by Malen Pijoan Molinas. Martín Piana.

Sexual dysfunction refers to the difficulty during any stage of the sexual act (which includes desire, excitement, orgasm and resolution) that prevents the individual or partner from enjoying sexual activity.

Sexual dysfunctions can manifest themselves early in a person's sexual life or can develop later. Some of them appear gradually over time, and others may appear suddenly as total or partial inability to participate in one or more stages of sexual intercourse. The causes of sexual dysfunction can be organic, psychological or both.

SEXUAL ERECTILE DYSFUNCTION

In 1992, the National Institutes of Health (NIH) organized a Consensus Conference that defined erectile dysfunction (ED) as: "man's partial or total inability to achieve and / or maintain a erection with sufficient rigidity to allow a satisfactory sexual relationship . "

By definition, if  doesn't  get an erection occasionally, this doesn't mean to have ED. Other sexual dysfunctions such as decreased libido, ejaculatory dysfunction, and anorgasmia may or may not accompany or even precede it.

ED is a frequent disorder (affects approximately 50% of men between the ages of 40 and 70) of multifactorial origin, where psychological and organic factors interact and alter proper erection, which affects the quality of life of men . During the last 2 decades, important advances have been made in the knowledge of its pathophysiology and new diagnostic and therapeutic strategies have been implemented. The importance of the subject in daily medical practice requires seeking simpler formulas that allow an easy understanding of this complex problem.

Physiology of erection

The erection mechanism is complex and requires perfect neuro-myo-vascular synchronization to reach its final goal.

In order for an erection to occur, three essential vascular phenomena must occur: relaxation of the intracavernous smooth muscle, arterial vasodilation, and an increase in the output venous tone and activation of the veno-occlusive mechanism. Smooth muscle (predominantly present in the arteries and cavernous sinusoid) plays a major role in regulating the local mechanism of erection.

Before a sexual stimulus that acts at the cortical level (psychogenic, visual, auditory, olfactory, evocative, fantasies) and / or tactile (reflex erection as a result of a direct stimulus on the genital area), the release of neurotransmitters occurs, of which nitric oxide is the most important, which determines the relaxation of the smooth muscles of the arteries and cavernous sinusoids with the consequent development of an erection. There are also nocturnal erections during the deep sleep phase (rapid eye movement or REM) that are believed to originate from the pontine nuclei. Its meaning is still a matter of controversy.

Pathophysiology of erectile dysfunction

The factors that intervene in the erection are psychological, neurological, vascular and hormonal; alterations in one or more of these factors can lead to erectile dysfunction.

Psychogenic factores It may be due to anxiety, depression, phobias, sexual deviations, obsessive-compulsive personality, previous traumatic experiences, stress, hostile environment, troubled partner, etc., the precise mechanism has not yet been established, but it could be the consequence of a direct inhibition from the brain to the spinal centers or by a peripheral increase in the level of catecholamines, determining an increase in smooth muscle tone with the consequent difficulty in achieving adequate relaxation.

Neurogenic factors Some authors consider the brain as the main sexual organ. Any defect in the transmission of the erectogenic message in the brain-medulla-cavernous nerves axis can cause erectile dysfunction.

At the brain level, injuries such as cerebrovascular accidents, Parkinson's disease, Alzheimer's disease, neoplasms, trauma, among others, can produce ED, due to alteration of the hypothalamic centers or due to an overinhibition of the spinal centers.

Spinal injuries such as spina bifida, herniated disc, syringomyelia, neoplasms, multiple sclerosis, demyelinating diseases, and others can affect both the afferent and efferent pathways. High lesions (supra sacras) tend to preserve the erectile mechanism much more frequently than low ones.

Vascular factors Due to arterial alterations at the level of the abdominal aorta, primitive iliac arteries, hypogastric, pudendal or cavernous, a decrease in arterial flow occurs.

Hormonal factors Androgen deficiency generally involves a loss of sexual interest, ejaculation disorders, and decreased frequency and magnitude of erections.

