home Analyzes A method for the treatment of venous insufficiency of the cavernous bodies of the penis by performing a new surgical intervention. Non-drug treatment of erectile dysfunction in men

A method for the treatment of venous insufficiency of the cavernous bodies of the penis by performing a new surgical intervention. Non-drug treatment of erectile dysfunction in men

" erectile disfunction

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erectile disfunction
(impotence)

Impotence (lat. Impotentia - weakness), or erectile dysfunction is a condition in which a man cannot achieve an erection or this erection is not enough for sexual intercourse. Erectile dysfunction affects men of all ages, from adolescence. There is hardly a grown man who has not suffered a sexual failure at least once in his life. In most cases, in young men under the age of 25-30, erectile dysfunction has a psychogenic root cause, which in most cases is successfully solved by a sex therapist-psychologist. It is preferable if both partners take the course.
Unfortunately, erectile dysfunction is such a widespread phenomenon that scientific conferences and symposia are devoted to it today. Dozens of scientific monographs are devoted to its individual types.
According to the most rough estimates, about 10 million men suffer from erectile dysfunction in the United States alone. According to German scientists, this figure in a united Germany is approaching 5 million. It is obvious that in Russia, there are no fewer men with erectile dysfunction. Chronic stresses characteristic of a society in a difficult economic period, malnutrition and, as a result, atherosclerosis, smoking, play a negative role in the state of the sexual sphere of people. Both in men and women.

Physiology of erection

It has now been established that the key importance in the process of erection and detumescence (lat. DETUMESCO - stop swelling) is a decrease in the size of the genital organs with a decrease in sexual arousal due to outflow
blood), has the function of smooth muscles of the cavernous bodies and the walls of the afferent arteries and arterioles. In the absence of an erection of the penis, the latter is in a reduced state under the influence of sympathetic nerves. In the presence of sexual stimulation, impulses that are supposedly transmitted along the parasympathetic nerves cause the release of so-called non-cholinergic and non-adrenergic erection neurotransmitters in the neuroendothelial structures of the cavernous bodies. Studies over the past 5 years have shown the greatest activity of nitric oxide as an erection neurotransmitter. It has been shown that nitric oxide, under the influence of nitric oxide synthetase, activates guanylate cyclase, as well as calcium-sensitive potassium channels and Ca / K ATP-ase, causes the accumulation of cGMP and relaxation of the smooth muscles of the cavernous bodies and afferent arterioles, which in turn causes a significant increase in arterial blood flow to the cavernous bodies. Increasing in diameter, the cavernous bodies compress the venules and there is a simultaneous significant decrease in venous outflow. The work of the so-called veno-occlusive mechanism is facilitated by the location of the venules directly under the albuginea, to which they are pressed by the expanding cavernous bodies. It is the significant predominance of blood inflow over outflow that leads to an increase in intracavernous pressure up to 100 mm H& and above and the development of a rigid erection. Detumescence resulting from ejaculation or cessation of sexual stimulation begins after the activation of synaptic structures, followed by the release of neurotransmitters such as norepinephrine, neuropeptide Y and endothelium into the cavernous bodies, causing again constriction of the smooth muscles of the cavernous bodies and arterioles, which underlies the processes opposite to erection. . An important integrating role in the implementation of erectile function is played by the middle preoptic zone of the cerebral cortex. At the same time, the most important neurotransmitters that determine sexual behavior are dopamine-like (stimulation) and serotonin-like (suppression) substances.

Classification of erectile dysfunction:

In accordance with the currently recognized classification of erectile dysfunction, 7 types of impotence are distinguished according to the etiopathogenetic principle.

Psychogenic impotence.
The leading pathogenetic link in psychogenic impotence is a decrease in the sensitivity of the cavernous tissue to the effects of erection neurotransmitters as a result of a direct inhibitory effect of the cerebral cortex or an indirect effect of the cortex through the spinal centers and an increase in the level of peripheral catecholamines. These phenomena are based on overwork, depression, sexual phobias and deviations, religious prejudices, associative psychotraumatic factors, etc. In recent years, with the development of methods for objective diagnosis of erectile dysfunction, psychogenic impotence in its pure form is diagnosed much less frequently.
Neurogenic impotence.
It occurs as a result of injuries or diseases of the brain or spinal cord, as well as peripheral nerves that prevent the passage of nerve impulses to the cavernous bodies. The most common cause of non-genetic impotence is spinal cord injury (up to 75%). Other causes may be neoplasms, cerebrovascular pathology, syringomyelia, multiple sclerosis, herniated disc, etc.
Arteriogenic impotence.
The age and pathomorphological dynamics of atherosclerotic lesions of the coronary and penile vessels approximately correspond to each other, which makes it possible to consider impotence as a disease of age. Other causes of arteriogenic impotence are trauma, congenital anomalies, smoking, diabetes mellitus, hypertension. In the presence of limited arterial inflow, the intracellular metabolism of the cavernous tissue and the endothelium of the afferent vessels suffers significantly, which forms a vicious circle and often leads to irreversible dysfunction of the cavernous tissue.
Venogenic impotence
The causes of impaired venocclusive function are not yet clear enough, but the following are already known: ectopic drainage of the cavernous bodies through the large saphenous dorsal veins or enlarged cavernous or leg veins; cavernous spongy shunt; insufficiency of the albuginea as a result of traumatic rupture, Peyronie's disease, primary or secondary thinning; functional insufficiency of cavernous erectile tissue as a result of a lack of neurotransmitters, psychogenic inhibition, smoking, ultrastructural changes.
Hormonal impotence
The leading cause of hormonal impotence is diabetes mellitus, which leads to serious structural changes in the penile vessels and cavernous tissue.
The well-known fact that a normal serum testosterone level is absolutely necessary for normal erections has been called into question. visually stimulated erection does not suffer in hypogonadal individuals. In this regard, it is now believed that the degree of digestibility of testosterone is more important than its level in blood serum. However, hormone replacement therapy for the treatment of erectile dysfunction is considered indicated in individuals with hypogonadism and in male menopause.
Dysfunction of the cavernous tissue (cavernous insufficiency).
The causes of cavernous insufficiency are different. They lead to intra- and extracellular changes in the cavernous bodies, their vessels and nerve endings, which interfere with the normal functioning of the erector mechanism.
Impotence caused by age-related changes, systemic
diseases and other reasons.

The main causes of erectile dysfunction:

All causes of erectile dysfunction, according to the above classification, are divided into two large groups - organic, when there is some kind of disturbance in the body, and psychological, which are due only to the characteristics of the patient's psyche.

Psychological impotence is characterized by:

sudden onset
Nocturnal spontaneous erections are preserved
relationship problem
Problems under certain circumstances
Organic impotence is characterized by:

gradual start
There are no nocturnal spontaneous erections
Normal libido and ejaculation
Problems under any circumstances
In practice, most often there is a combination of these causes, when some disease or disorder leading to erectile dysfunction is superimposed by psychological moments that prevent a man from always fully achieving an erection in the future. All organic causes of erectile dysfunction are divided into endocrine, drug, local, neurological and vascular.

endocrine causes. If a man's body produces an insufficient amount of the male sex hormone (testosterone), this can lead to erectile dysfunction. At the same time, symptoms such as an increase in the timbre of the voice, cessation of hair growth on the face, deposition of fat on the chest, hips, buttocks may appear. Usually, these are severe violations of the hormonal sphere of the body, in which the help of an endocrinologist is required.
In another situation, the pituitary gland (a gland in the brain) may develop a tumor that secretes the hormone prolactin. In this case, no other disorders in the body, except for erectile dysfunction, may not be observed. To diagnose this disease, in addition to examining an endocrinologist, it is necessary to perform computed tomography of the brain. Treatment in this case will be reduced to long-term use of the drug bromocriptine.

Medical causes of erectile dysfunction. Some drugs and other drugs with long-term use cause erectile dysfunction. As a rule, this is due to blockage of the nerve endings that provide the appearance of an erection. Erection is quickly restored after discontinuation of the drug. Substances that cause addiction (primarily drugs) lead to erectile dysfunction indirectly, as a result of a general effect on the body and a violation of the main vital systems. In this case, to restore an erection, it is necessary not only to stop using the drug, but also a course of treatment that will restore all impaired body functions.

Substances acting on the CNS

Alcohol
Aminazin
Amitriptyline
Arrametidine
Barbiturates
Haloperidol
Heroin
Hydroxyzine
Glutethimide
Guanethidine
Debrisoquin
Doxepin
Isocarboxazid
Imipramine
cannabis
Cocaine
mebanazine
Methadone
Morphine
Pargylin
Protriptyline
Lithium salts
Thioridazine
Tranylcypromine
Phenamine
Phenelzine
Phenoxybenzamine
Fluorphenazine
Chlomipramine

Antihypertensive agents

Clonidine
Clofibrate
Methyldopa
Reserpine

Means that affect synapses

Anaprilin
Anticholinergic drugs
Phentolamine

Hormonally active drugs

Antiandrogens
Estrogens

Antihistamines

Diphenhydramine
Suprastin

Antiparkinsonian drugs
Digoxin
Indomethacin
Spironolactone
Thiazide diuretics
Cimetidine

Local factors leading to erectile dysfunction are different, but they all lead to the development of sclerosis of the cavernous tissue of the penis. Normally, this tissue resembles a sponge with small cells. During an erection, each cell (cavity) is tightly filled with blood, the penis increases in size and becomes hard. With sclerosis of the cavernous tissue, the walls of the cells stick together, and they can no longer fill with blood.
Sclerosis of the cavernous tissue occurs normally in older men, and therefore they lose the ability to have sexual intercourse. Factors such as:

penis injury;
frequent practice of prolonged sexual intercourse, in which a man, wanting to deliver maximum satisfaction to his partner, delays ejaculation for a long time;
multiple injections (shots) into the penis;
transferred priapism (prolonged spontaneous erection).
Neurological causes of erectile dysfunction. Erectile dysfunction can develop after trauma to the brain or spinal cord, with Parkinson's disease, epilepsy, multiple sclerosis, after surgery on the small pelvis, trauma to the small pelvis or perineum. In almost all of these cases, the prognosis for curing the cause of the disease is poor.
Vascular causes of erectile dysfunction. The most common group of reasons. During an erection, there is a significant change in blood flow in the penis - the blood flow through the arteries increases sharply and the outflow of blood through the veins is practically blocked. Hence, there are two groups of vascular causes of erectile disorders - insufficient blood flow through the arteries to the penis (arterial insufficiency) and excessive discharge of blood during an erection through the veins (venous insufficiency).
Arterial insufficiency of the penis can develop with endarteritis, arterial atherosclerosis, aortic aneurysm, trauma to the pelvic area, perineum, pelvic fractures, and other arterial diseases. Venous insufficiency of the penis can occur with diseases of the veins, for example, with varicose veins. It should be said that the causes of vascular disorders of the penis have not been studied enough to date and it is not always possible to establish them.

