Quick selection: Definition | Frequency | Causes | Diagnosis | Therapy


Definition

In impotence, two forms are distinguished. Impotentia coeundi (erectile dysfunction) refers to the inability to perform the sexual act. It is the form that is understood in common usage under impotence. The second form, the impotentia generandi (sterility, infertility), stands for the inability to reproduce.

Erectile dysfunction (ED) is a form of impotentia coeundi in which sufficient rigidity (rigidity) of the penis can not be achieved or maintained to perform sexual intercourse. The emphasis is on the implementation of sexual intercourse. Masters and Johnson classified a male as impotent in 1970 when he was unable to penetrate at least 75% of his coital attempts for lack of rigidity. It is clear from the above that an ED is not defined by the maximum degree of tumescence (circumferential increase) and / or rigidity to be achieved. By definition, erectile dysfunction has persisted for at least six months.

This definition makes no statement regarding libido (lust for sex). This is also preserved in the majority of cases. If there is a libido deficiency, for example due to a hormonal disorder, no erection can be achieved, but the physiological conditions are not disturbed. An ED is not necessarily associated with an ejaculation or orgasm disorder.


Frequency

In Germany, about four to six million men are affected, although exact figures are not available due to the "sensitivity" of the topic. Of the 40-year-old men, around 2% are affected and of the 65-year-old men, an estimated 25% are affected, with a clear age dependency. Right here, however, it should be noted that the figures are subject to large fluctuations. Unlike in the past, when about 90% of erectile dysfunction was mentally related in the opinion of the scholars, this is said to be the case today in about one third of those affected. Half of the affected patients nowadays accept organic disorders (see above). The remaining 20% ​​is based on a combination of both causes. Diabetics are affected twice as often. It is important to know that in both sexes, sexual activity and sexual activity decline significantly before the age of 75. According to studies, libido disorders occur in 2% of all men.

Massachusetts Male Aging Study, Feldmann et al., 1994

Of the 1290 randomly interviewed men in Greater Boston, 52% had male erectile dysfunction of 40-70 years. It had:

# 17% a mild form,
# 25% a moderate form and
# 10% a severe form of erectile dysfunction.

 ImpoDoc

Meta-analysis of English-language literature, Spector and Carey, until 1990

3 to 9% of men suffered from erectile dysfunction; The basis was 23 studies in the last 50 years.

Cologne survey

In a survey of 8,000 Cologne men, of which 58% participated in the survey, 19.2% had an ED, but only 8% suffered from it.

National Health & Social Survey Survey, Laumann et al., 1994, 1999

Results of a survey with 1511 participants:

# 18-29 years: 7% ED
# 30-39 years: 9% ED
# 40-49 years: 11% ED
# 50-59 years: 18% ED

ImpoDoc

 Baltimore longitudinal aging study, Morley et al., 1986

# 55 years old: 8% ED
# 65 years old: 25% ED
# 75 years old: 55% ED
# 80 years old: 75% ED

ImpoDoc

Other

According to estimates, in 1995 approximately 152 million men worldwide had erectile dysfunction. The fact that approximately 322 million men will be affected by the year 2025 makes it easy to see the significance of the disease.


Causes

If one believed earlier that 80% of the ED was psychically conditioned, today multifactorial or organic diseases are assumed to be the main cause. In general, younger patients outnumber psycho-reactive factors, and older men are more likely to be affected by organic disorders.

General Causes
  • Age
    It is well known that the prevalence of erectile dysfunction increases with age (see also). With regard to the pathophysiological causes, there are so far only a number of conjectures whose relationship is not yet fully understood. Age-related structural changes in smooth muscle and tunica albuginea (change in collagen composition, reduction of elastic fibers) result in a reduction in elasticity and compliance of the penis. In addition, there is a reduction in blood flow in old age, including the sensitivity of the corpora cavernosa to nervous, hormonal and pharmacological stimuli.
  • Alcohol
  • Obesity
  • Nicotin
    • Smoking increases the risk of cardiovascular disease and is therefore a secondary risk factor for developing erectile dysfunction.
      Smoking also potentiates the risk of erectile dysfunction in patients with cardiovascular disease, ie.
      + in treated heart disease: 56% of smokers vs. 21% of non-smokers
      + in treated hypertensives: 20% of smokers vs. 8.5% of non-smokers
  • Drugs
Special Causes