Prevention of DSE

According to the World Health Organización (WHO)  sex education is a process that encompasses all the knowledge that contributes to forming the personality of the individual, to putting him in a position to recognize the social, moral, psychological and physiological character of his peculiar sexual configuration, as well as establish optimal relationships with people of the same sex and the opposite

Risk factor's 

• Toxic-medicated. Cigarette smoking occupies a place of relevance due to the large  population it covers. It is postulated that nicotine would act in a multifactorial way through a decrease of the cavernous arterial flow, the alteration of the veno-occlusive mechanism by a decrease in the relaxation of the sinusoidal muscle, and in a synergistic and aggravating way of other vascular risk factors.
• Medications would account for 25% of the causes of erectile dysfunction. The main groups by frequency and impact are: diuretics (thiazides and spironolactone), antihypertensives (beta blockers), lipid lowering drugs, tranquilizers (phenothiazines), antidepressants (tricyclics), H2 antagonists (ranitidine), hormonal (estrogens, antiandrogens, finasteride), and chemotherapy.
• Mellitus diabetes. It is estimated that 20 to 25% of diabetics have erectile dysfunction.
• Other chronic diseases. Untreated high blood pressure has an incidence of erectile dysfunction of 17%, as opposed to 7% of non-hypertensive patients. The incidence of ED in diabetic hypertensive patients treated or not, can reach 60%. On the other hand, dysfunction appears between 23 and 43% of hypertensive patients treated with any specific medication. E n relation to chronic renal failure, erectile refer patients alteration in 40% of cases, amounting to 75% of the dialysates. Atherosclerosis and arteriogenic insufficiency can develop in those patients who have high blood pressure, diabetes and / or hyperlipidemias.
• Surgical. Radical surgery for malignant tumors of the pelvic organs  can cause erectile dysfunction. A better understanding of the pelvic / penile neurovascular anatomy leads to a decrease in its post-surgical incidence.
• Traumatic Trauma to the pelvic anterior arch and spinal column should be considered  , which due to neurological and / or vascular mechanisms can cause erectile disability.

DIAGNOSIS

Evaluation of erectile dysfunction

In front of a patient who consults for ED, the approach must be comprehensive, including the organic and psychosocial aspects of the person, this will allow reaching an accurate diagnosis.

The medical history includes a detailed interrogation and physical examination, which are of fundamental importance to guide the origin of the dysfunction.

Interrogation

The diagnosis begins with giving the patient the opportunity to express their sexual problems in an environment of respect and empathy. To achieve this, you must:

• Listen with interest and know how to conduct a sexual interrogation
• Assess whether sexual problems exposed during  questioning are within the professional's competence.

The following points must be taken into account to carry out a correct anamnesis:

1. Circumstances of appearance and maintenance of ED: when, how, where and with whom does it occur?
2. Negative stimuli: in what situations or interpersonal context does the symptom worsen?
3. Positive stimuli: in what situations or interpersonal context does the symptom improve?
4. Patient and partner's attitude towards their problem: rejection, denial, rationalization, etc.
5. Consultations or treatments carried out previously
6. Binding circumstances.

As an important part of the questioning, the patient's age, history of psychiatric, neurological, vascular, endocrine-metabolic or other diseases, history of head, spinal, penile or testicular trauma, history of radiation therapy and / or pelvic surgery; to know if you take drugs (which ones, why and their doses), what are your toxic habits (consumption of alcohol, cigarettes, tobacco and narcotic drugs) and their magnitude, as well as to know your occupational history that will show if you have been in contact with metals heavy and / or toxic substances that compromise the erection. The psychosocial history will reveal the existence of personal and couple conflicts, personality and conduct disorders, stress and the possibility of neurotic or psychotic disorders. It is also important,