Of particular note are diseases such as diabetes mellitus and hypertension. With these diseases, erectile dysfunction often develops, which is caused by several reasons at once - vascular, neurological, local, and medical.

The psychological causes of erectile dysfunction occupy a special place in the development of this disease. They can independently lead to erectile dysfunction, but more often psychological factors are superimposed on the organic cause of erectile dysfunction, which greatly complicates the diagnosis and treatment of this condition. The psychological causes of erectile dysfunction may include anxiety and depression, indifference to a partner, fear of not being able to have sexual intercourse, conflicts between partners, inconsistency in the sexual habits of partners, strong excitement before sexual intercourse, fatigue, general poor health and health of a man. In favor of the psychological causes of erectile dysfunction, symptoms such as selective erection, the preservation of spontaneous erections, erections during masturbation, nocturnal erections (when a man notes an erection when waking up in the morning) speak. Such patients need the help of an experienced sexologist or psychotherapist.

Diagnostics
At the disposal of doctors and patients today there are six groups of methods for the treatment of impotence. The choice of one of them or their combination is determined by the results of the diagnosis and the opinion of the doctor, on the one hand, and the acceptability for the patient, on the other hand, which research methods are necessary to justify the use of one or another therapeutic approach. From this information it follows that in our conditions we have the opportunity to use almost all of them, except, perhaps, vascular operations, especially on the arteries, which require the use of more complex, invasive and expensive diagnostic methods.
Diagnostics

In the diagnosis of this “problem”, a comprehensive individual approach is required for each patient to identify the root cause. City Clinical Hospital No. 1 specializes in the diagnosis and treatment of all types of sexual disorders; has a full range of modern equipment necessary for accurate diagnosis. The treatment uses unique techniques, combined treatment regimens.
It is necessary to find out the cause of erectile dysfunction. It can be psychological, associated with damage to the nervous system, caused by chronic inflammation of the prostate gland, caused by disturbances in the hormonal regulation system or inadequate vascular supply of erection (reduced arterial inflow or pathological venous discharge).
The examination begins with the collection of anamnesis. The best way to collect anamnesis is to fill out questionnaires by the patient, the analysis of the data of which in many cases suggests the nature of erectile dysfunction. Often, talking to a partner helps a doctor.

In men with erectile dysfunction, there is a decrease in the quality and quantity of spontaneous erections during nocturnal sleep. This fact made it possible to use the study of nocturnal erections as a differential diagnostic test for organic and psychogenic forms of erectile dysfunction. The study of erection by the RigiScan device makes it possible to obtain all indicators of the quality of erection, as well as their complete statistical processing. RigiScan has software and data processing of erection research is carried out by a personal computer. Removal of parameters from the penis is carried out by contracting rings located at the base and at the coronal sulcus of the penis. The rings are connected to a microprocessor, which is fixed to the patient's thigh during the examination using a special cuff. As already noted, the registration of the parameters of rigidity and circumference of the penis and the acquisition of data in graphical and numerical terms is carried out for the base and apex of the penis.
Data from studies of nocturnal spontaneous erections allows for differential diagnosis between organic and psychogenic forms of erectile dysfunction.
An examination is carried out, including:

Psychotherapist consultations;
Consultations of a neuropathologist;
Ultrasound of the prostate and seminal vesicles with a rectal probe;
Study of the level of sex hormones;
Rheafallography (impedance plethysmography) - obtaining information about the blood supply by measuring electrical resistance in various parts of the arteries of the penis
Doppler study of the vessels of the penis, which allows to assess the state of the vessels of the penis, the speed of blood flow, as well as the condition of the cavernous bodies of the penis. Often, a study is carried out before and after the use of drugs that stimulate an erection;
Cavernosography, performed in two projections and demonstrating venous vessels, through which blood is mainly discharged from the cavernous bodies. ;
Monitoring of nocturnal erections and intracavernous injection test
Other diagnostic methods can be used, the choice of which is determined by the doctor after examining the patient. After that, it will be possible to determine the diagnosis and prescribe adequate treatment.

Treatment

In principle, all methods that contribute to the improvement and normalization of all body functions can be considered as methods of treating erectile dysfunction. Physiotherapy, hyperbaric oxygen therapy, magnetic and laser therapy are used.
However, a situation often arises in which, with all the modern possibilities of medicine, doctors are not able to cure the underlying disease (multiple sclerosis, diabetes mellitus). In this case, the treatment will not be aimed at curing the patient, but at eliminating erectile dysfunction as a symptom of the disease (symptomatic treatment). For this, a number of special methods have been developed that allow the patient to achieve an erection sufficient for sexual intercourse.

LOD-therapy (local negative pressure therapy). Special individual devices for LOD-therapy have been developed and produced. The essence of the method is that the patient places the penis in a special balloon and creates a negative pressure in this balloon. In this case, the arteries of the penis expand and an erection is achieved. Then a special rubber tourniquet is put on the root of the penis, which blocks the venous outflow, and the patient can have sexual intercourse. The method is simple, low cost, and absolutely safe to use. The disadvantages of the method include its inconvenience and a rather low quality of erection, which is achieved in this case. Thus, the penis remains in an erect state and it is possible to have sexual intercourse lasting no more than 30 minutes. The pressure achieved in the vacuum pump should be between 100 and 225 mm Hg.
The effectiveness of the method reaches 40-50%, the frequency of complications (subcutaneous hemorrhages, pain syndrome) does not exceed 5%. If ineffective, vacuum constrictor therapy can be used in combination with drug therapy, injections of vasoactive drugs, as well as to create a complementary erection after implantation of penile prostheses. For optimal efficacy and safety, patients who choose to treat with vacuum pumps should be given individual instructions for their use.

Intracavernous administration of drugs. The method has been used since 1975. Its essence lies in the fact that the patient, before sexual intercourse, injects the drug into the cavernous body of the penis. The result is a good and long-lasting erection. The method of intracavernous injections of vasoactive drugs is quite common and effective among conservative methods for restoring sexual function.
For the treatment of impotence, papaverine, phentolamine and prostaglandin E1 are used, both as monotherapy and in their various combinations.
Papaverine was the first drug used for intracavernous injections. Practical application has shown a fairly high efficiency of the drug to restore sexual function (60-80%). Monotherapy of impotence with papaverine is limited in duration due to the high risk of developing cavernous fibrosis, priapism and hepatotoxicity of the drug. A safer drug for intracavernous use is prostaglandin E1. The effectiveness of the method of intracavernous injections of prostaglandin E1 is 70-80%.

The selection of the dose of the drug should be strictly individual and be prescribed by a urologist. You can use intracavernous injections no more than 1 time per week. The disadvantages of the method include its inconvenience in use and a relatively high risk of complications - priapism and Peyronie's disease. However, modern drugs for intracavernous administration give a relatively low risk of complications.

Intraurethral administration of suppositories. The method consists in the fact that before sexual intercourse, the patient, using a special device, injects a dose of the drug into the urethra. After its introduction, an erection is achieved after 20 minutes and lasts at least 1 hour.
For intraurethral applications, the drug alprostadil is used, the active ingredient of which is prostaglandin E1. From the urethra, the drug is absorbed and enters the cavernous bodies with the bloodstream, where it causes a cascade of reactions leading to increased blood supply to the cavernous tissue and the onset of an erection.
The effect of the drug administered intraurethral is the same as with intracavernous administration. Intraurethral therapy is an effective method of restoring erection (60-70%), eliminating injection into the penis.
The transurethral system for the administration of vasoactive drugs is a polypropylene applicator containing a single dosage of the drug (MUSE). One of the side effects was pain in the penis, rarely leading to discontinuation of treatment.
After urination, the tip of the applicator is carefully inserted into the opening of the urethra to a depth of about 3 cm. Residual urine serves as a "lubricant" for the tip of the applicator and a solvent for the drug. By pressing a special button at the end of the applicator, the drug (in consistency and properties resembling a suppository) is injected into the urethra. After that, the applicator is removed from the opening of the urethra. Within 10 seconds, the patient should massage the penis for better dispersion of the drug.
Currently, the high efficiency of PGE1 when administered transurethral has been proven. At the same time, the unsatisfactory effectiveness of this method of treatment in patients with the organic nature of the disease was stated.

The disadvantages of the method include its high cost (one dose of the drug "suprastadil" costs about 40 US dollars) and relative inconvenience in use.

