Erectile Dysfunction
 
  Alliance Urology Specialists’ team of doctors and nurses are experts in the management of erectile dysfunction (ED). We offer the most current treatments available for this disabling condition.

ED is a very common problem that can afflict men of all ages. The problem is more prevalent with age, and is usually secondary to underlying medical problems that impact blood vessel health. ED may be the earliest symptom of several common serious conditions like diabetes, hypertension, coronary artery disease, and peripheral vascular disease. Aggravating factors can include obesity, smoking, medications, and excessive alcohol consumption.

The majority of cases of erectile dysfunction are associated with vascular disease. The mechanism of an erection is similar to that of a hydraulic crane with blood being the hydraulic fluid. When sexual stimulation occurs, the brain sends signals through nerves to the erectile structures in the penis, the corpora cavernosa. The corpora cavernosa are cylinders with a tough outer shell and a spongy blood vessel filled core.  The signals from the nerves cause the walls of the blood vessels to relax. This relaxation allows blood to flow into the penis filling the erectile bodies creating an erection. As the erectile bodies fill, the veins that normally drain the penis are compressed, preventing outflow of the blood. This process allows the pressures in the penis to actually exceed the blood pressure creating a rigid erection.

Anything that interrupts this process of filling can prevent a normal erection. Many medical problems can constrict the blood vessels thereby reducing the flow to the erectile bodies preventing the erection from becoming full. This process is not all or nothing which is why men will have a gradual decline in their sexual function as opposed to a sudden loss of function. Most of the treatments that we use for erectile dysfunction are directed at the blood flow problem. While the majority of the blood flow problems are on the inflow side, some people have problems on the outflow side. If the veins aren’t compressed in a normal fashion, then just like a crane with a leaky hydraulic line, the penis won’t stay erect.

There can also be problems with nerve signals needed for an erection. The nerves can be damaged with prior surgery or radiation for prostate cancer, severe diabetes, and spinal cord problems. The nerves tell the muscles in the vessel walls to dilate, so if there is no dilation there is no inflow. Additionally, a lack of nerve signals to muscles causes the muscles in the blood vessel walls to atrophy and weaken.
 
Low testosterone can also contribute to erectile dysfunction. The male hormone testosterone is important for sexual interest and function. The oral medications for erections don’t work as well if there is a low testosterone. Psychological conditions can impact erectile function, but are a less common cause than once thought.  A variety of blood pressure and anti-depressant medications can contribute to erectile dysfunction as can alcohol intake.

The evaluation of erectile dysfunction begins with a trip to the doctor. Discussion of sexual function is uncomfortable for many men; even speaking with their doctor can be a barrier to treatment. ED is an extremely common problem that the urologists at Alliance Urology Specialists are best equipped to evaluate and treat. 

A thorough medical history and physical exam is the most important initial step in the evaluation of erectile dysfunction and can clarify the underlying causes in most cases without the need for additional expensive testing. There are validated questionnaires including the IIEF (International Index of Erectile Function) and ADAM (Androgen Deficiency in the Aging Male) surveys that are useful for assessing the severity of the condition and the possibility of a hormone deficiency. Blood work may be indicated to evaluate for diabetes, elevated cholesterol, or low testosterone levels. More invasive testing including penile blood flow studies with ultrasound or arteriography to look for damaged vessels can provide additional information, but rarely impact primary treatment decisions.

The treatment of erectile dysfunction was revolutionized with the introduction of Viagra. Prior to Viagra, the treatment options were more invasive and less acceptable to men with mild to moderate erectile dysfunction. Viagra, along with Levitra and Cialis, are a class of drugs known as phosphodiesterase 5 inhibitors. These drugs function by blocking the action of phosphodiesterase which is an enzyme that breaks down the natural blood vessel dilators in the penis. By blocking this enzyme, the blood vessel dilators that are released when nerves transmit the signal for an erection to occur are able to accumulate increasing penile blood vessel dilation and the quality of the erection.

Viagra, Levitra, and Cialis all work in a similar fashion and have similar success rates and side effects. The medications need to be taken 30 – 60 minutes prior to anticipated sexual activity. They will not produce an erection without some sexual stimulation.  The less severe the underlying erectile dysfunction, the more successful the drugs are at improving the erection, but it is worthwhile to try the medication as a first option in almost all cases. Viagra and Levitra will be effective for 4-8 hours and Cialis can remain effective for up to 36 hours. 
 
The side effects of the oral medications are primarily related to blood vessel and smooth muscle (the type of muscle found in blood vessel walls, the intestine, bladder, and prostate) dilation and can included nasal congestion, indigestion, facial flushing, head ache, and occasional dizziness. Other side effects can include visual color perception changes (worse with Viagra) and delayed back ache (most common with Cialis). While these medications are quite safe for the heart, they can be very dangerous for patients who take nitroglycerin for heart related chest pain or angina.  The combination of the two medications can cause a precipitous drop in blood pressure that can potentially be fatal. There are other rare complications such as Priapism which is a prolonged erection which if left untreated can result in damaging penile scarring. Visual loss or blindness from decreased blood supply to the retina which is the light detector in the eye is a very rare complication that may be related to the medication.
 
While there are potential side effects, the medications are quite safe under a doctor’s supervision and have allowed many men to return to a more normal sex life.  The medications are expensive at about $8-15 dollars a pill and are not always covered by insurance. Cialis has recently introduced a daily dose which is most appropriate for men who are more sexually active. The daily Cialis costs about $120-$150 a month.
 
If oral medications are not effective or there is a contraindication to their use, there are several other options available including vacuum erection devices, penile injection therapy, MUSE intraurethral pellets, and penile prostheses.

