Erectile Dysfunction Treatment in Turkey

Erectile dysfunction treatment is implemented with a holistic approach that includes pharmacological, psychological, and lifestyle modifications targeting the underlying causes of erectile dysfunction. The treatment plan is determined by evaluating the patient’s clinical history, comorbidities, and hormone levels.

Drug treatment for erectile dysfunction includes the controlled use of agents that increase penile blood flow, especially phosphodiesterase type 5 inhibitors. These drugs provide effective results when used in appropriate doses and with physician recommendation, and contribute to the improvement of sexual function.

Treatment of psychogenic erectile dysfunction includes the management of factors such as anxiety, depression, and performance anxiety. Methods such as cognitive behavioral therapy and couples therapy help reduce psychological barriers related to the individual’s sexual function.

Management of erectile dysfunction through lifestyle changes includes measures such as regular exercise, healthy nutrition, and limiting smoking and alcohol use. Improving cardiovascular health supports the treatment process by showing a positive effect on penile circulation.

What is erectile dysfunction and why is it not just a condition of impotence?

Erectile dysfunction, known in medical literature as erectile dysfunction, is the inability to achieve sufficient penile rigidity to initiate sexual intercourse or bring this act to a satisfying conclusion, or the inability to maintain this rigidity even if it is achieved. For many years in society, it has been expressed with the extremely harsh and discouraging word “impotence,” which is actually far from reflecting the whole picture. However, this approach has completely changed in today’s modern medicine. We no longer see this condition merely as a dysfunction of a single organ or a simple mechanical failure. On the contrary, we accept it as a reflection of a disruption at any point in a huge mechanism ranging from vascular health to the integrity of the nervous system, from the delicate balance of hormones to the person’s psychological state.

This condition is a multidimensional health problem that deeply affects a man’s quality of life, self-confidence, and emotional bond with his partner. Understanding the underlying causes of the problem is the most important key to the treatment process. All systems in our body are in communication with each other, and any systemic disease that disrupts blood flow or nerve transmission to the penis may first show itself in this region. Therefore, this problem should not be evaluated as a final stop, but as an early warning system that gives us very important clues about the body’s general health.

How does advancing age affect the frequency of erectile dysfunction?

The human body undergoes change at the cellular level over time, and the aging process affects the reproductive and sexual organs just as it affects every organ. When we look at the statistics, the probability of encountering erectile dysfunction in men under the age of 40 is quite low. However, once the age of 40 is exceeded, a very clear and sharp increase in the frequency of this problem emerges. As age progresses, we know that these rates can reach up to half of society. However, it is necessary to make a very important distinction here; simply getting older, the passing of calendar pages, is not solely responsible for this problem.

The main danger that increases with age is the cellular fatigue accumulated in the body over the years, oxidative stress, and the burden imposed on the body by chronic diseases. With advancing age, physiological changes begin, such as the loss of elasticity in blood vessels, a decrease in the speed at which tissues renew themselves, and a reduction in hormone production capacity. While erectile dysfunction in a young man usually stems from psychological causes such as daily stress or performance anxiety, in an older man the underlying cause is mostly deterioration in the structure of the vessels or wear in the nerves. Therefore, the factor of age is one of the most important guides that leads us while investigating the source of the problem in treatment planning.

Which diseases and lifestyle choices impair erection quality?

The inner surface of the vascular network in our body is covered with a one-cell-thick but tremendously functional layer that we call the “endothelium.” The health of this layer determines the quality of blood flow. The choices we make in daily life and certain chronic diseases we have directly attack this protective layer and impair its function. When the endothelium is damaged, the vessels cannot dilate as they should, and sufficient blood cannot reach the penis.

The main diseases and conditions that impair erection quality are as follows:

• Type 2 diabetes
• Hypertension
• High cholesterol
• Obesity
• Sleep apnea
• Smoking addiction
• Alcohol abuse
• Metabolic syndrome

Each of the factors listed above is a mechanism of destruction that progresses insidiously in the body. For example, diabetes, that is, sugar disease, disrupts the structure of the smallest capillaries over time, leading to their blockage, and at the same time damages the nerve endings that provide stimulation. The thousands of toxic chemical substances in cigarette smoke directly stop the production of molecules that provide flexibility on the inner surface of blood vessels. Obesity and a sedentary lifestyle accelerate vascular hardening by creating a constant state of inflammation in the body. When all these factors come together, impairment of erection quality becomes an inevitable result.

How does a healthy erection mechanism work in our body?

The occurrence of a healthy erection resembles the “water and electrical system” in our body working in perfect harmony. This process begins in the central nervous system not only with physical contact, but also with a mental thought, a visual stimulus, or a smell. The brain rapidly transmits this stimulus through the spinal cord to the nerve endings in the pelvic region. When these electrical signals reach the target, a very special gas molecule called “Nitric Oxide” is released from the inner surface of the vessels and the nerve endings.