Medical therapy. There are a number of drugs that increase the overall tone of the body, blood pressure and indirectly improve blood flow in the penis. These include extracts and tinctures of ginseng, eleutherococcus, leuzea, golden root, zamaniha, pantocrine. It has been proven that the improvement of the arterial blood flow of the penis occurs with the use of yohimbine and tentex preparations.
Until recently, the main drug used to treat impotence was yohimbine. The efficiency of its application does not exceed 10%. The need for long-term use of the drug (from several months to a year) and the low effectiveness of treatment make this technique of little use. The indication for the use of yohimbine is only psychogenic impotence. The search for a pathogenetic substantiated, non-invasive, highly effective therapy for impotence was crowned with success and the creation of drugs - type 5 phosphodiesterase inhibitors. Sildenafil (Viagra) was the first drug in this group, but now new drugs have appeared - tadalafil (Cialis), verdenafil (Levitra).
Such drugs contribute to the onset and maintenance of an erection during intercourse. Indications for their use are impotence of psychogenic and organic origin. A contraindication for use is the patient's intake of nitrates in any dosage form.
The effectiveness of the use of drugs - inhibitors of phosphodiesterase type 5 in patients with psychogenic and organic forms of impotence is 75-80% according to numerous studies.
However, the most progressive drug in this regard is Viagra, which expands the arteries of the penis and dramatically increases blood flow in it. Unfortunately, drug therapy today can not help all patients with erectile dysfunction (Viagra, for example, affects only 75% of people).

Vascular operations on the penis. As already mentioned, the main part of erectile dysfunction is associated with vascular causes and changes in the blood flow of the penis. Therefore, one of the methods of treatment of erectile dysfunction is the rapid increase in blood flow in the arteries of the penis and the elimination of venous insufficiency. A large number of methods for performing such operations have been developed. Surgical treatment of venous insufficiency of the penis is performed in case of damage to the veno-occlusive mechanism of the penis.
The history of impotence surgery began more than 100 years ago and consisted in an attempt to block the venous outflow by ligating the deep dorsal vein. However, despite such a long history of this method of treatment and the apparent evidence of its effectiveness, this direction of vascular surgery for erectile dysfunction is the most controversial. The effectiveness of veno-occlusive surgery is no more than 50%, which is the reason for some skepticism regarding this kind of surgery.
Surgical treatment of arterial insufficiency of the penis is indicated in case of insufficient arterial inflow to the cavernous tissue.
Arterial blood flow to the cavernous bodies is an essential component for the development of an erection.
The causes of arterial insufficiency of the cavernous bodies are divided into 5 categories:

arterial dysplasia
atherosclerosis
post-traumatic occlusion at the level of the hypogastric arteries
cavernous insufficiency
arterial spasm
The effectiveness of arterial microvascular shunting is very variable according to different authors and ranges from 20% to 80%. Such significant fluctuations in efficacy depend on diagnostic criteria, patient selection principles and the type of operation performed.
The essence of this type of surgical treatment is the creation of a bypass arterial blood flow to the penis. This type of surgical treatment of erectile dysfunctions should be performed according to strict indications, preferably in young patients in whom the cause of arterial insufficiency of the penis is perineal and pelvic trauma.

It should be noted that no technique guarantees 100% of the result and the mandatory restoration of an erection. The effectiveness of different methods, depending on the complexity, ranges from 20 to 80%. This is due, among other things, to the risk of damage to the internal nerves of the penis during the operation. However, millions of people have already regained their normal ability to have sexual intercourse with the help of reconstructive operations on the vessels of the penis.

Endoprosthetics of the penis (Intracavernous phalloprosthetics). This method of restoring an erection is the most radical. It lies in the fact that the cavernous bodies of the penis are replaced by special prostheses. The simplest models of these prostheses are elastic rods that only prevent the penis from bending into the vagina during intercourse. More complex modern models are pumping structures, the cylinders of which are implanted in the place of the cavernous bodies, the reservoir with the pumped liquid is placed in the retropubic space, and the pumping device is placed in the scrotum. Before sexual intercourse, the patient must pump up the balloons, which provides an almost perfect erection, and after sexual intercourse, reduce pressure. The common disadvantages of these methods of endoprosthesis are their high cost and the risk of postoperative complications, and the disadvantage of a pump endoprosthesis is the possibility of its breakage.

How to avoid erectile dysfunction

To date, there is no clear answer to this question, so we will have to limit ourselves to only general recommendations. To prevent the development of erectile dysfunction, you should:

lead a normal healthy lifestyle, eat right and regularly, play sports, monitor your health;
do not abuse smoking, alcohol, do not use drugs;
do not use medications that can cause erectile dysfunction, or use them only strictly according to the doctor's prescription, in accordance with the instructions for their use;
have a regular sexual life, without long periods of abstinence and sexual excesses;
be sure to consult a urologist if you have been injured in the pelvic area, perineum, if you have surgery on the pelvis, if you have diabetes or hypertension.

penile prosthesis
(prosthesis of the penis)

Today, phalloprosthetics (prosthesis of the penis) is a radical method of treating erectile dysfunction. Phalloprosthetics (Greek phallos - penis + prosthesis - attachment, attachment), surgical prosthetics of the penis (penis).
Treatment involves the introduction of a silicone prosthesis into the cavernous bodies of the penis. Several types of prostheses have been developed, which will be discussed in detail below. Now we will discuss the indications for penile prosthetics:

Vascular (vasculogenic) erectile dysfunction
Ineffectiveness of conservative therapy for erectile dysfunction
Erectile dysfunction in Peyronie's disease
The presence of an artificial (artificial) penis as a result of operations to change the penis
Erectile dysfunction in diabetes mellitus and other metabolic diseases
Erectile dysfunction as a result of radical interventions on the prostate gland, rectum, bladder
Cavernous fibrosis
Psychogenic erectile dysfunction, with the failure of all conservative methods of treatment;
Ineffectiveness or unacceptability of vacuum erectors or intracavernous therapy by the patient;
Underdevelopment of the penis;
An atypical indication is psychogenic erectile dysfunction. Such a diagnosis in itself cannot be the basis for penile prosthetics. Prosthetics can be performed in such patients only in cases where psychogenic disorders cannot be corrected after multiple courses of conservative treatment (psychotherapy, sex therapy, erection drugs, vacuum erectors, intracavernous injections of vasoactive drugs).
There has been a significant increase in the number of patients with unsuccessful results after previous penile surgeries, which include revascularizations, penile venous surgery, and complications after prosthetics. The effectiveness of any vascular operations on the penis is low, and therefore, patients who have undergone such operations in most cases require the implantation of prostheses. The number of complications after penile prosthetics has also increased markedly due to the use of low-quality implants and an unprofessional approach to this complex category of patients. The only way to treat complications is to remove the implants, followed by delayed reprosthetics.

Before surgery, the surgeon always evaluates the feasibility of the operation, contraindications, and assesses the risk of complications. The most important aspect of prosthetics is the choice of prosthesis. Of course, the cost of the prosthesis matters. At present, Ambicor two-component prostheses have the best combination of price and quality. However, all ratios are relative.
The prosthesis is performed under general anesthesia. Penile implantation is not a "super operation", but requires the experience and skillful hands of a urologist or surgeon. Operative access depends on the model of the implantable prosthesis, as well as the individual characteristics of the patient. The incision can pass through the skin of the scrotum, under the pubis, and also through the foreskin.
After the incision is made, the surgeon gains access to the cavernous bodies, into which the main part of the prosthesis should be installed. If necessary (pronounced fibrosis), the cavernous bodies are expanded with the help of special tools.
One of the important points of penile prosthetics is the prevention of infectious complications. In the vast majority of cases, a powerful course of prophylactic antibiotic therapy is carried out in the postoperative period.
In 4-5 weeks after the operation, the wound is completely healed. During these periods, the resumption of sexual activity is possible.
Contrary to common misconceptions, penile prosthetics do not affect fertility, ejaculation, or urination. The prosthesis does not squeeze the urethra, so urine and semen pass through it without obstacles.
Prosthetics allows you to fully restore sexual life. In the vast majority of cases, patients get satisfaction from sex. In the vast majority of cases, sexual satisfaction is received by the partners of men who have undergone surgery. Moreover, prosthetics make a man a “perpetual motion machine”.

Modern medicine is able to help any patient, including those with such a previously hopeless pathology as penile fibrosis. The patient's problem is that he is unable to perform sexual intercourse. And after prosthetics, this lost ability returns to him. Moreover, truly unlimited sexual possibilities open up before a man, because the prosthesis allows you to perform multiple sexual acts of any duration.

Erectile dysfunction is a fairly common condition, affecting up to 2/3 of men with confirmed CAD, and endothelial dysfunction is now considered a common factor explaining the association between organic erectile dysfunction and CAD in men over 40 years of age.

The appearance of erectile dysfunction may precede the development of CHD symptoms in endothelial dysfunction of the same severity due to the small size of the penis arteries (1-2 mm) compared to the coronary arteries (3-4 mm).

It has now been proven that erectile dysfunction can be a marker and possibly an independent risk factor for asymptomatic CHD, with a time window of about 2-5 years from the onset of erectile dysfunction to the first manifestations of CHD. This opens up additional opportunities to reduce the risk of CVD in men with erectile dysfunction in the absence of cardiac symptoms. Thus, erectile dysfunction can be considered as equivalent to vascular or cardiac pathology. Erectile dysfunction may precede both the chronic course of coronary artery disease and acute. The performance of stress tests does not allow to determine the subclinical condition - the presence of lipid-rich and prone to rupture atherosclerotic plaques that stenose the lumen of the coronary arteries by less than 50%. However, the latest research methods using 64-layer MSCT make it possible to detect atherosclerotic changes in a normal ECG at the maximum load of the treadmill test in patients with erectile dysfunction in the absence of cardiac symptoms.

Both men and women with cardiac pathology should be properly informed about the nature of possible sexual activity as part of a comprehensive approach to rehabilitation. Some therapies are showing promising results in the treatment of erectile dysfunction. Currently, there is no evidence that erectile dysfunction therapy increases the risk of developing heart and vascular disease, provided that men (and their partners) have been properly examined. Sexual life is part of normal life for all age groups, and there is no reason why patients with cardiac pathology cannot satisfy desires in sexual relationships.

