How common is ED?
Men's health has been a neglected component of community health care. There are many programmes for the children and women; indeed many are sponsored by the State. Erectile function is an important component of men's health and can be a strategy to improve the provision of men's health. Erectile dysfunction or ED is defined by the National Institute of Health, U.S.A. as the persistent inability to initiate and/or maintain an erection of the penis sufficient to permit satisfactory sexual intercourse. The term 'ED' is referable to 'Impotence' because impotence implies a hopeless situation. According to established epidemiology surveys, at least 10% of men have ED. However, ED can be mild, moderate or severe. This figure rises to at least 50% in special risk groups, e.g. patients with diabetes or moderate hypertension.

Why bother with ED?
In the Asian community, ED is still a taboo subject, even with doctors. It is well known that ED impacts severely on the quality of life. The ED patient typically suffers from the following: guilt, depression, anxiety, frustration, low self esteem. The partner may feel rejected, thinking that the husband no longer desires her or is having an extra marital affair.

What causes ED?
Although there is an inevitable psychological component with ED, most ED patients have an underlying physical cause. Patients should not seek treatment for ED in isolation. The underlying causes should be treated:

• Arteriosclerosis or hardening of arteries.
• Hypertension.
• Diabetes.
• Heart disease.
• Neurological disorders.
• Neurological diseases.
• Diseases of the lower urogenital tract, e.g. cancer prostate, penile deformities.
• After pelvic surgery.
• Certain medications.

What lifestyle changes can you make to decrease ED?
Obviously, a healthy lifestyle contributes to the prevention and control of many of these diseases as well as to ED itself. This will include the following:

• Quit smoking.
• Reduce consumption of alcohol.
• Exercise.
• Reduced obesity.
• Diet modification to reduce high cholesterol or triglycerides.
• Adequate relaxation and rest.
• Better communication with your partner.

How do you assess?
Depending on the severity of symptoms scored on the International Index of Erectile Function (IIEF), ED can be classified as mild (score 12-21), moderate (score 8-11) or severe (score 5-7). The incidence of erectile dysfunction in Malaysia has been studied by the National Family Planning and Development Board and is very similar to the Massachusetts Male Aging study in U.S. It is also age related. Briefly, 50% of men at 50 years of age have ED, 60% at 60 years and 70% at 70 years.

What tests should be done to assess ED?
In addition to a detailed medical history and physical examination (including DRE, digital rectal examination of the prostate), certain tests can be done. The urine examination and blood sugar assessment are usually done. If the patient also suffers from a loss of libido (desire for sex), blood may be taken to check the hormonal profile (namely, total testosterone and prolactin). Depending on the underlying pre-existing medical illnesses, blood for cholesterol, kidney function, liver function may also be tested. If the patient also has urinary symptoms, then other aspects of men's health (e.g. urine flow rate and blood for PSA or prostatic specific antigen) may be done. In exceptional cases, detailed evaluation may be done and this includes colour doppler study of the blood flow to the penis and to test for nocturnal penile tumescence (NPT).

What treatment are available for ED patients?
Sildenafil (trade name, Viagra) was introduced in Malaysia in 1999 and that revolutionised the treatment of ED. Prior to that, the main treatment for ED was to inject a drug into the penis to cause vasodilatation and erection. If that fails, then the main treatment was to surgically insert a penile implant. In early 2004, the patients have a choice of two new oral medications for ED, namely, Tadalafil (trade name, Cialis) and Vardenafil (trade name, Levitra). These drugs enhance the penile erection when a person is sexually stimulated but the erection is not sufficient for sexual activity. Penile erection occurs when nerve stimulation causes the release of chemicals in the penis which in turn causes dilatation of the vessels. This group of oral medications block the breakdown of these chemicals (called vasodilators) and therefore help to enhance the penile erection. These drugs work only when the erection is insufficient for sexual activity and not if the erection is normal. If the erection is already normal, the vasodilator receptors are used up and taking these oral medications will not enhance a normal erection.

What do patients expect from the oral medications?
The oral medications are remarkably effective and the effectiveness range from 80% to about 50% in more severe cases. Patients have to see their doctors to see the underlying cause of their ED as well as to discuss treatment expectations. For those patients whose initial treatment with oral medication fails, further tests may be necessary.

What are the side effects of oral medications for ED?
As with all medications, there are some side effects. These drugs cause increased blood flow to the penis and to some other parts of the body as well and therefore, can cause a drop in the blood pressure. If patients are taking a class of drugs called nitrates for chest pain, then it is an absolute contraindication to the taking of these 3 types of oral medications. In addition, these 3 medications cause side effects which are mostly related to dilatation of blood vessels, namely:

• Facial flushing.
• Indigestion.
• Backache.
• Headache.
• Nasal congestion.
• Dizziness.

The side effects are mild and transient. If they persist, this usually means that the patient has to decrease the dosage of the oral medication. These 3 oral medications have been proven with a high level of scientific evidence by doing double-blind placebo controlled clinical trials to be effective. This is unlike most of the traditional medications or fake products which are touted in the market or Internet. It is therefore important to get such expensive medications from a quality assured outlet, e.g. Normah Medical Specialist Centre.

How are the medications taken?
The 3 types of medications are taken on an as required basis. The duration of action is 1/2 hour to 4 hours (Viagra and Levitra) although one of them can last up to 36 hours (Cialis). Cialis and Levitra may be taken with or without food.

Summary
Assessment and treatment for ED is an important avenue for improving men's health. For many, treating ED is just as important as treating underlying medical illness and adopting a healthy lifestyle.

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU, FAMM
Consultant Urologist