ED – Erectile Dysfunction

You need emotional input, normal nerves and blood flow to the penis, and testosterone to achieve an erection. One or more of these functions are disturbed with aging. The most common reason for ED is impaired blood flow. You have doubtless heard of the use of coronary stents or coronary bypass for clogged arteries to the heart. The penile arteries are even smaller than the coronary arteries, so it comes as no surprise that ED is related to atherosclerosis (hardening of the arteries), high blood pressure, and high cholesterol.

Some other causes include:

• Diabetes is a very common cause of ED because it will affect both the nerves and the blood flow to the penis.
• Neurological problems such as stroke, Parkinson’s disease, multiple sclerosis and spinal cord trauma may cause ED.
• If the blood trapped in the penis during an erection leaks out too quickly, this is called “Venous leak” or cavernosal dysfunction.
• Genital or pelvic trauma, including the trauma of surgery (radical prostatectomy or extensive rectal surgery for cancer) can affect blood flow and nerves to the penis and lead to ED.
• Low testosterone can contribute to ED.
• Peyronie’s disease – calcific plaque in the penis that prevents symmetrical filling of the penis with blood during arousal. This condition can cause either penile curvature with erection, an hourglass deformity of the penis during erection or very weak erections.
• Other sources of ED include anxiety, abuse of alcohol or narcotics, smoking, and certain medications (for high blood pressure, depression, antihistamines, ulcer medications).

A good history and physical examination is essential for diagnosing ED, with particular attention to blood pressure, signs of blood flow problems to other areas of the body, signs of low testosterone (small testicles, breast enlargement) or presence of hard plaques in the penis.

If not already done by your primary care doctor, we may order blood tests, including a lipid panel, a fasting blood sugar or Hemoglobin A1c (tests for Diabetes), a testosterone level.

Additional tests may be selectively ordered depending upon your circumstance. Occasionally, we do vascular studies of the penile arteries or veins; but in most cases, poor arterial inflow or venous leak problems cannot be corrected with vascular surgery.

If it appears that anxiety, stress, depression, emotional problem, or marital problems are related, we may ask for the help of a sexual counselor, psychologist or psychiatrist.

ED can be an early sign of generalized blood flow problems, so we may ask your primary care doctor or cardiologist to consider cardiac stress testing.

We would suggest starting with some behavioral changes – things like stopping smoking or drinking a lot of alcohol, losing weight, exercising, and eating a healthier. You may need to confer with your primary care doctor or other specialist if we feel that medications may need to be stopped or changed because they cause ED. You may also need to see a sexual counselor if there are marital problems or emotional issues that affect sexual function.

Medication – Oral Viagra (generic is Sildenafil), Cialis (generic is Tadalafil), and Levitra (generic is Vardenafil) are popular examples of drugs called phosphodiesterase inhibitors. These drugs increase blood flow to the penis during sexual stimulation. If the ED is not severe, these drugs often work well. Occasional side effects include headache, facial flushing, nasal congestion, but rarely cause visual disturbance. You urologist can review the differences between these drugs. You should not use these drugs if you have a history of angina (chest pain with exercise) and/or use nitrates (drugs related to nitroglycerin).

Testosterone replacement is an option for men with low levels. Testosterone will improve libido (sex drive) but it may not fully correct ED if there is poor blood flow. Often we need to use additional medication like the ones listed above.

Vacuum erection device – This is a kit that you can purchase that includes a plastic tube placed over the penis. A hand held pump is applied that creates a vacuum in the tube. This will cause blood to enter the penis. An elastic band is placed at the base of the penis to maintain the erection, then the tube is removed to permit sexual activity. Some men don’t like the “interruption” needed to apply the tube and get ready. Some men find the devices too hard to operate, but they are very safe and reuseable.

Intraurethral suppositories – We teach you how to place a small applicator into the opening of the penis that delivers a tiny pellet of drug (Prostaglandin). The drug causes increased blood flow to the penis. You get an erection within 10-20 minutes. Some men are unwilling to use it complain of urethral burning or penile aching. The urethral suppositories can be expensive.

Intracorporeal injections – We can teach you how to inject a medication into the side of the penis (Prostaglandin, sometimes mixed with Papaverine and Phentolamine). The drug will cause increased blood flow to the penis within 10 minutes. The dose of drug is adjusted so that the erection will not last too long. The needle is very small, so the injection is not very painful. Rarely the injection can cause a prolonged erection that becomes painful, and may require an urgent visit to your urologist or the emergency room.

Penile Prosthetic Surgery – We usually reserve penile implants for cases that don’t respond to other measures or men who do not wish to pursue those other measures. The penile implant is a great choice, but you cannot return to the use of a vacuum pump or penile injections once you have had this surgery.

The penis has two side by side corporal bodies into which we can implant a malleable penile prosthesis or an inflatable penile prosthesis. In the case of a malleable implant, there are two plastic cylinders with a steel core down the middle of each cylinder. Once implanted, the penis has fixed length and girth, but it can be concealed by bending both cylinders down. When you want to have sex, you simply bend both cylinders up. The inflatable implant uses cylinders that fill with water when activated by a pump placed in the scrotum. After you have sex, the cylinders can be emptied into a reservoir placed under the belly muscle. The inflatable implant is sometimes called a “three piece implant” because there are cylinders, a pump, and a reservoir.