Currently, erectile dysfunction is a fairly common condition affecting more than 150 million men worldwide. According to the results of the Massachusetts Study of the Process of Aging in Men, the incidence of erectile dysfunction was 52% in American men aged 40-70 years, progressing in proportion to age. Thus, men over 70 years of age are subject to erectile dysfunction three times more often than men aged 40 years. Given the general aging of the human population, age is no longer an obstacle to sexual activity, thereby increasing the importance of the task of identifying and treating patients with erectile dysfunction. According to the forecast, by 2025 more than 300 million people will be affected by erectile dysfunction.

Currently, a fairly large number of studies confirm the theory that erectile dysfunction is predominantly a vascular pathology with common risk factors with coronary artery disease and often occurs 2-5 years before the onset of cardiac symptoms. The presence of a common pathophysiological factor in the form of endothelial dysfunction, as well as the possibility of using erectile dysfunction as a marker or independent risk factor for asymptomatic CAD, is of great interest due to the possibility of reducing risk factors for CAD in men with erectile dysfunction in order to prevent further cardiac events.

Despite the fact that the most common cause of erectile dysfunction in men over 40 years of age is of an organic (vascular) nature, an integrated approach is very important in this situation, since the organic genesis of the disease invariably has psychological consequences in the form of depression, reduced self-esteem and the emergence of feelings of inferiority. Erectile dysfunction is a fairly common cause of the destruction of sexual relations, and therefore it is also desirable to involve a sexual partner in solving this problem. Thus, in addition to maintaining erectile function, the patient also needs to provide adequate psychosocial support. In turn, patients with a predominantly psychosomatic nature of erectile dysfunction may also have risk factors for the development of CVD that require special attention.

When consulting cardiac patients about the amount of possible sexual activity, an individual approach is very important, despite the existence of statistically standardized recommendations. So, for example, taking into account the functional state of the heart (including after a myocardial infarction), it is required to limit physical activity depending on the volume of the infarct zone. In addition, each patient has individual questions regarding the safety of sex, the treatment of erectile dysfunction, as well as the possibility of returning to their usual daily activities, including sexual activity. When making recommendations on sexual activity, it must be remembered that many problems in this area can precede the development of cardiovascular events and have serious consequences for relationships with partners.

Cardiovascular reactions during intercourse

The cardiovascular response during intercourse is similar to moderate or moderate daily physical activity. Several studies have been performed using ambulatory ECG and BP monitoring, the purpose of which was to compare heart rate, ECG and BP during daily exercise, as well as during intercourse. Nemec and colleagues studied ten healthy married men. They found only modest differences regardless of position during intercourse. Thus, in the "man on top" position, a peak heart rate of up to 114±14 per minute was recorded, which decreased to 69±12 per minute 120 s after orgasm. In the "man from below" position, the peak heart rate was 117±4 per minute. The peak of the rise in blood pressure, the same in both positions, was 160 mm Hg. at the moment of orgasm. Bohlen and colleagues, also in a survey of ten healthy men, evaluated the performance during intercourse in various positions, during masturbation, and also when stimulating partners and found no significant difference in heart rate and blood pressure. Although there are significantly fewer studies of women who have undergone, the cardiovascular response in men and women has similar rates with a peak heart rate of 111 per minute in men and 104 per minute in women, with a recovery period of 3.1 and 2.6 minutes, respectively. On 24-hour ECG monitoring in patients with stable angina, the average heart rate was 122 per minute with a range of 102-137 per minute (30 men and 5 women) during intercourse compared to a maximum heart rate of 124 per minute during the day.

Expressed in Metabolic Equivalent Units, sexual activity in couples in long-term sexual relationships at the peak of the load during orgasm is 3-4 METs (Metabolic Equivalent Load, 1 unit corresponds to energy expenditure at rest, namely 3.5 ml of oxygen per kilogram body weight per minute). Young couples, due to their greater activity, spend up to 5-6 METs during coitus. The duration of sexual intercourse is on average about 5-15 minutes, so sex is not a prolonged or excessive load on the cardiovascular system. However, casual sex can be associated with a high cardiovascular burden due to lack of close communication or mismatch in the age of partners, most often in older men with younger women.

Thus, with the help of MET units, we can advise our patients on the amount of possible sexual activity, using simple and understandable comparisons, such as walking at a moderate pace for 1.6 km (1 mile) in 20 minutes.

Metabolic Units (METs) as an opportunity to compare daily activities and sexual activity

Everyday loads	MET
Sexual contact with a regular partner
Low level (normal)	2-3
Orgasm during normal intercourse	3-4
High level (high activity)	5-6
Lifting and carrying weights (9-20 kg)	4-5
Race walking for 20 minutes for a distance of 1.6 km (1 mile)	3-4
Golf game	4-5
Activities in the garden (earthworks)	3-5
Repairs in the household, home-made production of something, pasting the walls with wallpaper, etc.	4-5
Light household work, such as ironing, dusting	2-4
Heavy domestic work, such as making the bed, washing floors, washing windows	3-6

Risk of cardiovascular complications during sex

There is a fairly low risk of myocardial infarction associated with sexual activity. The relative risk of developing myocardial infarction within 2 hours after intercourse is presented in the table.

Relative risk of myocardial infarction within two hours of intercourse: physical health reflects the ability to be sexually active

A patient who fails to reach 3-4 METs should be further examined using angiographic diagnostic methods.

Advice to patients about sexuality, based on the principles of determining MET in the clinical situation, should include advice on avoiding stress, limiting large meals or excessive consumption of alcoholic beverages before intercourse.

Although ECG monitoring during the exercise test is a method for assessing the risk of coronary events in patients with erectile dysfunction, it does not reveal the presence of lipid-rich and prone to rupture atherosclerotic plaques in coronary arteries that occlude the lumen by less than 50%.

Erectile dysfunction in cardiac patients

Erectile dysfunction and coronary artery disease are two pathologies with common risk factors, usually found in combination with endothelial dysfunction acting as a unifying link.

The clinical consequence of endothelial dysfunction is the development of atherosclerosis, acute coronary syndrome, CHF, and erectile dysfunction. It is now known that a defect in the NO-cyclic guanosine-3′5′-monophosphate system of smooth muscle cells serves as an early marker of systemic vascular damage that appears before the development of clinically overt cardiovascular disease in men with erectile dysfunction.

Endothelial function has been found to improve with drugs that reduce cardiovascular morbidity and mortality (ACE inhibitors in CHF; statins and ACE inhibitors in CHD), as well as drugs used to treat erectile dysfunction, CHF and diabetes mellitus (phosphodiesterase inhibitors fifth type). Over the past ten years, after a direct link between erectile and endothelial dysfunction has been identified, it has become apparent that erectile dysfunction can be treated with phosphodiesterase-5 inhibitors, acting on smooth muscle cells and thereby improving endothelial function.

Risk factors for cardiovascular disease

Common risk factors for cardiovascular disease and erectile dysfunction include smoking, hyperlipidemia, diabetes mellitus, hypertension, obesity, and a sedentary lifestyle.

In the Massachusetts Study of Male Aging, in a large population randomized sample of 1290 healthy men aged 40-70 years, the age-standardized probability of complete erectile dysfunction was 15% in patients receiving antihypertensive therapy and 9.6% in the entire population. In another study, the presence of erectile dysfunction was noted in 17% of men with untreated arterial hypertension compared with 25% of men receiving antihypertensive therapy.

However, more recent studies of hypertensive patients show that the prevalence of erectile dysfunction in hypertension is higher. Burchardt et al. sent out a questionnaire on the international index of erectile function to 476 male patients with arterial hypertension. One hundred and four patients (mean age 62.2 years) completed the questionnaire. Of these, 68.3% had isolated manifestations of erectile dysfunction, in 7.7% of cases, erectile dysfunction was mild, in 15.4% moderate and severe in 45.2% of cases. Compared with the general population, patients with hypertension had more severe erectile dysfunction (45.2% in patients with hypertension versus about 10% of the general population, as reported by the Massachusetts Male Aging Study). The authors concluded that erectile dysfunction is a more common pathology in patients with arterial hypertension, even after adjusting for age, and the degree of erectile dysfunction is more severe than in the male population as a whole. Another study also confirmed a very high rate of erectile dysfunction among hypertensive patients. In a survey of 7689 patients (mean age 59 years) using the Sexual Health Inventory in Men (SHIM questionnaire) in 3906 people with only arterial hypertension (without diabetes mellitus), erectile dysfunction was present in 67%, which is comparable to the above data - 68%. In 2377 men with diabetes, erectile dysfunction was present in 71%, and in 1186 men with hypertension and diabetes, erectile dysfunction was present in 77%. In 65% of cases, erectile dysfunction remained without therapy, although the majority of men agreed with the need for treatment. It becomes obvious that a significant number of patients with arterial hypertension may have a clinic of erectile dysfunction.

According to the Massachusetts Male Aging Study, smoking doubled the likelihood of developing erectile dysfunction over an 8-year follow-up period and increased the incidence in men with hypertension. Smoking is also known to be a risk factor for endothelial damage and vascular disease. And while smoking cessation later in life may benefit the 3-4 mm coronary arteries, it may be too late to reverse the damage done to the small (1-2 mm) penile arteries.

Organic nitrates (nitroglycerin, isosorbide mononitrate, isosorbide dinitrate) and other nitrate-containing drugs used to treat angina pectoris, as well as amyl nitrite, are completely incompatible with phosphodiesterase-5 inhibitors. Their joint appointment leads to an increase in the level of cGMP in the cells, an unpredictable drop in blood pressure and symptoms of arterial hypotension. The duration of interaction of organic nitrates with phosphodiesterase-5 inhibitors for specific phosphodiesterase-5 inhibitors and nitrates is being studied.

If a patient taking phosphodiesterase-5 inhibitors develops chest pain, nitroglycerin should be administered no earlier than 12 hours in the case of sildenafil (or vardenafil, which has a half-life of 4 hours) and no earlier than 48 hours in the case of the use of tadalafil (half-life 17.5 hours). If a patient develops angina pectoris while taking phosphodiesterase-5 inhibitors, he should be informed about the need to stop sexual activity and assume a vertical position, then the formation of a pool in the venous bed will mimic the venodilating effect of nitrates. If the pain persists, it is necessary to prescribe other drugs under medical supervision in a hospital setting or to carry out intravenous administration of nitrates under strict medical supervision.

