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As previously mentioned, there is a well-defined sequence of events that take place to enable an erection.

ED can occur when any of these events are disrupted. Brooks & Jordan (2001) states the cause in more than 75 % of the cases is physical rather than psychological and that the most common cause is damage either to arteries, smooth muscles or fibrous tissues and those damages accounts for approximately 70 % of the cases. The condition can be categorized as psychological or physical or both.

Psychological factors include stress, anxiety, and guilt, lack of self-esteem, depression, and fear of sexual failure. Physical factors are more prominent, and can be things such as: System diseases, for example: cardiac, hepatic, renal, pulmonary, cancer, metabolic, post organ transplant, pelvic irradiation.

Androgen deficiency, as androgen resistance, other endocrinopathies.

Vascular insufficiency, like atherosclerosis, pelvic steal, penile Raynaud’s syndromE, venous leakage. Neurological disorder: Parkinson’s, Alzheimer’s, Shy-Drager, encephalopathy, spinal cord or nerve injury. Penile disease: Peyronie’s disease, priapism, phimosis, smooth muscle dysfunction, trauma.

Many of the above causes of this disease relate to high age. (2007) states that 69.4 % of all 70-76 year old men suffer from erectile dysfunction to some extent. In this study, at the age of 50-54, 26.0 % of all men have ED, which supports the above statement. In the US, erectile dysfunction is more common among obese men and men with diabetes (Carson et al., 2007). ED is and will continue to be a significant problem. Today patients developing ED generally have a higher expectation in terms of quality of life and the effects of ED will most certainly be even harder to cope with for these patients. Due to the many different causes of ED there are numerous treatment methods, spanning from oral drug treatment to surgical methods such as penile implant. However, most physicians agree that the treatment path adopted should begin with the least invasive and end with the most invasive procedure.

The steps are usually referred to as first, second and third line treatment.

The primary goal of treatment is to restore satisfactory erections with minimal adverse effects.

In case of psychological causes, the urologist refers the patient to a qualified psychologist, psychiatrist, sex therapist or marriage counsellor. This treatment line is not included here, as Implantica’s device is not designed for the use such patients. Usually, oral drugs are the first step in ED treatment and are referred to as first line treatment.

There are a number of pharmaceuticals used to treat erectile dysfunction, the most common being so called PDE5 inhibitors.

Oral drug treatment is relatively easy to explain and maintain and patients are easy to motivate.

Many different agents exist, but in recent years, two groups of agents have become the most commonly used: Phosphodiesterase (PDE5) inhibitators. The erection process involves the release of nitric oxide (NO) in the corpus cavernosum.

This step increases the levels of cyclic guanosine monophosphate (cGMP), which leads to smooth muscle relaxation (vasodilation) in the corpus cavernosum, which in turn increases in the inflow of blood.

The most known phosphodiesterase-5 (PDE5) inhibitor Sildenafil Citrate (Viagra™) was introduced in the US in 1998. It is one of three oral PDE5 treatments used today (the other two being Cialis™ and Levitra™).

the patient’s normal sex drive is not affected directly but the ability to get a full erection is enhanced.

They are not suitable for patients that take nitrates for angina or hypertension.

Common side effects include headache, dizziness, facial flushing, sneezing and visual changes (due to its effect on PDE6, which is present in the retina of the eye) (Pfizer, 2007).

About 30 % of men fail to respond to PDE5 inhibitors and another 20 % suffer significant side effects (McCullough, 2007). Apomorphine is a dopamine receptor agonist that stimulates dopamine D1 and D2 in the brain to induce erection by producing signals to begin the erectile process. This drug can be taken orally, but is more effective in its sublingual (under the tongue) and intranasal (through the nose) administration forms. There are other oral agents developed for ED treatment, for example different types of oral testosterones, but they are not commonly used. The reason is that PDE5 inhibitors such as Viagra are efficient and currently dominate the market (Frost & Sullivan, 2005).

Penile injection has been used as a second line treatment for over a decade.

