Vascular impotence - what is it, why does it occur, how to treat? Massage and physiotherapy treatments. Diagnosis of erectile dysfunction

Are there remedies to increase potency in old age? Of course, they are, and not necessarily medication. Folk remedies are practiced to increase libido, and tips on general strengthening of the body are also effective. The whole variety of methods and drugs to enhance potency in old age is presented in this material.

Stage one: diet and daily routine

When sexual desire is discussed, this issue also applies to older people - do not think that a man or woman in years is not interested in the joys of sex. Another thing is that old age is often accompanied by significant health problems, in particular with the cardiovascular system. The following tips are necessary not only to improve potency, but also to strengthen the body as a whole and increase libido.

• Smart diet. Treatment of erectile dysfunction in older men is unthinkable without a well-chosen diet. First, you should eliminate or significantly reduce the consumption of foods containing cholesterol. This category includes egg yolks, dark, fatty pork, high-calorie foods filled with preservatives. Otherwise, an elderly man risks getting problems with blood vessels, increasing the likelihood of heart attacks and strokes. In addition, poor blood permeability will inevitably cause a violation of circulation in the inguinal region, which will cause a decrease in potency in men of middle age, and there is no longer any talk of increasing it. As for useful products to enhance erection, these include nuts, garlic, honey and a lot of greens. They contain a lot of vitamins, minerals that improve the functioning of the prostate, stabilize sexual function and libido. These products are considered natural aphrodisiacs.
• Attention to the body. Ignoring chronic ailments that inevitably come to the elderly is an unaffordable luxury. Diabetes mellitus, atherosclerosis, insufficiency in the production of thyroid hormones are especially negatively reflected in the weakening of potency. An increase in libido is possible only with the elimination of diseases.
• Physical activity. It involves not only daily long walking, but also exercises for the lower press, as well as special complexes that strengthen the muscles of the inguinal region. Regular Kegel exercises can improve erectile function.

For a greater effect of the treatment, you need to adjust the diet.

Down with breaks! How to increase potency without resorting to drugs and other therapeutic agents? The answer to many will seem unusual: to train her! It is regular sex that will help restore a strong erection and desire. In any case, breaks of more than two weeks should not be allowed. Your lady will definitely be pleased.

Bad habits are a persistent taboo. Especially on the condition of the vessels is affected by smoking. Of course, alcoholism and addiction to drugs also do not bring benefits to the body. psychological component. Often, protracted conflicts between a husband and wife can provoke a decrease in potency in men. By the way, female impotence, which, contrary to popular belief, also exists, is often caused precisely by a long-term unfavorable psychological situation in the family. If the erection does not please, and the penis is not filled enough to have sexual intercourse, then you should take care of this side of the issue.

In order for a man to be excited and give joy to his partner, first of all, these rules should be followed. But sometimes the causes of impotence lie much deeper and these methods are not enough to increase erection. Is there a drug that can increase potency?

Stage two: medication

How to excite an elderly man with the help of various medicines? Modern medicine offers a whole list of drugs that will make the male member stand like an iron one:

• "Impaz". This is the most popular remedy for improving potency. Tablets do not cause practically any side effects and have no contraindications. The excitatory effect is complemented by a therapeutic one, which is also a plus of this remedy. But only the attending physician should prescribe the dosage of the drug.
• "Viagra". Effectively excites an elderly man this proven French remedy, which has long proven itself in the pharmacy market. It is not recommended to take Viagra in tandem with fatty foods, as well as for men who do not have a clear violation of potency.
• "Vardenafil". An old lover can consider him ideal, since the remedy has a minimum of contraindications and a maximum of effect. The duration of the drug lasts up to 5 hours. Only one condition - do not exceed the recommended dosage.
• Avanafil. The second name of the drug is Stendra. The tool can be taken in parallel with alcoholic beverages. Almost immediately after taking the penis of an elderly man is qualitatively filled, which allows you to know the joys of sex without fear of possible failures.
• Levitra. This German remedy is best taken on an empty stomach to increase its speed. The daily norm is no more than 20 mg, and the range of action is about 36 hours.
• "Cialis". An American-made tool works almost immediately, and lasts up to a day and a half. But the effect is significantly influenced by abundant gastronomic libations.

To excite an elderly man, you can use medications.

Creams and gels. The Himkolin cream (gel) proved to be excellent in terms of strengthening the potency. It is a herbal extract-based product that gently increases libido and strengthens the erection of an elderly man. In general, all external agents are applied to the pubic area about an hour before the planned copulation. One caveat: you should buy drugs only in pharmacies.

dietary supplements. Now there are a great many such funds on the market, and the reviews about them are mostly good. Trust is caused by Yohimbine, Furunbao Super, Tentex Forte. Among other things, to increase potency and libido, an andrologist can prescribe hormone therapy, but it should be used with caution and only with the permission of a specialist. But in order for the remedies to work and the man to feel a clear excitement, he must love his woman and want to have sex, otherwise the effect will not be complete. It doesn't matter if the partner is young or an elderly woman - the main thing is that she be desirable. An additional aphrodisiac before sex can be a penis massage.

Stage Three: People's Experience

The methods tested by folk experience also deserve attention. For example, ginseng alcohol tincture helps a lot. It regulates the hormonal status, fills the penis with strength and makes the elderly organism more resilient. Also justified is the use of perga (unprocessed flower pollen). It gives energy to men of advanced age and motivates them to actively copulate.

To improve the potency of older men, hemp seed helps a lot. This folk remedy accelerates spermatogenesis and stimulates the production of testosterone. Especially effective for men over 60. A decoction of Dubrovnik grass has an almost instantaneous effect: the penis is filled with blood, which makes it hard and capable of anything. Enhanced potency appears within an hour after taking this remedy.

To increase potency, you can use ginseng alcohol tincture.

An exotic alcohol tincture based on a stream of a male musk deer is a fast-acting remedy for stimulating potency in older men, which will not leave any woman indifferent. Seeds of asparagus and dodder are used in the complex of therapeutic measures in the treatment of erectile dysfunction.

There is an ancient recipe for increasing male power that has come down to our days: rose hips, mountain ash and viburnum (2: 2: 2) are poured with boiling water and insisted for about an hour. Take the remedy twice a day, mixing it with honey.

To increase the potency of an elderly man, it is advisable to use an alcohol infusion of aralia root. It has been insisted on strong vodka for a whole decade. The course of use is half a month, 15 drops three times a day. To increase potency, libido, strengthen erectile function, there are a lot of remedies, both herbal and medicinal. It is important to pay attention in time to the failure that occurred in the body of an elderly man.

Erectile dysfunction can develop for various reasons. In adulthood, the occurrence of a problem is often associated with disruption of the vascular system - the blood flow to the penis and scrotum decreases and its outflow increases. Treatment of vascular impotence is a set of measures, including, and normalization of the day and night regimen.

Impotence of vascular origin: causes

The most common type of organic impotence is vascular erectile dysfunction. - this is a violation of arterial blood flow in the pelvic area and an increase in venous outflow of blood.

Such changes are the result of various diseases, dietary errors, bad habits and lifestyle features:

• Diabetes mellitus leads to a malfunction in the activity of the arteries;
• Constant high blood pressure causes changes in the structure of blood vessels;
• Atherosclerosis provokes the accumulation of cholesterol plaques on the vascular walls, which reduces blood flow;
• Cardiac pathologies lead to low blood filling of the cavernous bodies of the reproductive organ;
• Injuries in the abdomen and groin can cause vascular pathology in the pelvic area;
• Surgical intervention in the genitourinary system provoke the appearance of venous shunts;
• Abuse, fatty and fried foods with the addition of hot spices leads to an increase in the venous lumen;
• Age-related changes, sedentary lifestyle, chronic lack of sleep, genetic predisposition also lead to disorders of the vascular system.

