Erectile dysfunction / Top clinic in Germany, Friedrichshafen

Erectile dysfunction

Disturbances of the erection (limb stiffening) often have a psychological and / or physical (physical) cause. But there are many treatment options.

Erectile Dysfunction (ED) literally means erectile dysfunction (limb stiffening), in English erectile dysfunction. It is understood as the permanent inability to achieve or maintain an erection sufficient for a satisfactory sexual act. Among other things, it is clear from this definition that the diagnosis also depends on the subjective assessment by the person concerned and that an occasional absence of the erection does not mean ED.

Erectile dysfunction is colloquially also referred to as potency disorder or impotence (from Latin potentia = fortune, power, power). However, this is medically incorrect, because both terms also include the inability to normal ejaculation (ejaculation), the inability to produce (sterility) and the lack of urge to sexual activity (lack of libido = "desire").

In undisturbed libido and normal hormonal position, certain areas of his brain are excited in erotic situations under the influence of the mental state of the man, for example, through visual impressions, touch, odors or ideas. Through special centers in the spinal cord and nerve fiber plexuses in the area around the bladder and prostate, the impulses then reach the penis. There, they relax the musculature of the afferent blood vessels (arteries) and erectile tissue, causing an increase in the diameter of the afferent arteries. Thus, the blood supply increases in the cavities of the erectile tissue, so that they expand and a high pressure in the cavernous body arises. This pressure in turn squeezes the laxative blood vessels (veins), the blood no longer drains from the erectile tissue, the high pressure remains and the penis becomes large and stiff. The cavernous bodies have a stable connective tissue envelope, which limits their extent (tumescence) and together with the balance of inflow and outflow of blood determines the hardness (rigidity) of the erection.

The afferent blood vessels (arteries) are barrier arteries whose width can be regulated via the musculature of the arterial wall. The emptying of the cavernous bodies is also under the control of the brain via nerve impulses. These regulate the smooth muscles of the barrier arteries, the arteries occlude and thus the pressure falls in the erectile tissue. The low pressure is no longer sufficient to squeeze the laxative vessels. As a result, the blood stream is released, the erectile tissue emptied, the penis relaxed again. From erectile dysfunction, there are two terms that are sometimes used synonymously: impotence and sterility. Impotence is a very general and vaguely defined term, as earlier distinction was made between inability to cohabit (Impotentia coeundi), and impotence for reproduction (Impotentia generandi). Sterility means the incapability of the male for reproduction, colloquially also called fertility, whereby the erection ability is usually not limited.

Erectile dysfunction can occur occasionally or for a limited period of time, leading to permanent loss of erectile function. In a medical sense, erectile dysfunction is referred to when the affected person can not achieve a sufficient erection within 6 months from about 70% of the experiments.

Frequency of erectile dysfunction

Many men are affected by a more or less pronounced erectile dysfunction, in Germany alone up to 6 million. The incidence increases with age, according to studies to more than 50%. However, only 10-25% of them can be treated, although up to two-thirds of men are sexually active even at a higher age.

The unreported number is so high. Shame probably prevents many sufferers from going to the doctor (or the fear of not being a real man). Often the partnership is burdened. This in turn builds up psychological pressure, which only aggravates the problem.

Causes of erectile dysfunction

It can be seen from the process of erection described above that it can be organically (physically) disturbed in a variety of ways. However, the psyche (e.g., failure anxiety, stress at work, partnership conflicts) also plays a significant role in erectile dysfunction (ED). It can trigger and amplify problems.

Physical causes include, for example:

  • Supply of pleasure poisons (such as alcohol, nicotine) or drugs.
  • Cardiovascular diseases, e.g. coronary heart disease, hypertension, arteriosclerosis ("vascular calcification").
  • Metabolic diseases, e.g. Diabetes mellitus (diabetes), lipid metabolism disorders, thyroid diseases.
  • Taking medicines, e.g. Blood pressure and lipid lowering drugs, heart medicines, anti-inflammatories, psychotropic drugs, tranquilizers and strong analgesics, appetite suppressants, hormonal preparations (including antiandrogens and LH-RH analogues for the treatment of prostate cancer, see Hormone therapy).
  • Benign prostate syndrome (benign prostate enlargement, see BPS).
  • Diseases of brain or spinal cord, e.g. multiple sclerosis, stroke.
  • Nerve damage, e.g. by poisons or in prostate cancer by radical prostatectomy or radiotherapy.
  • Changes in hormone levels due to diseases of the pituitary (pituitary gland), testes or adrenal glands.
  • Malformations, injuries or penile diseases.
  • As major risk factors for ED as well as for cardiovascular diseases are: lack of exercise, obesity, smoking, hypercholesterolemia (increased blood lipid levels) and the metabolic syndrome (combined metabolic disorder in diabetes mellitus).

Investigation in case of erectile dysfunction

The basis is the detailed collection of the anamnesis (previous history) in order to limit the number of possible causes. This also includes questions about the intake of medication, the psychological situation and the sex life. The sexual history should include the partners and questionnaires may also be used (for example the IIEF, International Index for Erectile Function).

Then follows the physical examination, including the measurement of blood pressure and pulse as well as a DRU (see digital rectal examination). Whether laboratory tests are carried out depends on the results so far. Further investigations can be: the determination of blood sugar, blood fats and sex hormones (see also sex hormones), if necessary also further ones like the PSA value (see PSA determination).