Co-administration of phosphodiesterase-5 inhibitors with antihypertensive agents (ACE inhibitors, ARBs, slow calcium channel blockers, β-blockers, diuretics) can lead to a slight increase in the hypotensive effect, which is usually not very pronounced. In general, the side effects of phosphodiesterase-5 inhibitors do not increase with antihypertensive therapy, even when the patient receives combination antihypertensive therapy.

parenteral therapy

Direct intracavernous injections of vasodilators began to be used in 1980. Prostaglandin-E 1 is a substance produced in the body that leads to relaxation of muscle cells and dilation of arterioles, increasing blood flow in the penis. Alprostadil is the commercial name for the dosage form of prostaglandin-E 1, the action of which develops within 5-15 minutes, and the resulting erection usually lasts longer than 30 minutes, and sometimes several hours. The initial dose of alprostadil is 1.25 mcg, it can be increased to 40 mcg depending on the effect. It is important to inform the patient about the correct injection technique, patients with impaired motor activity in the hands (due to arthritis of the joints of the hand, tremor) need the help of a partner when performing the injection. It is known that injection can be part of sexual activity. After the introduction of the drug and removal of the needle, the injection site must be firmly pressed and gently massaged for better distribution of the drug in the penis for about 30 seconds. In the case of taking anticoagulants, the injection site must be pressed for 5-10 minutes.

Erections as a result of the action of alprostadil occur without stimulation, but stimulation can increase its severity. Sometimes an erection can be painful, but the sensations are usually the same as those experienced with a natural erection. The drug should not be used more often than once every 4 days.

Alprostadil is effective in more than 80% of cases, and its use is accompanied by the resumption of spontaneous erections in 35% of patients. It is effective and safe in diabetic patients receiving insulin therapy. Despite the high efficiency, the frequency of refusal of treatment with alprostadil is quite high, which is most often associated with local pain and loss of spontaneous erections.

intraurethral therapy

Intraurethral therapy with alprostadil is an alternative to injection therapy. The intraurethral drug delivery system is intended for single use and involves the administration of a 1.4 mm diameter pill using a hand-held device after urination and approximately 15 minutes before sexual intercourse. As with the use of injection therapy, the patient must be informed about the correct technique for administering the drug. Patients should receive an initial dose of 250 micrograms of the drug with gradual titration in the range of 125-1000 micrograms under medical supervision until the effect is sufficient. Doses of the drug for intraurethral therapy are much higher than for injection therapy, since the drug is distributed in the total volume of circulating blood. During the day it is allowed to use no more than 2 doses. It is necessary to choose a suitable dose for the patient, at which an improvement would be achieved in 60%, although in a study with parenteral administration this figure decreased to 43% (70% received parenteral treatment).

Non-drug therapy

Psychotherapy

In the case of the development of psychogenic erectile dysfunction, patients need to provide specialized psychotherapeutic assistance. Even if the cause of rectile dysfunction is an organic pathology, very often there can be a secondary psychological component, which requires the joint work of the attending physician and psychotherapist.

Vacuum pumps

The vacuum pump has long been used as a means of conservative treatment of erectile dysfunction. This is a non-invasive method that provides an erection by creating a negative pressure of up to 250 mm Hg, thereby causing blood flow to the corpora cavernosa. Further, the erection is maintained by rubber rings placed on the base of the penis. However, the time of use of the constriction ring should not exceed 30 minutes due to the risk of ischemic damage.

It should be noted that while taking anticoagulant therapy, patients may develop hematomas (in 10% of cases, minor hemorrhages), which is a relative contraindication to the use of the pump. Thus, before using vacuum devices, a doctor's consultation and special training are required. The use of pumps is also not recommended for men with curvature of the penis.

Surgery

When conservative methods of treatment do not give positive results, and also if there was a history of trauma to the penis, surgery remains another treatment option. Cardiac patients should not be deprived of this type of treatment. Obviously, consultation with a doctor is necessary, and the attending physician should consult with a urologist and, together with a cardiologist, assess the risk of cardiac problems.

Testosterone

There is now increasing evidence that low testosterone levels in men are associated with all-cause mortality, and especially cardiovascular death. Thus, the question arises: will substitution therapy in old age have a beneficial effect, especially given the age-related decline in androgen levels?
Low testosterone is associated with many risk factors for CVD, including visceral obesity. Considering that testosterone replacement therapy in patients with hypogonadism reduces obesity, and obesity, in turn, is an independent risk factor for CVD, the concept of replacement therapy to reduce cardiac risk factors is of considerable interest. In addition, low testosterone levels are associated with reduced glucose tolerance, type 2 diabetes (regardless of obesity), and metabolic syndrome. Thus, the likelihood that replacement therapy in men with low testosterone levels will help prevent the development of type 2 diabetes mellitus, the progression of the metabolic syndrome and reduce the risk of CVD associated with these diseases increases.

With regard to the blood coagulation system, there is evidence that testosterone replacement therapy reduces fibrinogen levels and increases the activity of the fibrinolytic system, as well as reduces platelet aggregation. Low testosterone levels are associated with increased levels of inflammatory markers (interleukin-6 and C-reactive protein), which are risk factors for CVD. Data on hyperlipidemia during replacement therapy are rather contradictory (a 10% decrease in LDL levels is compensated by a 10% decrease in HDL).

The vascular effect of testosterone is also considered to be potentially beneficial, influencing smooth muscle cells directly through potassium and calcium channels. The experiment revealed the development of dilatation of the coronary arteries after a single injection of testosterone. In men with stable angina, after 3 months of transdermal testosterone administration, there was a decrease in ischemia during exercise, as well as an increase in the threshold for angina pectoris.

The results of the European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) study have recently been published. During the 6-10-year study of the causes of death from cancer and CVD, testosterone levels were also assessed. Baseline endogenous testosterone levels were inversely related to all causes of death. Although the authors concluded that low testosterone levels may be a marker of high CV risk, they noted the need for a randomized, placebo-controlled trial. The Rancho-Bernardo study found similar results over a 20-year follow-up period, including that men with testosterone levels in the lower quartile had a 40% higher risk of dying mainly from diseases of the cardiovascular and respiratory systems. Interestingly, this indicator did not depend on age, lifestyle, hyperlipidemia and obesity.

Currently, there is not enough evidence that testosterone replacement therapy reduces the risk of developing CVD, which raises the question of the need for an extensive placebo-controlled study. Reassuringly, replacement therapy does not increase the risk of CVD and can also be used safely in patients with hypogonadism.

Advice for cardiac patients on sexual issues

Arterial hypertension

Not a contraindication if recommendations for blood pressure control are followed

If the patient is receiving medical therapy: antihypertensive drugs (mono- or combination therapy) are not a contraindication, but care must be taken when prescribing doxazosin (and other non-selective α-blockers) and phosphodiesterase-5 inhibitors

You can use any means for the treatment of erectile dysfunction

The antihypertensive agents least likely to cause erectile dysfunction include angiotensin receptor blockers and doxazosin.

angina pectoris

Patients with stable angina have a minimal chance of complications from sexual activity or treatment of erectile dysfunction.

Taking nitrates or nicorandil is a contraindication for phosphodiesterase-5 inhibitors. Removing them is safe in most cases.

Drugs that reduce heart rate are the most effective antianginal agents: β-blockers, verapamil, diltiazem.

If necessary, use exercise ECG for risk stratification.

Past myocardial infarction (postinfarction cardiosclerosis)

To determine the possibility of resuming sexual activity, you can conduct a stress test with ECG registration before and after discharge; in case of satisfactory results, the resumption of sexual activity should not be delayed

Given the decline in confidence of both the patient and his partner, a gradual return to previous sexual activities should be recommended.

Rehabilitation programs have a positive effect.

Sexual relations should be avoided in the first two weeks (during the period of maximum risk).

Condition after major and percutaneous interventional surgery

If the intervention is successful, the risk of complications is low.

The sternal suture may be painful; recommended position on the side and the position when the patient is on top. You can use a soft pillow, placing it in the area of the sternal suture.

If in doubt, use an exercise test with ECG recording.

Heart failure

The risk of complications is low if exercise tolerance is good.

If symptoms are present, select appropriate drugs; the patient should take a more passive side in sexual relations.

In the case of severe symptoms, sexual activity may be unacceptable due to the limitation of physical activity, and may also contribute to the decompensation of CHF.

A physical rehabilitation program may facilitate a return to sexual activity; physical condition reflects opportunities for sexual activity.

Valvular defects

In mild cases, the risk is low.

Severe aortic stenosis can lead to sudden death and is aggravated by the use of phosphodiesterase-5 inhibitors due to their vasodilating effect.

Arrhythmias

Controlled atrial fibrillation does not increase the risk of complications, which depends on the cause and exercise capacity.

Warfarin is not a contraindication to vacuum devices, but care must be taken when using them and when injecting.

Complicated arrhythmias: Perform 24-48 hour ECG monitoring and exercise testing, and follow up after treatment.

The presence of artificial pacemakers is not a contraindication.

In ICD, a stress test should be done first to determine the possibility of sexual activity. In most cases, this is not a hindrance.

Other states

In the case of pericarditis, it is necessary to wait for a complete recovery, after which there is no increase in the risk of complications.

In the case of obliterating diseases of the vessels of the lower extremities, stroke or transient cerebrovascular accident, the risk of developing myocardial infarction is increased, therefore, additional examinations are necessary before making recommendations.

In hypertrophic obstructive cardiomyopathy, there is an increased risk of syncope and sudden death on exertion. It is recommended to perform a stress test with ECG recording. Phosphodiesterase-5 inhibitors and alprostadil can lead to an increase in the degree of obstruction due to a vasodilatory effect. It is recommended to start treatment with a trial dose in a hospital under the supervision of medical personnel.