Symptoms and signs

When a man is diagnosed with vascular impotence, the symptoms appear slowly and progressively, in contrast to erectile dysfunction caused by psychological problems. For a long time, the disease does not make itself felt, then minor failures may occur, but over time the situation worsens, regardless of the conditions for sexual intercourse and the severity of exciting factors.

Impotence associated with vascular pathology is determined by the following signs:

• or its complete absence in an environment conducive to sexual arousal;
• Ejaculation that occurs before the onset of intimacy;
• Lack of spontaneous erection at night and in the morning.

Vascular erectile dysfunction: treatment

Treatment of impotence of vascular origin always requires a doctor's consultation. First of all, it is necessary to clarify what exactly led to the development of the disease - a violation of the arterial vessels or pathology of the veins. Depending on this, an individual treatment regimen will be selected.

Peculiarities

An integrated approach is required for the treatment of vascular erectile dysfunction. Drug therapy includes taking vasodilators that normalize blood circulation in the cavernous bodies. If necessary, even prosthetics and physiotherapy are prescribed.

Preparations

With conservative therapy of a disease such as vascular impotence, drugs are prescribed based on the clinical picture. They can be divided into 3 types:

• . Expand the lumen of the arterial vessels, so that the penis is better filled with blood. Medicines act in the presence of exciting factors and are aimed directly at stimulating an erection.
• statics. Improve the condition of the arteries by lowering the amount of cholesterol. Medicines prevent the formation of plaques and the development of atherosclerosis, which in 90% of cases leads to erectile dysfunction.
• Antispasmodics and alpha1-adrenergic blockers. They reduce the tone of arterial vessels, as a result of which the blood filling of the cavernous bodies increases.

As an adjuvant, they are sometimes prescribed, which have a beneficial effect on the functioning of the vascular system, stimulation of testosterone synthesis and physical endurance.

Most often in the modern world, dietary supplements are used, as well as stimulants with the abbreviation PDE-5. Let's talk about them in more detail.

Phosphodiesterase type 5 inhibitors

Almost always, when vascular erectile dysfunction is diagnosed by a doctor, treatment involves taking medications containing one of the phosphodiesterase type 5 inhibitors.

Viagra

Sildanafil is the active ingredient. The dosage is determined and may vary from 25 mg to 100 mg per day. You need to take half an hour before intercourse. According to empirical data, the drug was effective for 82% of men. There is also evidence that it is positive if diabetes mellitus is diagnosed or there are injuries.

Contraindications:

• Combination with ;
• Individual intolerance to the components of the drug;
• Combination with alcohol;
• Children and teenagers.

Levitra

Vardenafil is contained in the drug Levitra. The dosage varies depending on the severity of the disease, the age of the patient and comorbidities (from 5 to 40 mg). A single dose per day is recommended 20-40 minutes before the start.

Contraindications:

• Age up to 16 years;
• Hypersensitivity to the components of the drug;
• Joint reception with alcohol.

Cialis

is the active ingredient. The recommended dosage is 20 mg, if necessary, adjusted by the attending physician. It is necessary to take the remedy once at least 15 minutes before the start of intimacy. The action can last up to 36 hours (a feature of Cialis). You can also take a little alcohol in parallel (if necessary).

Contraindications:

• minor age;
• Allergic reaction to components.

Zidena

Zydena contains the reversible inhibitor udenafil. Depending on the prescription of the attending physician, the therapeutic dose may vary from 100 to 200 mg. The medicine must be drunk 1 time per day approximately 1 hour before the onset of sexual intercourse.

Contraindications:

• hypersensitivity to the components of the drug;
• age up to 18 years;
• combination with alcohol.

Stendra

The inhibitor avanafil is the main active ingredient in Stendra. It is recommended to take the drug at a dosage of 50 mg, if necessary, an increase to 200 mg is possible. Reception frequency - 1 time per day, half an hour before sexual contact. During use, you should stop drinking grapefruits and juices based on them. The active substances of the fruit, reacting with avanfil, lead to serious side effects.

Contraindications:

• The first 6 months after a heart attack or stroke;
• Chronic or hypotension;
• Stomach ulcer;
• Anatomical curvature.

It is very important to carefully observe the prescribed dosages of medications, excess is fraught with occurrence. All of the above cannot be combined with the use of products containing organic nitrites or nitrates, nitric oxide donors.

dietary supplements

In the event of vascular erectile dysfunction, dietary supplements must be selected together with the doctor. It is important to take into account concomitant diseases and possible contraindications. Supplements that are effective in our case should contain components that stimulate the work of blood vessels and increase blood flow to the genitals.

These include the following:

• Innovative tool;

Folk remedies

Some traditional medicine recipes can also help cure vascular impotence, however, before starting herbal medicine and preparing decoctions, we strongly recommend that you coordinate the decision with your doctor. The basis of erectile dysfunction of vascular origin is a serious disease that requires medical monitoring.

Ginseng

Ginseng root enhances sexual desire, qualitatively changes the composition of seminal fluid for the better and improves blood supply to the cavernous bodies of the penis.

Recipes for the preparation of potions based on it:

• Pour 4.5 liters of high quality vodka into a large glass container and place a whole ginseng root there. During the day, the product should be infused in a dark room. It should be taken 50 g per day, dividing the portion into 3 doses.
• The crushed root must be poured with 250 g of alcohol with a concentration of 70%. The glass bottle should be placed in a place where the sun's rays do not fall for 1.5 weeks. You need to take 15 drops per day.
• 25 g of powdered root should be mixed with 700 g of honey and infused for a week. Apply 1 tablespoon at night.

Parsley

Reduces the level of estrogen in the blood and stimulates the activity of blood vessels. Parsley can be eaten fresh, made into an infusion or juiced from it:

• 15 g of crushed root should be poured into 150 ml of boiling water and left overnight. You need to take 1 dessert spoon 30 minutes before meals three times a day. To get the result, you need to prepare a fresh infusion daily.
• To prepare juice, fresh and large leaves need to be scrolled through a meat grinder or use a blender. Squeeze the juice through a clean cloth and drink daily 1 teaspoon 3 times a day. The course of treatment is 20 days.
• Fresh parsley and cilantro in equal proportions should be chopped and added to any dish.

Nettle

Thanks to the healing properties of nettle, blood vessels and the heart muscle are strengthened, blood filling of the pelvic organs improves, and inflammatory processes are reduced. For the treatment of vascular erectile dysfunction, seeds and plants are used:

• 50 g of dry seeds must be mixed with 0.5 liters of red wine and put on fire. After boiling, wait 5 minutes, remove from the stove and cool. The resulting product is used in 50 ml once, you can divide the portion into 2 or 3 times.
• Equal shares of nettle seeds, red wine and honey should be mixed to a homogeneous consistency and taken once a day, 1 tablespoon.
• 10 g of the dry root of the plant should be crushed and poured into 1 liter of vodka, poured into a glass jar. Means to insist in the cold and dark for 2 weeks, then drink 20 drops 1 time per day.

Ginger

It has vasodilating properties, breaks down cholesterol plaques, positively affects the blood filling of the penis and stimulates. Ginger tea, tinctures and ginger with honey are used for treatment:

• Finely chop 400 g of ginger root, pour 500 ml of vodka and insist in the dark for at least 2 weeks. The remedy should be taken half an hour before meals, 30 ml.
• Dry root and whole must be passed through a meat grinder and mixed with honey. The drug should be infused for 1 hour in the refrigerator. Apply 1 teaspoon half an hour before sexual intercourse.
• Ginger rub on a grater and cook in 2 liters of water over low heat for a quarter of an hour. You should drink 250 ml after meals.

