The evaluation and treatment of erectile dysfunction (ED) differ from that of many medical conditions. An intimate dialogue between the patient and Dr. Shoengold must be established for accurate assessment of ED severity and successful therapy. It is best to include the patient’s partner in this discussion as education on the nuances of oral phosphodiesterase inhibitor therapy is important to maximize treatment success with this currently first-line therapy.
Dr. Shoengold is a trained and understanding physician who is willing to take the time to understand his patient’s problem, he will then identify which therapeutic option will ultimately be most appropriate and successful. Realistic expectations for the erectile response and patience are necessary to resume satisfactory sexual functioning. Relationship issues or partner resistance can contribute to a suboptimal erectile response to therapy, in which case the patient may benefit from sexual therapy referral.
Happily, there are enough options available that every man who wants to be sexually active can be, regardless of the cause of the problem. These include sexual counseling if no organic causes can be found for the dysfunction, oral medications, external vacuum devices, or some type of invasive therapy. One of the most difficult aspects of treatment is teaching men that sex entails more than simply achieving an erection.
An increasing array of medications is available to assist in the management of ED. New agents are still undergoing clinical testing, and more are in the early phases of development. For any medication to be effective, the physiologic components involved in the erectile process must be functional. Serious impairments render the medication either completely or partially ineffective.
In current practice, PDE5 inhibitors were the first effective oral treatment available and are the most commonly used treatment for ED. This class of drugs blocks the degradative action of cGMP-specific phosphodiesterase type 5 (PDE5) on cyclic GMP in the smooth muscle cells lining the blood vessels supplying the corpus cavernosum of the penis. PDE5 inhibitors such as sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) are clinically indicated for the treatment of erectile dysfunction. Sildenafil and tadalafil are also indicated for the treatment of pulmonary hypertension.
Men who present with diminished libido and ED may be found to have low serum testosterone levels (hypogonadism). Hormone replacement may benefit men with severe hypogonadism and may be useful as adjunctive therapy when other treatments are unsuccessful by themselves. Libido and an overall sense of well-being are likely to improve when serum testosterone levels are restored to the reference range.
An intracavernous (or intracavernosal) injection is an injection into the base of the penis. This injection site is often used to administer medications to check for or treat erectile dysfunction in adult men (in e.g.combined intracavernous injection and stimulation test). The more common medications administered in this manner include Caverject, Trimix (Prostaglandin, Papaverine, and Phentolamine), Bimix (Papaverine and Phentolamine), and Quadmix (Prostaglandin, Papaverine, Phentolamine, and either Atropine or Forskolin). These medications are all types of vasodilators and cause tumescence within 10-15 minutes. Common side effects include but are not limited to, priapism, bruising, fibrosis, Peyronie’s, and pain.
Intraurethral Suppository (MUSE)
Intraurethral alprostadil (Vivus’s MUSE) is an intraurethral medication (i.e., a drug that is injected into the urethra) that was approved by the FDA in June 1998. Alprostadil is a synthetic form of a normal body chemical, prostaglandin E1, that causes increased blood flow into the penis. As an oral therapy for ED, MUSE works differently than sildenafil (Viagra). That is, the prostaglandin in MUSE stimulates the production of a chemical called cAMP, which, like cGMP, can cause the relaxation of smooth muscle thus increasing blood flow to the penis.
MUSE is an on-demand medication, meaning that you must take it each time that you wish to achieve an erection. Once applied to the penis, the alprostadil is absorbed through the urethral tissue and travels via blood vessels into the corpora cavernosa (the erectile tissue of the penis). Once there, it will stimulate dilation of the arteries and provides for relaxation of the cavernosal smooth muscle within 10 to 20 minutes. The onset of a response to the MUSE is quick, usually occurring within 7 to 20 minutes after it is administered. The duration of the response varies with the dose and ranges from 60 to 80 minutes.
External Erection-Facilitating Devices
Men who have a vascular (venous) leak phenomenon may need a constriction device placed at the base of the penis to maintain their erection (see the image below). Such a device may be effective by itself or in combination with a PDE5 inhibitor. In selected cases, combination therapy with one of the PDE5 inhibitors plus an intraurethral or intracavernosal agent may be tried.
