis of the Causes of Erectile Dysfunction and a Comprehensive Guide to Five Major Clinical Treatment Options

Erectile Dysfunction

Erectile dysfunction (ED) is one of the most common male sexual dysfunctions. Many people mistakenly believe that the inability to penetrate is ED, but this is not the case. When penetration is impossible, the female partner should be ruled out first. Vaginal spasms, thickened hymen, and vaginal structural abnormalities can all cause intercourse failure, but these are not necessarily caused by male ED. The International Society for Erectile Dysfunction defines ED as: "The inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse." In China, the medical community defines ED as: the inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse, or the inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse. Only when these symptoms are met can it be termed ED.

Modern sexual medicine generally classifies ED into psychogenic (also called mental or functional), vascular (further divided into arterial, venous, and mixed types), neurogenic, endocrine, and drug-induced ED. From another perspective, erectile dysfunction can be categorized into primary, secondary, and situational types.

Among these, vascular erectile dysfunction accounts for the majority of organic erectile dysfunctions, and among the three types—arterial, venous, and mixed—venous erectile dysfunction has the highest incidence. It is now believed that venous erectile dysfunction is caused by abnormalities in the venous system of the corpora cavernosa, resulting in reduced pressure and causing a large amount of blood to leak from the veins during erection, leading to insufficient erection rigidity or short duration.

If work stress, fatigue, alcohol consumption, illness, or significant psychological stress occurs, temporary inability to achieve or maintain an erection may occur. However, once these factors disappear, the penis will return to normal erection; this situation does not constitute true erectile dysfunction. However, if the aforementioned factors persist over a prolonged period, the individual may experience new negative psychological states such as anxiety, depression, shame, and low self-esteem. If this is compounded by a wife's lack of understanding, complaints, or even ridicule, this temporary phenomenon can transform into a recurring or even long-term pathological condition, thus becoming true erectile dysfunction. The patient may feel guilty and desperately try to regain an erection during sexual activity, but their inability to achieve it exacerbates their anxiety and leads to a loss of self-confidence. Clearly, erectile dysfunction and negative psychological states can create a vicious cycle, gradually worsening the symptoms. Regardless of the type of erectile dysfunction, treatment is often ineffective without overcoming negative psychological factors. Therefore, the first step in treating erectile dysfunction is psychological counseling to relieve the patient's psychological burden. Some cases of erectile dysfunction are caused by early childhood or even childhood psychological disorders, or by subconscious negative factors that are not easily detected; in these cases, psychological treatment is even more necessary.

Behavioral Therapy

Behavioral therapy is one of the treatment methods for psychogenic erectile dysfunction. Sexual behavior, like other behaviors, is learned, and sexual dysfunction is the result of incorrect learning. Therefore, it can be corrected through relearning. The specific method involves a series of progressively more challenging sensual focus training exercises to separate the patient's fear response from the sexual intercourse scenario, thereby eliminating anxieties. Sensual focus training mainly includes three steps:

① Mutual touching of non-sexually sensitive areas between partners.

② Mutual touching of sexually sensitive areas (such as breasts, external genitalia, and individual specific sensitivity areas).

③ Completion of penile insertion and intercourse. This is a systematic desensitization process, lasting 1-2 months, aiming to remove anxiety about intercourse through progressively escalating physical contact and expression of sexual pleasure between partners.

Instrumental Therapy

Psychogenic erectile dysfunction is often treated with non-invasive male genital therapy devices. This device simulates the vagina and passively erects the penis, allowing patients to witness the entire process of their penis swelling and becoming erect, building their confidence in achieving an erection. Since its purpose is not immediate intercourse, it eliminates anxiety and other negative psychological factors, clearing obstacles to natural erection. The device also improves blood circulation in the penis, stimulates and promotes the reconstruction of a benign erectile reflex in the sexual nerve center, with a success rate exceeding 80%.

Medical Treatment: This primarily treats systemic diseases. For example, in early-stage diabetes patients, appropriate dietary control, intramuscular insulin injections, or oral hypoglycemic agents often lead to rapid improvement in sexual function; discontinuing medications that affect sexual function is also important. Many medications, such as antihypertensive drugs, antipsychotics, diuretics, hormones, anticholinergics, and cardiovascular drugs, can cause erectile dysfunction; therefore, discontinuing these medications will facilitate the recovery of sexual function. However, before discontinuing medication, the patient's overall condition must be carefully assessed to determine whether to continue treatment of the primary disease by reducing the dosage, switching to other medications, or completely stopping the medication. In addition, there is endocrine therapy, including the use of sex hormones or gonadotropins, adrenocortical hormones or thyroid hormones, dopamine enhancers or dopamine agonists, etc.

Penile Prosthesis Implantation Surgery

Patients with complete erectile dysfunction can undergo surgical treatment by implanting a penile prosthesis. In recent years, two new inflatable penile prostheses have been introduced. Their characteristic is that the cylindrical silicone capsule, infusion pump, and reservoir are assembled into a single prosthesis, reducing the occurrence of mechanical failures even during surgical placement. Another type of prosthesis uses a mechanical knob to adjust the penis from a flaccid state to an erect position without the need for fluid filling and emptying. While penile prosthesis implantation within the corpora cavernosa is widely recognized as an effective treatment for erectile dysfunction, a perfect prosthesis is still lacking and requires further improvement.

Vascular Surgery

With advancements in diagnostic technology, many cases of erectile dysfunction have been found to be caused by vascular lesions. Common causes include insufficient arterial blood supply, venous abnormalities, and arteriovenous fistulas. For arterial insufficiency, procedures such as endarterectomy, percutaneous endovascular angioplasty, vascular resection and transplantation, or bypass surgery can be performed. Surgical methods for small artery lesions include vascular reconstruction of the corpora cavernosa, microsurgical reconstruction of penile vessels, and venous arterialization. Erectile dysfunction caused by venous abnormalities can be treated with deep dorsal vein surgery and direct treatment of venous fistulas. Erectile dysfunction caused by arteriovenous fistulas requires direct treatment of the fistula to improve blood supply to the corpora cavernosa.

Intracavernosal injection of vasoactive drugs: Papaverine is a potent smooth muscle relaxant. Injection into the corpora cavernosa causes arterial dilation and relaxation of the trabecular smooth muscle, thereby increasing blood flow to the penis and inducing erection. It is suitable for vascular, neurogenic, endocrine, and refractory psychogenic erectile dysfunction.