How to understand the erectile function? How to define erectile dysfunction? In general, erectile function is evaluated by the quality of penile erection. If penis shows good erection, we think erectile function is normal. Otherwise, erectile dysfunction occurs. This concept is reflected in the definition of erectile dysfunction (ED). ED is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance1,2. It can occur due to both physiological and psychological reasons.
Accordingly, first of all, we need to know what the erection is. The erection of the penis is its enlarged and firm state. It depends on a complex interaction of psychological, neural, vascular and endocrine factors3-6. Penis erection usually results from exposure to sexual stimulation from sexual arousal, but can also occur by such causes as a full urinary bladder or spontaneously during the course of a day or at night, often during REM sleep (Nocturnal Penile Tumescence). In the presence of mechanical stimulation, erection is initiated. The arteries dilate, filling the corpora spongiosum and cavernosa with blood. An erection results in swelling, hardening and enlargement of the penis3-6.
Erection enables sexual intercourse and other sexual activities (sexual functions), though it is not essential for all sexual activities. An erection may also occur once woken up, called nocturnal penile tumescence. The scrotum may also become tightened during an erection3-6. Then we went back to the definition of erectile dysfunction. ED is defined as the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. From the definition of erection and erection dysfunction, it is comprehensible that if penis shows good enlarged and firm state, we think erectile function is normal. Otherwise, erectile dysfunction occurs. Therefore, the penile erection is mostly related to the enlarged and hardness of penile erection. If the enlarged and hardness of penile is sufficient to complete a satisfactory sexual intercourse, we could consider the erectile function is normal. Conversely, if the enlarged and hardness of penile is not enough, erectile dysfunction is indicated. This is especially appeared in the forensic identification.
Forensic identification of erection function is based on the general principle and practice of clinical diagnosis but has more stringent requirements. Because the diagnosis can significantly affect legal outcomes, objective evidence is extremely important. Currently, both the clinical and forensic workups focus on the hardness of the penis. As a consequence, the results of the Nocturnal Penile Tumescence (NPT) test, which has been widely used to record the rigidity of erectile penis with the aim to distinguish psychogenic ED from organic etiology, are required in China to grade and diagnose ED in forensic identification, as specified in the “guidelines for male sexual dysfunction forensic identification (SF/ZJD0103002-2010).”
Also, the treatment methods of ED are mostly around improving the enlarged and firm state of penis, to permit satisfactory sexual performance. For instance, oral PDE5 inhibitors, vacuum erection devices, shockwave therapy, intracavernous injections and surgical implantation of a penile prosthesis, etc.
However, sometimes we meet the following kinds of patients in clinics.
Firstly, the morphology of penile erection is abnormal. Such as: 1) Phallocampsis. The morphology of penis is flexural after erection. (upward bending, down bending, left bending, right bending, S-shaped curve or rotating, et al.). 2) Micropenis. 3) Abnormal angle of erection. Such as acute erection angle7 and abnormal angle of erection due to injury-related penile deformities8, causing problems with intercourse. 4) Stiff penis. The length of penis can’t be changed during erection due to injury-related penile deformities8, et al.
Secondly, the stability of penile erection is abnormal. In some patients, proximal part of penis is much more slender than glans, like a spindle. Full erection could be achieved in these patients without any abnormalities indicated by Nocturnal Penile Tumescence (NPT) test, IntraCavernous Pressure (ICP) measurement and color duplex ultrasonography. But, the penis is very easy to swing during the sexual intercourse and the stability of penile erection is abnormal7, causing the couples could not achieve satisfactory sexual intercourse.
Although the hardness of penile erection in these two kinds of patients is normal, they could not achieve satisfactory sexual intercourse due to the abnormality of morphology or unsteadiness of penis erection. These patients are very distressed for these situations.
According to these, one question arises in our mind: How to understand the erectile function? Is it reasonable that the erectile function is simply assessed by the enlarged and hardness of penile erection? In our opinion, this traditional understanding related to erectile function has its limitations. The hardness, the morphology and the stability of penis can’t be isolated, and should be assessed as a whole, during evaluating erectile function.
Therefore, to perfectly evaluate erectile function, we suggest the following three levels should be considered: the hardness, the morphology and the stability of penile erection. Only if all of the three levels of penile erection are normal, we could consider the erectile function is satisfactory. Traditionally, the hardness abnormal of penile erection (erectile dysfunction), the morphology abnormal of penile erection (phallocampsis, micropenis, acute erection angle, et al.) and the stability abnormal of penile erection are three independent diseases in clinics. They may lead to the same outcome, which is unsatisfactory sexual intercourse. However, the traditional definition of ED excludes the latter two diseases, the abnormality of morphology and stability of penile erection.
Thus, we wonder whether it is feasible to apply a new concept of Erectile Abnormal Syndrome (EAS) in clinical practice. EAS refers to the persistent abnormalities in hardness, morphology and/or stability of penile erection which does not allow satisfactory sexual performance. It can be subdivided into three levels: 1) the hardness abnormal of penile erection (just as the traditional definition of erectile dysfunction); 2) the morphology abnormal of penile erection, and 3) the stability abnormal of penile erection. We believe the new concept of EAS might contribute to the integral and comprehensive understanding of normal and abnormal erectile function.
Taken together, we would like to present the definition of EAS in this paper based on our clinical and Forensic identification findings that some patients complain unsatisfactory sexual performance due to the abnormality of morphology or unsteadiness of penis erection. However, great challenges in quantitative methods are lack to evaluate the morphology and stability of penile erection, and also diagnostic criteria is absent to diagnose EAS. This requires further discussion and studies by experts in sexual medicine, andrologist and urologist in the future.
This work was supported by National Natural Sciences Foundation of China (No. 81370705, 81471450 and 81070487).
1. Lue TF, Giuliano F, et al. Summary of the recommendations on sexual dysfunctions in men. J Sex Med. 2004; 1(1):6-23.
2. Hatzimouratidis K, Amar E, et al. Guidelines on Male Sexual Dysfunction: Erectile Dysfunction and Premature Ejaculation. Eur Urol. 2010; 57(5): 804-14.
7. Nugteren HM, Pascal AL, Weijmar Schultz WC, van Driel MF. Surgery for an “acute erection angle,” when counseling fails. J Sex Med, 2010, 7(3):1311-1314.
8. Cai L, Jiang M, Wen Y, Peng C, Zhang B. Forensic identification for erectile dysfunction: experience of a single center. Urology, 2015, 86 (1): 68-71.
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