Exercise and physical activity

To eliminate stagnant processes and improve blood circulation in the pelvic organs, it is also recommended to do special exercises.

The complex, designed for 7 exercises, not only, but also has a strengthening effect on the body as a whole:

• "Rotation of the pelvis". Circular movements should be described first to the right, then to the left.
• "March step". Walking in place, it is important to reach your knees to the abdominals.
• "Keeping the Stone" Slightly bending your knees, you need to tighten and relax the muscles of the buttocks.
• "Bridge". Lie horizontally and, leaning on your shoulders and feet, lift your hips up. The loin should come off the surface.
• "Bike". You should lie down, raise your legs bent at the knees and perform movements that imitate cycling.
• "Muscle training". In the prone position, you need to bend your legs, rest your feet on the floor and strain and relax the pubococcygeus muscle.
• "A vacuum cleaner". It is required to sit down and strain the area between the anus and the scrotum, without using the gluteal muscles.
,
• Fast food and fast foods;
• Carbonated drinks and energy drinks.

Prevention

It is easier to prevent the development of the disease than to treat it for a long time. To prevent vascular impotence, you need to be guided by simple recommendations:

• Refuse food high in fat and hot spices, smoked meats, fried foods. This will keep the elasticity of the vascular walls.
• Stop and drink alcoholic beverages. Bad habits tend to have a detrimental effect on blood vessels.
• Regularly walk and ride a bike to maintain muscle tone and blood vessels.
• Sleep at least 8 hours a day, go to bed and get up at about the same time. The correct daily routine supports the normal functioning of the central nervous system.
• Avoid exposure to the body (if it is impossible to treat problems easier).
• To undergo preventive examinations annually, this will help to "capture" the pathology at an early stage, when it is easily treatable.

Compliance with these rules will preserve men's health and avoid getting to know the unpleasant problem of impotence.

Impotence, or sexual impotence,- a serious problem for a man, not only physical, but also psychological. In modern conditions, this term as a diagnosis is not considered correct; instead, urologists and related specialists use the term "erectile dysfunction". This is more accurate and correct from the point of view of medicine, in addition, such a definition of pathology is not so difficult psychologically perceived by the patient himself.

For many men, this is a difficult period in life, but they are embarrassed to seek help from a doctor in such a delicate matter, preferring to look on the Internet or on the advice of friends for home remedies and methods for treating impotence. This approach is fundamentally wrong, because dubious methods, various “drugs” often only exacerbate the problem, and self-selected medications can do even more harm, leading to persistent and often irreversible consequences.

Erectile dysfunction: definition and causes

The term erectile dysfunction (formerly impotence) is understood as a condition of a man of any age when he is not able to achieve an erection (the penis is filled with blood and is ready for sexual intercourse). At the same time, even if an erection occurs, it is impossible to maintain it for a sufficient time to conduct a full-fledged sexual intercourse and obtain complete sexual satisfaction for both partners. In addition, the same definition includes dissatisfaction with the quality of sexual intercourse due to potency disorders, premature or early ejaculation, the inability to complete the act before ejaculation (secretion of seminal fluid with orgasm).

Any of the symptoms of erectile dysfunction, occurring episodically or constantly, lead to a decrease in the quality of life due to the inability to have full-fledged intimate relationships, regardless of the factors that caused sexual disorders.

Potency disorders lead to physical discomfort and emotional depression, nervousness and stress, which significantly affects the quality of relationships between sexual partners. Given the special attitude of a man to intimate life, any reason that affects the quality of potency and the duration of sexual intercourse, satisfaction with it, leads to feelings and problems in relationships. The situation is aggravated by the fact that most men who experience difficulties in intimate life do not go to the doctor, considering it shameful and inappropriate, preferring useless and dangerous treatment of erectile dysfunction at home. Treatment does not bring results, leads to disharmony in intimate life and is a reflection of unsatisfactory male health in general.

Causes and conditions for the formation of erectile dysfunction

According to statistics, men in our country are more neglectful of their intimate health than Europeans or Asians. Therefore, potency disorders and various sexual disorders are much more common, they are detected in later and advanced stages.
One of the concomitant conditions for the development of erectile dysfunction is a high degree of traumatism of the genitals, as well as the influence of bad habits (smoking and alcohol).

In addition, in the minds of men, there was a wrong opinion that having this problem, starting treatment for erectile dysfunction is a kind of recognition of the fact that you are already “not on a horse” and cannot satisfy your partner.

The stress that men are exposed to at work or in everyday life has a strong influence on the intimate sphere and potency - depressed mood, manifestations of depression, lack of sleep and fatigue lead to erectile dysfunction.

If we talk specifically about the causes of intimate problems, they are divided according to their origin into two large groups:

• organic pathologies caused by developmental anomalies or acquired defects in the structure of the genitals,
• functional disorders associated with psychogenic or other factors, when the structure of the genitals is normal.

Often, men also have associated problems associated with certain deviations in the structure of the penis and other reproductive organs, as well as functional and psychogenic disorders.

Effective treatment of erectile dysfunction: what is needed for this

For the success of measures aimed at combating erectile dysfunction, it is important to determine the true cause of the disorders, take all measures to eliminate or, if this is not possible, weaken the negative impact. Adequately and fully, in a short time, this can only be done by a doctor, who must be consulted, discarding false shame and doubts. Initially, it can be a urologist or an andrologist, a sexologist, but if necessary, doctors of other specialties can also be involved in the treatment of impotence, depending on the cause that underlies the dysfunction. So, consultation and treatment is often required from an endocrinologist, therapist, cardiologist, vascular surgeon, neurologist, psychotherapist.

Often the problem has a psychogenic origin, in which case it is important to identify and eliminate the root causes. Although men are less emotional than women, various types of psychogenic disorders are also typical for them:

• stressful situations;
• anxiety and neurotic disorders;
• neuroses and neurosis-like disorders (tics, logoneuroses);
• depressive states, up to clinically expressed depression.

The intimate sphere can be significantly influenced by interpersonal relationships and conflicts with a partner, as well as a state of fatigue, feelings. If such "misfires" are rare and irregular, they do not apply to erectile dysfunction. If difficulties in intimate life began to appear constantly, this is a reason to contact a specialist.
The psychological causes of erectile dysfunction cannot be discounted at any age. The disease can be corrected much easier and easier than organic disorders.

Organic causes of erectile dysfunction

Among the reasons of an organic nature that interfere with the normal blood supply to the genitals to achieve a full erection, there are three leading ones:

• hormonal factor (violation of the synthesis of hormones or the perception of hormone signals);
• neurogenic disorders (associated with sensory disorders);
• vascular factor (vascular problems that prevent the penis from filling with blood).

Hormonal imbalance is one of the leading causes of erectile dysfunction. Deficiency of testosterone and androgens, the predominance of estrogen leads to a decrease in sexual desire.

It is the decrease in sexual desire with age that is the first sign of testosterone deficiency, and in this case, the treatment of impotence in men is prescribed by a specialist based on the results of relevant tests.

Violations of the functioning of the brain associated with tumor processes, disorders of innervation as a result of pathologies of the intervertebral discs, vertebral bodies, roots or peripheral nerves in the lumbar region and sacrum can lead to erectile dysfunction. Epilepsy, multiple sclerosis, head and spinal cord injuries, and Alzheimer's disease are also common causes of decreased sexual function in middle-aged and older men.

