Facts / Viagra / Penile Injections / Urethral Suppository / Vacuum Device / Penile Prothesis / Surgery

The process of erections is a complicated interaction between mind and body, but in general there are 5 problems areas.

1. Psychologic. In the past, many physicians and patients believed that most ED was psychologic in origin. Today, with better understanding and testing, we know the exact opposite is true.  Nevertheless some ED, especially in younger males, stems from relationship problems with their sexual partner, or from anxiety associated with other conditions such as premature ejaculation. These issues can be helped with therapy to reduce tension, improve communication, and create realistic expectations for sex.
2. Neurologic. A man must have an intact neurological system in order for an erection to occur. The nerves going to the penis coordinate the arterial inflow and venous outflow of blood. The most common reason to have neurogenic ED are diabetes, post-prostatectomy, Multiple sclerosis, or Stroke. Neurogenic ED, responds best to medical therapies because the nerve input can be easily circumvented. Additionally some medications (antihypertensives, antidepressants, and Acid blockers) have side effects affecting the nerve input for erections
3. Inflow (Arterial Blood). A man must be able to move blood into the penis in order to achieve an erection. Arteries are the vehicle which bring the blood into the penis. Any process which damages the arteries and increases the chances of vascular disease (i.e., heart attacks, strokes and peripheral vascular disease) would make a man more likely to have erectile dysfunction. In fact, erectile dysfunction will appear before any of these more severe manifestations of vessel disease. Smoking is one of the most common contributing causes to erectile dysfunction because it is known to promote disease in the arteries. Other causes include high blood pressure, especially if it uncontrolled, heart disease, high cholesterol and diabetes.
4. Outflow (Venous Drainage) I addition to getting the blood into the penis via arteries, the outflow from the penis (the venous system) must be controlled to maintain an adequate erection. This is normally accomplished by the venous outflow being compressed by the rush of blood into the penis. Venous Leak ED can be a problem for men with Peyronie's Disease which causes hard plaques form in the penis, or in men who have had prior surgery or trauma to the penis. The veins cannot be compressed adequately and the blood leaks out.
5. Hormonal. Significantly low testosterone, thyroid problems, or elevation of the hormone prolactin may cause problems with erections. It is not always necessary to check blood work for these hormonal problems as a good history and examination can usually rule them out. Alcohol and illicit drugs can also cause hormonal imbalance leading to ED.

Evaluation and Diagnosis : Includes screening for risk factors: Hypertension, Diabetes, High Cholesterol, Low sex drive (testosterone) and defining the probable etiologies (#1-5 above) of the ED to guide therapy.

Treatment Options

Viagra (Sildenafil)

Viagra ® improves erections by causing the smooth muscles of the penis to relax, enabling blood to flow into the corpora cavernosa. Viagra is absorbed and processed rapidly by the body and is usually taken 30 minutes to 1 hour before intercourse. Ease of administration makes oral medication advantageous as a first line therapy. There are options, but we will concentrate on Viagra as it is the most effective.

Viagra has truly revolutionized the treatment of erectile dysfunction. It is relatively effective and safe in approximately 60% of men. It is taken one hour prior to intercourse and will work only if a man has significant stimulation. In most patients it will result in a very rigid erection that is well maintained and satisfactory.

It is strictly contraindicated in all men who take nitrates (Like Nitroglycerin). It is also strictly contraindicated in men with retinitis pigmentosa.
Risks should be weighed in individuals with unusually low blood presure, uncontrolled angina, Heart failure, multiple antihypertensive drug regimens, heart attack/stroke/arrythmia in the last 6 months.

Its side effects can include headaches, nausea, facial flushing or temporary visual changes including blurring, blue-green tinges and some increased intensity of light. It should not be taken with a fatty meal as this will delay its absorption. It is best taken on an empty stomach.