It has a 70-90% success rate, higher than PDE5 inhibitors, but it is not generally considered a popular form of treatment with patients because of the need to administer regular self-injection into the corpora cavernosa of the penis (Belsley et al., 1998; Brooks & Jordan, 2001). The most common drug is prostaglandin E1 under the name Alprostadil. This drug is a vasodilator, which causes blood vessels to expand and thus blood flow to the penis increases. The use of injections can lead to scarred tissue and risk of wrong dosage that in severe cases damaged tissue in the corpora cavernosa. Alprostadil usually begins to work in about 5 to 20 minutes.

Intercourse should be attempted within 10 to 30 minutes after using the medication. This will produce an erection that lasts about an hour.

It is advised to use no more than three times per week with at least 24 hours between each use.

There is a reported 37-70 % dropout rate, mostly due to fear of injections or lack of spontaneity (Kandeel et viagra tablets online buy al., 2001; British Society for Sexual Medicine, 2007).

With a better method of treatment the high dropout rates will certainly fall. Furthermore, an easier method of drug delivery may reach a broader patient group, patients that cannot take injections due to various problems.

This is another second line treatment, but without the injections. Following urination, a small pellet is inserted approximately an inch deep into the urethra via an applicator at the tip of the penis. It is most commonly known under the name of MUSE, “medicated urethral system for erection”. Since the introduction of above mentioned oral PDE5 inhibitors, urethral suppositories have diminished.

The method is just slightly easier to self-administer than injections and it also suffers from the lack of spontaneity. Due to the scaring of injections of Alprostadil and the cardiac side effects of existing oral treatments such as Viagra, intranasal therapy and topical therapy are interesting alternatives for future patients.

Intranasal therapy method uses a faster way of delivering an active substance for ED patients through the nose.

Using this method gives rapid drug absorption via highly vascularised mucosa and a rapid onset of action (Frost & Sullivan, 2005). Topical therapy is a method already existing under the name of Befar (with Alprostadil) produced by NexMed.

It is a cream that delivers the active substance through the skin. It is applied to the opening of urethra and is therefore a less invasive way than injections.

Mechanical vacuum devices cause an erection by creating a partial vacuum around the penis, which allows the inflow of blood and the penis to engorge and expand in a way similar to a natural erection. The device is made of three necessary components: a plastic cylinder that covers the penis, a hand or battery pump, which draws air out of the cylinder, and an elastic ring, which is fitted over the base of the penis and maintains the erection.

A typical erection lasts up to 30 minutes using a vacuum pump and should not be longer because of the development of ischemia (absolute or relative shortage of the blood supply to an organ) Third line treatments. Patients generally have tried both drugs and other treatments

before

In some cases, surgery is used to repair damaged arteries and tie off veins. The most common methods are called: Penile venous reconstructive surgery, also called venous ligation, is a method used when the blood drains out too quickly through the veins.

If this occurs, the veins that drain the penis may be tied off. This type of dysfunction is often called Corporal Veno-Occlusive Dysfunction (CVOD). Penile arterial reconstructive surgery, also called penile revascularization, is a method used in younger men who have injuries that affect blood flow to the penis.

During surgery, a portion of a blood vessel from elsewhere in the abdomen is used to bypass the damaged portion of artery that supplies blood to the penis. Penile prostheses for the treatment of ED have been available for more than 30 years in the US. A key discovery in the field of penile prosthetics was that the corpora cavernosa could be accessed surgically without damaging the penile vessels, urethra or sensory nerves.

(Garber, 2005) The used implants can be divided into three main categories: Semi-rigid rods, which consists of two bendable rods, with the outer surface of each being silicone and the inner component being silver or stainless steel wires or interlocking plastic joints held together with a cable.

Once implanted, the penis can be manually bent up or down as required by the user.

The rods can be implanted as an outpatient procedure using local anaesthetic. The major disadvantage is that the penis has to be well hidden under clothing since it is permanently stiff, even when bent down. Self-contained devices, where two cylinders are placed inside the penis, each one containing a pump, fluid and a release valve.

A squeeze to the head of the penis forces fluid to transfer and cause rigidity. Conversely, bending the penis forces the fluid back to the storage area.

Multi-component inflatable implants, consisting of two or three components.

Inflatable cylinders placed in the corpora cavernosa, a fluid reservoir implanted in the abdomen or lower pelvis and a small pump placed in the scrotum. The user squeezes the pump and fluid moves from the reservoir into the cylinders to create an erection.

