Erectile Dysfunction (ED)

Overview of Erectile Dysfunction 

• The term impotence has been replaced by the term erectile dysfunction.
• Moreover, the prevalence of partial or complete ED is about 50% in men 40 to 70 and increases with aging. However, many men can be successfully treated.[1]
• The incidence of moderate or severe ED more than doubled between the ages of 40 and 70.
• Incidence was highest among men in the age group 50–59 (21%) and men who were poor (14%), divorced (14%), and less educated (13%). [3]

Epidemiology of Erectile Dysfunction

The epidemiology of erectile dysfunction (ED) in India varies across studies, but several findings emerge:

• Prevalence:

  • A study in primary health care centers in Qatar, including Indian participants, found an overall ED prevalence of 57.3%, with 32.7% mild, 18% moderate, 4.3% moderate to severe, and 2.3% severe cases (Al-Ansari et al., 2011).
  • Another study in Punjab found a 56.4% prevalence of ED among men with type 2 diabetes, with varying degrees of severity (Endocrine Abstracts, 2018).
  • In a rural North Indian study, ED was reported by 5% of men, though other sexual health disorders were more common (Singh et al., 2018).

• Risk Factors:

  • Al-Ansari et al. (2011) identified obesity, having more than one partner, and chronic disease as significant risk factors.
  • Singh et al. (2018) found associations with never being married, smoking, cannabis use, diabetes, and hypertension.
  • Other studies have reported links to smoking, alcohol consumption, diabetes, hypertension, and depression (IJDMSR Journal, 2023).

• Additional Considerations:

  • Studies often report higher ED prevalence among older men and those with specific health conditions.
  • Cultural factors and underreporting may influence the accuracy of prevalence estimates.

References:

• Al-Ansari, A. A., Alkhawaja, S., & El-Menyar, A. (2011). Prevalence and risk factors of erectile dysfunction among patients attending primary health care centres in Qatar. Eastern Mediterranean Health Journal, 17(7), 577-585. [9]
• Endocrine Abstracts. (2018). Prevalence of erectile dysfunction among the subjects with type 2 diabetes mellitus in the indian state of punjab. Endocrine Abstracts, 73, EP205. [10]
• IJDMSR Journal. (2023). To study the prevalence rate of erectile dysfunction and associated risk factors in elder male population. International Journal of Development and Medical Science Research, 6(2), 1-5. [11]
• Singh, P., Gupta, S., & Kumar, A. (2018). Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study. Journal of Family Medicine and Primary Care, 7(4), 737-742. [12]

Causes of Erectile Dysfunction 

• Primary ED (the man has never been able to either attain or sustain erections) is rare also is almost always due to psychologic factors or clinically obvious anatomic abnormalities.
• Guilt, fear of intimacy
• Depression
• Severe anxiety
• Psychologic factors
• Most often, ED is secondary
• A man who previously could attain also  sustain erections no longer can.
• ED may be situational, involving a particular place, time, or partner
• Atherosclerosis of penile arteries
• Diabetes
• Prostate surgery
• Hormonal disorders also drug [1]
• Hypogonadism. [2]

Types of Erectile Dysfunction 

• Primary
• Secondary

Risk factor of Erectile Dysfunction 

• Smoking
• Medications used in treating either diabetes or cardiovascular disease
• There is a higher incidence of ED among men who have undergone radiation or surgery for prostate cancer also in those with a lower spinal cord injury
• Stress
• Anger. [3]

Pathogenesis of Erectile Dysfunction

• Vascular Factors:

  • Atherosclerosis: The most common organic cause of ED. It impairs arterial inflow to the penis and reduces venous outflow.
  • Endothelial Dysfunction: Impaired production of nitric oxide (NO), a key vasodilator, leads to inadequate relaxation of penile smooth muscle and poor erection.
  • Venous Leak: Dysfunction of the veins in the penis can prevent adequate trapping of blood, leading to weak or unsustained erections.

• Neurologic Factors:

  • Central Nervous System (CNS) Disorders: Conditions like stroke, Parkinson’s disease, and multiple sclerosis can disrupt nerve signals to the penis.
  • Peripheral Neuropathy: Damage to nerves supplying the penis, often seen in diabetes, can impair erection.

• Hormonal Factors:

  • Hypogonadism: Low testosterone levels can decrease libido and erectile function.
  • Hyperprolactinemia: Elevated prolactin levels can interfere with testosterone production and action.

• Psychogenic Factors:

  • Stress, anxiety, and depression can significantly affect sexual desire and performance.
  • Performance anxiety and relationship problems can also contribute to ED.

