Erectile Dysfunction

This condition is one of the most common sexual problems for men and increases with age. It is estimated between 15 to 30 million American men suffer from ED, although not all men are equally distressed by the problem.

Today, there are several treatment options available to men suffering from this disorder. Lifestyle changes are the first line of treatment with weight loss, smoking cessation and exercise associated with improved erections. For most men, the initial medical treatment will be an oral medication such as Sildenafil citrate. If this treatment is unsuccessful, second-line treatment options are ordinarily considered. These include using a vacuum erection device, intra-urethral medication or penile injection therapy. If these second-line treatments fail or if the patient and his partner reject them, then the third-line treatment option, penile prosthesis implantation, is considered.

Risk Factors:

  • Age over 50
  • Diabetes
  • High blood pressure
  • High cholesterol
  • Smoking
  • Cardiovascular disease

These diseases over a period, can lead to a degeneration of the penile blood vessels, leading to restriction of blood flow through the arteries and to erectile tissue damage, which allows leakage of blood through the veins during erection.

Causes:

ED can result from medical, physical or psychological factors. ED may be caused by a combination of factors that could also include medicine, alcohol or drugs. The physical and medical causes of ED include three basic problems:

  • Not enough blood flows into the penis. Many conditions can reduce blood flow into the penis, examples include heart disease, diabetes and smoking
  • The penis cannot store blood during an erection. A man with this problem, called venous leak or cavernosal dysfunction, cannot maintain an erection because blood does not remain trapped in the penis. This condition can occur to any man regardless of age.
  • Nerve signals from the brain or spinal cord do not reach the penis.

Certain diseases, injury or surgery in the pelvic area can damage nerves in the penis. Sexual activity requires the mind and body to work together. Psychological, emotional or relationship problems can cause or worsen ED; and include but are not limited to:

  • Depression
  • Relationship conflicts
  • Stress at home or work
  • Anxiety about sexual performance

Many prescription and over-the-counter medications may have sides effect often causing erection difficulties. Drugs such as marijuana, heroin, cocaine and alcohol can lead to sexual problems.

If your ED is due to a hormonal problem, such as low testosterone or diabetes, you may be referred to an endocrinologist. Your healthcare provider may also refer you to a mental health professional. These specialists treat psychological or emotional causes of ED. Even if your ED is not caused by these factors, it may contribute to them. It may be helpful to get counseling, alone or with your partner, in addition to getting medical therapy for ED.

Diagnoses:

ED is diagnosed by an urologist or another medical professional and for most patients; the diagnosis will require a simple medical history, physical examination and a few routine blood tests.

Medical History: exam requires health care providers to ask about you, and your ED experience. The doctor will also want to know if you have any other conditions that might affect your ED, such an any endocrine problems or depression. They may ask questions about your sexual history and performance, which may be very personal but necessary to understand the root cause of the problem. The important thing to remember is not to be embarrassed while speaking with your physician and to be very open to allow for the best treatment options for you. Other questions the physician is likely to ask are the following:

  • Your current sexual function
  • When you started noticing changes
  • Any past medical or sexual problems
  • Surgery or injury to the pelvic area
  • Current and past medication usage
  • Lifestyle and personal habits (i.e. smoking, drinking, use of illicit drugs, etc.)
  • Relationship with current and past partners

Physical Examinations means the doctor will check your overall health and physical condition. They will look for signs of problems with your circulatory, nervous and endocrine system. This includes checking your blood pressure, penis and testicles and you may need to have a rectal exam to check the prostate. These tests are not painful and may provide valuable information about the cause of ED. Most patients do not require extensive testing before beginning treatment.

The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment like oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied, then further steps may be taken. In general, as more invasive treatment options are chosen, testing may become more complex.

Treatment:

Non-surgical Treatments: The first line of therapy for uncomplicated ED is use of oral medications known as phosphodiesterase-5 inhibitors (PDE-5):

  • Sildenafil citrate (Viagra®)
  • Vardenafil HCl (Levitra®)
  • Tadalafil (Cialis®)
  • Men with ED take these pills before beginning sexual activity and the drugs boost the natural signals that are generated during sex, thereby improving and prolonging the erection itself. The medication works by relaxing the muscle cells in the penis allowing for better blood flow and production of a rigid erection. These medications are often effective, and nearly 80% of men show improvement once they begin use. The drugs are effective regardless of race and age. Although studies have shown these medications can be used by heart patients, men taking nitrates should speak with their physician before use to understand the possible drug interactions or effects on their other health conditions.

    The side effects of PDE-5 inhibitors are mild and usually transient, decreasing in intensity with continued use. The most common side effects are headache, stuffy nose, flushing and muscle aches. In rare cases, sildenafil can cause temporary blue-green shading of vision. There is no long-term risk and decreases as the amount of the drug in the body decreases. It is important to follow the medications instructions in order to get the best results. Tests have shown 40 percent of men who do not respond to sildenafil will respond when they receive proper instruction on the medications use.

    For men who do not respond to oral medications another drug, alprostadil, is approved for use in men with ED. This drug comes in two forms: injections that the patient places directly into the side of the penis and an intraurethral suppository. Success rates in achieving a firm erection useful for sexual intercourse with self-injection can reach 85 percent. Modifying alprostadil to allow intraurethral delivery avoids the need for a shot, but reduces the likelihood of successful treatment. The most common adverse effects of alprostadil use are a burning sensation in the penis and a prolonged erection lasting over four hours, requiring medical intervention to reverse the erection.

