Erectile dysfunction (ED)

Erectile dysfunction (ED) is the recurring inability to achieve or maintain an erection firm enough for satisfying sexual activity. It is a common condition that significantly affects quality of life and can be an early sign of cardiovascular disease. It results from a combination of vascular disease, hormonal disorders, neurological or urological conditions and psychological states (stress, anxiety, depression, relationship problems); most often several factors are involved, including lifestyle (smoking, alcohol, obesity, physical inactivity), previous surgery (pelvic or abdominal operations) and certain medicines (antihypertensives, antidepressants).

An erection is a complex neurovascular process in which sexual stimulation, through nerve pathways and the release of nitric oxide (NO), relaxes the blood vessels in the penis, increases arterial blood inflow and blocks venous outflow, causing the penis to swell. Erectile dysfunction occurs when this mechanism is disrupted, most often due to vascular changes and endothelial dysfunction. ED is therefore often a symptom of an underlying health problem, so comprehensive care includes finding the cause, assessing general health and individually tailored treatment.

Occasional erection problems are common and usually nothing to worry about. If they recur or last longer, a urological examination is recommended. The urologist will try to find the cause of the erectile dysfunction; the evaluation usually includes a consultation with an erectile function questionnaire, a clinical examination, laboratory tests if needed (HbA1c, lipid profile and morning testosterone) and an assessment of cardiovascular risk. Selected patients need further tests, such as a penile Doppler ultrasound.

Treatment is tailored to the cause, the patient's health and his wishes. The first step is to address risk factors such as smoking, excess weight, lack of physical activity, diabetes and cardiovascular disease. PDE5 inhibitors (e.g. sildenafil and tadalafil) are the first step in treating erectile dysfunction. If they are not effective enough, vacuum devices, intracavernosal therapy with alprostadil (Caverject) and psychosexual therapy are available. For severe ED that does not respond to other treatments, a penile prosthesis is also an option.

Caverject® (alprostadil) is an effective treatment for erectile dysfunction in men for whom oral medication is ineffective or unsuitable. Alprostadil relaxes the smooth muscle of the corpora cavernosa and increases blood flow to the penis, which produces an erection.

The first injection and dose titration must be performed or supervised by a urologist; only after appropriate training can the patient learn to self-inject. As a rule, no more than 1 injection per day and no more than 3 injections per week are recommended, with at least 24 hours between injections.

Injection procedure:

• The medicine is prepared immediately before use and used aseptically.
• The side of the proximal third of the penis is chosen; visible blood vessels, the dorsal neurovascular bundle and the urethra must be avoided.
• The skin at the injection site is cleaned with an alcohol swab.
• A suitably fine needle is inserted into the corpus cavernosum at an appropriate angle; the injection should go in without significant resistance.
• The medicine is injected slowly, then the needle is removed and the injection site is pressed for a few minutes to reduce the risk of bleeding or bruising.
• For the next injection, the side and site should be changed to reduce the risk of fibrosis.

An erection usually occurs within about 5–15 minutes. If an erection lasts 4 hours or more, immediate medical attention is needed because of the risk of priapism. When using Caverject, regular urological check-ups are needed to monitor its effectiveness and any development of nodules, curvature or fibrosis of the penis.