Other Factors:

• Medications: Certain drugs used to treat hypertension, depression, and other conditions can cause ED.
• Lifestyle factors: Smoking, excessive alcohol consumption, and obesity can increase the risk of ED.
• Peyronie’s disease: A condition characterized by the development of scar tissue in the penis, causing curvature and pain. [13]

Pathophysiology of Erectile Dysfunction 

ED may result from three basic mechanisms:

1. Firstly, Failure to initiate
2. Secondly, Failure to fill (in other words, arteriogenic)
3. Thirdly, Failure to store adequate blood volume within the lacunar network

These categories are not mutually exclusive, also  multiple factors contribute to ED in many patients. [3]

Clinical Features of ED

Common Clinical Features as described in Smith’s General Urology:

Primary Complaint:

• • Difficulty achieving an erection
  • Difficulty maintaining an erection
  • Decrease in erectile rigidity

Associated Symptoms:

• • Reduced sexual desire (libido)
  • Premature ejaculation
  • Delayed ejaculation or anorgasmia
  • Loss of morning erections

Additional Considerations:

• • Onset: Gradual or sudden
  • Severity: Mild, moderate, or severe
  • Situational: Occurs in all situations or specific contexts (e.g., with a partner vs. masturbation)
  • Impact on Quality of Life: Significant distress and relationship difficulties

Physical Examination:

• • Assessment of secondary sexual characteristics
  • Examination of the penis for abnormalities (e.g., Peyronie’s disease)
  • Evaluation of peripheral pulses and sensation
  • Digital rectal examination (DRE) to assess the prostate

Additional Notes:

• ED can be a symptom of underlying medical conditions (e.g., cardiovascular disease, diabetes, depression), so a comprehensive medical history is crucial.
• Psychosocial factors can play a significant role, and assessment of mood, stress, and relationship dynamics is important.
• The clinical presentation of ED often guides further diagnostic testing (e.g., hormonal assays, vascular studies) and treatment decisions.) [14]

Sign & Symptoms of Erectile Dysfunction 

• Infertility
• Trouble getting erection
• Trouble keeping an erection
• Reduced sexual desire
• Feeling of either embarrassment or guilt
• Low self-esteem [4]

Clinical / Physical Examination For Erectile Dysfunction 

• Generally, Medical, surgical, psychological and sexual history should be taken.
• Inspection: In detail, In light of the increasing recognition of the relationship between lower urinary tract symptoms and ED.
• A history of either nocturnal or early morning erections is useful for distinguishing physiologic ED from psychogenic ED.
• All in all, Questions should be asked about whether ejaculation is normal, premature, delayed, or absent. [3]

Diagnosis of Erectile Dysfunction 

 Clinical evaluation i.e.:

• Include history of drug also  alcohol use, smoking, diabetes, hypertension, and atherosclerosis and symptoms of vascular, hormonal, neurologic, also psychologic disorders
• Satisfaction with sexual relationships should also be explored. Additionally, Partner sexual dysfunction ( e.g. atrophic vaginitis, depression) must be considered and evaluated

Screening for depression i.e.:

• Screen for depression, which may not always be apparent. The Beck Depression Scale or, in older men, the Yesavage Geriatric Depression Scale is easy to administer and may be useful.

Testosterone level i.e.:

Differential Diagnosis 

Differential Diagnosis Categories as described in Smith’s General Urology:

1. Organic Causes:

   • Vascular:
     
     • Atherosclerosis
     • Hypertension
     • Hyperlipidemia
     • Peripheral vascular disease
     • Venous leak
   • Neurogenic:
     
     • Diabetes mellitus
     • Parkinson’s disease
     • Multiple sclerosis
     • Spinal cord injury
     • Peripheral neuropathy
   • Endocrine:
     
     • Hypogonadism
     • Hyperprolactinemia
     • Thyroid disorders
   • Anatomical:
     
     • Peyronie’s disease
     • Penile trauma or surgery
   • Medications:
     
     • Antihypertensives (e.g., beta-blockers)
     • Antidepressants (e.g., SSRIs)
     • Antipsychotics
     • Other medications (e.g., H2 blockers, anticonvulsants)

2. Psychogenic Causes:

   • Depression
   • Anxiety
   • Stress
   • Relationship problems
   • Performance anxiety

3. Mixed Causes:

   • Combination of organic and psychogenic factors

Additional Considerations:

• Age: The likelihood of organic causes increases with age.
• Medical History: Preexisting conditions like diabetes, hypertension, and cardiovascular disease can predispose to ED.
• Medications: A thorough review of medications is essential to identify potential culprits.
• Psychosocial Factors: Assessment of mood, stress, and relationship dynamics can help uncover psychogenic contributors. [14]

Complications

1. Psychosocial Complications:

   • Relationship Problems: ED can strain relationships, leading to decreased intimacy, communication difficulties, and potential infidelity.
   • Depression and Anxiety: The inability to perform sexually can contribute to feelings of inadequacy, low self-esteem, and mood disorders.
   • Reduced Quality of Life: ED can significantly impact overall well-being, affecting work performance, social interactions, and personal satisfaction.