Conclusion

Patients with heart disease may have concerns about sexual activity due to their unreasonable beliefs about a possible increased risk of complications. Erectile dysfunction is a frequent occurrence in patients with CVD, as there are common risk factors that have a negative impact on endothelial function. Symptoms of erectile dysfunction often precede overt symptoms of heart disease, so clinical evaluation for CVD is warranted in these patients even in the absence of a history of cardiovascular disease. Currently, there is an increasing amount of information about the treatment of erectile dysfunction, but many patients are reluctant to accept advice. In routine clinical practice, physicians should discuss with patients with cardiovascular disease the problems of the possibility of sexual activity and advise them on the treatment of erectile dysfunction. Treatment is currently available. With support, encouragement and detailed explanation, patients with CVD who have received appropriate advice can continue sexual relationships.

Future prospects

Knowing that erectile dysfunction is an early warning sign of the presence of asymptomatic lesions of the coronary and other vessels, it is always necessary to conduct a screening examination of men with erectile dysfunction and without symptoms of cardiovascular pathology. According to the Princeton Consensus Guidelines, all men with erectile dysfunction who do not have symptoms of heart disease should be treated as having a heart (or vascular) disease until proven otherwise. Such patients should be given a complete medical evaluation to determine whether their cardiovascular risk is high, moderate, or low. Patients at low risk should be advised to make lifestyle changes, including increased physical activity and weight loss, as well as regular follow-up and examination with their physician. Patients at increased risk of adverse cardiovascular events should undergo exercise testing and treatment to reduce risk.

Although an exercise stress test with ECG recording is encouraged to identify patients with increased cardiovascular risk, this method will only help in the detection of stenosing, blood-limiting, coronary artery disease. Whenever possible, patients of intermediate and high risk should be referred for selective CT, coronary angiography to identify atherosclerotic plaques containing lipids that do not restrict blood flow, but are prone to rupture. Prior to these studies, taking advantage of the 2-5-year "time window" between the development of symptoms of erectile dysfunction and coronary artery disease, early aggressive therapy should be initiated, if possible, aimed at reducing the risk of developing CVD in patients at high risk. However, to fully realize this potential, a comprehensive education program is needed to encourage men with erectile dysfunction to seek medical attention as early as possible when symptoms appear. In addition, an interdisciplinary approach is required, including the joint work of the family doctor, nurses, pharmacist, urologist, diabetologist and cardiologist.

Diseases of the heart and blood vessels. Ed. A.J. Camm, T.F. Luscher, P.V. Serrius. Translation from English. / Ed. E.V. Shlyakhto

Erectile dysfunction (ED)(IMPOTENCE) - is one of the most common diseases of modern andrology. According to the latest data, ED occurs in 53-55% of men over 45 years of age. In Russia, according to some data, every third man over 40 suffers from ED; in Ukraine, this figure for men reaches 52%.

According to the modern definition, ED is understood as "the inability to achieve and (or) maintain an erection of the penis sufficient for satisfactory sexual activity."

For many years it was believed that the occurrence of ED is more of a psychogenic factor. Based on numerous studies, it has been proven that ED is most often based on the factor of vascular damage.

In accordance with the currently generally recognized classification of ED, 7 types of ED are distinguished according to the etiopathogenetic principle:

I. Psychogenic erectile dysfunction
The leading pathogenetic link in psychogenic impotence is a decrease in the sensitivity of the cavernous tissue to the effects of erection neurotransmitters as a result of a direct inhibitory effect of the cerebral cortex or an indirect effect of the cortex through the spinal centers and an increase in the level of peripheral catecholamines. These phenomena are based on overwork, depression, sexual fears and deviations, religious prejudice, etc. In recent years, with the development of methods for objective diagnosis of erectile dysfunction, psychogenic impotence in its pure form is diagnosed much less frequently.

II. Vasculogenic erectile dysfunction
It is divided into 2 forms:
Arteriogenic erectile dysfunction.
The age and pathomorphological dynamics of atherosclerotic lesions of the coronary and penile arteries approximately correspond to each other, which makes it possible to consider erectile dysfunction as a disease of age. Other causes of arteriogenic impotence are trauma, congenital anomalies, smoking, diabetes mellitus, hypertension. In the presence of limited arterial inflow, the intracellular metabolism of the cavernous tissue and the endothelium of the afferent vessels suffers significantly, which forms a vicious circle and often leads to irreversible dysfunction of the cavernous tissue.

Venogenic erectile dysfunction.
For reasons of violation of venocclusive function, 3 types of venous erectile dysfunction are distinguished:
Primary venous erectile dysfunction occurs with congenital pathological drainage of the cavernous bodies through large dorsal saphenous veins or enlarged cavernous or leg veins, cavernous-spongiform shunting, etc.
Secondary venous erectile dysfunction occurs due to a decrease in the elasticity of the cavernous tissue, as a result of which there is no compression of the emissary veins of the albuginea and the implementation of a passive veno-occlusive mechanism. The reasons for this are the functional insufficiency of the cavernous erectile tissue as a result of a lack of neurotransmitters, psychogenic inhibition, smoking, sclerosis and fibrosis of the cavernous tissue.
Corporovenous insufficiency occurs due to insufficiency of the albuginea as a result of traumatic rupture, Peyronie's disease, primary or secondary thinning.

III. Hormonal erectile dysfunction
The cause of hormonal erectile dysfunction is the insufficiency of the male sex hormone, either due to congenital or acquired hypogonadism, or due to age-related decline in male sex hormone (PADAM syndrome).
With androgen deficiency, the pathogenesis of erectile dysfunction has three components:
Decreased sexual desire (emotional and motivational tension) and, as a result, a decrease in erectile function
Inhibition of the formation and release of neurotransmitters and nitric oxide (the main mediator of erection). these processes are hormone-dependent.
Reversible dystrophy of the cavernous tissue with androgen deficiency, which leads to a decrease in its elasticity and the formation of secondary venous erectile insufficiency.

IV. Neurogenic erectile dysfunction
It occurs as a result of injuries or diseases of the brain or spinal cord, as well as peripheral nerves that prevent the passage of nerve impulses to the cavernous bodies. The most common cause of non-genic erectile dysfunction is spinal cord injury (up to 75%). Other causes may be neoplasms, cerebrovascular pathology, syringomyelia, multiple sclerosis, herniated disc, etc.

V. Medical erectile dysfunction
Drug-induced erectile dysfunction occurs in individuals taking medications that adversely affect sexual function.
The drugs most commonly associated with ED include:
- cardiovascular drugs (hypotensive, β-blockers, sympatholytics, diuretics, cardiac glycosides),
- hormonal (estrogens, corticosteroids, antiandrogens, progestins),
- psychotropic drugs (antidepressants, MAO inhibitors, lithium preparations, tranquilizers)
- drugs of other groups (cytostatics, non-steroidal anti-inflammatory drugs, weight loss agents).

VI. Cavernous erectile dysfunction
The causes of cavernous insufficiency are different. These causes lead to dystrophy of the smooth muscles of the cavernous tissue, to a decrease in the percentage of elastic fibers and induction of the development of fibrous tissue. All this leads to a decrease in the elasticity of the cavernous bodies and the formation of secondary venous leakage. This is due to a violation of vascular, nervous and biochemical processes in the cavernous tissue against the background of the underlying disease.
The main causes of cavernous erectile dysfunction are diabetes mellitus, chronic intoxication (alcoholism, chronic heavy metal poisoning), smoking, etc.

VII. Mixed form of erectile dysfunction
With a mixed form of erectile dysfunction, various etiological factors can be the cause.

Turning to the urologist with complaints of weakening of erection, in most cases, the doctor mistakenly puts the diagnostic emphasis on identifying any form of prostatitis and its further treatment. Of course, prostatitis can cause weakening of erections, but more often the reason is not in it.

Erectile dysfunction (ED) due to inflammatory diseases of the genital organs. The cause of ED can be inflammatory processes in the genital organs caused by sexually transmitted infections (chlamydial, mycoplasmal, gonococcal, trichomonas). The pathogenesis of these lesions lies in the fact that, on the one hand, ED can develop as a result of lesions of the genital organs (prostate gland, seminal tubercle, seminal vesicles), and on the other hand, as psychogenic. In ED caused by these diseases, along with damage to the receptor apparatus, there is a violation of other parts of the nervous regulation of sexual function, in particular, sexual spinal centers are involved in the pathological process. Patients often present with various neurological disorders.

The chronic course of inflammatory processes in the genital organs, frequent relapses, fear of complications that can lead to violations of sexual function, excessive fixation of patients' attention on their condition cause a permanent and prolonged psychotraumatic situation. Often, the patient's attempt to have sexual intercourse ends in failure due to the lack of an adequate erection at the right time. As a result, the clinical course of ED worsens.

The clinical picture of ED caused by inflammatory lesions of the genital organs is characterized by a progressive decrease in potency with a weakening of erection while maintaining sexual desire. However, in some cases, such patients also showed a decrease in sexual desire. Characterized by weakness, sleep disturbance, decreased performance, depression, which are caused by impaired sexual function and in themselves can be the causes of functional disorders, maintain the spinal centers of erection and ejaculation in a state of pathological excitation, and thereby contribute to the development of ED.

DIAGNOSTICS.

So, we can distinguish the main diagnostic methods for erectile dysfunction:
1. Physical examination and conversation with the patient.
2. Laboratory tests (general blood count, urine, blood glucose, cholesterol).
3. Blood test for sex hormones.
4. Testing the patient according to the international index of erectile function (IIEF).
5. Tests with the use of vasoactive drugs.
6. Dopplerography of the vessels of the penis (at rest and erection).
7. Cavernosography.
8. Ultrasound of the abdominal cavity and small pelvis.
9. Urethral secretion analysis, prostate secretion analysis, prostate secretion culture tank.
10. Examination for STDs.