Vascular lesions of atherosclerotic origin, hypertension or myocardial infarction with circulatory failure lead to impaired blood filling of the pelvic organs and problems with potency. The narrowing of the lumen of the arteries that carry blood to the penis also causes sexual dysfunction, they progress with age.

Among other pathologies that need to be taken into account in the treatment of the "male problem" - impotence, one can name adenoma and prostate cancer, diabetes mellitus with its progressive lesions of small vessels, as well as liver damage (cirrhosis, hepatitis), scleroderma. Problems also develop as a result of surgical interventions in the prostate, brain or spinal area, as well as various manipulations in the pelvic and abdominal cavity, in the bladder area.

It is worth highlighting the side effects and negative impact on the potency of taking certain medications - antidepressants, drugs against arterial hypertension, antiulcer drugs or alpha-reductase inhibitors, antihyperlipidemic drugs and antipsychotic drugs. If erectile dysfunction occurs during drug treatment, you need to consult a doctor to correct the scheme.

Treatment of erectile dysfunction

It is important to understand that erectile dysfunction is a disease that, with the joint and coordinated actions of the patient's doctor, is successfully treated. Even the treatment of mild erectile dysfunction should be carried out in men under the supervision of a specialist and in accordance with an individually selected therapy regimen.

At the initial stage, all negative changes can be corrected without resorting to taking drugs or surgery, using various instruments and devices. Modern medicine has reached a level where fast and complete treatment of impotence is carried out, effective and safe. You should not practice dubious and untested methods, take various dietary supplements and pills that affect potency, you should undergo a full examination, find out the true cause of erectile dysfunction and, based on these data, take drugs or undergo other treatment.

Many mistakenly believe that the treatment of sexual dysfunction will be expensive and difficult, various painful manipulations or a number of medicines will be needed, but this is not true. Often more effective are just non-drug methods, psychotherapy, changes in lifestyle, nutrition and intimate habits. In each case, the method of impotence treatment is selected individually, based on the age, duration of the disorder, severity and presence of concomitant diseases and complications. Surgical interventions are applicable only in a small percentage of men with serious organic defects.

Erectile dysfunction: treatment methods

Treatment begins with home therapy, including lifestyle changes and the elimination of negative factors that provoke “misfires” in bed. So, it is necessary to provide sufficient physical activity, give up bad habits and correct existing chronic pathologies, evaluate the effect on the potency of the medications taken and, if necessary, replace them with those that do not have similar side effects. No less important is the psychological state of the man. So, the treatment of psychological impotence involves mostly the use of non-drug methods. In the treatment of this type of erectile dysfunction, the support and help of the partner, her participation and tactful attitude to such a delicate problem are more important than ever.

Speaking in general about the treatment of erectile dysfunction, doctors use the following methods of treating impotence:

• non-drug effects (lifestyle change, giving up bad habits, fighting overweight);
• taking medications to normalize sexual functions;
• hormone therapy according to indications;
• physiotherapy techniques;
• the use of various devices to improve erection;
• non-traditional methods of treatment (acupuncture, homeopathy, osteopathic practices, herbal medicine);
• psychotherapy.

Any medication in the treatment of impotence is prescribed only by a doctor, if indicated. Usually these are drugs that affect concomitant somatic pathologies, eliminate latent sexual infections and suppress inflammatory processes in the prostate. With testosterone deficiency, micronized testosterone preparations are prescribed (orally), used according to a special scheme, which allow you to return the brightness of sensations, sexual desire, and restore potency. They are used in courses, only under the supervision of a doctor, with mandatory monitoring of blood counts.

The generally accepted classification of drugs that regulate potency:

1. Means that increase the level of nitric oxide:
   • Selective PDE5 inhibitors: sildenafil citrate, tadalafil, vardenafil;
   • NO-synthase activators;
2. Alpha blockers:
   • Selective alpha2-blockers;
   • Non-selective alpha blockers;
3. Analogues of prostaglandin E;
4. Means of complex composition;
5. Androgens;
6. Myotropic antispasmodics: papaverine.

With testosterone deficiency, micronized testosterone preparations are prescribed (orally), used according to a special scheme, which allow you to return the brightness of sensations, sexual desire, and restore potency. They are used in courses, only under the supervision of a doctor, with mandatory monitoring of blood counts.

Widely advertised non-hormonal drugs for the treatment of erectile dysfunction are used as an additional source of vitamin and mineral components, as well as complexes of plant extracts that have a certain stimulating effect on the synthesis of endogenous testosterone. As an isolated remedy for the treatment of serious problems, these drugs are useless, they are ways to provide a preventive and additional effect that enhances the main therapy.

Physiotherapy for the treatment of impotence in men

In the treatment of erectile dysfunction, a physiotherapeutic effect is used, which, when used systematically, leads to an improvement in blood circulation and microcirculation in the genital area, enhances erection and sensations during sex, improves sperm quality and gives a man confidence.

The most applicable methods are four main areas:

• sedative therapy in the form of transcranial electrical stimulation, electrophoresis with drugs, color therapy, electrosleep;
• techniques that improve the trophism of the tissues of the intimate zone - rectal electrical stimulation, laser therapy, mud treatment, ultrasound exposure, interference therapy;
• effects that activate the synthesis of hormones - ozone therapy, transcerebral UHF method of exposure;
• physiotherapy techniques leading to vasodilation - magnetotherapy, electrophoresis with drugs, LOD-therapy and others.

The combination of psycho-correction with physiotherapy is the best treatment for impotence, leading to stable and pronounced results even without medication.

Various devices for the treatment of erectile dysfunction

The method of vacuum massage (LOD-therapy) in the penis area is considered to be quite effective. It helps to stimulate an erection and eliminates circulatory disorders. The mechanism of action is simple, due to the special design of the device, a rarefied atmosphere is created around the penis, stimulating artificial blood flow to the area of ​​the cavernous and spongy body, which leads to an erection. During the session, in addition to decompression, the exchange of oxygen between blood and tissues is also activated, the transport of metabolic products and fluid is normalized. This improves tissue nutrition and eliminates dystrophic processes in the genital organ.

Additionally, against the background of decompression, irradiation with a monochrome light spectrum (red area) is performed, which irritates the penis receptors that are involved in the formation and further maintenance of an erection. Due to the effect on blood flow, the blood filling of the organ improves and its functions are normalized.

Additional remedies for the treatment of erectile dysfunction

In addition to the main ones, as additional, auxiliary methods, you can use acupuncture and the impact on biologically active points with the help of massages, as well as homeopathic medicines and manual therapy, osteopathy is used as a method of soft and delicate exposure, relieving spasms and clamps in the lumbar region and small pelvis.
Full-fledged psychotherapy and support of a partner, close people and normalization of relations in a couple are extremely important, which together leads to a quick and irrevocable elimination of the problem.

Ask a question to the doctor

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Erectile dysfunction is the inability to develop and maintain an erection necessary for a full sexual intercourse. Synonyms for this condition are impotence and copulatory dysfunction. This is not an independent pathology - as a rule, it is a syndrome that occurs against the background of others - somatic, neurological, mental disorders. Every fifth man on our planet suffers from erectile dysfunction. More often it occurs in men of mature and elderly age (one of the manifestations of male menopause), but in some cases it also occurs in young people - over the age of 18 years.

About why and how impotence develops, what are the clinical manifestations of this condition, as well as the principles of diagnosis and treatment of it, in particular, without the use of medications, you will learn from our article.

Causes and types of erectile dysfunction

We combined these two sections because they are closely related to each other - the disease is classified depending on the cause that caused its development. So, erectile dysfunction can be:

• hormonal;
• psychogenic;
• neurogenic;
• organic, or vasculogenic (occur due to arterial or venous insufficiency of the penis, or due to sclerosis of its cavernous tissue);
• medical.

