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Study of the relationship between physical symptoms and psychological state of patients suffering from erectile dysfunction

Introduction

Erectile dysfunction (ED) is a polyetiological pathology, which is one of the most significant clinical and social problems among men. For most men, a full sex life is the most important factor in physical and mental health. Many sociological studies show that sexual health is the key to not only a good quality of life, but also a longer life.
Erectile dysfunction is the inability to achieve and maintain an erection at the level necessary for sexual intercourse. Despite the fact that this condition is not considered a serious health disorder, it occupies a special place in medicine, particularly because it is closely related to the psychological state of patients suffering from this disease.
The main reasons for the development of such pathology as erectile dysfunction are considered to be vascular and nervous disorders, hormonal imbalances and psychological problems. Often, patients experience a combination of all three causes of pathology. Sometimes only one component predominates. In particular, psychogenic sexual dysfunction is a disorder of sexual function caused by subjective traumatic or stressful factors. Psychological causes of erectile dysfunction may include guilt, fear of intimacy, stress, depression or anxiety.
Psychogenic erectile dysfunction can be situational, related to a specific place, time or partner; constant; as well as temporary – this type can occur in men who are subject to frequent mental and physical fatigue, who have certain psychological difficulties or problems finding a partner, and the erection returns to normal after the normalization of their lifestyle.
Psychogenic ED, the pathogenesis of which is a decrease in the sensitivity of cavernous tissue to neurotransmitters due to the suppressive effect of the cerebral cortex or due to indirect influence through the spinal centers, can occur against the background of sexual phobias and deviations, associative psychotraumas and religious prejudices.

Relationship between physical symptoms and psychological state of patients suffering from erectile dysfunction

Before starting treatment for erectile dysfunction, a thorough diagnosis must be carried out in each specific case.
The patient’s examination begins with filling out a special questionnaire “International Index of Erectile Function” (IIEF-5) and a detailed conversation. The doctor details the patient’s complaints, history of his illness, injuries he has suffered, operations, medications taken, bad habits and physical condition. Satisfaction with sexual relationships should also be examined, including assessment of partner interaction and partner sexual dysfunction (e.g., vulvovaginal atrophy, dyspareunia, depression).
The examination should focus on the genital area and extragenital signs of hormonal, neurological and vascular diseases. The external genitalia are examined for developmental abnormalities, signs of hypogonadism, fibrous bands or plaques.
Psychological causes must be excluded in young healthy men with a sudden onset of erectile dysfunction, especially if the onset of the disease is associated with a certain emotional experience or if the dysfunction appears only under certain circumstances. A history of ED with spontaneous improvement also indicates a psychogenic etiology. Men with psychogenic erectile dysfunction usually experience normal night and morning erections, while men with organic pathology do not. It is important to screen for depression, which may not always be clinically obvious. There are several depression scales that provide accurate results and are easily applicable in clinical practice.
Laboratory studies should include morning testosterone levels. If levels are low or below normal, prolactin and luteinizing hormone levels should be determined. Screening for latent diabetes mellitus, dyslipidemia, hyperprolactinemia, thyroid disease, and Cushing’s syndrome should be performed based on clinical indications. Doppler ultrasound is usually performed to assess penile blood flow. This method allows to determine the presence of vascular disorders and their type, as well as differentiate the vascular and psychogenic genesis of ED. If neurogenic erectile dysfunction is suspected, electromyography of the penis is performed, which can confirm or refute a violation of the innervation of the organ.
The difficulty in assessing the relationship between the physical symptoms and the psychological state of patients suffering from erectile dysfunction is due in part to the fact that information obtained both from direct examination of patients and from various medical institutions is not sufficiently reliable. This is due to the fact that, firstly, patients often hide the sexual disorders they have, secondly, the data obtained depend on the clinical qualifications and orientation of the researcher, and thirdly, there are serious differences in diagnostic issues among sex therapists belonging to different schools , and there are also significant differences in research methods. For most men, communicating with a doctor about sexuality is very difficult. This is evidenced by the fact that among young and middle-aged men who tried to commit suicide, more than half have some kind of sexual problems. Erectile dysfunction ranks second among the motives for suicide in men.
The lack of knowledge of general practitioners about the diagnosis and course of affective disorders often leads to long-term ineffective therapy, as a result of which depression and other psychological problems become chronic with a noticeable decrease in the level of socio-psychological functioning and quality of life of the patient and his family. Another equally significant aspect of this problem is the insufficient attention of psychiatrists to the somatovegetative symptoms of depression, especially at the stage of its reverse development and the establishment of drug remission, which increases the likelihood of relapse. In light of the above, it seems important to analyze the connection between somatovegetative (in our case, sexual) and depressive disorders in the pathogenetic aspect.
Constitutional or acquired disorders in the hypothalamic-pituitary-adrenal system are reflected in the clinical picture of depression, which is confirmed by the phenomenon of neuroendocrine disinhibition. Depletion of central mediator noradrenergic structures reciprocally causes an increase in peripheral hormonal adrenomedullary activity. Thus, a somatic sympathetic-tonic syndrome is formed, which causes an inhibitory effect of higher centers on the spinal center of the erectile reflex, blocking the parasympathetic impulses necessary for dilation of the vessels of the penis, as well as increased sympathetic tone, leading to an increase in the tone of the smooth muscles of the penis, causing difficulty blood flow and, as a result, erectile dysfunction. This affects the neurohumoral component and the copulatory cycle. All together causes erectile dysfunction of varying severity, and also leads to ejaculation disorders (acceleration or slowdown, even absence).
In the pathogenesis of depression, disturbances of activity and the pineal gland play a certain role, which lead to the so-called low melatonin syndrome. A deficiency of melatonin produced by the pineal gland disrupts the circadian rhythm of cortisol secretion, explaining the circadian dynamics of the mental state in depressive disorders. Usually this is a deterioration in the mental state in the morning and its improvement in the evening, and this corresponds to the sexological complaints of patients: increased sexual activity in the evening hours and a decrease or absence in the morning.

Conclusion

Normal sexual activity is currently defined as an extremely complex psychophysiological function, localized along the hypothalamus-pituitary-gonad axis, on the one hand, and having representation in the higher cortical centers, on the other, not to mention the participation of the limbic system. Sexual dysfunctions in mental disorders have a complex pathogenesis, since they are associated not only with the neurodynamic changes discussed above, but also with previously formed behavioral conditioned reflex stereotypes of sexual behavior relating to all its manifestations – desire, arousal, orgasm, ejaculation.
The physical symptoms and psychological state of patients suffering from erectile dysfunction represent a single and multi-level complex. Accumulated knowledge indicates that there is a biological two-way connection between the psychological state of a man and many sexual disorders, and problems caused by the psychosexual sphere can be a psychogenic factor in the development and maintenance of existing psychological disorders. This indicates the importance of understanding the pathogenesis of sexual disorders, which is key for their adequate and highly effective therapy. The approach to the treatment of these conditions must be comprehensive, taking into account all components of the disease and aimed not only at the core syndrome, but also at accompanying syndromes, without influencing which it is impossible to achieve normalization of impaired functions

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