Changes in the arterial current path
The mostly atherosclerotic vascular changes lead to an insufficient filling of the erectile tissue, which as a rule affects the entire arterial current path in the sense of atherosclerosis ("arteriosclerosis"). Risk factors for such vascular changes are, in addition to lipid metabolism disorders, hypertension (arterial hypertension), diabetes (diabetes mellitus) and the already mentioned Nicotine abuse. Associated diseases are:

Coronary artery disease (CHD, coronary heart constriction)
The severity of CHD seems to correlate with the incidence and extent of erectile dysfunction.

Peripheral arterial disease (PAD)
First and foremost, the leg arteries are affected - pAD, also known as "intermittent claudication", can be manifested by shortened walking distance, cold and / or open feet and legs.

Diabetic microangiopathy
In diabetes, in addition to the large vessels and small arteries can be damaged by rebuilding processes.

Aortic coarctation, aortic aneurysm
These are changes in the main artery. While there is a congenital or acquired narrowing in the aortic arch during aortic coarctation, aortic aneurysm is a pathological enlargement of the aorta.

Occlusion or hypoperfusion of the internal iliac artery and / or arteria pudenda
These are vessels of the pelvic flow, which supply the penis with oxygen-rich blood in addition to the pelvic glands.

Occlusion or under-circulation of the radioluclear artery
This vessel serves to supply the spinal cord with oxygen-rich blood.

Venous and / or cavernous insufficiency, veno-occlusive dysfunction, venous leak
Premature or increased blood flow leads to insufficient rigidity or failure to achieve an erection. The cause of this is remodeling of the penile tissue (fibrotic remodeling of the cavernous musculature, defect of the corpora cavernosa [tunica albuginea]); or transmitter disturbances in the corporal tissue in question. These remodeling processes can not least have been caused by years of circulatory disorders. Investigations have shown that the hypoxia-related remodeling occurs first in the most peripheral small arteries and leads first to a partial remodeling of the smooth muscle into fibrotic connective tissue. As a result, a cavernous veno-occlusive dysfunction first develops, without the pathological changes in the penile arteries being detectable in ultrasound examinations. At a later date, the penile arteries will be affected by this transformation.

Neurogenic causes
This includes all diseases of the central (brain and spinal cord) and peripheral nervous system (nerves). Here are some examples of diseases that can cause erectile dysfunction:

# Amyloidosis
# Herniated disc (NPP: nucleus pulposus prolaps)
# Diabetic neuropathy
# Parkinson's disease (shaking palsy)
Multiple sclerosis (encephalitis disseminata)
Spinal cord tumor, trauma, compression
#Spina bifida
#Tabes dorsalis in neurolues
# Shy-Drager syndrome
# Arnold-Chiari syndrome
#Morbus Alzheimer
# Guillain-Barre Syndrome
# Temporal lobe epilepsy
#Vitamin B12 deficiency

Metabolic disorders

# Diabetes mellitus

+ About 35 to 75% of men with diabetes mellitus have an ED
+ 50% of diabetics develop an ED within the first ten years
+ In about 12% of diabetics, erectile dysfunction is the first symptom
+ Diabetics develop ED 10 to 15 years earlier than non-diabetics
+ Type I diabetics: usually neurogenic ED
+ Type II diabetic: usually vascular ED

# Chronic renal insufficiency
# Chronic hepatic insufficiency
# Chronic alcohol abuse
# Hyperlipidemia and low HDL serum levels (lipid metabolism disorders)

Condition after surgical operations, e.g.