The scope of the examination is carried out selectively and individually for each patient and depends on many factors.

TREATMENT.
Treatment of ED today includes non-invasive (drug therapy, the use of vacuum constrictor devices) and invasive methods (intracavernous injections (ICI) of vasoactive substances and surgical treatment).

In the treatment of ED, three lines of therapy can be distinguished:
First line therapy.
The first line of therapy consists of prescribing a range of oral medications. To date, there are three selective phosphodiesterase type 5 inhibitors on the market, approved by the European Medicines Agency, with proven efficacy and safety in the treatment of ED: sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra).
Vacuum-constrictive devices. Can be used by patients who do not want to take medications or in the complex therapy of ED. The device creates negative pressure around the penis, which promotes the flow of venous blood into it, which is then retained in it by a compression ring worn on the base of the penis. Side effects of this treatment include penile pain, numbness, and delayed ejaculation.
Psychotherapy. Psychotherapy is the leading method of treatment for all forms of sexual disorders. It can serve both as monotherapy and in combination with other therapeutic methods. Practice shows that even with organic disorders of potency, when resorting to surgical correction, psychotherapeutic effects must be applied both before surgery and after surgical treatment.

Second line therapy.
Patients not responding to oral medications, as well as in complex therapy, can be offered intracavernous injections or intraurethral drugs eg. Prostaglandin E1 (underutilized recently). Several drugs have been proposed for intracavernous administration, they can be used individually and/or in combination. An erection occurs after 5-15 minutes, its duration depends on the administered dose of the drug.

third line therapy.
The third line of therapy includes surgical treatment, namely endophalloprosthetics and vascular surgery. Surgical implantation of penile prostheses may be offered to patients who have failed medical treatment or who prefer a permanent solution to their problem.

Of course, today, the most effective method of treating severe forms of erectile dysfunction is endophalloprosthetics, but, in most cases, preference is given to non-surgical methods of treatment.

We use all modern non-invasive and invasive methods of treating all types of erectile dysfunction, including the most modern technique - low-energy shock wave therapy (NUVT), which promotes neoaniogenesis in the cavernous bodies of the penis.

Under erectile dysfunction (impotence) refers to the inability of a man for at least three months to achieve and maintain an erection to satisfy sexual activity and sexual intercourse.

The term "impotence" according to modern concepts is untenable, since this diagnosis assumes an extreme degree of such a problem as sexual dysfunction with the ineffectiveness of conservative therapy.

Causes of decreased erectile function

ED (erectile dysfunction) can be of several types depending on the mechanisms of its development and causes:

Psychogenic ED is caused by:

depression
overwork;
associative psychotraumatic factors;
various deviations and phobias.

The influence of these factors determines the fact that a number of processes are triggered in the cerebral cortex that negatively affect the mechanism of the normal development of erection processes:

direct inhibitory effect;
indirect inhibitory effect (through the spinal centers responsible for the erection mechanism);
increased levels of norepinephrine and adrenaline.

At the core arteriogenic ED vascular lesions lie:

congenital anomalies of the vessels of the penis;
hypertonic disease;
penis injury;
atherosclerosis;
diabetes;
smoking.

This form of the disease is often accompanied by degenerative changes in the cavernous tissue due to insufficient blood supply. As a result, a vicious circle arises, which, in the absence of timely therapy, leads to changes in the cavernous bodies of an irreversible nature.

Cause venogenic ED is a violation of the veno-occlusive mechanism:

abnormal bleeding(ectopic drainage) through dorsal, great saphenous, enlarged pedunculate or cavernous veins;
shunting of blood into the spongy body from cavernous (cavernous-spongy shunt);
insufficiency of the albuginea(Peyronie's disease, traumatic rupture, thinning (primary or secondary));
functional insufficiency of erectile cavernous tissue(psychogenic inhibition, lack of nephrotransmitters, ultrastructural changes, smoking).

Cavernous insufficiency(a form of ED, which is a dysfunction of the cavernous tissue). The causes of this pathology are very diverse and cause extra- and intracellular changes in the cavernous bodies, as well as their nerve endings and blood vessels, preventing the normal function of the erector mechanism.

Neurogenic ED caused by various injuries and diseases of the spinal cord and brain, pathologies of the peripheral nerves of the small pelvis (as a result, for example, of open surgery for cancer or prostate adenoma).

Structural (anatomical) ED It is caused by violations of the anatomy, as a rule, by a pronounced curvature of the penis, such as:

fibrosis of the cavernous bodies, usually associated with surgical interventions, the introduction of foreign bodies into the urethra, injuries, etc.;
Peyronie's disease;
congenital curvature.

Anatomical ED is treated surgically, the best option of which is penile prosthesis.

The mechanism of development of hormonal ED is due to a number of processes. Vasodilation is caused by the action of nitric oxide, synthesized in the body with the participation of an androgen-dependent enzyme. A decrease in the level of testosterone (male sex hormone) leads to a decrease in the activity of this enzyme and, accordingly, to a deterioration in erection. That is why an attempt to treat the described form of ED with phosphodiesterase type 5 inhibitory drugs (Cialis, Viagra, Levitra) is ineffective.

In addition, a decrease in testosterone concentration provokes an increased deposition of fat cells in the cavernous bodies and dystrophy of smooth muscle cells, leading, as a result, to the fact that the veno-occlusive mechanism is disturbed.

Also, the normal level of testosterone determines the sexual desire (libido).

Age-related impotence is caused by changes in the body that occur in older people, namely a decrease in:

blood flow speed;
sensitivity of the nervous system;
testosterone levels;
elasticity of the vessel walls.

This age-related natural decline in erectile function should be differentiated from a decline caused by somatic pathologies, for which the likelihood of developing with age also increases. The absence of chronic diseases allows you to have a full sexual life (according to age norms) even at the age of 80.

In addition to the described forms of ED, a number of andrologists also distinguish medicinal (medicated) ED.

Diagnostics

Anamnesis.
inspection data.
Laboratory research.
Instrumental research.

It is optimal to collect information through adapted questionnaires.

Data interpretation (according to the scoring system):

norm(22–25 b.);
mild degree(17–21 b.);
easy-medium degree(12–16 b.);
average degree(8–11 b.);
severe ED, impotence(5–7 b.).

Laboratory diagnostics involves determining the hormonal status of the patient. If there are indications, to identify somatic diseases, general blood and urine tests are performed, as well as the definition of:

lipid spectrum;
HDL and LDL;
total cholesterol;
PSA (PSA);
blood glucose, etc.

Instrumental diagnostics:

Monitoring of spontaneous nocturnal erections for differentiation of psychogenic, with preservation of nocturnal erections, and organic forms.
UZDG (ultrasound dopplerography) penile arteries to assess microcirculation, identify structural changes in Peyronie's disease and cavernous fibrosis. For greater information content, ultrasound of the arteries of the penis should be carried out in a state of erection and rest, and then compare the results.
Intracavernous administration of vasoactive agents(usually the prostaglandin E analogue alprostadil) to detect vasculogenic ED. The result of the test for normal veno-occlusive and arterial hemodynamics is the occurrence after injection after 10 minutes of a pronounced erection, which persists for half an hour or longer.

It is possible to conduct other studies if there are indications:

the main test for direct assessment of the degree of violation of elasticity and the closing ability of the sinusoidal system - cavernosometry (determination of the volumetric velocity of saline pumped into the cavernous bodies, which is necessary for the development of an erection);
cavernosography, which displays the venous vessels through which the predominant discharge of blood from the cavernous bodies occurs;
radioisotope phalloscintigraphy, which makes it possible to assess quantitative and qualitative indicators of regional hemodynamics in the cavernous bodies of the penis;
neurophysiological studies, such as the determination of the bulbocavernosus reflex in patients with spinal cord pathology, with diabetes mellitus.

impotence treatment

Conservative treatment

When deciding how to treat ED conservatively, the doctor can choose from the following options:

Surgery

The use of surgical methods for the treatment of impotence is recommended in the presence of convincing evidence of a violation of the blood supply to the penis, as well as in the absence of a result in the application of any other therapeutic measures. In case of arterial or venous insufficiency, it is possible to carry out surgical treatment with the subsequent restoration of normal blood circulation. An alternative method of surgical treatment is penile prosthesis - implantation of a penis prosthesis.

The reluctance of men to seek help from specialists with such a problem as ED is a common phenomenon all over the world, Russia is no exception. With such problems, it is not customary to go to the doctors. Indeed, it is difficult for a tired urologist to imagine how they will look at a man in an ordinary clinic who, at the end of the working day, complains about failures in bed. Especially if it's a female doctor.

In addition, men perceive any change in their sexual “features” very sharply. Therefore, “problems in personal life” usually go into the category of “personal problems”, those that you can’t tell anyone about.

It is important to understand that ED is not uncommon. Medicine has long had an impressive arsenal of tools to help such patients. Do not neglect a visit to a sex therapist. This category of doctors specializes in the treatment of psychosexual disorders. ED of a psychogenic nature is his profile. As for organic or mixed ED, drug therapy is indispensable here.

TALK FOR CLEANLINESS

Today, virtually any man, regardless of age, is afraid to face such a problem as erectile dysfunction (ED). For many representatives of the strong half of humanity, this disease becomes a real tragedy. After all, almost every one of them perceives the change in their sexual "features" very sharply.

Statistical data demonstrate a rather low frequency of requests for specialized assistance. It is unacceptable to talk about it. Meanwhile, the issue of ED deserves careful consideration from different points of view. Both the psychological aspect and the understanding of the physiology of the process are important here.

It is traditionally believed that this problem affects only men. But is it really so? After all, sexual relationships are relationships between two people, and often failures in the intimate sphere can destroy even the strongest couples. Responsibility for maintaining the relationship in this case lies with both partners.