A further squeeze of the pump reverses the process. Numerous studies show that penile implants have a very high satisfaction rate.

According to European Association of Urology (EAU), the overall satisfaction rate is as high as 70-87 %.

The dominating implant is the multi-component with three components (see Figure 4), which accounts for 75 % of all implants (HBS 2007). The most commonly mentioned problems with the inflatable 3-piece implants are unwanted erections due to mechanical pump functionality, unnatural appearance of scrotum (pump is placed there), and the lack of spontaneity due to the manual pump. It is difficult to estimate the costs for society that are related to erectile dysfunction.

However, there are some studies in the area that make an effort to quantify that very cost.

A prevalence-based cost of illness study was performed from the perspective of the UK National Health Service (NHS), to evaluate the annual direct cost of managing Erectile Dysfunction (ED) between 1997 and 2000.

The main outcome and result for 2000 was that the total direct cost for the UK society (in this case NHS) of managing ED was estimated at USD 110 million (GBP 74 million) (Brown et al., 2002). By extrapolating the UK cost to the European and the US population, we estimate the total direct cost for society of managing ED in these geographic areas at USD 2 billion.

Quality of life and affect on mental health parameters should not be underestimated.

Erectile dysfunction (ED) — also known as male impotence — is a condition which prevents a man from having or sustaining an erection to finish having sex.

Our experts offer patients ED treatments, including hormone therapy and specially designed penile implants to improve function. Causes of Erectile Dysfunction Erectile dysfunction is not typical of aging, though getting older can affect ability to achieve and sustain an erection. It can be caused by different factors, including: Diabetes High blood pressure (hypertension) Atherosclerosis (artery hardening) Stress, anxiety or depression Alcohol and tobacco use Some prescription medicines Fatigue Brain or spinal cord injuries Hypogonadism (the body doesn't produce enough testosterone) Multiple sclerosis Parkinson's disease Radiation therapy to the testicles Stroke Prior prostate or bladder surgery Trauma.

Treatment for Erectile Dysfunction Treatment depends on what causes your ED.

ED may go away once the condition causing it, such as hypertension or diabetes, is diagnosed and controlled.

Other approaches also can help, including: Lifestyle changes Sex therapy Medicines Penile implants. Lifestyle changes Your physician may recommend lifestyle changes if ED cannot be linked to a medical condition.

Quitting smoking, eating a healthy diet, increasing exercise and reducing stress could improve erectile function.

Sex Therapy Your doctor may recommend you make an appointment with a sex therapist may help you if you can achieve erection during sleep, but not for sex.

The therapist may suggest reading about sexuality, trying performance anxiety reduction exercises and strengthening sexual communication skills.

Medicines Your physician may prescribe medicines such as sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra or Staxyn) if your ED is not caused by a medical condition.

These drugs intensify the effects of nitric oxide, a natural chemical the body produces that relaxes penis muscles and increases blood flow, allowing for an erection in response to sexual stimulation. Hormone Therapy A man’s testosterone level is key to sex drive and erections. Men have the highest testosterone levels during their early 20s.

Men lose 1 percent of testosterone every year as they age.

As testosterone levels drop, men notice sex drive and erectile function decline.

Testosterone replacement improves ED and libido in many men.

Penile Implants A penile implant, also called a penile prosthesis, may be an option if less invasive ED treatments are ineffective.

This surgically implanted device enables you to have an erection using a pump (inflatable implant) or manual mechanism (malleable implant).

Penile implant surgery can take as long as an hour, during which you’ll be under general or local anesthesia. Most men resume normal activities about six weeks after surgery.

We prefer the term “ erectile dysfunction ”, which does not only refer to impotence, but also includes other problems such as a reduced sex drive (libido), short erections, a curved penis, etc. Erectile dysfunction is certainly a very common problem . The 1994 Massachusetts Male Ageing Study (MMAS) was carried out on a large-scale and is often referred to in this respect. 50% of all men suffer light to serious erectile dysfunction.