It is necessary to know the previous sexual habit and the characteristics of the dysfunction, inquire when and how it began, rapidity of the appearance, presence or absence of morning erections and uniformity of the condition (if it occurs with all couples and in all situations). In general, predominantly psychogenic ED and secondary to trauma or regional surgeries have an abrupt onset with a marked cause-effect relationship, morning and night erections are maintained, and conduct, personality, sexual conflict disorders can be observed during questioning. anxiety and / or depression, while in the latter, the dysfunction is complete, the absence of erection is absolute regardless of the partner and / or situation. In the rest of the predominantly organic,

The term predominantly psychogenic or organic erectile dysfunction is used to clarify that the existence of a psychogenic component does not completely exclude the organic one and vice versa. Patients with a psychogenic cause have an alteration of the central reflex mechanism with peripheral repercussion that leads to functional changes in the smooth muscle cells of the corpora cavernosa. Likewise, the organic cause has a psychological repercussion, since the patient begins to show anxiety about his sexual performance and fear of failure before starting a new experience, thus forming a true vicious circle.

From the data obtained, it will be possible to: Classify the dysfunction, identify the compromised phases of the sexual response (desire, excitement, plateau, orgasm and resolution), and detect the triggering, maintaining and aggravating factors.

Erectile Dysfunction Classification

1. Primary : Inability to achieve and maintain a satisfactory erection from the start of sexuality.
2. Secondary : Inability to acquire erections and sustain them after a period of normality.
3. Generalized : In all situations, with or without a companion.
4. Occasional or circumstantial : Related to particular situations or companions.
5. Mixed : Associated with other sexual dysfunctions.
6. Unique : No other simultaneous dysfunction.

Physical exam

The physical examination must be thorough; aimed at looking for signs of psychiatric, neurological, endocrine, cardiovascular or other diseases. A complete general, regional, and apparatus physical examination should be performed, with special attention to the andrological examination; that is, observe the characteristics of the skin, thickness and surface; hair quantity and distribution; the volume, consistency and sensitivity of the testicles and prostate, pigmentation and roughness of the scrotum; the characteristics of the penis, if it has any palpable fibrous plaque or deformity; body habit, strength and muscle development, the severity of the voice and the presence of gynecomastia.

Laboratory

Laboratory tests should include complete blood count, glycidic, lipidic and minimal hormonal profile with testosterone determinations. The conduct to be followed from this moment on will depend on the clinical and laboratory findings found.

Hormonal evaluation in the male with sexual dysfunction . The objective of hormonal evaluation in a male with sexual dysfunction (DS) is to identify a significant endocrine problem, which is liable to respond to specific treatment. It may be present as the sole cause, or associated with other etiologies responsible for ED.

Endocrine evaluation in the patient with ED.

Dosing total T (testosterone) between 8 and 10 in the morning is a simple, cheap and accessible method to rule out an abnormality in serum T. When the values ​​are close to the lower limit, the determination of the free and bioavailable fractions is useful. In case of obtaining a pathological result, it must be confirmed with a second test, being necessary to evaluate the gonadotrophins LH and FSH, in order to establish the level of injury.

The prolactin determination can be carried out initially together with testosterone.

Other complementary studies

Regiscan: is the portable monitoring of tumescence and penile stiffness to objectify the presence and characteristics of nocturnal erections, assessing their stiffness and tumescence during sleep.

Vascular evaluation: Penile echo Doppler is an important minimally invasive diagnostic tool to study morphology, caliber, flow of the penile arteries and the changes experienced after injection of intracavernous vasoactive drugs not only on arterial blood flow, but also on the flow of the dorsal deep vein of the penis in real time.

EJACULATORY DYSFUNCTIONS

Premature ejaculation: It is that picture in which ejaculation occurs with a minimum stimulation before, during or quickly after penetration without the person wanting it, persistently or repeatedly.

Delayed ejaculation: Unwanted significant delay or inability to achieve ejaculation

Anejaculation: is the inability to ejaculate during a normal orgasmic phase, whether during masturbation or during intercourse.