Francesco Montorsi


Erectile dysfunction

Definition and Causes of Erectile Dysfunction

Erectile Dysfunction (ED or commonly impotence) is defined as the persistent or recurrent inability to obtain or maintain an adequate penile erection for the completion of sexual intercourse. 
Depending on the etiology, erectile dysfunction is classified in organic and psychogenic. ED is psychogenic when it arises in a patient without particular risk factors, in which the physician cannot find a cause of the problem. In most cases, however, the dysfunction is on an organic basis, in particular vascular.

Epidemiology and causes of impotence

It is estimated that 50% of men with 50 years of age or older have had an episode of erectile dysfunction at least once in their life. 
The causes and risk factors of erectile dysfunction are manifold: 
• Disorders affecting the central or peripheral nervous system: traumas or pathologies that affect the spinal cord, causing a nerve conduction deficit; trauma or neuropathy causing peripheral neurotransmission deficiency (diabetes mellitus, vitamin deficiency, chronic alcohol abuse), prostate surgery or rectal surgery, performed not using the nerve-sparing technique. 
• Psychological disorders: all psychological disorders (in particular anxious / depressive Syndromes) can cause or aggravate an erectile deficit.
• Hormonal disorders that lead to a state of hypogonadism. 
• Disorders affecting the cardiovascular system leading to arterial and venous damage (diabetes, hypertension, ischemic heart disease, systemic atherosclerosis).

Clinical Presentation and Diagnosis of Impotence.

The classic symptomatology of erectile deficit is the inability to obtain (erectile deficit of achievement) or maintain (erectile maintenance deficit) an erection for the completion of sexual activity. 
The diagnosis of erectile dysfunction is based on multiple tests: 
• Hormonal profile: essential to rule out the presence of hypogonadism. 
• The cornerstone for the diagnosis of an erectile deficit is the execution of an ultrasound examination called Power-Color-Doppler. The exam consists of an eco-color doppler of the erected penis. The erection is obtained by injecting prostaglandins in the penis. With this examination, penile hemodynamics (arterial and venous flows) is carefully examined, allowing to discriminate between arterial dysfunction (flow deficit affecting the cavernous arteries), venous dysfunction (deficit in the venous mechanism that allows the blood to escape from the penis) or a mixed dysfunction. 
• Evaluation of nocturnal erections: with this examination, physiological nocturnal erections are assessed (mainly used to exclude an erectile deficit on a psychogenic basis).

Therapy: Pills for Erectile Dysfunction and Penile Prostheses

The pills for erectile dysfunction

Patients with vascular and, in some cases psychogenic, erectile deficit can benefit from treatment with type 5 phosphodiesterase inhibitor drugs (sildenafil, tadalafil and vardenafil), which can be administered as needed or according to daily cadence. 

 The subjects refractory to these drugs or with damage to the nerve fibers responsible for the erection, can benefit from a treatment with intracavernous pharmacotherapy or, according to the patient’s will, it is possible to opt for a surgical therapy of ED by means of prosthesis implantation penile.

Penile prostheses

Prosthetic therapy aims to replace the erection mechanism with devices applied 
inside the corpora cavernosa that are capable of developing adequate rigidity. It is typically reserved for cases where other therapies are not effective. There are two main types of prostheses: 
• Semi-rigid prostheses, which have a fixed degree of rigidity and keep the penis in a state of constant semi-rigidity 
• Hydraulic prostheses, which thanks to a series of devices are able to vary their degree of rigidity . 
In particular, the latter consists of cylinders which are implanted inside the corpora cavernosa and are connected to a tank containing sterile water and to a pump implanted subcutaneously in the scrotum. By acting on the pump, it is possible to make the liquid flow or flow from the tank to the cylinders, thus creating the erection and flaccidity phases.

Heart, Diabetes and Erectile Dysfunction

Large-scale population studies have shown the high incidence of erectile dysfunction in the male population, with episodes of unsatisfactory erection reported in 50% of cases. Although there is a known association between advancing age and the development of erectile dysfunction, approximately a quarter of patients requiring medical attention for ED are under 40 years of age. Over the past 20 years, clinical research on erectile dysfunction has focused on the pathophysiology underlying this disorder and its relationship with cardiovascular disease; in fact, it emerged that patients with ED have a greater risk of presenting heart disease in the following years. This concept has been corroborated by several clinical research studies around the world and it has recently emerged that other pathologies (diabetes mellitus, hormonal and metabolic disorders) are also associated with ED, suggesting erectile dysfunction to be considered as a proxy of “general health”. These data therefore underline the importance of a correct clinical evaluation of patients suffering from ED.


Gentili pazienti, segnalo che in internet sono comparsi numerosi siti che pubblicizzano prodotti pseudo-miracolosi per il trattamento di malattie prostatiche o dell’apparato genito-urinario ed il mio nome compare come specialista che raccomanda queste cure. Sono informazioni del tutto false che ho segnalato all’Ufficio Legale del San Raffaele e che saranno perseguite secondo legge. Non partecipo mai ad iniziative di sostegno pubblicitario online per alcun prodotto para-farmaceutico. Grazie per l’attenzione. 
Prof. Francesco Montorsi