Erectile Dysfunction

Problems getting erections are quite common and nothing to be ashamed of. It has been shown that 50 percent of all men aged 40-70 have at least some degree of erectile dysfunction. Erectile dysfunction is defined as the consistent inability to maintain an erection sufficient for sexual intercourse.

The degree of erectile dysfunction can vary from being able to get a full erection that lasts only a couple of minutes to not being able to get any erection at all. Any degree of erectile problems that prevents completing sexual intercourse to ejaculation is obviously a concern to both the man affected by it as well as his partner.

Being able to get an erection that is not as hard as it used to be but workable enough to have intercourse and ejaculate, while not fitting the definition of erectile dysfunction, can also be disturbing. We commonly refer to this as erectile problems. There are multiple potential causes of both erectile dysfunction and erectile problems. There are also a multitude of treatment options available to treat these conditions.

How do erections work?

When a male is sexually aroused, nerves to the penis cause a series of chemical changes that ultimately lead to dilation (widening) of the arteries (blood vessels) supplying it. As these vessels dilate, more blood is able to enter the penis. This causes the penis to elongate and harden as it becomes engorged with blood. As the penis becomes erect, the veins that drain the blood out of the penis are compressed. The end result is more blood is entering the penis than is leaving it, thus it becomes erect.

Once ejaculation takes place, the arteries to the penis become less dilated. This leads to a decrease in the amount of blood entering the penis. The penis then becomes less erect, the veins that drain the blood are no longer compressed, more blood leaves the penis than enters it, and it becomes flaccid.

What are the causes of erectile dysfunction?

Anything that affects the arteries to the penis can cause difficulty with erections. The risk factors for coronary artery disease are also risk factors for erectile dysfunction. These include:

Depression
Hormonal abnormalities, most often low serum testosterone
Drug use
Hypothyroidism
Stress or anxiety
Spinal injury
Medications. The most common offenders are blood pressure medications, anti-depressants, heart condition medications, and cancer drugs.
Pelvic surgery.

What tests should be done if somebody has erectile dysfunction?

The basic tests urologists will look at when seeing somebody with erectile dysfunction include (most of these have already been done by a primary care doctor):

Are there any imaging tests that should be done?

How is erectile dysfunction treated?

Medications

The arrival of Viagra (sildenafil) in 1998 forever changed the treatment of erectile dysfunction. For the first time there was a pill that actually worked in helping millions of men getting return of their erections. This landmark medication is a phosphodiesterase type-5 inhibitor. The ultimate result of taking this pill is an increase in the amount of nitrous oxide in the blood vessels to the penis, causing an increase in blood flow to the penis and thus improved erections.

Levitra (vardenifil), another PDE-5 inhibitor, was made available in August 2003. This drug works in a similar fashion to Viagra. Cialis (Tadalafil), a third PDE-5 inhibitor, received FDA approval shortly after Levitra. Cialis aids erections the same way that Viagra and Levitra do. Cialis is more longer acting, however, in that it can help men get erections 36-48 hours after taking it.

All of these medications work by increasing blood flow to the penis once the man is aroused. The pill does not give one an automatic erection. They help the male attain a natural erection, that is one that comes about by arousal. Viagra and Levitra can be taken 30 minutes to four hours prior to intercourse. Cialis can be taken anytime during the day to help erections.

For more information on these medications one can refer to their respective websites:

MUSE

If oral medications do not work to get a full erection, then there are medications that can still work. One is a urethral suppository, wherein a medicated pellet can be placed in through the tip of the penis with the aid of a small applicator.

The most common urethral suppositories are known as MUSE®, which stands for "medicated urethral system for erection." The drug in MUSE is alprostadil. Directly inserted into the penis, the urethral suppositories are absorbed by the tissue and relax muscles in the penis. This allows blood flow to increase, creating an erection.

How to use urethral suppositories
Physicians will commonly have a patient try a suppository in the office to determine appropriate dosage. Before using urethral suppositories, the man urinates. This helps to insure the moist surfaces that help the medication to be absorbed. With a small applicator, the man inserts a pellet of medication into his urethra, the small hole on the tip of the penis. He then massages his penis for about a minute to help the pellet dissolve. To help speed absorption, he should also remain upright for several minutes. He may also place a small rubber band around the base of his penis before inserting the suppository. This can help hold the medication in his penis.

A man generally will get an erection within 10-15 minutes of application. The erection will last about 30-60 minutes. Urethral suppositories can be used twice in any 24-hour period. They should not be used a second time immediately following a first erection. Urethral suppositories are available only with a doctor's prescription.