The inflatable implant looks more natural than a malleable device. The inflatable cylinders are flaccid when it is not being used. The inflatable cylinders get a little larger than the malleable device when it is activated. The inflatable device has more working components, so there is more possibility for mechanical malfunction and re-operative surgery. Another risk of any type of prosthetic surgery is infection. This may require removal and replacement of the device.

Penile prosthetic devices provide total spontaneity when you desire sexual activity. Unlike any other treatment listed, there is no waiting to get ready!

Injection of a penile plaque /Removal of the plaque with grafting/Plication of the penis – these are procedures offered specifically for Peyronie’s disease with bothersome penile curvature. Severe cases of Peyronie’s disease may require placement of an inflatable penile prosthesis.

Cialis
A phosphodiesterase inhibitor that improves blood flow to the penis during stimulation. It can be taken with or without food. It can be taken on demand (only when you plan to have sex) or it can be taken on a daily basis at a lower dosage. Daily dosing of Cialis may also help urinary symptoms caused by an enlarged prostate.

Erectile dysfunction
Inability to achieve and/or sustain an erection sufficient for sex.

Intracorporeal injections
A needle is placed into the side of penis to inject a drug that causes increased blood flow and induces an erection.

Intraurethral suppository
An applicator is placed into the urethra, then a pellet of Prostaglandin is released and dissolves in the urethra to produce and erection.

Levitra
A phosphodiesterase inhibitor, a drug that increases blood flow to the penis when stimulated. It must be taken on an empty stomach for better absorption. It may cause headache or facial flushing. It is an “on demand” drug – you take it only when you want to have sex.

Peyronie’s disease
Not so much a disease as it is a condition in which a calcific plaque builds up in the penile corporal bodies. The plaque prevents full expansion of the penis when achieving an erection. There may be curvature to the erection or very weak erections from restricted blood flow.

Penile prosthesis or implant
A device that allows for a hard erection – two cylinders are placed into the two penile corporal bodies. Implants may be malleable (they simply bend down or up) or inflatable (cylinders fill with water when activated, but they can be emptied when not in use).

Venous leak
Blood can enter the penis, but the blood is not trapped in the penis long enough to sustain an erection because the penile veins are leaky.

Viagra
A phosphodiesterase inhibitor, a drug that increases blood flow to the penis when stimulated. It must be taken on an empty stomach for better absorption. It may cause headache or facial flushing. It is an “on demand” drug – you take it only when you want to have sex.

I ejaculate within minutes of having intercourse. I have no interest in having sex. I cannot reach orgasm. Is this ED?
No! These problems are not ED and they are not treated in the same way. You could be experiencing one of the following:

• Premature ejaculation – reaching a climax sooner than desired – this leads to detumescence (erection goes away), but it is not erectile dysfunction. The treatment could involve sexual therapy, possibly the use of drugs that will slow down the time when you ejaculate.
• Loss of libido or sex drive – sometimes seen with erectile dysfunction, but not the same. We would check your testosterone and perhaps other hormone levels. We would also explore whether there are psychosocial issues that might be related.
• Anorgasmia – inability to reach orgasm – can be caused by medical problems, pelvic surgery, genital trauma, psychological issues – but it is not ED.

If I keep my diabetes in the best control possible, will my ED go away?
Probably not, since the ED is probably related to neurovascular disease already caused by the diabetes. Nevertheless, it’s important to manage your diabetes carefully to prevent other serious vascular events like a stroke or heart attack.

I get a headache when I use Viagra or Levitra or Cialis. What can I do about it?
If the headache is mild, ignore it. If it is annoying, take Tylenol when you take the drug for ED to pre-treat for possible headache.

I get a good erection if I inject my penis with Papaverine (common trade names, EDEX or Caverject). So can I give myself a big dose to last even longer?
Your urologist will help you find the dose that gives you an erection that lasts 30-60 minutes. Injecting even more drug may cause a prolonged erection that will become painful. If the erection does not come down, you will have to see your urologist or an emergency room doctor to have another penile injection of saline or phenylephrine, a drug that reverses the one that caused the erection. Prolonged erections lead to scarring within the penis. Future efforts to inject the penis may be less effective.

Is sensation and ejaculation the same when I have a penile implant placed?
Yes – the surgery does not affect nerves that go to the penis, so penile sensation and ejaculation are unchanged. Men who have had prostate surgery have either limited or no ejaculation, but this is not improved or made worse by placing a penile implant.

I had a penile implant and my erection is not as large as I am used to! Is this expected?
Your urologist should tell you that a penile implant provides rigidity to the shaft of the penis, but the head of the penis remain soft even when you are using the penile prosthesis to have sex. The erection won’t be as large as you had at age 18, but the erection is quite serviceable!

If I don’t like my penile prosthesis, can I go back to the other therapies?
Not easily. Applying a vacuum pump or doing penile injections may damage the cylinders or cause an infection. If the cylinders are removed, there may be scarring that prevents the other therapies from improving any blood flow to the penis. It’s best to try any of the other therapies before choosing to have surgery to place a penile prosthesis.