2. Medical Complications:

   • Cardiovascular Disease: ED is often a marker of underlying vascular disease, increasing the risk of heart attack, stroke, and other cardiovascular events.
   • Diabetes: ED can be an early warning sign of diabetes or exacerbate existing diabetes complications due to shared vascular risk factors.
   • Metabolic Syndrome: ED is associated with metabolic syndrome, a cluster of conditions (e.g., obesity, high cholesterol, hypertension) that elevate the risk of cardiovascular disease and diabetes.

3. Treatment-Related Complications:

   • Medication Side Effects: ED treatments like oral medications (e.g., PDE5 inhibitors) or injections can cause side effects such as headaches, flushing, dizziness, and vision changes.
   • Surgical Complications: Surgical interventions for ED (e.g., penile implants) carry risks of infection, bleeding, and implant malfunction.

Additional Considerations:

• Untreated ED: Ignoring ED can perpetuate the complications listed above, worsening both physical and mental health.
• Partner’s Well-being: ED can also affect the partner’s emotional and sexual well-being, potentially leading to their own distress and relationship difficulties. [15]

Investigation of Erectile Dysfunction 

Blood test i.e.:

• Glucose
• Prolactin
• Testosterone
• Luteinising hormone (in other words, LH)
• Follicle-stimulating hormone (in other words, FSH).

Plethysmograph: In brief, To establish whether blood supply and nerve function are sufficient to allow erections.

Internal pudendal artery angiography [2]

Treatment of Erectile Dysfunction 

• Treatment of cause
• Usually, an oral phosphodiesterase inhibitor
• Sometimes a mechanical device or an either intracavernosal or intraurethral prostaglandin
• Apomorphine
• Alprostadil
• Surgery: In detail, For patients who do not respond to drug therapy.[1]
• Drugs: e.g. Antidepressants, Antihypertensive, Tranquilizers
• Hormones: e.g. Progesterone, Estrogens, Corticosteroids, GnRH agonists [3]

Prevention of Erectile Dysfunction 

• Stop smoking
• Maintain healthy diet
• Prevent diabetes and hypertension
• Be physically active
• Avoid taking stress [4]

Homeopathic Treatment of Erectile Dysfunction 

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Erectile Dysfunction:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

Anacardium Orientalis:

• Generally, Dual personality, Lack of self-confidence with severe depression associated with impaired memory

Argentum Nitricum:

• Very Apprehensive from the first night of marriage, fearful and nervous, leading to premature ejaculations. Moreover, “Erection fails when coition attempted”.

Agnus Castus:

• Especially indicated in old men with history of sexual excesses and in premature old age, arising in young persons from abuse of sexual powers.
• Apathy, melancholy and self-contempt from sexual abuse. Impotence with gleet (with those who have frequently had Gonorrhoea.)
• Lastly, Penis is small, cold, also flaccid; no desire or power; complete impotence. [6] [7]

Caladium:

• Penis remains relaxed, even when excited.
• In point of fact there is sexual desire and excitement; no emission and no orgasm during an embrace.
• Impotence in vigorous persons from suppressed gonorrhoeal discharge.
• Worse – motion. On the other hand, Better – after sweat after sleeping in daytime [6] [7]

Lycopodium:

• Reputed to be one of the best remedies for impotence.
• Furthermore, Erections imperfect or absent.
• In “old men who marry again but find themselves impotent.”
• Besides this, Young men who become impotent from masturbation or sexual excesses.
• Old men with strong desire but imperfect erections.
• Worse – Right side, from right to left, from above downward, especially, 4 to 8pm, from heat or warm room, hot air, bed. Whereas, Better – Motion, particularly after midnight, warm food and drink, on getting cold, being uncovered.[6] [7]

Natrum Mur:

• Male – Impotence with delayed emission. Emission even after coitus.
• Worse – noise, music, warm room, lying down, about 10 am, specifically; at seashore, mental exertion, heat. On the other hand; Better – open air, cold bathing, going without regular meals, lying on right side, pressure against back, especially by tight clothing. [6] [7]

Cantharis:

• Painful swelling of genitals.
• Pulls at penis.
• Sexual desire increased not better by sex.
• Bloody semen. Additionally, Pollutions.
• Burning in urethra after sex.
• Strong desire, painful erection.
• Worse – During or after urination, drinking cold water or coffee, sound of water, bright objects.
• Better – Better from rubbing, warm applications, warmth. [5]

Selenium:

• Irritability after sex.
• Loss of sexual power with lascivious fancies. In addition, Lascivious but impotent.
• On attempting sex, penis relaxes. Moreover, Easy loss of semen during sex with feeble erection, but long continued voluptuous thrill during stools.
• Semen watery, odorless. Dribbling of semen during sleep.
• Prostatitis, prostatic adenoma.
• Bedwetting, chronic urethritis. Papilloma on the penis
• Worse – By touch, pressure, motion, after seminal losses, specifically after stools, loss of sleep, night watching, after sleep, rest, in open air, draft, even if warm.
• Better – Better after sunset, inhaling cool air, taking either cold air or cold water into mouth. [5]

Conium:

• Suppressed sexual desires.
• Desire increased; but power decreased.
• Sexual desire without Sexual nervousness with feeble erection.
• Erections imperfect and of too short duration. Impotence. Seminal discharge, provoked by mere presence of a woman or contact. Additionally, Cutting in urethra while semen passes.
• Sexual nervousness, dejection after sex. Prostatitis. Dribbling of prostatic fluid, worse stools, emotions, etc. Prostate cancer. Testicles hard also  enlarged. Itching in prepuce.
• Besides this, Worse- sexual abuse or excess, from celibacy, alcohol, pressure of tight clothing, raising arms, standing, lying down with head low.
• Better- while fasting, from letting limbs hang down, walking bent, sitting down, stooping, walking, motion, pressure sun, dark.[5]

Dioscoria:

• Suited very well to tea drinkers.

Phosphoric Acid:  

• Generally, Gives excellent results in Oligo-asthenospermia. It increases the motility of sperm.

Titanium:

• In brief, Too early ejaculation

Tribulus Terrestris:

• A very good medicine for patients in their mid- 40’s having partial impotence caused either by overindulgence or advancing age.

Diet & Regimen of Erectile Dysfunction 

• Avoid Smoking
• Be physically active
• Reduce stress level

These foods could be beneficial for men’s health. In addition to decreasing ED:

• Blackberries
• Watermelon
• Spinach
• Oatmeal
• Avocado
• Pomegranate juice
• Fish
• Bananas

These should be Avoid for ED diet i.e.:

• Alcohol
• Sugary drinks
• Soy based products [8]

Do’s & Don’ts

Erectile dysfunction do’s & don’ts

Do’s

• DO seek professional help: Consult a doctor or urologist if you experience persistent or recurrent difficulties with erections. Early diagnosis and treatment can improve outcomes.
• DO be open and honest with your partner: Communication is crucial. Discuss your concerns openly with your partner to reduce anxiety and strengthen your relationship.
• DO adopt a healthy lifestyle:
  
  • Maintain a healthy weight.
  • Exercise regularly.
  • Eat a balanced diet rich in fruits, vegetables, and whole grains.
  • Limit alcohol consumption.
  • Avoid smoking.
• DO manage stress: Stress and anxiety can worsen ED. Practice relaxation techniques like yoga, meditation, or deep breathing exercises.
• DO follow your doctor’s advice: If prescribed medication, take it as directed. Discuss any concerns or side effects with your doctor.
• DO consider therapy: If psychological factors contribute to your ED, therapy can help address underlying issues and improve your sexual function.

Don’ts

• DON’T ignore the problem: ED can be a symptom of underlying health conditions. Delaying treatment can worsen the condition and lead to complications.
• DON’T self-medicate: Avoid taking medications or supplements for ED without consulting a doctor. Some remedies can interact with other medications or have harmful side effects.
• DON’T feel ashamed or embarrassed: ED is a common issue. Seeking help is a sign of strength and can lead to improved sexual health and overall well-being.
• DON’T give up: There are many effective treatments for ED. Work with your doctor to find the best approach for you.
• DON’T isolate yourself: Reach out to your partner, friends, or family for support. Joining a support group can also be helpful.

Additional Tips:

• Get enough sleep: Aim for 7-8 hours of sleep per night.
• Limit caffeine intake: High caffeine consumption can contribute to anxiety and sleep problems.
• Practice safe sex: Use condoms to protect against sexually transmitted infections (STIs).

Terminology

Erectile Dysfunction (ED):

The persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance.

Pathogenesis:

The origin and development of a disease or condition, including the sequence of events leading to its manifestation.