Intracavernosal Injections

Prior to the FDA approval of Viagra, injection therapy was the most effective medical treatment available. Injection therapy works by injecting a type of medication through a very small hypodermic needle at the base of the penis five minutes before intercourse. The medication causes dilation of the blood vessels to the penis, increasing blood flow. Prior injections consisted of a mixture of papaverine and phentolamine.

Prostaglandin E-1 (Alprostadil - Caverject or Edex) has been the drug used for injections since 1995. Alprostadil is a naturally occurring substance in penile tissue. It can be self-injected safely at home with few side effects. A dull penile ache is experienced by 40 percent of patients using prostaglandin E-1. This is transient and well-tolerated in the majority of patients. Tests show that scarring from prostaglandin E-1 injections is minimal (5 percent of patients using it) and the satisfaction rate is high. Success is achieved about 75 percent of the time using this injection. This is currently the only FDA approved medication for penile injection.

Off-label use of Trimix (Papaverine, Phentolamine, and Alprostadil) is very successful and safe, and is currently the preferred penile injection method. The instance of long-term use, however, is poor; more than 50 percent of men stop using the injection method after two months and less than 30 percent use this technique for more than two years.

Vacuum Device

Another erectile aid is the vacuum device. This device consists of a cylinder that is placed around the penis which is attached to a pump. Once the pump is activated, the negative pressure (vacuum) in the cylinder pulls blood into the penis. Once the penis elongates and becomes erect,a rubber band is rolled off the base of the cylinder ontothe base of the penis, holding the blood in the penis.

The vacuum device does work well for some patients. Others are not satisfied with it as the erection does not stand as well as it does naturally or with other methods.

Osbon makes an vacuum device called the ErecAid, which works well for a number of patients.

Penile Implant

Another option for patients suffering with erectile dysfunction is the placement of an artificial penile implant, or penile prosthesis. In fact, this treatment has the highest patient satisfaction of any form of treatment, 90-98 percent!

These devices can be placed through a small, 3-4 cm incision in the scrotum and can be done on an out-patient basis or with an overnight stay in the hospital. The device is completely hidden and appears and functions the same as a natural full erection does.

There are two types of penile implants. One is the semi-rigid prosthesis and the other is an inflatable penile prosthesis. The semi-rigid prosthesis, shown belowconsists of two flexible cylinders that are placed into the two cavities of the penis that hold the blood in the penis for natural erections.

With this type of prosthesis, the penis is always elongated and stiff.& nbsp; When having intercourse, the device is bent upwards. When not in use, it is bent down so that it fits comfortably in one's shorts. Satisfaction with this type of prosthesis is 65-75 percent.

The inflatable penile prosthesis is a more sophisticated type of implant that involves two cylinders, a pump, and a reservoir, as shown in this diagram.

The reservoir sits next to the bladder and holds sterile fluid. This is attached by tubing to a pump, which sits in the lower scrotum, which then is attached by tubing to the two cylinders that are in the penis. While flaccid, most of the fluid is in the reservoir. When one wants an erection, all he does is squeeze the pump in the scrotum a few times and fluid goes into the two cylinders, giving a completely natural appearing erection! Again, all this is placed via a very small incision in the scrotum.

These devices are 97.5 percent reliable. In rare cases, some part of the device may malfunction or leak, causing it to no longer work. This can be easily fixed by finding the broken part and replacing it. Another risk is infection of the device, which currently occurs 2.5 to 5 percent of the time and is more common in diabetics. If this happens, then the whole device needs to be removed, antibiotic solutions are used to irrigate the area, and often times a new device can be placed in the same setting. There is also a risk that part of the device may migrate a little bit or erode through the skin or adjacent tissue. This is rare and most often involves removing the offending portion and replacing it either immediately or later.

Placement of these devices is covered by insurance in most cases.

Dr. Hendricks has placed a large number of these devices and has seen outstanding results with their use. He has used devices made by both Mentor and AMS.

If you would be interested in discussing any of these options for erectile dysfunction with Dr. Hendricks, give us a call at (707)224-7944.

There is also an excellent resource about erectile dysfunction by the National Kidney and Urologic Diseases Information Clearinghouse available by clicking here.

Urologyhealth.org, a site created by the American Urological Association, also has an excellent site on non-surgical treatment for erectile dysfunction here.

They also have another section on surgery for erectile dysfunction, most notably the placement of a penile prosthesis, here.