# Transurethral prostate resection (TUR-P) in prostate adenoma
# Radical retropubic prostate vesiculectomy (RRP) for prostate cancer
# Cystectomy for bladder cancer
# Rectal amputation of rectal cancer

Condition after injuries

# Penile injuries
# Pelvic ring fracture
# Blunt perineal trauma

Hormonal imbalances
Hormonal disorders are rare with 5%. In addition, here is the lack of desire (libido) in the foreground of the complaints.

# Primary or secondary hypogonadism
# Other endocrine diseases:
+ Hyperprolactinaemia (increased level of prolactin in the blood)
+ Hyperthyroidism (hyperthyroidism) usually associated with decreased libido, less with erectile dysfunction
+ Hypothyroidism (hypothyroidism)

Drugs
A variety of medications can interfere with the complicated mechanism of erection. A selection of causally relevant drug groups are:

#Nitrate
#Psychopharmaceuticals (antidepressants, hallucinogens, neuroleptics, hypnotics, tranquillizers), e.g. Amytriptyline, Phenytoin, Lithium,
# Beta blockers
# H2 blocker, e.g. Cimetidine, Famotidine
#Proton pump blocker, e.g. omeprazole
# ACE inhibitors
# Ca antagonists, e.g. verapamil
#Antiepileptika
#Anti-androgens, female sex hormones
# Lipids lowering, e.g. clofibrate
#Diuretics, e.g. thiazide diuretics
#NSAR, e.g. Naproxen, indomethacin
# Cardiac glycosides, e.g. digoxin
#A modified tabular list of drugs that affect sexual function can be found here (Spark RF: Male Sexual Health: A Couple's Guide. Yonkers: Consumer Reports Books, 1991.117-118).

Other

#Induratio penis plastica (IPP, Peyronie's disease, penile curvature)
#Priapismus
#Natural and / or acquired fistulas in the area of ​​the corpora cavernosa
#Interestrogenicity (medicinal and / or surgical, for example in the treatment of prostate cancer
#Chronic obstructive pulmonary disease (COPD)
# Scleroderma, systemic
#Chronic infectious diseases
#Radiotherapy (radiotherapy) of the small pelvis
#Chronic Ulcer Disease (?)
#Chronic Arthritis (?)
#Allergies (?)
#Chronic perineal trauma: e.g. Cycle (?)

 

Metal Causes

# Power pressure
# Partnership problems
# Depression, acute or chronic
# Stress
# Fear of failure
# Tiredness
# Inexperience


Diagnosis

It should be noted that due to the sensitivity of the topic still many men conceal their problems. Estimates suggest that in more than 70% of cases, the diagnosis of erectile dysfunction (ED) is not even made!

The diagnosis of erectile dysfunction can be divided into three sections:
# Non-invasive diagnostics
# Semi-invasive diagnostics
# Invasive diagnostics

The individual examinations of the respective diagnostic sections are explained below.

Non-invasive diagnostics

Anamnesis (medical history)

The questioning of the patient should include the entire sexual (dysfunction) function. This can be divided into three parts, which may be disturbed together or for themselves: sexual desire (libido), erection and ejaculation. The International Index of Erectile Function (IIEF) is helpful in objectifying and monitoring complaints. A five-question version of this questionnaire is the so-called IIEF5, whose sensitivity and specificity are still at 98% and 88%, respectively. The IIEF5 is available as a self-test. Particular attention is paid to concomitant diseases of the patient (for example, diabetes mellitus, hypertension), risk factors (alcohol, nicotine) and the use of medication; but also the question of partnership problems should not be forgotten.

The survey should clarify the following points:

# Duration of erectile dysfunction
# Type of onset of erectile dysfunction (slow, sudden)
# Libido: present, restricted or missing? More information about libido disorders can be found here [here]
# Reachable erection grade according to the Bähren classification:

E0 No erection

E1 Low tumescence, no rigidity

E2 Medium tumescence, no rigidity

E3 Full tumescence, no rigidity

E4 Full tumescence, medium rigidity

E5 Full tumescence, full rigidity

# premature detumescence (relaxation)? Read also [here]
# Can sexual intercourse be exercised?
# Does the penis have normal shape or is there deviations (deviation)?
# Pain in the erection?
# Hardening on the penis?
# Are morning and / or night spontaneous actions available?
# How often, if at all possible, does intercourse take place; how was it earlier?
# Is the ejaculation too early, normal or too late? Information about ejaculation disorders can be found [here]
# Is there an external disturbance that affects the erection (stress, vacation)?
# Is the disorder also present during masturbation?
# Is the disorder dependent on the partner or sexual practices?
# What is the patient's level of suffering?
# Does the patient have an explanation for his erectile dysfunction?
# Question about accompanying and / or previous illnesses. Compare also [here].
# Ask about surgeries and / or injuries in the past. Compare also [here].

Physical examination

The physical examination usually follows the survey of the medical history. The examination and evaluation of the external genitalia (also read: anatomy and physiology of the male reproductive organs) as well as the primary and secondary sexual characteristics have special priority. The following organs or body parts are examined in particular:

# Mammary glands (mammae); Is there a gynecomastia? Read also [here]
# Penis, also read: penis measures
# Scrotum, including testes, epididymis and spermatic cord
# Prostate
# Assessment of physique (habitus) hair pattern
# Miscarriage and / or malformation
# Urethral malformations (hypospadias, epispadias)
# Foreskin constriction (phimosis)
# Induratio penis plastica (IPP)
# Neoplasms (benign, vicious)
# Inflammatory changes ([e.g., epididymitis]), infection, discharge
# Residuals after trauma or surgery (for example, circumcision, removal of the testes due to a testicular tumor [orchiectomy])
# Disease (s) of testes / epididymis / prostate / seminal vesicle

Laboratory

The blood and urine examination helps to detect diseases that can cause erectile dysfunction. These include, for example, hypogonadism, diabetes mellitus or renal insufficiency. [Here] you will find norm values ​​(men) for blood counts, electrolytes, liver enzymes, kidney scores, tumor markers and hormones.

# Blood count
# Cholesterol, triglycerides, blood sugar, possibly HbA1c
# Optional or suspected of having a disease

# Liver and kidney values
# Testosterone in men over 50 years of age or decreased libido or clinical hypogonadism
# Total Testosterone and Sex Hormone Binding Globulin (SHBG); From this it is possible to calculate free testosterone with knowledge of the serum albumin fraction
# LH, FSH at low testosterone levels; if necessary pituitary test (GnRH test)
# Prolactin with reduced libido and / or gynecomastia and / or testosterone <4ng / ml
# Thyroid scores (fT3, fT4, TSH)

Semi-invasive diagnostics

# Ultrasound examination (sonography / duplex sonography), possibly in conjunction with the SKAT examination

The simple ultrasound examination allows an evaluation of the penile condition. Thus, changes in shape and / or calcifications and / or plaques can be diagnosed. Color-coded duplex sonography allows arterial perfusion to be seen in a side-by-side comparison and in comparison with an extrapenile (i.e., non-penile) artery. For more information about duplex sonography, see [here].

# Neurological and neurophysiological studies

# Basic neurological examination
# Corpus cavernosum electromyogram (CC-EMG)
# Penile sympathetic skin response (PSHA)
# Pelvic floor EMG
# Nervus pudendus latency determination
# Bulbus cavernosus reflex
# Acquisition of nocturnal tumescences (Rigiscan)
# Sleep-laboratory

# Cavernous injection test (SKIT)

# An erection is usually induced with a PGE1 supplement, for which purpose the substance is injected into the erectile tissue (dorsolateral into the proximal third of the erectile tissue)
# It should be started with a low dosage (5μg or 10μg) and a maximum of one test per day
# The success of this test can be improved by 70% through visual stimulation
# the following information can be derived:
  # Success at low dosage: autonomic-neurogenic, psychogenic or endocrinological cause of ED likely
  # Success at high dosage: arterial or cavernous-mycotic degeneration likely
  # Success at very high dosage: veno-occlusive dysfunction likely

Invasive diagnostics

# Cavernosography, dynamic infusion cavernosography and -metry

This is a procedure in which X-ray images of the penis and the pelvis are made after the administration of a contrast agent in order to diagnose structural changes and / or pathologically draining vessels. More information can be found here]
Example of venous leakage

#Pharmakophalloarteriography (rare)

before planned vascular reconstruction interventions
after injuries
Meanwhile, the so-called CT angiography is considered equivalent, so that an arteriography is required only in exceptional cases. The sensitivity is 93%, the specificity 79%.


