Overview:

We, as a culture, are becoming more comfortable addressing issues of sexual health. Erectile dysfunction is becoming increasingly more common, partially because men are willing to talk about it, but also because of the increased incidence of confounding factors such as obesity, diabetes, and hypertension. Until the last two decades it was felt that erectile dysfunction was of psychological origin, but in reality, this explanation probably accounts for less than 10% of the incidence. Modern data suggests that the rate of ED, moderate or severe, is as high as 50% for men over age of 50.

Causes of Erectile Dysfunction:

Erectile dysfunction is usually related to vascular problems in the penis. The mechanism that allows you to get an erection is a complex balance between an increased blood flow to the penis and a decrease in the blood that is leaving the penis. The blood is filling a pair of chambers called corpra cavernosa (erectile bodies), and when these chambers are engorged, there will be a successful erection. There have been several large male aging studies which have identified diabetes mellitius, heart disease, and hypertension as independent risk factors for the development of ED. Additional causes of ED can be related to hormone imbalance, trauma, neurologic conditions, or it can be drug induced.

Treatment Options:

It was in the late 90’s, with the introduction of Viagra and a new class of medications called PDE-5 inhibitors (phosphodiesterase Type-5 inhibitors), that the topic of ED became mainstream. Prior to this time, we had medications and surgery to help men achieve an erection, but the ease of these meds revolutionized the treatment protocol for ED. The PDE-5 inhibitors work by improving the ability of the penile arteries to dilate and increase blood flow to the penis as well as the chambers responsible for erections.

There are additional forms of treatment which include; vacuum assist device, urethral suppository, penile injection therapy, hormone replacement (if low), and penile prosthesis.

The vacuum assist device works by pulling the blood into the penis via a pump that creates suction to pull blood into the penis. There is then a ring type device which is placed at the base of the penis to prevent the blood from leaving the penis. This creates an artificial erection, but the device should not be left in place longer than 30 minutes. The benefit, is that it relatively easy to use, but there are some unwanted side-effects and serious complications that can occur if misused. Complications include a cold and dusky appearance to the penis and the ring can trap ejaculation. Additionally, people who are on blood thinners have to be really carful or they risk bruising. In short, there can be a role for this device, but it important to be under the care of a urologist who can guide you in its proper use.

Urethral suppository is a medicine delivery system which allows the medication to be placed directly into the urethra and absorbed into the tissue directly. The medication typically used is alprostadil which will act as a vasodilator to allow more blood into the penis. As the blood flow increases an erection occurs. The main side effect is penile pain and some urethral burning.

Penile injections consist of a small needle being placed into the side of the penis. There are multiple formulations of medications that are used for injection, and your urologist will determine which one to use. The injection is done in the office for the first time and typically a penile doppler is done at the same time to detect efficacy and document change in vasculature. After the injection, you will need to massage the medication into the penis to generate the full effect. The two most serious side effects are fibrosis and priapism. There tends to be a higher dropout rate for this treatment than other forms of therapy.

Penile prosthesis is the last line of therapy for erectile dysfunction. This is typically reserved for patients who have failed all other therapeutic modalities. The implantation of a prosthesis is a surgical procedure done on an out-patient basis which takes about 1-2hours and will require several days to recover. The patient be unable to have sexual activity until he has fully healed. There are several different implants, but the two basic types are the inflatable and the malleable prosthesis. The inflatable prosthesis allows you to pump fluid into the cylinders to create an erection whenever you want, and then release the fluid when it is no longer needed. The malleable prosthesis is always firm and needs to be bent into the proper position to have sexual intercourse. The satisfaction rate for this procedure is quite high nationally for both the patient and the partner. The most significant complication is an infection of the prosthesis, which would require removal of the prosthesis. The patient will usually take antibiotics for several days after the procedure to help to reduce the risk of infection.

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