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
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
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.
- Increasing age
- All of these are associated with
narrowing or "plugging
the arteries throughout the body, so that blood can no longer enter the
penis as it once could. Some blood pressure medications and many other
medications can also cause decreased blood flow to the penis and erectile
Other potential causes of erectile dysfunction
- Hormonal abnormalities, most often low serum testosterone
- Drug use
- 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
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):
chemistries, including a fasting blood glucose level
- Thyroid function tests
- Either a total blood testosterone level, free testosterone
level, or both.
- If either testosterone level is low,
then other hormonal tests would be done to ensure there
is not an abnormality in the secretions of hormones from
the pituitary gland that stimulate the testicles to make
Are there any imaging tests that should be done?
These are rarely done these days, as the treatment
algorithm is very simple.
- A penile
duplex doppler can show if there is constriction of the
main artery supplying blood to the penis.
- A cavernosagram can be done to see if a venous leak is causing the erectile
dysfunction. This is an invasive test that involves injecting the blood
vessels to the penis with intravenous contrast. This
is rarely, if ever, indicated.
- Cavernosograpy can also be
done to see if there is a venous leak. This also is rarely
How is erectile dysfunction treated?
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:
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
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
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.
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.
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.
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.
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.
Flexible Rod Implant
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.
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.
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.
There is also an excellent
resource about erectile dysfunction by the National
Kidney and Urologic Diseases Information Clearinghouse available by
Urologyhealth.org, a site created by the American Urological Association,
also has an excellent site on non-surgical treatment for erectile
also have another section on surgery for erectile dysfunction, most notably the
placement of a penile prosthesis, here.
2006 Napa Valley Urology Associates