Psychogenic impotence develops with a man's psycho-emotional distress - in the case of depressive disorders, asthenoneurotic syndrome, against the background of stress. There is such a thing as "fear of coitus" - this is a condition in which a man experiences fear of the upcoming sexual intercourse, fear of failure in its implementation, fear of ridicule. Often, in the presence of this syndrome in a man, it really becomes problematic to have sexual intercourse - erectile dysfunction occurs.

Psychogenic dysfunction is primary and secondary. The primary one is conditioned by upbringing, personal characteristics, character traits of the patient (self-doubt, propensity to experience, emotionality), and the secondary one develops as a result of previously received negative sexual experience, a certain situation in a relationship with a partner or in life in general. Secondary erectile dysfunction always occurs acutely and is often accompanied by sexual disorders of a different nature.

It is noteworthy that this type of impotence is selective - under some circumstances it appears, and under others it is absent.

Neurogenic impotence develops in various diseases of the nervous system, in particular, with spinal tabes, Parkinson's disease, epilepsy, tumors and injuries of the brain and spinal cord, as well as congenital pathology of the development of the organs of the central nervous system.

Endocrine impotence It is the result of a hormonal imbalance in the body. First of all, it occurs with a decrease in the level of male sex hormones, in particular, testosterone in the blood, which we observe during the male menopause. Often, endocrine impotence accompanies diabetes mellitus.

Arterial insufficiency of the penis can cause a number of reasons: damage to the arteries of the small pelvis by atherosclerosis, congenital underdevelopment of the arteries of the penis, traumatic injuries of the perineum and pelvic bones, especially with damage to the urethra. The main pathogenetic mechanism of this form of the disease is circulatory failure. In persons suffering from hypertension, erectile dysfunction occurs 15-20% more often than in healthy individuals.

Arterial insufficiency develops gradually and does not depend on the relationship of a man with a partner.

To venous insufficiency of the penis give genetically determined features of the structure of its venous system, which are often combined with the pathology of veins of other localization.

Erectile dysfunction due to sclerosis of the cavernous tissue occurs, as a rule, in elderly patients as one of the manifestations of changes in the body associated with age. In addition, priapism can lead to sclerosis, since in this condition there is prolonged hypertension inside the cavernous bodies, which leads to ischemia (oxygen deficiency) of the cavernous tissue - one of its outcomes is sclerosis. Also, this process develops as a result of injuries of the penis and diabetes.

Erectile dysfunction caused by medication. Drugs such as alpha and beta-blockers, H 2 blockers, antidepressants and tranquilizers can become the cause of its development. Patients who are shown taking such drugs should be aware of their side effects, including erectile dysfunction.

Clinical manifestations

Actually, the leading sign of impotence is the inability of a man to have sexual intercourse. Variants of this state depend on the reasons that caused it. Sexual desire may or may not be preserved. Spontaneous erections may persist, weaken or be absent altogether.

An erection can be unstable, occur in certain positions of the body, and disappear in others (this indicates an excessive outflow of venous blood from the cavernous bodies when changing position).

The tension of the penis during intercourse can increase, but slowly, sluggishly - this is also a pathology, and it is most likely associated with insufficient arterial blood flow with intact venous outflow.

The psychogenic nature of impotence will be indicated by the preservation of masturbatory and spontaneous erections, combined with a weakening or lack of adequate ones.

In many cases, the nature of the clinical course of the disease will already tell the doctor in which direction to carry out a diagnostic search in order to help his patient as soon as possible.

Diagnostics

The very fact of erectile dysfunction is quite problematic for a doctor to detect, therefore, a preliminary diagnosis, as a rule, is based on the patient's complaints about the constant or periodic impossibility of a full-fledged sexual intercourse, as well as the history of life and disease. In fact, the doctor already at this stage diagnoses "impotence", and further examination is carried out to establish the cause of this condition.

When examining a patient, the specialist pays attention to the visual signs of hormonal imbalance (body build, hair growth, development of male sexual characteristics), the structure of the external genital organs, traces of injuries, manifestations of the inflammatory process. After the examination, he examines the genital reflexes. Then, in order to confirm the diagnosis, the patient will be assigned a series of laboratory and instrumental studies, in particular:

• semen analysis;
• study of the secret of the prostate gland;
• the level of hormones in the blood (testosterone, estradiol, prolactin and others);
• study of the conduction of the distal nerve bundle;
• determination of the bulbocavernosus reflex;
• pharmacological artificial erection (a solution of papaverine, phentolamine or another drug is injected into the cavities, and then they evaluate how quickly an erection occurs, its degree on a six-point scale, duration and changes when changing body position);
• ultrasonic doppler scanning of the vessels of the penis (the accuracy of the study is up to 90%; during it, the doctor evaluates the nature of the blood flow, the state of the protein shell, cavernous tissue, and can also diagnose Peyronie's disease);
• spongiosography (a study with contrast; it is carried out in order to assess the outflow of venous blood from the penis);
• cavernosography (also a radiopaque diagnostic method; it allows you to assess the condition of the cavernous bodies and the outflow of venous blood from them);
• perfusion artificial erection (it is performed to obtain an image of the venous vessels of the penis and assess the condition of the cavernous tissue);
• compression perfusion of the cavernous bodies (to assess the state of the venous vessels of the penis with a developing erection);
• arteriography (for the study of the arterial system of the penis);
• impedance plethysmography of the penis (allows you to assess the pulse filling of the organ);
• measurement of the penobrachial index (a value obtained by dividing the value of systolic pressure in the vessels of the penis by systolic pressure, measured classically - on the carotid artery; allows you to judge the functional state of the vessels);
• radioisotope pharmacopenography (examines the rate of excretion of a radioisotope in different phases of erection);
• study of nocturnal swelling of the penis;
• consultation of specialized specialists - a neuropathologist, psychologist, psychiatrist, endocrinologist and others, if necessary.

Treatment tactics

Treatment can be conservative or surgical - it depends on the disease against which erectile dysfunction occurred.

Conservative treatment

The main direction of treatment is the treatment of the underlying disease, however, if it is impossible to completely get rid of it, the andrologist should try to eliminate impotence in order to achieve the patient's sexual adaptation - this will undoubtedly improve his quality of life.

The therapy is carried out in order to restore blood supply and innervation of the penis, correct hormonal imbalance.

An important component of complex treatment is psychotherapy, as well as taking psychotropic drugs, if necessary.

Medical therapy may include:

• drugs that improve metabolic processes in the wall of blood vessels - angioprotectors;
• phosphodiesterase-5 inhibitors (sildenafil, tadalafil and others);
• hormone replacement therapy;
• drugs that dilate blood vessels (nicotinic acid, chimes);
• alpha-blockers (phentolamine);
• antihypoxants;
• antiplatelet agents;
• adaptogens (extracts of eleutherococcus, golden root, ginseng);
• vitamins, especially group B;
• prostaglandin E (kaverject, alprostadil).

Surgery

In order to restore the normal blood supply to the penis, surgical interventions on the vessels of the pelvis or revascularization of the cavernous bodies can be performed. With extensive sclerosis of the cavernous bodies, the patient is recommended penile prosthetics. Unfortunately, this technique is not physiological, it makes all further attempts at physiological correction of erectile dysfunction impossible in advance.

Physiotherapy

The techniques can be used as part of the complex treatment of erectile dysfunction. They are used to improve nutrition (trophostimulating methods) and blood flow in the prostate area, correct hormonal imbalances, and also to stimulate inhibitory processes in the cerebral cortex, which provide a sedative effect.

