Erotic stimuli create pro-erectile processes in the basal ganglia of the cerebral cortex. The excitation formed in the central nervous system is carried out due to the peripheral mechanisms of erection. The main one is the relaxation of the smooth muscle elements of the cavernous bodies and cavernous arteries. The main pro-erectile mediator is nitric oxide (NO). The development of detumescence also involves phosphodiesterases (PDE), enzymes that destroy cyclic mononucleotides (cGMP and cAMP). The greatest value in the smooth muscle structures of the penis is phosphodiesterase-5.
Drugs for the treatment of erectile dysfunction
In healthy men, sexual stimulation causes the release of the nitric oxide mediator from non-adrenergic and non-cholinergic neurons that innervate the corpus cavernosum of the penis. NO is involved in the transmission of an intracellular signal, which leads through the activation of protein mechanisms to a decrease in the concentration of intracellular calcium and relaxation of the smooth muscles of the penis, vasodilation, and the development of an erection.
The emergence of an erection is the result of the interaction of neurogenic, neurochemical, and endocrinological mechanisms. The tone of the smooth muscles of the cavernous bodies and blood vessels is controlled by complex biochemical mechanisms regulated by the peripheral and central nervous systems. This control is provided by neuroanatomical connections that are part of the innervation of the lower urinary tract.
The PDE inhibitors Sildenafil (Viagra), Vardenafil (Levitra), and Tadalafil (Cialis) are selective inhibitors of PDE-5, an enzyme that breaks down cGMP in various tissues. The drugs of this group enhance the relaxing effect of NO on smooth muscles. Sexual stimulation releases NO in the nerves of the corpora cavernosa, vascular endothelium, and smooth muscle cells, leading to vasodilatation and penile erection. By preventing the destruction of cGMP, PDE-5 inhibitors enhance the vasodilating effect of NO and restore erection in patients with impotence.
The results of the study confirmed the effectiveness of three PDE-5 inhibitors (with equivalent doses of Levitra and Cialis, their effectiveness is approximately comparable to Viagra). There are differences between the drugs, for example, Vardenafil (Levitra) has a weak hypotensive effect. Levitra reduces blood pressure to 5-10 mm Hg and also increases the heart rate at a dose of 40 mg. For these reasons, some PDE-5 inhibitors should not be prescribed for severe hypotension.
Treatment of elderly patients should be started with low doses of sildenafil 50 mg, vardenafil 10 mg, and tadalafil 10 mg (or 2.5 mg per day) due to the increase in peak plasma concentrations of the drug in these patients and the duration of the elimination half-life.
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Since many patients are convinced that erectile dysfunction is not a disease, but a natural process that accompanies the aging of the male body, and also because of the particular delicacy of the problem, only a few patients suffering from this disease go to the doctor.
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The vacuum devices for the treatment of ED
A special compression is applied to the base of the penis, limiting the venous outflow. The resulting erection is not physiological. The device leads to a rush of blood to the cavernous bodies, which causes an erection. Indications for the use of vacuum devices are the impossibility of medical treatment or other inefficiencies, as well as elderly men. About 30% of patients subsequently refuse to use vacuum devices. The reasons for refusal are most often pain syndrome, subcutaneous hemorrhages, difficult ejaculation, and pain in the glans penis.
Penile implants are devices placed inside the penis to allow men with erectile dysfunction (ED) to get an erection. Penile implants are typically recommended after other treatments for ED fail. There are two main types of penile implants, semirigid and inflatable.
Additionally, urologists use low-energy shock wave therapy as an alternative therapy in the absence of the effect of PDE-5 inhibitors. It is assumed that an acoustic wave, passing through biological tissues, causes an increase in tension, and an increase in the level of nitric oxide, stimulating the process of neovascularization in the cavernous bodies.
Surgical treatment of impotence – with the ineffectiveness of conservative treatment of impotence, which is manifested by the absence of positive clinical dynamics and an increase in indicators during re-examination. Application of phalloplasty using penile prostheses, three-piece rigid or inflatable penile prostheses. Surgical treatment is also chosen at the request of the patient, the optimal method of treatment, in this case, is phalloplasty with prostheses.
There are two types of penile prostheses: rigid and three-piece, inflatable. Most patients sexually prefer three-piece prostheses. The prosthesis of the penis creates a constant axial rigidity of the organ. Satisfaction with sexual life after implantation is found in 90% of operated patients.