This is one of many types of constricting devices placed at the base of the penis to diminish venous outflow and improve the quality and duration of the erection. This is particularly useful in men who have a venous leak and are only able to obtain partial erections that they are unable to maintain. These constricting devices may be used in conjunction with oral agents, injection therapy, and vacuum devices.
Vacuum devices for drawing blood into the penis are a relatively inexpensive method for producing an erection that has been used for many years. These devices are plastic cylinders that are placed over the penis. Air is pumped out, causing a partial vacuum. Releasing the vacuum after a few minutes and then reapplying the vacuum sometimes gives a better result. After an erection is obtained, a constricting band is placed at the base of the penis (see the images below).
Shockwave Therapy to Treat Erectile Dysfunction
A new way to manage erectile dysfunction is shockwave therapy. This new treatment is about regenerative medicine Shockwaves create microtrauma to the tissue stimulating the body’s natural healing response. As the body heals blood flow is increased and growth factors create new blood vessels to the treated areas.
This shockwave therapy is painlessly applied to the penis by an FDA approved machine called the PR OLYF I X. Shockwave therapy has not been cleared by the FDA for this use at this time. Emerging research suggests excellent outcomes with little or no side effects and long-lasting results.
Prior to the introduction of shockwave therapy, all existing treatment options for erectile dysfunction have been palliative in nature. This means that instead of correcting the underlying problem existing treatments only treat symptoms on an episodic basis.
This also has been used in combination with the injection of PRP – platelet-rich plasma into the penis. PRP contains a large number of growth factors. These growth factors stimulate healing and growth of new blood vessels.
Selected patients with ED are candidates for surgical treatment.
A small number of healthy young men have developed ED as a result of trauma to the pelvic arteries. Revascularization procedures such as rotating the epigastric artery (or even smaller vessels) into the corpora have been attempted. Long-term results have been marginal. AUA guidelines recommend arterial reconstructive surgery as a treatment option only in healthy patients who have recently acquired ED as the result of a focal arterial occlusion and who have no evidence of generalized vascular disease.
Surgical Elimination of Venous Outflow
On occasion, men who have difficulty maintaining erections as a result of venous leaks may benefit from undergoing a surgical procedure designed to eliminate much of the venous outflow. Although there was considerable initial enthusiasm for this and other surgical approaches was significant, this type of surgery has become rare because of a lack of long-term efficacy. AUA guidelines recommend against the use of such procedures.
Placement of Penile Implant
In the past, the placement of prosthetic devices within the corpora was the only effective therapy for men with organic ED. At present, however, it is the last option considered, even though more than 90% of men with an implant would recommend the procedure to their friends and relatives. Before selecting this form of management, the patient and his sexual partner should be counseled regarding the benefits and risks of this procedure.
Counseling and Psychological Care
Sexual counseling is the most important part of treatment for patients with sexual problems. Many professional sexual counselors are skilled in working with patients, but the primary care physician, the urologist, and the gynecologist also serve in this capacity to some degree. These are usually the first professionals to learn about the problem, and they often have to extract the information about the sexual problem from the patient.
Men are frequently reluctant to discuss their sexual problems and must be specifically asked. Opening a dialogue allows Dr. Shoengold to begin the investigation or to refer the patient to a consultant. Regardless of any subsequent therapy, the emotional aspects of the disorder must be addressed. Ideally, the patient’s partner should be involved in counseling, but even if this is not possible, the time spent may help resolve or at least clarify the problem and certainly helps determine which of the other options would be most beneficial and appropriate.
Regardless of the cause of ED, a psychological component is frequently associated with the disorder. The ability to achieve erection is intimately connected to a man’s self-esteem and sense of worth. Pure psychogenic ED is generally evident when a man reports that he has normal erections some of the time but is unable to achieve or to maintain a full erection at other times. Once the man has a doubt regarding sexual performance, he loses confidence; thus, future attempts to have sexual relations provoke anxiety.
In many instances, the couple must work together to resolve the problem, although in some cases, the relationship itself may be responsible for the problem. Referral to a sex therapist may be helpful.