So, sedative methods include:

• medicinal bromine on the collar zone;
• (applications of mud on the panty zone);
• (improves blood flow in the prostate area, affects the parasympathetic erection centers).

To correct the hormonal status, transcerebral ultrahigh-frequency therapy is used, which stimulates the work of the adenohypophysis, normalizing the processes of its production of hormones. It also has an immunostimulating effect.

In order to dilate blood vessels appoint:

• local vacuum magnetotherapy (normalizes vascular tone, improves arterial blood flow, accelerates venous outflow);
• SMT-phoresis of drugs that dilate blood vessels (dihydroergotamine, papaverine; the cathode is placed above the pubis, and the anode is placed on the penis);
• Microwave therapy for the prostate.

Spa treatment

Men suffering from impotence are shown treatment at resorts and sanatoriums with a steppe, forest or sea climate, with the possibility of balneotherapy and pelotherapy. These are Pyatigorsk, Anapa, Sochi, Southern Coast of Crimea, Ust-Kachka, Krasnousolsk and other hospitals. An important component of therapy at the resort is physiotherapy exercises - and therapeutic exercises, which improve blood flow in the pelvic area, preventing congestion in it.

With urinary incontinence, prostate adenoma II-III degree, urethral stricture or gross hematuria (excretion of large amounts of blood in the urine) of any nature.

Conclusion

Erectile dysfunction is a very unpleasant condition faced by every fifth man on the planet. There are a lot of reasons for it, and therefore, types. The main direction of treatment is the therapy of the underlying disease - the one that caused the development of impotence. The task of the andrologist is, even if it is impossible to eliminate the underlying disease, to try to improve the erectile function of the patient - this will significantly improve the quality of his life. Treatment can be conservative (by taking medication) or surgically. An important component of complex treatment is physiotherapy, the methods of which help to improve blood flow in the penis, and therefore normalize the nutrition of the tissues around it, as well as calm the patient's excited nervous system.

In most cases, erectile dysfunction is treatable - patients complete it with a positive result. That is why if you have symptoms similar to those described above, please do not self-medicate, but seek help from an andrologist-urologist.

Urologists of the medical center "ON Clinic Donetsk" talk about erectile dysfunction:

TVC, program "Doctor I", issue on the topic "Erectile dysfunction":

E.B. Mazo, S.I. Gamidov, V.V. Iremashvili Urological Clinic (Head - Corresponding Member of the Russian Academy of Medical Sciences, Prof. E.B. Mazo)
GOU VPO Russian State Medical University of Roszdrav

Against the background of the rapid growth of the world's population, life expectancy continues to lengthen, which leads to a significant increase in the number of older people. According to the forecasts of the United Nations over the next 25 years, the number of older people (over the age of 65) will increase three times. This leads to an increase in the number of patients with a number of diseases, more often affecting older people. One such disorder is erectile dysfunction (ED), defined as the inability of a man to achieve and/or maintain an erection sufficient for sexual intercourse. The results of epidemiological studies clearly indicate that age is the most important factor in determining the likelihood of developing ED. Even in the first large-scale epidemiological study of sexual dysfunction, performed by Kinsey et al. in 1948 and including 15781 men aged 10 to 80 years, it was shown that ED among men aged 55 to 65 years is significantly more common (25%) than in persons under 30 years of age (1%). According to the Massachusetts Study (MMAS), among 1290 men aged 40 to 70 years, the overall prevalence of ED was 52%, while among 40-year-old men this figure was 39%, and among 70-year-old men - 67%. Similar data were obtained in a number of other studies, the results of which are presented in Table 1.

There are two different explanations for the nature of the relationship between age and the likelihood of developing ED. Firstly, the occurrence of ED in older men may be the result of systemic changes, primarily of a hormonal nature, and / or violations of the structure and function of the penis, regardless of other diseases, that is, it can be a manifestation of the aging process itself. On the other hand, an increase in the risk of ED in men with age may be associated with certain diseases that develop in older men and have an adverse effect on erectile function.

Hormonal Causes of ED

One of the possible reasons for the development of ED in old age is hormonal changes. It is well known that aging is accompanied by a progressive decrease in the synthesis of testosterone, dehydroepiandrostenone (DHEA), thyroxine, melatonin and growth hormone. The question of the existence of a connection between these changes and the development of ED currently continues to be controversial. There is no doubt that hypogonadism leads to a decrease in libido and erectile function, but the relationship between a moderate decrease in the level of sex hormones and ED has not been conclusively proven. Ahn et al. investigated the correlation between sexual activity, androgen (total and free testosterone) and sex hormone-binding globulin (SHBG) levels in 213 older men with lower urinary tract symptoms. The authors found a 36% decrease in free testosterone levels and a 22% increase in SHBG in men over the age of 70 compared to men under 40 years of age. When comparing laboratory data with the results of a questionnaire (International Index of Erectile Function (IIEF)) after eliminating the influence of age, a relationship was found only between the concentration of free testosterone and erectile and orgasmic functions. At the same time, there was no correlation between the level of total testosterone and SHBG and erectile function. Schiavi et al., examining the state of erectile function and the levels of pituitary and sex hormones in 77 healthy men aged 45 to 74 years, found a negative relationship between age and the level of bioavailable testosterone, as well as a correlation between the level of bioavailable testosterone and sexual activity. However, when statistically analyzed for age, there was virtually no relationship between bioavailable testosterone levels and sexual activity. This allowed the authors to conclude that age-related changes in the concentration of sex hormones do not significantly affect erectile function in healthy older men. Interesting results were obtained by Feldman et al., who analyzed the effect of the initial concentration of DHEA and dihydroepiandrostenone sulfate (DHEA-S) on the likelihood of developing coronary heart disease (CHD) in men during a 9-year follow-up. The analysis showed that the effect of androgens on the state of erectile function in older men may be mediated through an increase in the likelihood of developing vascular pathology, in particular coronary artery disease, the relationship of which with ED will be discussed below. Thus, at present, the question of the effect of an age-related decrease in the concentration of sex hormones on erectile function in older men has not been finally resolved and needs further study.

Structural changes in the penis

As we age, the penis develops significant structural changes. Collagen and elastic fibers of the albuginea are the main elements that provide an increase in the thickness and length of the penis during tumescence. Studies of biopsy specimens of the penis have shown that the number of elastic fibers in its tissues decreases with age. This, in turn, leads to a decrease in the elasticity of the tunica albuginea and plays an important role in the pathogenesis of ED in older men. In addition, there is evidence that in men over the age of 60 there is a decrease in the number of smooth muscle cells in the penis, reaching 35%. A change in the ratio between smooth muscle and connective tissues leads to an increased likelihood of developing venous leakage and veno-occlusive ED. This may also be facilitated by a decrease in the number of type III collagen fibers and an increase in the number of type I collagen fibers found in the penis with aging. It has been suggested that violations of the content of collagen and elastic fibers are primary, subsequently leading to chronic ischemia of the cavernous bodies, which causes the death of some of the smooth muscle cells. A possible mechanism leading to ischemia is the decrease in the number and duration of nocturnal spontaneous erections, which occurs in older men.