Therapy

Causal treatment

This is understood as the recognition and elimination of the cause of the disease. Thus, in the case of a testosterone deficiency (for example in hypogonadism), the testosterone can be substituted.

Medication

There is now a whole range of medications that are usually prescription and their use should be well thought out. Here the conversation with the doctor of trust is absolutely necessary. An uncontrolled intake of medicines, for example by ordering via the Internet, can only be strongly advised against. There are a number of different classification systems, with the following sorted by the different modes of action. It should be emphasized once again that with regard to the active ingredients information from the literature are reproduced and they do not claim to be exhaustive.

1. agents that cause a relaxation of the smooth muscles of the penis

L-arginine
Nitrite oxide (NO) is catalyzed by L-arginine via NO synthetase. So far, there is only a small study based on the oral administration of L-arginine for the treatment of ED. There, only a weak efficacy could be detected. Of course, good results are expected in patients who initially have low NO levels.

Phentolamine (Vasomax®)
This is a non-selective sympatholytic (alpha-blocker) that blocks both the alpha-1 and alpha-2 receptors, thus supporting an erection. A dose-dependent (20 to 60 mg) improvement in erection was described. However, the use of phentolamine is currently only under clinical study conditions. Side effects include rhinitis, dizziness and headache. The efficacy is lower compared to apomorphine and sildenafil.

Sildenafil (Viagra®)
One of the most well-known active ingredients for the treatment of erectile dysfunction is sildenafil (Viagra®). Meanwhile, the use of sildenafil is considered as the treatment of choice in erectile dysfunction, especially since numerous clinical studies have tested the safety of the drug and the number of side effects is low. You will find a comprehensive essay on the effect of the drug [here]. A list of nitrates and NO donors available in Germany, the use of which can lead to dangerous interactions with the drug Viagra®, can be found [here]. What German courts say regarding the reimbursement, you can read [here].

Contraindications
Ingestion of nitrates, NO donors (e.g., molsidomine)
Retinitis pigmentosa
Myocardial Infarction / Apoplexy <6 months
Hypotension <90/50 mm Hg
Sickle cell anemia, leukemia, multiple myeloma (risk of priapism)
Decompensated hepatopathy
Non-compliance patients
Severe fibrotic penile changes / bends
Unstable angina, severe heart failure

Side effects
Headache 16%
Facial flushing 10%
Indigestion 7%
Swelling of the nasal mucosa 4%
Visual disturbances 3%
Dizziness 2%
Rash 2%

Tadalafil (IC351, Cialis ™) [Information Note]]
This drug, developed by Lilly Icos, is one of the selective phosphodiesterase inhibitors (PDE 5 inhibitors), like sildenafil. The drug was approved for Europe in November 2002. Since February 1, 2003, this drug has been approved in Germany.

Phase III studies with Cialis showed that men with moderate to severe erectile dysfunction achieved a significantly better erection in 85% of cases. Diabetics reported an increased erection in up to 64% of cases. The most common side effects were headache, back pain and dyspesia. Continue reading...

Trazodone (Thombran®)
This drug is a serotonin agonist with peripheral sympatholytic activity (alpha receptor blocker) and is used as a non-tricyclic antidepressant. The effect is mediated by an inhibition of serotonin reuptake and an alpha-receptor blockade. As an aside, an increase in nocturnal erections was observed. At doses of 100 to 200mg, 60% of patients had an erection increase, with the best results seen in psychogenic impotence. In combination with yohimbine, the success rate was increased to 70%. In another study, the improved erectile response to placebo was not demonstrated. Regardless of these results, in patients with mixed causes of erectile dysfunction, an effect could not be demonstrated in placebo-controlled double-blind studies at a dose of 50-100mg.