Nitric oxide penetrates the smooth muscle cells in the spongy tissues inside the penis and triggers a series of chemical reactions. As a result of these reactions, the calcium level inside the cell decreases and the smooth muscles completely relax. High-pressure blood rapidly begins to fill between these relaxed spongy tissues from the arteries. As the penis fills with blood and expands, the veins that provide the return of blood are compressed and closed between the firm outer sheath surrounding the penis and the expanding tissue. We call this the “veno-occlusive mechanism,” in other words, the venous locking system. Thanks to this locking system, blood is trapped inside the penis and the strong rigidity required throughout the sexual act is maintained. When the process is completed, the body secretes another enzyme to unlock the system and the blood returns to circulation.

Is erectile dysfunction psychological or physical, how is this distinction made?

One of the biggest steps in solving the problem is to correctly determine whether its source lies in our mind or in our body. Many people want to believe that the problem they experience is entirely psychological, but physical causes are much more common. In order to make this distinction, the patient’s history must be listened to with the meticulousness of a detective.

If the erectile dysfunction appeared suddenly, overnight, occurs with certain partners but not during self-stimulation, the likelihood of the problem being psychological in origin is very high. Work stress, financial worries, arguments with the spouse, or performance anxiety that appears in the form of “what if I fail again?” instantly cut off the relaxation signals going from the brain to the body. When the body is under stress, it releases adrenaline, and adrenaline is one of the strongest hormones that constrict blood vessels; therefore blood flow stops immediately.

However, if the problem has progressed slowly over months or even years and full rigidity cannot be achieved under any circumstances, we suspect a physical (organic) problem. The most determining physical evidence in this distinction is the presence of “morning erections,” which occur in healthy men during the REM phase of sleep. If the person continues to wake up with a strong erection in the morning, we understand that the bodily mechanism, vessels, and nerves are anatomically sound, and that mental barriers come into play while awake. The complete loss of morning erections is one of the clearest indicators of vascular or neurological damage.

What hidden connection exists between erectile dysfunction and heart health?

Although the heart and penis seem like very independent organs, they are actually parts of the same vascular network and are subject to the same health rules. While the coronary arteries that feed our heart have an average diameter of 3-4 millimeters, the arteries carrying blood to the penis are only about 1-2 millimeters in diameter. When a process of vascular hardening (atherosclerosis) begins in the body due to high cholesterol, sugar, or smoking, these blockages first affect the narrowest pipes, that is, the penile vessels.

Because of this anatomical reality, erectile dysfunction of vascular origin is a harbinger of a much greater approaching danger. In the medical world, this situation is likened to canary birds in coal mines that sense poisonous gas in advance and warn workers. On average 2 to 3 years after erectile dysfunction begins, heart attacks or serious coronary artery blockages may emerge. Therefore, it is of vital importance that the cardiovascular system of every individual presenting with this complaint is evaluated in detail. The heart’s exercise capacity is measured according to the person’s age, weight, and existing diseases, and if necessary, a joint roadmap is drawn with a cardiology specialist.

Which tests and methods are used when diagnosing erectile dysfunction?

The diagnostic process does not end with just listening to the complaint; we need clear data that show the internal functioning of the body. In the first stage, comprehensive blood tests are requested to see the hormonal and metabolic balance in the body. The total and free forms of the “Testosterone” hormone, which is at the highest level in the blood in the morning hours, are measured. Testosterone is the main fuel of sexual desire (libido); when it is deficient, the system becomes unwilling to function. In addition, Prolactin, known as the milk hormone, and TSH values that show the functioning of the thyroid gland are also examined. Furthermore, fasting blood sugar and the three-month average blood sugar (HbA1c) are analyzed in detail to detect hidden diabetes, along with the lipid (cholesterol) profile, which is the mirror of vascular health.

If the blood tests are normal and the problem is suspected to be due to a fault in the vessels, we resort to Penile Color Doppler Ultrasonography (RDUS), which we accept as the “gold standard” in diagnosis. This is an extremely detailed imaging method. During the procedure, a special drug that dilates the vessels is injected into the spongy tissue inside the penis with a needle as thin as a hair. Thanks to this drug, an artificial and full erection is created without needing stimulation from the brain. Then, with the ultrasound probe, the speed of the blood flow coming from the arteries (peak systolic velocity) and the amount of blood leaking back from the veins (end-diastolic velocity) are measured millimetrically. In this way, it is definitively diagnosed whether the problem is the inability of blood to come from the arteries, or the inability to keep the incoming blood inside (venous leak).

How do lifestyle changes and pills work in the treatment of erectile dysfunction?

At the core of all treatments lies correcting the general health of the body. An individual on the border of obesity losing weight, a smoker quitting this habit, and switching to a Mediterranean-type diet while doing regular cardio exercises make an incredible contribution to the repair of the damaged vascular inner surface. The effect of drugs used without making these lifestyle changes will always remain incomplete.

The first step of medical treatment is formed by oral PDE5 inhibitor group drugs, which created a revolution all over the world. These drugs do not increase sexual desire; their task is to temporarily stop the functioning of the enzyme that causes the blood filling the penis with stimulation to leak back. In other words, they prevent the lock system from opening, allowing the blood to remain inside longer and stronger.