Functional disorders in the penis

In addition to structural, a number of functional disorders can also develop in the penis in older men. Rowland et al. revealed a decrease in the sensitivity of the penis to vibrotactile stimulation in men older than 70 years. Animal studies have also examined changes in the innervation of the penis that develop with aging. The results of these studies have been conflicting. For example, Carrier et al. found a decrease in the number of nerve fibers in the penis in aged rats, while Warburton and Santer and Amenta et al found no such change. It should be noted that these works may not reflect the real picture, due to the fact that in them the number of nerve fibers was estimated by the content of certain substances, which, in some cases, may undergo changes regardless of the number of nerve endings. Due to the importance of the role of nitric oxide NO in the mechanism of erection, a large number of studies have been conducted on the study of changes in the activity of NO synthetase (NOS) in the tissues of the penis during aging. The complexity of such studies is due to the fact that there are three types of NOC in humans: endothelial (eNOC), neuronal (nNOC) and inducible (iNOC). The first two types are located predominantly in endothelial cells and nerve endings, respectively, and are activated with an increase in intracellular calcium content. The enzyme iNOC is located in macrophages and is involved in the synthesis of NO during

exposure to various cytokines during the inflammatory response.

Most studies have found an increase in both eNOC and iNOC activity in penile tissues with aging. If the former may be a compensatory reaction in response to a decrease in NO bioavailability, associated in particular with the accumulation of protein glycation products with aging, then the latter may cause damage to smooth muscle cells as a result of the formation of peroxynitrite, the effect of which leads to their apoptosis and proteolysis. Thus, an increase in the activity of various types of NOC during aging can be both a compensatory reaction and a mechanism of damage to the smooth muscle tissue of the cavernous bodies, leading to a decrease in erectile function.

The structural and functional changes of the penis described above can ultimately lead to changes in its hemodynamics, noted in older men. So Chung et al. showed a decrease in systolic blood flow velocity during pharmacodopplerography using injections of prostaglandin E1 as the age of the examined men increased. It should be emphasized that all men who participated in this study did not have cardiovascular risk factors, which makes it possible to exclude their influence on the results obtained.

Thus, the results of a large number of studies suggest that age-related hormonal disorders, as well as structural and functional changes in the penis itself, are an independent cause of the development of ED in some older men. In addition to the age-related factors described above, various somatic diseases can also lead to the development of ED, the frequency of which increases with age. Among them, the most important are cardiovascular diseases (CVD) and diabetes mellitus (DM). It is well known that atherosclerotic lesions of the coronary, carotid and other large arteries and ED have common risk factors, among which the most important are arterial hypertension, diabetes, smoking, hypercholesterolemia, obesity and physical inactivity. The presence of several common risk factors explains the frequent combination of various forms of coronary artery disease and ED, which are particular manifestations of systemic vascular disease. The prevalence of ED in patients with coronary artery disease, according to various sources, ranges from 44 to 65%. With atherosclerotic lesions of other large arteries, manifested clinically in the form of cerebrovascular disease and peripheral circulatory disorders, the frequency of ED reaches 86% and 87%, respectively.

Diabetes mellitus and atherosclerotic vascular disease

Diabetes mellitus, the incidence of which increases significantly with age, was one of the first diseases considered as a cause of ED. The prevalence of ED among patients with diabetes significantly exceeds that in the general population and, according to various studies, ranges from 20 to 85%, while there are no significant differences in the frequency and severity of ED between patients with type 1 and type 2 diabetes. The presence of diabetes increases the risk of developing ED by 2-4 times compared with healthy men of the same age. In total, about 75% of men with diabetes sooner or later encounter ED, and these disorders appear much earlier in comparison with healthy men, are more severe and have a greater adverse effect on quality of life.

Currently, the previous ideas about the pathophysiological mechanisms of the relationship between DM, CVD and ED are being revised. For a long time, it was customary to consider ED as a late, secondary complication of systemic vascular pathology, but in recent years this point of view has undergone significant changes due to the accumulation of new clinical and fundamental data. In a significant proportion of older men, erectile dysfunction precedes the onset of symptoms of atherosclerotic lesions of large vessels, in particular coronary artery disease. Montorsi et al found that in 300 patients with acute coronary syndrome, ED preceded the onset of signs of coronary artery disease in 67%, with a mean interval of more than 3 years. It should be noted that myocardial infarction in many cases is an early manifestation of coronary artery disease and can occur in the absence of a significant narrowing of the lumen of the coronary vessels by atherosclerotic plaques. Taking into account the peculiarities of the course of atherosclerosis, which affects large vessels earlier and to a greater extent, it can be assumed that in a significant part of such patients, at least during the period of erectile dysfunction, there was no pronounced organic narrowing of the internal genital and tricky arteries, small in diameter.

Another circumstance that casts doubt on the organic nature of arterial blood flow disorders to the cavernous bodies is the potential reversibility of such disorders during drug therapy. Currently, it is known that the effectiveness of the treatment of arteriogenic ED with the use of oral phosphodiesterase type 5 inhibitors, as well as vasoactive drugs for intracavernous administration, exceeds 70%. Such a high efficiency of drug treatment, which leads to partial or complete restoration of erectile function, at least for the period of action of the drugs, is not consistent with the examples of treatment of atherosclerotic lesions of other arteries. For example, medications used in the treatment of IHD do not allow to fully restore the functional capacity of the heart muscle, but, on the contrary, by reducing the load on it, they have an antianginal effect.

Not consistent with the theory of atherosclerotic lesions as the cause of the development of all cases of arteriogenic ED are also the data of recent studies that have shown the possibility of restoring erection in some patients after the elimination of risk factors. Pourmand et al. studied the effect of smoking cessation on erectile function and found that among patients with ED one year after quitting smoking, there was an improvement in erectile function in more than 25% of cases, while among patients of the same age who continued smoking, there was no improvement in erectile function. It was . Esposito et al. noted an improvement in erections in about one-third of obese men 2 years after weight loss and increased physical activity. The possibility of restoring impaired erectile function after correction of dyslipidemia has been established.

Also shown is the restoration of erectile function after treatment with the PDE-5 inhibitor tadalafil. Caretta et al. observed 60 men with ED aged 60 to 70 years who received tadalafil at a dose of 20 mg every other day for 3 months. Before the start of treatment, all patients underwent an ultrasound examination of the wall thickness of the carotid arteries. Upon re-examination 1 month after discontinuation of the drug, restoration of erectile function was noted in 25 patients (41.7%). At the same time, it was found that the restoration of spontaneous erections took place in 65% of patients with normal wall thickness of the carotid arteries and only in 16% of patients with atherosclerotic lesions. The authors explain this fact by the functional nature of the damage to the arteries of the penis in most men with intact carotid arteries.

These data indicate that the basis of arteriogenic ED in a significant proportion of older men is not organic, but functional, potentially reversible damage to the arteries - endothelial dysfunction, which is currently considered as a functional stage in the development of atherosclerosis. All the vascular risk factors mentioned above have an adverse effect on the endothelium, leading to a disruption in the synthesis of various vasorelaxant factors by its cells, the most important of which is NO. Given the key role of NO in the mechanism of erection, it is obvious that disturbances in its production and/or bioavailability can lead to ED. In older men, the adverse effects of vascular risk factors may be combined with age-related disturbances in the production and action of NO, discussed above. Thus, in this group of patients, endothelial dysfunction may be the leading mechanism for the development of ED, both in combination with CVD and DM, and without them.

Benign prostatic hyperplasia and ED

Many studies have also shown an association between the presence of benign prostatic hyperplasia (BPH) and ED. The incidence of BPH tends to increase with age, and therefore it has been suggested that these two diseases only accompany each other in older men, however, large-scale epidemiological studies conducted in recent years, in most of which the diagnosis of BPH was assumed by the presence of symptoms lower urinary tract, convincingly proved that the presence of the latter is an independent, age-independent, risk factor for ED. Possible pathophysiological mechanisms that combine the symptoms of the lower urinary tract and ED are the imbalance of the sympathetic nervous system, as well as the endothelial dysfunction and age-related hormonal disorders already discussed above. It should be noted that, despite the great clinical significance, this problem is currently insufficiently studied and needs further study.

