By Dr. Dineshani Hettiarachchi Sirisena Erectile dysfunction (ED) or impotence is a taboo topic among most of us. However, it is a common clinical entity that mainly affects men over 40 years of age. It’s estimated that the worldwide prevalence of ED will probably increase from 152 million men in 1995 to 322 million men in 2025, representing an increase of 170 million. Much of this increase will occur in the developing world and is associated with the aging of the world's population. Other related factors (secular increases in weight, dietary changes, smoking behaviour, and an emerging diabetes pandemic) are also contributing to the increase. In commemoration of men’s health week which was celebrated from 10-16 June, we spoke to an expert in the field – University of Colombo, Faculty of Medicine Professor in Urology and Consultant Urological Surgeon Prof. Ajith P. Malalasekera – to find solutions to this problem. Erectile dysfunction is defined as the inability to attain or maintain an erection sufficient for satisfactory sexual performance. However, one might experience this from time to time which is completely normal and may resolve on its own. But the stigma or embarrassment of having ED symptoms may lead to denial of the problem. Broadly, it can be recognised as having persistent trouble with initiating and sustaining an erection which might be associated with a reduced sexual desire. When should you see a doctor?

• If you have concerns about your erections or you are experiencing other sexual problems such as premature or delayed ejaculation
• If you have diabetes, heart disease, or another known health condition that might be linked to erectile dysfunction
• If you have other symptoms along with erectile dysfunction
• When asked about the causes of ED, Prof. Malalasekera said that it could be either due to physical and/or psychological issues.

  Common physical causes

• Tobacco use
• Heart disease
• Clogged blood vessels (atherosclerosis)
• High cholesterol
• High blood pressure
• Diabetes
• Obesity
• Metabolic syndrome – a condition involving increased blood pressure, high insulin levels, body fat around the waist, and high cholesterol
• Parkinson's disease
• Multiple sclerosis - Certain prescription medications including antidepressants, antihistamines, and medications to treat high blood pressure, pain, or prostate conditions
• Peyronie's disease – development of scar tissue inside the penis
• Alcoholism and other forms of substance abuse
• Sleep disorders
• Treatments for prostate cancer or enlarged prostate
• Surgeries or injuries that affect the pelvic area, perineum, or spinal cord
• Psychological causes
• Depression, anxiety, or other mental health conditions
• Stress - Relationship problems due to stress, poor communication, or other concerns

(Source: www.myoclinic.org) He went on to say that sometimes, treating the underlying condition is enough to reverse ED. In other cases, medications or other direct treatments might be needed. Hence, it’s important to identify the risk factors and address them before symptoms worsen. The prevalence and degree of ED (minimal, moderate, and complete) clearly increase with age. Prolonged use of tobacco can occlude the small arteries overtime thus restricting the blood flow. Hence, smokers are at a significantly higher risk. Erectile dysfunction may be a sign of insulin resistance in young men. Therefore, ED could be the first sign of an underlying generalised problem affecting the blood vessels. Prof. Malalasekara stated that by making healthy lifestyle choices and by managing risk factors, ED can be managed or prevented. Investigations for ED Assessments of fasting blood sugar and total testosterone are two basic laboratory investigations that should be done. However, because erectile dysfunction is a strong predictor of vascular disease, a lipid profile should also be done. Treatment options For many patients, especially young men and their partners, knowing whether or not the disorder is reversible is part of the treatment as it alleviates the anxiety and depression associated with the condition. However, drugs such as oral PDE5-Is are the mainstay of treatment. Other treatment modalities include lifestyle modification, injection therapies, testosterone therapy, vacuum erection devices, penile prosthesis surgery, and psychotherapy. Prof. Malalasekara went on to say that understanding the pathophysiology of erectile dysfunction has led to the development of successful oral therapies and present research is focusing on cutting-edge therapeutic strategies including gene and cell-based technologies with the aim of discovering a cure for ED. The majority has a physical basis for the condition. Hence, the bottom line is – if you're concerned about erectile dysfunction, talk to your doctor; even if you're embarrassed, because it might not be “all in your mind” and the underlying cause should be addressed without delay. The good news is with the right information and the right attitude it is treatment.