Vacuum erection device is a plastic cylinder with a vacuum pump that is either electric or manual. The cylinder is fitted with a constriction band and then lubricated.  The lubricated cylinder is placed over the penis and held firmly to create an air tight seal at the base of the penis. The pump is then activated to create a vacuum which causes the penis to fill with blood and become erect. Once the erection has been established, the constriction band is slipped down onto the base of the penis and the cylinder is removed. The erection can be maintained for about 30 minutes before the band should be removed.

The vacuum device can be very effective, but often takes practice to master. There are some drawbacks and risks with this technique. The erection will be hinged at the base since it stops at the constriction band. The ejaculation can be constricted and possibly uncomfortable from the band. The penis will also be cooler than normal since the blood is not actively circulating. It is possible to develop small bruises on the penis, and rarely there can be bleeding from the head of the penis if the vacuum is too strong. This treatment is not indicated for men who take blood thinners like coumadin.

Penile injection therapy can be a very effective therapy even for men who have failed oral agents. A blood vessel dilator (Prostaglandin E1, Papaverine, and Phentolamine are most commonly used either alone or in combination) is injected using a very fine needle into the erectile bodies in the penis. The direct injection of the medication is much more potent than the effect from the oral medications, but works in a similar fashion by allowing blood to flow into the vascular spaces in the erectile bodies. About 70% of men will have a response.

The injection is usually self-administered about 10-15 minutes prior to sexual activity, and we try to adjust the dose to provide a 30-45 minute erection. The technique is easily taught, but some men are unable to master it, and the drop out rate with injections is about 50%. The risks of the injection therapy include bruising at the injection site, rare infections, penile pain, penile scarring with prolonged use, rare systemic reactions and priapism, an erection lasting more than four hours. If priapism occurs, a medication needs to be injected to reverse the initial medication and should be administered as soon as possible to prevent scarring and penile damage. The cost of the medication is variable depending on the dose, the medication combination, and whether a generic or brand name preparation is used. The generic medications are prepared as a liquid and must be refrigerated. The brand form, Caverject, is a dry powder that is mixed with liquid when needed and doesn’t require refrigeration, but it is much more expensive.

MUSE therapy uses a pellet of Prostaglandin E1 that is placed with a special applicator into the end of the urethra which is the tube the urine passes through and the pellets are then absorbed. The urethral pellets are not as effective as direct injection therapy, but work in a similar fashion and can be useful for men who are not able to do the injections. The risks include penile pain, urethral irritation, priapism, and systemic reactions.

If none of the previously described options are effective or appealing, a penile prosthesis can be placed. While a prosthesis can be a primary treatment option, I prefer that patients try at least one of the non-surgical options first, and many insurance companies will require documentation of a non-surgical treatment before agreeing to cover the implant. There are two basic types of penile implants, semi-rigid and inflatable. The inflatable prosthesis can be self-contained or multicomponent. 

Semi-rigid prosthesis is the least expensive type and requires the least complicated surgical procedure. The device is usually composed of a soft metal core with a silicone shell and can be implanted through small penile incisions into the erectile bodies known as the corpora cavernosa. A tunnel is created in the spongy vascular tissue within the corpora cavernosa and the implant cylinders are placed into the space, one on each side. The incisions are closed over the implant. Once inside the penis the semi-rigid rods can be straightened when an erection is desired or bent to be concealed. The penis will remain firm at all times. The advantages of the semi-rigid prosthesis include the ease of placement and use, lower cost, and a lower risk of malfunction. The disadvantages include the persistently firm penis and a smaller, narrower erect penis when compared to an inflatable device.

Multicomponent inflatable prostheses are available as a “2 piece” which is composed of 2 cylinders and a pump, and as a “3 piece” which is composed of 2 cylinders, a fluid reservoir, and a pump. The inflatable cylinders are placed into the erectile bodies at the base of the penis, the pump is placed in a pouch created under the scrotal skin so that it can be activated easily, and the reservoir is placed under the abdominal wall muscles in the lower abdomen if a “3 piece” implant is chosen. The “2 piece” implant is usually placed through a scrotal incision, and the “3 piece” can be placed through a scrotal incision or an incision just above the base of the penis on the lower abdominal wall. The choice of incision is based on a patient’s anatomy and the surgeon’s preference.

The “3 piece” prosthesis is the most commonly chosen by our patients and provides potentially greater penile expansion than that of the “2 piece” device, but the insertion is more complicated, and there are more components that can potentially fail.  The “2 piece” device is a good option if there has been prior surgery in the pelvis that might make reservoir placement difficult. The current devices are reliable with up to 80% failure free rates out to 10 years. Satisfaction rates with inflatable penile prostheses are greater than 90%.

Implantation of a penile prosthesis is performed either as an outpatient or with an overnight stay in the hospital. Insurance coverage is variable. The risks of the procedures include bleeding, infection which can require removal of the device, but is unlikely to occur with the newest prosthesis which can have antibiotic coatings, injury to the urethra or bladder that might prevent implant placement and a small possibility of chronic pain. There are also risks associated with the anesthesia. The initial recovery takes about two weeks, but it is recommended that the implant not be used for sexual activity for at least six weeks to allow adequate time for healing.
       
Erectile dysfunction is a common problem that can have a serious negative impact on individuals and their relationships. At Alliance Urology Specialists, we can expertly diagnose and treat ED in the majority of men. Don’t let embarrassment stop you from getting the help you need. We want to hear about your problems with ED, so that we can help you overcome this debilitating condition. 



 
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