Results vary depending on the cause of erectile dysfunction, but studies have shown that Viagra is effective in 75% of cases. It helps men with erectile dysfunction associated with diabetes mellitus (57%), spinal cord injuries (83%), and radical prostatectomy (43%). Common side effects include headache, flushing, and indigestion. Viagra should not be taken more than once a day and is not suitable for men using nitrites, medications taken for chest pains. Newer drugs in the same class of medication are on the way. Taldinafil (Cialas), by Eli Lilly, should be available around 2002. It has quicker onset of action and lasts for a full 24 hours. Vardenafil, by Bayer, should arrive somewhere in 2003.
 

A few brief comments on alternative medications/supplements to erectile Dysfunction. Overall they are largely ineffective and have high likelihood of side effects.

• Uprima (Apomorphine) - not available in the US at present.
• Yohimbine - effects have not been studied thoroughly, but some studies suggest that 10% to 20% of men respond to treatment with the drug. Its efficacy is controversial, although it is generally believed to produce modest improvement in erectile dysfunction. It must be taken three times each day chronically, not only prior to intercourse.
• L-Arginine
• Trazadone - this medication was given for psychotic behavior. Some patients experienced a side effect of erection (priapism). As a result, some have used this medication with little to no success to achieve erections.

Penile Injection Therapy

SUCCESS
Many men will get erections comparable to those achieved at their sexual peak, and these often last through their ejaculation. They are well tolerated because when correctly administered they do not hurt. The idea is intimidating, and getting the patient to try it is often the greatest hurdle, especially when it has been presented to them in a negative light.

The patient compress the injection site for 2-5 minutes after the injection to prevent bleeding/bruising.. After this, he begins foreplay. It is recommended that self-injection be performed no more than once every 4 to 7 days. During the titration phase, the patient receives injections in the office. These are designed to assess how much medication the patient will need and to teach the patient how to inject.

Injectable Medications:

• Prostaglandin E1 (PGE1/Caverject/Edex): Only FDA approved medicatoiin. Approximately 15% of patients will experience aching with the Prostaglandin E1, feeling almost as if the penis were "overused." This is not dangerous, but represents a response of their tissues to the medication and can certainly inhibit them from using it.
• Papaverine: First agent used in this manner. Also acts by relaxing the smooth muscle. Burning and aching are not encountered. Systemic effects are rare, but this medication causes more fibrosis at the injection site.
• Phentolamine (Vasomax/Regitine): Phentolamine does not work by itself. Rather it is used as an adjunct to papaverine and/or PGE1.
• Various Mixtures: Bi-mix, Tri-mix. Super Tri-mix. They combine the above drugs to take advantage of different mechanism of action to allow for overall lower dosing of each medication. It can be hard to find pharmacy that supplies these special mixtures.

Complications:

Penile nodules: Patients may develop painless fibriotic nodules within the corpor-cavernosa. These are thought to be secondary to the trauma of injection or inadequate manual compression of the injection site. They usually develop after prolonged use and rarely require cessation of therapy. On rare occasions, these nodules may lead to penile curvature.

Priapism: Patients may develop priapism, defined as a prolonged erection lasting longer than 4-6 hours. Because the penis in this state is relatively ischemic, if priapism is not treated within 24 hours, it may lead to severe scarring of the corpora cavernosa and subsequent impotence not responsive to intracavernosal injections. The development of priapism is rare when the medication is titrated appropriately and it almost always occurs during the dosage determination phase. Patients should be instructed to call their physician if an erection following injection lasts for more than 4 hours. Patients with priapism are usually treated with an reversing injection.

MUSE Intraurethral Suppository

Vacuum Erection Devices

Vacuum devices work best in men who are able to achieve partial erections on their own. They are easy to use at home, require no other procedure, and typically improve erections regardless of the cause of impotence. Some men experience a numbing feeling after placing the O-ring. Since the penis is flaccid between the ring and the body, the erection may be somewhat floppy.

Penile Implants

Vascular Reconstructive Surgery