    For men who cannot or do not wish to use drug therapy, an external vacuum device may be acceptable. This device combines a plastic cylinder or tube that slips over the penis, making a seal with the skin of the body. A pump on the opposite end of the cylinder creates a low-pressure vacuum around the erectile tissue, which results in an erection. To keep the erection once the plastic cylinder is removed a rubber constriction band goes around the base of the penis, which maintains the erection. With proper instruction, 75 percent of men can achieve a functional erection using a vacuum erection device.

    Some men who have severe penis tissue degeneration do not respond to any of the treatments listed above. While this is a small number of men, they usually have the most severe forms of ED. Patients most likely to fall into this group are men with advanced diabetes, men who suffered from ED before undergoing surgical or radiation treatment for prostate or bladder cancer and men with deformities of the penis called Peyronie’s disease. For these patients reconstructive prosthetic surgery (placement of a penile prosthesis or "implant") will create an erection, with patient satisfaction rates approaching 90 percent. Surgical prosthetic placement normally can be performed in an outpatient setting or with one night of hospital observation. Possible adverse effects include infection of the prosthesis or mechanical failure of the device.

    After Treatment: All of the treatments, with the exception of prosthetic reconstructive surgery, are temporary and meant for use on demand. The treatments compensate for but do not correct the underlying problem in the penis. It is important to follow-up with your doctor and report on the success of the therapy. If your goals are not reached, if your erection is not of sufficient quality or duration and you are still distressed, you should explore the alternatives with your doctor. Because the medications used are not correcting the problems leading to ED, your response over time may not be what it once was. If such should occur again, have a repeat discussion with your physician about the remaining treatment options

    Penile Prostheses: Penile prostheses are devices that are implanted completely within the body. They produce an erection-like state that enables the man who has one of these implants to have normal sexual intercourse. Neither the operation to implant a prosthesis nor the device itself will interfere with sensation, orgasm, ejaculation or urination. There are two erection chambers (corpora cavernosa) in the penis. All penile prostheses have a pair of cylinders that are implanted within both of these erection chambers.

    There are different types of penile prostheses:

    • The simplest penile prostheses consist simply of paired flexible cylinders that are usually made of medical-grade silicone, and produce a degree of permanent penile rigidity or firmness that enables the man to have sexual intercourse. These devices are either malleable or inflatable. A malleable cylinder prosthesis can be bent downward for urination or upward for intercourse. Inflatable penile prostheses are fluid-filled devices that can be inflated for erection. They are the most natural feeling of the penile implants, as they allow for control of rigidity and size.
    • The inflatable devices have fluid-filled cylinders that are implanted within the erection chambers. Tubing connects these cylinders to a pump that is implanted inside the scrotum, the sac that contains the testicles. In the simplest of these inflatable devices, the pump transfers a small amount of fluid into the cylinders for erection, which then transfers out of the cylinders when erection is no longer needed. These devices are often referred to as two-component penile prostheses. One component is the paired cylinders and the second component is the scrotal pump.
    • Three-component inflatable penile prostheses have paired cylinders, a scrotal pump and an abdominal fluid reservoir. With these three-component devices, a larger volume of fluid is pumped into the cylinders for erection and out of the cylinders when erection is no longer needed.

    Penile prostheses are usually implanted under anesthesia. Usually one small surgical cut is made either above the penis where it joins the abdomen or under the penis where it joins the scrotum. No tissue is removed, blood loss is small and blood transfusion is almost never required. A patient will typically spend one night in the hospital.

    Most men have pain after penile prosthesis implantation for about four weeks. Initially, oral narcotic pain medication is required and driving is prohibited. If men limit their physical activity while pain is present, it usually resolves sooner. Men can often be instructed in using the prosthesis for sexual activity one month after surgery, but if pain and tenderness are still present, this is sometimes delayed for another month.

    Vacuum erection devices: Vacuum erection devices have proven to be safe alternatives in producing rigidity of the penis by drawing blood into the organ with a pump and holding it with an "occluding band."

    Penile injection therapy: Penile injection therapy is a relatively quick and effective way to send vasoactive drugs directly into the corpora cavernosa where they expand the vessels, relax the tissue and increase blood flow for an erection.

    After surgery: Infection occurs in 1 to 3 percent of cases. This is a significant complication because in order to eliminate the infection, it is almost always necessary to remove the prosthesis. In 1 to 3 percent of cases, erosion occurs when some part of the prosthesis protrudes outside the body. Erosion often is associated with infection and removal of the device is frequently necessary.

    Mechanical failure is more likely to occur with inflatable than with a malleable or semi-rigid prostheses. The fluid present inside the inflatable prosthesis leaks into the body; however, these prostheses contain normal saline that is absorbed without harm. After mechanical failure, another operation for prosthesis replacement or repair is necessary if the man wants to remain sexually active. Today's three-component inflatable penile prostheses have about a 10 to 15 percent likelihood of failure in the first five years following their implantation.

    Citations:

    ED: Non-Surgical Management (Erectile Dysfunction. (2013, April). Retrieved October 7, 2013, from Urology Care Foundation website: http://www.urologyhealth.org/urology/index.cfm?article=60&display=1

    ED: Penile Prostheses (Erectile Dysfunction). (2013, July). Retrieved October 24, 2013, from Urology Care Foundation website: http://www.urologyhealth.org/urology/index.cfm?article=11&display=1

    Erectile Dysfunction (ED): Surgical Management. (2013, April). Retrieved October 24, 2013, from Urology Care Foundation website: http://www.urologyhealth.org/urology/index.cfm?article=28&display=1


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