Denton Urology: ED

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ERECTILE DYSFUNCTION*

Erectile dysfunction (ED) is a common malady affecting men. It is more common as men age, but can be present even in young men. Causes of ED are listed below, but often no clear cause is identifiable. Fortunately there are fairly good treatment regimens for ED. Some information here is provided for your benefit.

*ED is NOT a particular focus for Dr. Casey, and most ED can now be treated by the primary care physician. Thanks for your understanding.

Some causes of ED:

Diabetes

Hypertension

Medications

Surgery

Vascular Disease

Hormonal Deficiency

Neurological Illness

Smoking

This list is certainly not all inclusive, but lists some of the more common problems men presenting with ED have. Occasionally ED is the initial complaint alerting the physician to a potential new medical problem. Therefore, it is imperative that certain tests be done to make sure a patient doesn't have diabetes or another condition.

Tests that are commonly done in men with ED include: History and physical exam (with directed neurologic exam, and check of femoral pulses), serum testosterone (male hormone), CBC (complete blood count), and serum chemistries.

There are many other tests to evaluate ED including nocturnal tumescence testing, doppler sonogram, penile plethysmography, cavernosometry, cavernosography, and others--I will not comment on these in particular, because in most cases these tests are (I believe) unneccessary as they will not likely change the treatment offered. Other websites on the internet may explain these procedures in more detail.

After an evaluation for and diagnosis of ED is made, it is appropriate to discuss treatments in a "goal-directed therapy" system. Treatments will be briefly discussed below. It is imperative to discuss the treatment options with your personal doctor to determine what is best for you. Active treatment may be recommended right away, or perhaps a trial of behavior alteration, or lifestyle changes (i.e. smoking cessation) will be recommended. Also, if you are on a medication highly suspected of causing ED, your doctor may elect to try you off these medications first.

Treatments for ED:

Vacuum devices

Injection therapy

MUSE

Prosthetics

Oral medications

Please click on a treatment option above to learn more.

Vacuum devices

Vacuum devices are cylindrical devices that fit over the penis and create a vacuum that draws blood into the penis, creating an erection. The erection is kept in place with a constriction ring, usually made of some sort of rubber or flexible plastic. Vacuum therapy has been around for a long time, and is probably one of the most cost effective methods of treating ED. You may find a few men on the alt.support.impotence newsgroup who use the VED with success. There have been very few side effects noted with vacuum device therapy. Several companies manufacture these devices, and Osbon Medical is an example of a very good company, but others make a fine product as well.

Intracavernosal Injection Therapy (ICI)

ICI involves injection of active medication or medications directly into the penile erectile tissues with a fine needle. This is a very popular way of treating ED, and many men swear by it. More recently there have been a couple of products called Caverject and Edex which have come onto the market to make ICI easier. These drugs are Alprostadil (a prostaglandin smooth muscle relaxant) in a powder form. The patient has to mix this powder with saline, and then inject at the time the erection is desired. This is considered an improvement over older medications since the older medications are mixed by the pharmacist and need to be refrigerated at all times--powder form Alprostadil can be kept at room temperature. Older mixes include a "tri-mix" or "bi-mix" which are mixtures of prostaglandin, phentolamine, and papaverine (bimix is usually the latter two only). These are still used with good success by many. Treatment dropout rates are fairly significant due possibly to side effects, needle fear, lack of spontaneity, or a combination of the above. Side effects with ICI include pain upon injection, scarring of the lining of the erectile bodies which could lead to curvature, escape of the drug into the systemic circulation causing heart problems or lowering of blood pressure, or priapism. Priapism is defined as a painful unrelenting erection lasting longer than 4-6 hours that can lead to permanent penile damage and the inability to have erections in the future. This complication is generally treated urgently by removing some penile blood with another needle and injecting vasoconstricting substances. Of course this should be only done by a physician. Sometimes oral medications are tried first, but in my experience are rarely successful.

MUSE

MUSE is a form of Alprostadil delivered via a urethral suppository. The theory is that the drug will dissolve into the urethral lining and diffuse into the erectile tissues and promote an erection. Initial enthusiasm with MUSE has waned as the success rate of patients has been poorer than expected. It is easy to administer, but poor results and a problem with penile and scrotal aching pain which occur in about 20-30% have blemished the reputation of this drug among ED patients. I think it is still worth a try in select individuals who desire to try it, but I question what role MUSE will have in ED treatment over the long-term. For an example of the response of patients to MUSE, one only needs to peruse the alt.support.impotence newsgroup archives.

Prosthetics

Penile prosthetic surgery has been around for a number of years. Although highly successful, it is quite invasive, and should not be considered first line therapy in my opinion. There are two general types of prostheses, inflatable, and malleable. The inflatable prosthesis (IPP) consists of cylinders that are surgically fitted into the corpora cavernosa of the penis. A hydraulic mechanism generally implanted into the scrotum, and attached to the cylinders by silicone tubing is activated to pump fluid from a reservoir (implanted in the space in front of the bladder) into the cylinders causing an erection. After intercourse, the cylinders are deflated by pushing a button on the scrotal pump and squeezing the fluid from the cylinders back into the reservoir. Prosthetic surgery should usually be considered a last resort, as other less invasive therapies cannot be used once the prosthetic cylinders are implanted into the penis. This is due to the destruction of the smooth muscle in the corpora that is necessarily done to create a space for the cylinders. The other prosthesis mentioned is the malleable penile prosthesis (MPP). This means there is no hydraulic system, and only malleable, or bendable rods implanted into the corpora. Essentially there is "always" an erection, but the device has a "joint" allowing concealment of the erect penis when not in use. The problems with prosthetics are mechanical malfunction (more common with the IPP), infection of the foreign material, and erosion of the cylinders into the urethra. The latter two complications can be quite devastating, and once the cylinders are removed, scarring can occur within the corpora creating a very difficult situation where replacement of a new prosthesis is difficult or impossible. As mentioned, other therapies are not likely to be successful after prosthesis placement and removal. (*It should be noted that some reports of fairly good function with a vacuum device in this situation HAVE been reported.) In summary, this therapy is effective, but not nearly as popular as some of the other therapies.

Oral Medications

Viagra is an oral medication (released March, 1998) that is approved for oral treatment for ED. The success of this drug has been astounding. The company reports an overall "success" rate of 70% across the board. The results are not as great for men with diabetes (50-60%), or for men suffering ED secondary to radical prostatectomy (40-50%). The drug is administered as a tablet 1-4 hours before anticipated intercourse. It requires stimulation by the patient or from a partner to elicit an erection. It has been touted as a more "natural" erection in this regard. Currently the drug is available in 3 doses: 25mg, 50mg, and 100mg. Side effects reported are headache, facial flushing, and visual changes among others more uncommonly reported (see prescribing information for Viagra for further information.) Cost is an issue as the drug averages a retail price of $10, but this compares favorably with the approximately $20 per dose for Caverject or MUSE. The drug has revolutionized ED treatment. The alt.support.impotence newsgroup has many stories floating around about Viagra, and you should have no difficulty learning more about the medication on that newsgroup.
Newer additions Levitra and Cialis (2/04) are now available. Levitra has no clearly superior characteristics, and possibly a few more side effects or potential cautions (i.e. with alpha blockers) and Cialis may be beneficial as its longer half-life causes it to be effective for a longer period of time (~36 hours) making it a good choice for 'weekends'. Both Levitra & Cialis are 5 PDE inhibitors (like Viagra) and have a somewhat similar side effect profile.

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