Vardenafil (Levitra ™) [Specialist information]
This drug developed by Bayer, like sildenafil, is one of the selective phosphodiesterase inhibitors. The drug has been approved in Germany since March 2003.

Results from a Phase II study found an 80% success rate, regardless of patient age, and the severity and etiology of ED. The onset of action occurs after about 20-30 minutes. The half-life is about four hours.

In a phase III trial, 452 men with diabetes mellitus tested vardenafil for 12 weeks. 72% reported a better erection and 54% of the study participants had a successful sexual intercourse after oral administration of 20mg of the drug. The most common side effects were headache, rhinitis and flushing. Continue reading...

2. Injections

Alprostadil, prostate gland E1, PGE1
Alprostadil is used for SKAT therapy (cavernous auto-injection therapy). This means that the patient uses a syringe to inject an optimized dose of the drug into the erectile tissue in order to achieve an erection. The success rate is 70 to 80% and thus comparatively high. Systemic side effects are hardly observed. An unpleasant side effect of overdose is priapism, the occurrence of cavernosal fibrosis and local inflammatory or pain reactions have been described. More information about SKAT can be found [here].

Alprostadil can also be used for local application. The drug is introduced into the urethra (MUSE®) and from there via diffusion into the blood vessels to the erectile tissue. Again, an individual dose adjustment is required. A dosage between 250 and 1000μg is usual. The achieved success rates vary between 30 and 66%, whereby the acceptance is quite high. Local side effects included pain in the penis; Systemic side effects were rare (dizziness). More information about MUSE® can be found [here].

Phentolamine and Papavarin combination preparation (Androskat®)
The combination preparation has a synergistic effect compared to the effects of the individual substances. The effectiveness is very good at 60-75%. After testing the individual dose, prolonged erections are seen in 1% of all injections. Local problems of cavernous auto-injection with this drug are described in 10-30% of cases. Due to the higher rate of prolonged erections compared to alprostadil, the drug is only used for PGE1 complications or in combination with PGE1 as a triple mix in its sole ineffectiveness.

3. Central effective substances

Apomorphine (Uprima®, IXense®)

operation
Apomorphine is a brain-active substance that stimulates specific receptors (dopamine receptors [D1 and D2]) and was actually used as an emetic in poisoning. Stimulation of the central D2 receptors in the paraventricular nucleus of the central nervous system (CNS) activates erection-promoting pathways. The advantage of apomorphine is also the increased libido - the drug works in both healthy and impotent men, although other authors deny an influence on the libido. The drug works only in the presence of testosterone and oxytocin; For example, it does not work for castrated men. The function of nitrite oxide synthesis both centrally and peripherally is another prerequisite of the drug's efficacy. The latter also explains the fact that the effectiveness of apomorphine is attenuated to neutralized by NO synthesis inhibitors. Although the drug can be detected in the blood already ten minutes after ingestion, the average onset of apomorphine is after 18 to 19 minutes.

application
Apomorphine is used as a sublingual tablet, i. the tablet is placed under the tongue. There it dissolves and enters the bloodstream. The tablet should be taken about 20 minutes before sexual intercourse. The effect of the drug requires sexual stimulation. Prior to use, consultation with a doctor is essential.

dosage
In dose-finding studies, a sufficient erection was achieved in about 60% of patients at a dose of 6 mg and only 2.7% reported the major side effect, nausea (the side effects are strictly dependent on the dose used).

Recent clinical data show that in moderately to severely erectile dysfunctional doses of 3 mg (as a sublingual tablet) have the most favorable risk-benefit ratio. About half of all patients achieved an erection sufficient for intercourse. After administration of 4mg, the success was not significantly increased, but the rate of nausea increased significantly (14%).

The currently recommended dosage is 2 to 3mg. At this dosage, a good effect on erection formation is observed with only minor side effects.