It has been repeatedly suggested that depression, which often occurs in older men, may be the cause of their development of ED. Despite the existence of a connection between these two diseases, emerging new data suggest that depression in this group of patients is often a manifestation of age-related changes in hormonal status, and cast doubt on the independence of its role in the development of ED.

There are a number of neurological diseases that predominantly affect the elderly and can lead to the development of neurogenic ED in men. The most important of these diseases are herniated discs, Parkinson's disease and Alzheimer's disease.

It is impossible not to mention the possibility of developing iatrogenic ED in older men as a complication of surgical interventions on the pelvic organs and taking various medications. Of greatest importance in the first group of causes is radical prostatectomy for prostate cancer, which is the most common form of malignant disease in men in developed countries and affects mainly the older age group. Many older men receive conservative therapies that can lead to ED, such as antihypertensive drugs, blood cholesterol lowering drugs, tranquilizers, and 5-alpha reductase inhibitors and antiandrogen drugs.

Examinations, collection of analyzes

Examination of patients with ED includes the collection of general medical and sexual history, general examination of patients, laboratory tests. When collecting a general medical history, it is important to find out whether a patient has coronary artery disease, arterial hypertension and other CVD, diabetes, urination disorders, as well as the medication he is receiving at the time of the examination. In order to facilitate the assessment of the risk of resuming sexual activity for patients with cardiovascular pathology, appropriate recommendations have been created (Table 2). When collecting a sexual history, it is necessary to pay attention to the state of health and sexual function of the partner, since often the sexual partners of older men are in menopausal and postmenopausal age and have sexual dysfunctions, which plays a large role in the development of ED in their partners. In a general examination, special attention should be paid to the genital area, as well as secondary sexual characteristics and the study of the pulse on the peripheral vessels, in addition, in all elderly men, a digital rectal examination is mandatory. Laboratory examination includes the study of glucose, lipids and prostate-specific blood antigen, as well as hormonal status.

Specific studies for the diagnosis of ED, which allow to determine its form and severity of organic disorders, include an intracavernous pharmacological test, tests with type 5 phosphodiesterase inhibitors, pharmacodopplerography of the vessels of the penis, a study of nocturnal tumescences of the penis, electromyography of the penis, and if there are appropriate indications - angiography, cavernosometry and cavernosography. In addition, given the importance of endothelial dysfunction in the pathogenesis of erectile dysfunction in elderly men, in order to diagnose arteriogenic ED in this group of patients, it is possible to use the method of ultrasound examination (ultrasound) of post-compression changes in the diameter of peripheral arteries. These techniques are non-invasive and are not inferior in their diagnostic value to pharmacodopplerography. We recommend starting an instrumental examination of elderly patients with ED with a study of the endothelial function of the brachial artery using the ultrasound method of its post-compression changes (Figure 1). As our studies have shown, all patients with arteriogenic ED have impaired functional ability of the endothelium of the brachial arteries, so the study of cavernous arteries, aimed at diagnosing arteriogenic ED, should be performed only in the presence of disorders at the level of the brachial artery. In addition, the study of the endothelial function of the brachial artery, which reflects the state of systemic endothelial function, makes it possible to assess the state of the entire cardiovascular system, which is extremely important for men of the older age group.

Treatment of ED in older men

Oral selective inhibitors of the enzyme phosphodiesterase type 5 (PDE-5) are currently the drugs of choice in the treatment of ED. This type of this enzyme is predominant in the smooth muscle tissue of the cavernous bodies and, as a result of its action, cGMP is degraded, which leads to an increase in intracellular calcium concentration and a reduction in smooth muscle cells. Inhibition of this enzyme reduces the tone of smooth muscle cells, contributing to the development of an erection. It is important to note that these drugs do not exert their effect in the absence of sexual arousal, since they do not by themselves increase the concentration of NO in the cavernous tissue, but only increase its effect.

Sildenafil (Viagra, Pfizer) was the first drug from the group of oral selective PDE-5 inhibitors, the appearance of which marked the beginning of a new era in the treatment of ED, and two more drugs from this group are currently approved for clinical use - tadalafil (Cialis, Lilly / ICOS ) and vardenafil (Levitra, Bayer & GlaxoSmithKline).

Given the same mechanism of action of all three drugs, pharmacodynamic and pharmacokinetic characteristics are important for their comparison. According to in vitro studies, vardenafil is the most potent PDE-5 inhibitor. In addition, vardenafil is also the most selective drug in its group, while sildenafil and tadalafil at therapeutic concentrations also weakly inhibit PDE-6 and PDE-11, respectively. The most important pharmacokinetic feature of tadalafil from a clinical point of view is its longer period of action, reaching 36 hours. On the other hand, it should be noted that sildenafil is the most well-studied drug in the clinical setting, with more than 8 years of experience in its use. Thus, at present, there are no convincing data on the benefits of certain PDE-5 inhibitors, and therefore all of them are classified as first-line drugs.

The nature and frequency of side effects when taking drugs from the group of PDE-5 inhibitors do not have significant differences. The most common adverse effects associated, apparently, with the inhibition of PDE-5, contained in small amounts in smooth muscle tissue outside the penis, are headaches, facial flushing, nasal congestion and dyspeptic disorders. At the same time, due to the action on PDE-6, when taking sildenafil, visual impairment is possible. The consequences of the possible influence of tadalafil on PDE-11 are not currently known.

Despite the dominant role of oral PDE-5 inhibitors in the treatment of ED at the present time, it is worth briefly dwelling on other methods of treatment. These methods are characterized by a number of disadvantages and should be used only in case of inefficiency or contraindications to the use of PDE-5 inhibitors. Thus, intracavernous injections of vasoactive drugs, despite their rather high efficiency, are an invasive method of treatment, in many cases accompanied by pain at the injection site and can lead to complications, the most important of which are priapism and the formation of fibrous plaques. The main indication for the appointment of intracavernous drugs is the intake of nitrates by patients, which in turn is the main contraindication for the use of PDE-5 inhibitors. The use of vacuum devices is characterized by the unnaturalness of the erection itself, as well as frequent pain and the formation of bruises at the location of the compression ring. Performing operations on the vessels of the penis is indicated only for patients under the age of 40 years who do not have vascular risk factors and is completely inapplicable in elderly patients. Psychosexual therapy in this group of patients is also of little use, since in the vast majority of cases erectile disorders are of organic origin. In a small proportion of older men with clinical and laboratory evidence of hypogonadism, hormonal therapy may be considered. And, finally, penis prosthesis, despite its high efficiency, is characterized by invasiveness and irreversibility and should be used only when all other methods of treatment are completely ineffective.

As knowledge about the molecular mechanisms of erectile function and dysfunction has been accumulating, studies have begun to focus on gene therapy for ED. So Champion et al. using adenovirus to transfer genetic material into the cells of the cavernous bodies of elderly rats, they noted an improvement in the quality of erections during stimulation of the cavernous nerves after the introduction of eNOC genes and a peptide associated with the calciotonin gene into rats. This area is extremely promising and needs further study. Thus, the prevalence of ED has a clear tendency to increase with aging, which is associated both with age-related changes of a systemic and local nature, and with the accumulation of concomitant diseases that have a pronounced adverse effect on erectile function, among which DM and CVD are of the greatest importance. The frequent combination of ED with DM and CVD may be associated with the development of endothelial dysfunction in this category of patients, which is not only of fundamental but also important clinical significance - the study of endothelial function is a promising approach to the diagnosis of arteriogenic ED. Due to their high efficacy and safety, PDE-5 inhibitors are currently the drugs of choice in the treatment of ED in older men.