The main active ingredients used are as follows:

• Sildenafil
• Vardenafil
• Tadalafil
• Avanafil

Each of these active ingredients has a different duration of stay in the body and speed of absorption into the bloodstream. Sildenafil and Vardenafil are short-acting, are taken about an hour before intercourse, and their absorption decreases significantly when taken with fatty meals. Tadalafil, on the other hand, is much longer acting, can remain active in the body for up to 36 hours, and is not affected by food. Avanafil is the fastest-acting molecule. The most important rule of these pills is this: People who use drugs containing “nitrates” (especially sublingual drugs) for heart disease are absolutely contraindicated, in other words forbidden, from taking these pills, because they may cause life-threatening low blood pressure.

In recent years, the strategy of using these drugs not only when needed but also regularly in low doses (for example daily 5 mg) has also produced quite successful results. This method constantly nourishes the smooth muscles in the penis, keeps the vessels open, and creates an environment of permanent healing, almost by applying physical therapy to the tissues.

Which new methods come into play in cases of erectile dysfunction where pill treatment does not work?

In cases where pills are insufficient, cannot be used due to their side effects, or the patient does not want to live his sexual life in a planned way (according to pill timing), we move on to second-step treatment methods offered by medical technology. Our aim is not only to save the day, but to renew the tissue at the cellular level.

Low-Intensity Shock Wave Therapy (ED-SWT) comes at the forefront of these innovative methods. It is a version of the sound waves used to break kidney stones with their power greatly reduced. These sound waves applied externally to different points of the penis create intentional micro-traumas in the tissue. Our body sends growth factors intensely to that region to heal these tiny traumas, and brand new, healthy capillary networks begin to form there. It is a painless procedure and offers the chance of permanent healing.

Another natural method is PRP (Platelet-Rich Plasma) application. A tube of blood taken from the patient’s own arm is separated in special devices to obtain a serum very rich in healing cells (platelets). This serum is injected back into the penile tissue with fine-tipped needles. This method, which maximizes the tissue’s own capacity to repair itself, gives very pleasing results in vascular problems especially when combined with shock wave therapy.

If no response is obtained despite all these regenerative methods, Intracavernosal Injection treatment is applied. The patient is taught how to inject a special vasodilator drug into the shaft of the penis with a syringe as fine as an insulin needle immediately before sexual intercourse. The greatest advantage of this method is that the drug is delivered directly to the target organ without passing through the stomach and liver, making its effect very strong and certain.

What is the happiness stick surgery, which is a permanent solution for erectile dysfunction, and to whom is it applied?

In patients where all medical treatments, pills, shock waves, or injections have been exhausted and no response has been obtained from any of them, the final and most definitive solution is surgical intervention. Especially in those who have had uncontrolled diabetes for many years, in people who have undergone severe pelvic surgeries such as for prostate cancer and whose nerves are completely damaged, or in men whose vascular structure is irreversibly deteriorated, Penile Prosthesis, popularly known as the “Happiness Stick” surgery, is the only and definitive remedy.

In this procedure, the completely nonfunctional spongy tissue inside the penis is removed and synthetic cylinders sized according to the patient’s anatomy are placed in its place. These prostheses are never visible from the outside and do not cause any harm to the man’s functions such as urination or ejaculation (orgasm).

The types of prostheses used are basically as follows:

• One-piece prostheses
• Three-piece prostheses

The one-piece ones are bendable in structure; they remain at a certain rigidity at all times but can be directed by hand and concealed inside clothing. They are very easy to use and have no risk of mechanical failure. The three-piece ones, on the other hand, are the closest and most perfect systems to natural anatomy. They consist of cylinders placed inside the penis, a small control pump hidden in the scrotum, and a fluid reservoir placed under the abdominal membrane. When the person wants intercourse, he squeezes the pump in the scrotum a few times to fill the penis with fluid and start the erection. When the act is over, he presses the deflation button on the pump to send the fluid back to the reservoir, and the penis returns to its completely natural, soft state. With the development of surgical techniques and the production of antibiotic-coated prostheses that prevent infection, the success and satisfaction rates of these operations today have risen above 95%.

How is erectile dysfunction due to venous leak treated?

Venous leak is the condition in which, although there is no problem with the penis filling with blood, the valves (lock system) that are supposed to keep this blood inside cannot fully close. The incoming blood quickly leaks back through the veins, resulting in the erection fading before it can fully begin or right at the start of intercourse. In the past, surgeries were performed to tie off the leaking veins to correct this condition, but since it was seen that the body immediately created new vessels and continued the leak, these surgeries have been largely abandoned today. In the modern approach, low-intensity shock wave therapy (ESWT) and stem cell or PRP injections are first used in combination to increase the elasticity of the tissue and strengthen the lock system at the cellular level. If the damage in the connective tissue is too severe to be repaired with these treatments, penile prosthesis (happiness stick) surgery, which mechanically assumes the role of trapping the blood, is the definitive solution that completely frees the patient from this problem.