Vascular:

Relating to blood vessels and circulation.

Neurogenic:

Originating from or caused by the nervous system.

Endocrine:

Relating to glands that secrete hormones directly into the bloodstream.

Psychogenic:

Originating from or caused by psychological factors.

Atherosclerosis:

A disease in which plaque builds up inside arteries, narrowing them and reducing blood flow.

Hypertension:

High blood pressure.

Hyperlipidemia:

Elevated levels of fats (lipids) in the blood, including cholesterol and triglycerides.

Diabetes Mellitus:

A metabolic disorder characterized by high blood sugar levels due to insufficient insulin production or action.

Hypogonadism:

Decreased testosterone production by the testes.

Peyronie’s Disease:

Development of fibrous scar tissue inside the penis, causing curved, painful erections.

PDE5 Inhibitors:

A class of medications (e.g., Viagra, Cialis) that improve blood flow to the penis, commonly used to treat ED.

Libido:

Sexual desire or drive.

Premature Ejaculation:

Reaching orgasm and ejaculation sooner than desired during sexual activity.

Anorgasmia:

Difficulty or inability to achieve orgasm.

Homeopathic Terminologies:

Vital Force:

The fundamental energy or life force that animates living beings and maintains health. In homeopathy, ED is seen as a disturbance of this vital force.

Miasm:

A predisposition to chronic disease inherited from previous generations. Homeopaths believe miasms can contribute to ED.

Repertory:

A reference book listing symptoms and the homeopathic remedies associated with them. It helps homeopaths select the most suitable remedy for ED.

Materia Medica:

A comprehensive collection of information about homeopathic remedies, including their sources, preparation, and symptom profiles. It helps understand the potential of each remedy for ED.

Potency:

The strength or dilution of a homeopathic remedy. Different potencies may be used for different stages or presentations of ED.

Aggravation:

A temporary worsening of symptoms after taking a remedy, often considered a positive sign of healing.

Proving:

A systematic process of testing a remedy on healthy individuals to determine its symptom profile.

ED-Specific Terminologies:

Impotence: An older term for ED, still used in some homeopathic texts.

Loss of Libido: Decreased sexual desire, often accompanying ED.

Premature Ejaculation: A condition where ejaculation occurs sooner than desired during sexual activity.

Performance Anxiety: Fear of failure during sexual encounters, which can contribute to ED.

Constitutional Remedy: A remedy chosen based on the individual’s overall physical and mental characteristics, not just their ED symptoms.

Examples of Homeopathic Remedies for ED:

Agnus Castus: For ED with low libido, lack of erections, and emotional distress.

Caladium: For ED with lack of erections, premature ejaculation, and anxiety.

Lycopodium: For ED with performance anxiety, lack of confidence, and premature ejaculation.

Selenium: For ED with weak erections, low libido, and fatigue.

References use for Article Erectile Dysfunction 

1. The Merck Manual
2. Davidsons Principles and Practice of Medicine (PDFDrive.com)
3. Herrison-s_Principles_of_Internal medicine_19th_Eddition-2…
4. https://www.everydayhealth.com/erectile-dysfunction/
5. Nature’s Materia Medica by Robin Murphy, Md
6. Homoeopathic Body-System Prescribing – A Practical Workbook of Sector Remedies
7. The Homoeopathic Prescriber By K. C. Bhanja
8. https://www.singlecare.com/blog/erectile-dysfunction-diet/
9. Al-Ansari, A. A., Alkhawaja, S., & El-Menyar, A. (2011). Prevalence and risk factors of erectile dysfunction among patients attending primary health care centres in Qatar. Eastern Mediterranean Health Journal, 17(7), 577-585.
10. Endocrine Abstracts. (2018). Prevalence of erectile dysfunction among the subjects with type 2 diabetes mellitus in the indian state of punjab. Endocrine Abstracts, 73, EP205.
11. IJDMSR Journal. (2023). To study the prevalence rate of erectile dysfunction and associated risk factors in elder male population. International Journal of Development and Medical Science Research, 6(2), 1-5.
12. Singh, P., Gupta, S., & Kumar, A. (2018). Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study. Journal of Family Medicine and Primary Care, 7(4), 737-742.
13. Campbell-Walsh Urology (12th Edition) (2021) by Alan J. Wein, Louis R. Kavoussi, Andrew C. Novick, Alan W. Partin, Craig A. Peters, published by Elsevier
14. Smith’s General Urology (19th Edition) (2020) , by Emil A. Tanagho, Jack W. McAninch, published by McGraw Hill Professional
15. Ferri’s Clinical Advisor 2024, by Fred F. Ferri, Published by Elsevier