We also know that quite a few types of medication can cause erectile dysfunction, e.g. diuretics (which promote the excretion of fluids), agents that lower blood pressure (hypotensives), heart medication, tranquillisers, antidepressants, H2 antagonists (stomach medication), hormonal preparations etc.

Quite a few illnesses can also be linked to erectile dysfunction, e.g. atherosclerosis (narrowing and hardening of the arteries), diabetes (high levels of sugar in the blood), arterial hypertension (high blood pressure), a heart attack, kidney failure, liver cirrhosis, epilepsy, multiple sclerosis, chronic lung diseases, thyroid disease, Peyronie's disease, depression, leukaemia, etc. A number of procedures and traumas can also cause erectile dysfunction, e.g. procedures on the head, spinal cord trauma and surgery, blood vessel surgery (aortoiliac bypass and aortofemoral bypass), bowel operations (low anterior resection, abdominoperineal resection, etc.), surgery on the pelvis and pelvic fractures, urological treatment (complete removal of the prostate, bladder removal). We can use various score lists to diagnose erection problems.

The most important list used for this is the IIEF questionnaire .

It is also imperative to distinguish the different types of erections. First, the so-called erotic erection, which is the most well-known and can be induced through visual stimulation, auditory stimulation, olfactory stimulation (smell), imagination, contact, etc.

The second erection type, the nightly erection, is very important to urologists and andrologists.

These erections occur 4 to 6 times a night during the REM sleep and strongly resemble erotic erections.

Their function is to give non-sexually active men erections in order to ensure the quality of the corpora cavernosa.

Lastly, the reflex erection - such as the morning erection - is much less important from an andrological point of view. As we mentioned earlier, erectile dysfunction covers a lot more than just plain impotence.

An important and common condition is Peyronie's disease , which is a type of chronic inflammation of the wall of the corpora cavernosa and possibly involves symptoms such as pain, reduced erection quality and malformation of the penis. Premature ejaculation and insufficient penis length are also erectile dysfunctions. Erectile Dysfunction (Impotence) What is erectile dysfunction? Erectile dysfunction (ED) or impotence means you can’t get an erection.

It can also mean you are not happy with the size or hardness of your erections, or how long your erections last.

In the past, ED was thought to be due to psychological problems. It is now known that for most men ED is caused by physical problems. These are most often related to the blood supply of the penis.

These are some of the most common: Premature ejaculation. This is the inability to keep an erection long enough for mutual pleasure. Being depressed can affect your ability to get an erection. Some anti-depressants cause erection problems, too. It is the most common cause of ED, especially in older men.

It can be related to hardening of the arteries throughout the body.

Injury or a venous leak in the penis may also cause ED.

It causes early and severe hardening of the arteries.

Problems with the nerves controlling erections are also often seen in men with diabetes. For instance, multiple sclerosis, stroke, and spinal cord and nerve injuries.

Blood pressure medicines, anti-anxiety and anti-depressant medicines, glaucoma eye drops, and cancer chemotherapy medicines are just some of the many medicines that can cause ED. These include increased prolactin, a hormone made by the pituitary gland.

They also include steroid abuse by bodybuilders, too much or too little thyroid hormone, and hormones used to treat prostate cancer. ?In rare cases, low testosterone can be linked to ED.

Smoking, excessive alcohol use, being overweight, and not exercising can also lead to ED.

ED is a symptom that is linked to many health problems such as: Prostate problems Type 2 diabetes The testicles are not making hormones the way they should (hypogonadism) High blood pressure Vascular disease and vascular surgery Heart disease or heart failure High cholesterol Low levels of HDL (high-density lipoprotein) Nervous system disorders Curvature of the penis (peyronie disease) Depression, stress, or anxiety Alcohol use Relationship problems Many long-term (chronic) diseases, especially kidney failure and dialysis Smoking, which worsens the effects of other risk factors, such as vascular disease or high blood pressure.

The symptom of ED is not being able to get or keep an erection firm enough for sex. Or it can mean you can’t get an erection consistently, or can only get brief erections.

Diagnosis of ED may include: Review of health and sexual history. It can also help your healthcare provider tell the difference between problems with erection, ejaculation, orgasm, or sexual desire. To look for an underlying problem, such as: A problem in the nervous system. This may be involved if your penis does not respond as expected to certain touching.