Because the cardiovascular risk in sexual activity among those affected by ED is increased, the diagnosis also aims to assign the affected person to a corresponding risk class, possibly with the help of a cardiologist or internist. Thus, at high risk (for example, unstable angina pectoris = "chest tightness"), the ingestion of PDE-5 inhibitors (see above) is usually prohibited. At low risk, however, a trial with these drugs may be considered without further investigation.

Only rarely are special examinations, such as the cavernous injection test (SKIT) and sonography (ultrasound examination) of the penile vessels required. Measurements of nocturnal erections (NPTR, nocturnal penile tumescence and rigidity), activity measurements of cavernous body musculature (CC-EMG, corpus cavernosum electromyography), X-ray contrast imaging of cavernous bodies or blood vessels, and functional tests of nerves or hormone control circuits are only available in particularly complicated cases and are usually only carried out by specialized institutes.

Treatment of erectile dysfunction

First and foremost, the elimination of the risk factors (for example through physical training, weight loss, smoke stop) and the treatment of possible causes (such as adjustment of blood pressure and blood sugar, switching to other drugs, hormone replacement, surgery of malformations, psychotherapy).

At the same time - or if this is not enough or not possible - symptomatic measures (directed against the symptoms, ie the ED) can be used. It should be noted that these are not a benefit of the statutory and private health insurance and are therefore not reimbursed.

The selection depends on the cause of the ED, the findings and the individual needs and expectations of the affected couple. Success, satisfaction and adverse effects should be reviewed regularly and therapy should be adjusted if necessary.

Be available:

PDE-5 inhibitors: Decisive for the erection is the muscular relaxation in the cavernosum and the afferent blood vessels. The reaction begins with a stimulus that triggers a nerve impulse in the brain. Up to the muscle cell, the signal is conducted nervally. Within the cell, complex biochemical processes ultimately lead to a relaxation of the blocking muscles (see also disorders of erection) in the blood vessels, blood flows in more and the erection develops. One element of the complicated rule chain is cGMP. A high concentration of cGMP creates and sustains the erection. cGMP is degraded by the enzyme phosphodiesterase. By inactivating this enzyme, the level of cGMP remains high and the erection mechanism works. Inhibition of phosphodiesterase is achieved or facilitated by the drug phosphodiesterase-5 inhibitor (PDE-5 inhibitor).

PDE-5 inhibitors are taken in tablet form and cause erection in about 80% of men. They are standard today, but only work with sexual stimulation and intact nerve supply of the penis. Also, the list of absolute and relative contraindications is long (contraindications, for example severe diseases of the heart, circulatory system, liver, gastrointestinal tract and eyes, intake of nitrate-containing medicines and nitrite-containing sexual stimulants). At present, four different active ingredients (avanafil, sildenafil, tadalafil, vardenafil) are available in Germany. They differ in their action profile and the adverse effects, so that a change may be beneficial.

Other drugs: Several drugs with different mechanism of action (eg yohimbine) are available, others are currently being developed and tested. It is important to warn against uncritical use of over-the-counter medications and stimulants (aphrodisiacs). In particular, from orders on the Internet you should absolutely refrain, since the resources offered there may even be life-threatening. Some products contain PDE-5 inhibitors or other highly effective substances, while others are completely ineffective or prohibited (for example for protection of species).

SKAT (Schwellkörperautoinjektionstherapie): In the SKAT, the person affected tips himself a drug in the erectile tissue. Alprostadil (= prostaglandin E1) is usually used in individual doses, sometimes other active substances or a combination are used. Advantage is a high response rate of up to more than 90%, regardless of the cause of ED. It is extremely important that a dose adjustment takes place with the urologist before the independent application. Otherwise it can lead to a priapism, a painful and damaging permanent erection. A priapism must be treated after a period of at least four hours as an emergency urologist or in a clinic.

Intraurethral prostaglandin E1: In this case, the person involved introduces the active substance alprostadil in the form of a rod with an applicator into the urethra (intraurethral). The method is an alternative to SKAT, but the response rate is much lower.

Vacuum erection systems (vacuum pumps): They create a passive erection. In a cylinder attached to the base of the penis, a negative pressure is generated by a pump. Due to the negative pressure, blood is sucked into the penis and an erection occurs. About the attached cylinder, almost simultaneously with the removal of the cylinder, a very solid thick rubber ring (cock ring) attached. This prevents the blood drainage and maintains the erection. Since the ring can damage the penis and urethra, it should be removed again at the latest after 30 minutes. The success rate is relatively high, but the procedure is uncomfortable and often painful, which is why most patients shy away from regular use.

Penile implants (penile prosthesis): The implantation of stiff, elastic or inflatable prostheses in the erectile tissue is rarely performed. Disadvantages lie in the final change of the corpora cavernosa by the operation, in general surgery risk, in the risk for a subsequent infection, the slipping of the prosthesis and in the high costs. The advantage is the permanent correction of erectile dysfunction.

Erectile dysfunction

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Medical Staff

MD Claus F. Fieseler

MD Claus F. Fieseler
Head of the Urology and Nephrology Department

MD Eberhard Köhler

MD Eberhard Köhler
Head physician assistant

MD Carsten Sippel

MD Carsten Sippel
Head physician assistant

Prof MD Wilhelm Esser-Bartels

Prof MD Wilhelm Esser-Bartels
Head physician assistant

MD Christina Schmitt

MD Christina Schmitt
Senior physician


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