Side effects / tolerability
The apomorphine has been proven to be a well-tolerated and above all safe drug. Side effects at doses between 2 and 3mg were mainly nausea (6.8%), headache (6.7%), dizziness (4.4%) and fatigue (1.9%). The syncope (sudden drop in blood pressure with loss of consciousness) is very rare at around 0.2%.

Advantages)
Due to its mode of action, apomorphine may also be given in patients with the following secondary diseases: coronary heart disease (CHD), arterial hypertension, BPH, diabetes mellitus.

Contraindications
The drug should not be given in patients with unstable angina pectoris, recent cardiac infarction, severe heart failure and / or low blood pressure (hypotension) and intolerance.

A-melanocyte-stimulating hormone
An advantage of this centrally effective drug is the application under the skin (s.c.). This is important because many men are afraid of "injecting into the penis" as used in SKAT.

Naltrexone (Nemexin®)
This drug belongs to the opiate antagonists. The effect is stronger and longer-lasting, in contrast to the known naloxone. In placebo-controlled trials in men with non-organic ED, improvements in morning erections but no increase in libido and number of intercourse were shown.

Yohimbine
Yohimbine is a relatively selective antagonist of alpha-2 receptors and acts in the central nervous system. It has already been tested in many studies for its effectiveness. It is currently used mainly for the treatment of psychogenic erectile dysfunction and showed a moderate improvement in erection compared to placebo.

operation
Yohimbine is an iridoidal indole alkaloid that acts as a centrally acting alpha adrenoceptor 2 antagonist. In this capacity yohimbine acts on the circulation (lowering blood pressure, reflex tachycardia) and the bladder (relaxation of the bladder neck, posterior urethra and prostate -> lowering the bladder outlet resistance). But yohimbine also affects sexual behavior and was used early in West Africa as an aphrodisiac. The advantage of yohimbine is its favorable side effect profile. The main indications are failure anxiety-related or moderately pronounced organic erectile dysfunction.

application
Yohimbine works best with psychogenic impotence.

ingredients
The active substance is extracted from the bark of the native Yohimbin tree in West Africa.

dosage
On the first three days should be taken 3x5mg and then 3x10mg, with a success is not expected 14 days ago. The total duration of treatment is at least six weeks.

side effects
Restlessness, dizziness, hands trembling, stuffy nose, sleep disturbances

4. Hormones

Testosterone
The male sex hormone is also often prescribed as an additional empirical therapy or is part of numerous aphrodisiacs except for isolated deficiency. Testosterone influences central neurotransmitters (dopamine and serotonin) and thus interferes with erection formation. Thus, in the healthy man, there is an increase in stiffness (rigidity) of nocturnal erections, whereas the frequency remains unchanged.

Dehydroepiandrosterone (DHEA)
This is a steroid hormone of the adrenal cortex. It is a precursor of testosterone and can be obtained as a prescription drug in the US. In a phase III study, an improvement in ED after administration of 50 mg was described.

5. Aphrodisiacs
The aphrodisiacs are called sex drive and potency-strengthening agents. These are usually herbal ingredients that have been in use for several thousand years. But also drugs (hashish), alcohol and the belladonna are due to their stimulating and detoxifying effect in this group. In addition, these include substances that stimulate the genitourinary system (parsley, celery herb) or increase the blood supply of the abdominal and genital organs (basil, ginger, chilli). Also referred to as Potenzholz Muira puama or Maca belong to this group. Continue reading...

Operative treatment

An operative therapy of erectile dysfunction is performed when all possible conservative therapies have failed. The proportion is approximately between 5 and 10%. This step must be carefully thought out, as the surgical procedures, in particular the implantation of a penile prosthesis, lead to a destruction of the natural architecture of the penis. The sexual appetite, the ejaculatory ability and the orgasmic life are not affected. Continue reading...

Plastic surgery
prostheses
Re-vascularization
Venous leaks

Psychotherapy / Partnertherapy

If organic causes are excluded and a psychogenic genesis is most likely, psychotherapeutic treatment should always be undertaken. An involvement of the partner in the therapy should be sought.

Consultation
sexual counseling
sex education

Psychotherapy
Behavior therapy
Talk therapy