The role of a woman is very important! To provide comprehensive support to your loved one, you need to take into account all the nuances - from diet to lifestyle in general. After all, first of all, ED requires an individual approach, sensitivity and awareness.

In the WHO program dedicated to sexual and reproductive health, much attention is paid to the problem of ED. According to American studies, 39% of the male population under the age of 40 complain of problems with potency. After 70 years, 67% already face such a problem. However, only a small proportion of men suffering from ED seek medical help. The rest do not consider it a disease and perceive it as a normal manifestation of aging, a consequence of stress and fatigue.

As a rule, under the term impotence, doctors and patients mean different concepts. In medicine, impotence is commonly understood as the complete inability of a man to have sexual intercourse, under any circumstances. Fortunately, this term is outdated and today it is customary to talk about erectile dysfunction, since absolutely any erectile dysfunction can be treated today.
But, before talking about the reasons for its occurrence, it is worth paying attention to another issue.

An erection is not only a necessary component of a full-fledged sexual relationship, but also a kind of barometer that reflects the state of physical and mental health. This is a complex complex process of interaction of three physiological systems: the central nervous system (CNS), peripheral nerve fibers and vascular smooth muscles.

MECHANISMS OF ORACTION OF AN ERECTION, BRIEFLY AND CLEARLY:

With sexual stimulation - physical and / or under the influence of thoughts of erotic content (in other words, activation of the brain areas responsible for libido), the nerves are “instructed” to provide increased arterial blood flow to the cavernous bodies. They are responsible for the quality of erection. At the same time, the outflow of venous blood decreases. ED occurs due to a violation of these mechanisms.

CAUSES OF ERECTILE DYSFUNCTION:

As for the causes of ED, they are usually divided into three groups:
— Psychogenic
— Organic
— Mixed

What do they mean when they talk about the psychogenic causes of ED? Here we are talking about all kinds of stress, depression and problems with a partner. Fear of sexual contact, expectation of failure, and self-doubt complete the list.

In the first place among organic causes - vascular diseases. These include atherosclerosis of large arteries, hypertension and varicose veins.

The second place is occupied by failures in the endocrine system. A decrease in the activity of the gonads leads to insufficient production of the "hormone of masculinity" - testosterone.

Taking drugs and substances that inhibit the activity of the cerebral cortex are also causes of ED.
The list of neurological diseases leading to ED is also quite extensive - from epilepsy to trauma to the brain and spinal cord.

And, finally, sclerosis of the cavernous bodies, when elastic tissues are replaced by fibrous ones. However, most often the causes of ED are mixed.

RISK GROUP:

Almost every man can experience ED. But there are those who are especially prone to it. So, they are at risk.

Motorists
Vibrations and shaking disrupt blood circulation, which leads to congestion in the pelvic organs and inflammation of the prostate. And this, in turn, leads to a weakening of the erection.

overweight men
Obesity affects the functioning of the muscular and cardiovascular systems. In addition, adipose tissue slows down the production of testosterone.

alcohol lovers
Alcoholic drinks depress the centers of the spinal cord responsible for the mechanisms of ejaculation and erection. Over time, such men generally forget about what sexual attraction is.

smokers
When smoking, the human circulatory system suffers significantly. Nicotine, getting into the body with cigarette smoke, causes a short-term vasospasm, and regular smoking keeps the vessels almost all the time in a spasmodic state, which inevitably leads to a deterioration in the quality of erection.

FIRST SYMPTOMS OF ERECTILE DYSFUNCTION

Symptoms can be conditionally divided into several types:

- disorders associated with the weakening of sexual desire (libido)
- erectile dysfunction
- violation of ejaculation and orgasm (in this case it is customary to talk about anorgasmia)

Violation of libido or unwillingness to physical intimacy is perhaps the most common symptom. This can occur both due to the discord in the relationship of partners, depression, and due to hormonal disorders. Hypogonadism leads to a decrease in testosterone production. It is worth saying that in addition to erectile dysfunction, a man also faces other signs of a low level of the “hormone of masculinity”. The timbre of the voice changes towards a higher one, the growth of hair on the face and body slows down or stops. Fat deposits appear “according to the female type” - on the chest, hips, buttocks. However, such obvious changes occur already with severe disorders of the hormonal system,

Weak, defective erection can occur against the background of vascular diseases. This is especially true for older people. Also among the causes are sclerosis of the cavernous bodies of the penis. At the same time, the thin and elastic tissue is partially or completely replaced by a coarse, solid connective tissue, which is not capable of stretching and erection.

It is extremely rare to encounter the phenomenon of anorgasmia in men. Orgasm in this case is fleeting or completely absent. The absence or partial violation of ejaculation, as well as anorgasmia in some cases indicates psychological problems, however, they may be the result of an organic lesion of the central nervous system, or the surgical treatment of the pelvic organs or the spine that was transferred the day before.

ORGANIC (VASCULAR) FORM OF ERECTILE DYSFUNCTION

Vascular disorders are the most common cause of organic ED.
An erection is directly related to the circulatory system of the penis. Any violation of the outflow of blood affects here. With insufficient arterial inflow, an erection occurs for a long time and slowly, it is rarely of high quality - the penis is in an "intermediate" position between a calm state and arousal. The opposite reason is also possible: too strong venous outflow of blood. In this case, the excitement comes quickly, the erection is very good, but quickly passes, not allowing to complete, and sometimes even start sexual intercourse.

PSYCHOGENIC FORM OF ERECTILE DYSFUNCTION, HOW TO RECOGNIZE IT,

According to experts, psychogenic ED can occur at any age against the background of apparent well-being. There are studies confirming the correlation of psycho-emotional conditions, such as depression, with ED.

A distinctive feature of ED associated with psychological factors is the preservation of morning and night erections. Problems are observed before or during sexual intercourse.

There are many reasons for the occurrence of psychogenic ED. The most unpleasant thing is that the dysfunction progresses exponentially. A man, faced with a problem, often neglects going to specialists and withdraws into himself. Begins with fear to expect another failure in bed, which only exacerbates the situation. Coping with psychogenic ED in some cases is much more difficult than with partial impotence caused by organic problems. Establishing the true causes of psychogenic ED is not an easy task.

Often the causes of psychogenic ED lie in the area of memories from childhood or adolescence. They are also associated with some kind of psychological trauma or painful sensations that accompanied the first sexual contact.

Fear of pregnancy or sexually transmitted diseases, fear of losing control of oneself or not satisfying a partner quite often gives rise to problems with excitability.

So what foods will help a man get back to normal as soon as possible?
Pumpkin juice. It is recommended to use it daily for several months. (fig. glass of juice)
Fruit tea. Leaves of cherries, white currants, strawberries, raspberries and blackberries, taken in equal proportions.
Green vegetables. Celery and spinach contain many substances that increase blood flow.
Oysters and shrimp. They are rich in zinc, which is involved in the production of testosterone.
Red fruits and vegetables. Grapefruit and tomatoes contain lycopene, which affects blood circulation. The greatest effect of lycopene is achieved with the parallel use of fatty vegetables such as spinach and avocado.
Foods rich in protein. Cottage cheese, meat, boiled fish and eggs.
Dried dates also help increase a man's sexual power.
Pistachios. They contain arginine, which relaxes the walls of blood vessels.

Mentions of sexual disorders in men are found in ancient Egyptian papyri, as well as in myths and legends. Around 400 BC, the ancient Greek physician Hippocrates noted that constitutional elements are an important factor in influencing the strength of sexual desire. The ancient Roman physician Galen wrote about the influence of mental factors on the possibility of developing impotence, he called neurogenic impotence"neurological paralysis"

Modern view of the problem

According to WHO, approximately one in five men on the planet has some form of erectile dysfunction.

Today, associations of urologists understand the term erectile disfunction inability to achieve or maintain erection, sufficient to satisfy sexual activity, if these disorders continue for at least three months.
Thus it is a prolonged inability to achieve erections or support her. Term erectile disfunction proposed in the USA to replace the old " impotence”, implying too categorical perception of the problem. According to the MMAS study, up to 50% of men over 40 have erectile dysfunction varying degrees of severity, and with age their number increases significantly and reaches 67% by the age of 70.

According to WHO, approximately one in five men on the planet has some form of erectile dysfunction. There is evidence that only 20% of men suffering from erectile dysfunction seek medical attention and only just over 30 percent of them receive treatment. The rest do not consider erectile dysfunction a disease, but perceive it as a normal manifestation of aging, a consequence of stress and fatigue. More than 75% of men do not go to the doctor with this problem, and ineffective self-treatment leads to further progression of the disease. It is important to note that erectile dysfunction is often a manifestation of many serious chronic diseases. And if we talk about prostatitis, then if it plays a negative role, then at the very least and only in the presence of severe symptoms characteristic of prostatitis.

Diabetes increases the risk of developing erectile dysfunction by 55%, coronary heart disease by 39%, heart disease and smoking by 56%, arterial hypertension 15%, depression 90%, hypercholesterolemia 25%.

Reasons for the development of erectile dysfunction:

There are two groups of causes - psychological and organic disorders.

To the first(psychological problems) include depression, drug addiction, alcoholism, specific psychopathic disorders, "fear of impotence", coitophophy and others. An interesting study was conducted by scientists at the University of Frankfurt am Main (Germany). 240 men aged 35 to 64 years were interviewed, it was found that the most common causes of erectile dysfunction were tension and stress caused by work 33% and personal problems 19%.

If speak about second group causes (organic causes), then the dominant position is occupied by lesions of the vascular system.

So reason number one vascular pathology - congenital anomalies of the arteries of the cavernous bodies, atherosclerotic lesions of the aorta, angiopathy of the vessels of the penis against the background of diabetes, smoking and obesity, hypercholesterolemia (increased levels of cholesterol and triglycerides, LDL in the blood), hypertension. It is important to note that in 30% of cases, arterial insufficiency of the penis manifests itself earlier than systemic lesions of the cardiovascular system. Since the diameter of the cavernous arteries is less than the diameter of the coronary arteries.