Erectile Dysfunction (ED)

How common?

In a study from John Hopkins Institute in 2007, the overall prevalence of ED in men aged above 20 years was 18.4% suggesting that ED affects 18 million men in the USA. Among men with diabetes, the prevalence of ED was 51.3%, so it’s a fairly common problem.

What causes ED?

• Lifestyle choices (smoking, excessive alcohol, obesity, lack of exercise)
• Diabetes
• Medications (blood pressure, antidepressants)
• Cardiovascular disease (high blood pressure heart disease)
• Hormone problems
• Prostate cancer treatment
• Surgery (prostate, bladder, colon)
• Spinal cord injuries

Treatment options?

Penile Doppler scan with an injection may be required occasionally in special situations.

Whatever is causing ED, there is a treatment option that can provide a satisfying solution.

If you try one of the treatment options listed and it doesn’t work for you or you aren’t completely satisfied, don’t be discouraged and give up hope.

These treatment options have varying degrees of success for each man depending on the cause of the ED. Irreversible blood vessel or nerve damage may impact the success of some of these treatments.
It is important to know all of your available options and discuss them with your doctor to determine which will be appropriate for you and your lifestyle.

Lifestyle modifications: Exercise regularly (5 times a week), healthy weight, avoid smoking, restrict alcohol intake to 2 drinks or less per day, adopt better sleep habits, take care of your other health issues such as high blood sugar and heart, artery or kidney disease.

Non-Surgical Options: Oral medications, penile injections, vacuum erection device

Surgical option: Penile implants

Non-Surgical options

Oral medications:
These drugs are known as phosphodiesterase type 5 (PDE-5) inhibitors. They work to relax muscle cells in the penis for better blood flow and to produce a rigid erection. These medicines work in about 7 out of every 10 men with ED. They can be effective regardless of age or race. However, they only work if a man is sexually stimulated. Their effects last for only a set amount of time. Men should take these medications 30-60 minutes before sexual activity. These drugs do not treat a lack of sexual desire. As with any drug, some men may experience side effects when taking PDE-5 inhibitors. The most common are headaches, flushing (redness) of the face, runny or stuffy nose, upset stomach, dizziness and muscle aches. Those side effects are usually mild-moderate, but taking these drugs with alcohol may make them worse. Be sure you tell your doctor about all drugs you are taking, including prescriptions, over-the-counter medications or supplements or recreational drugs before you take any PDE-5 inhibitors.

Penile self-injection:
Alprostadil (Prostaglandin) Injection therapy uses a needle to inject medication directly into the base or side of the penis. These medications improve blood flow into the penis to cause an erection. The recommended frequency of injection is no more than three times weekly and should produce an erection in 5-20 minutes. Beyond a possible fear of needles, men may experience pain, fibrosis and risk of a persistent erection with these injections. 60-65% of men discontinue this mode of treatment after 1 year.

Fig: Penile Alprostadil Injection

Vacuum Erection Devices (VED):
A mechanical ED pump used to pull blood into the penis can cause an erection. The system includes a plastic cylinder, an external penile pump and a tension band to place at the base of the penis. When the penis is erect, the ring is placed at the base to maintain an erection long enough to have sex (up to 30 minutes). This is a drug-free non-invasive method of treatment, but the person will not be able to ejaculate soon after the orgasm due to a constrictive ring at the penile base.

Fig: Vacuum Erection Device (VED)

Surgical option

Penile Implants:
In use since 1971, penile implants have helped many men return to active sex life. A penile implant is a medical implant that is implanted into the penis in the operation theatre. The implant is entirely concealed within the body. Two basic types of implants are available. With malleable or bendable implants, two silicon-type cylinders are inserted into the penis. To have an erection, a man bends his penis upward into an erect position. The second type, an inflatable implant has a pair of inflatable cylinders which is attached to a fluid reservoir and a pump hidden inside the body. To have an erection, a man presses on the pump. This transfers fluid into the cylinders, making the penis rigid. To return the penis to a natural flaccid state, the pump is deflated.

• Penile fillers
• Suprapubic fat reduction
• Pubic lipectomy
• Pubic liposuction
• Penile implant and multiple corporotomy incisions

Priapism got the name from Priapus. Roman statue showing Priapus – the god of fertility. The distinguishing feature of the deity is the great erect penis, which was to symbolize the economic well-being of the owners of the House of the Vettii in Pompeii.

There are two types of priapism:

• Ischemic priapism: when blood cannot leave the penis. This erection can last for more than four (4) hours. The penis shaft may be very hard, while the tip is soft. It is known to cause pain and discomfort. This type may stop and start (stuttering priapism).
• Nonischemic priapism: when too much blood flows into the penis. This is a less painful erection, but it can also last for more than four (4) hours. The penis shaft is erect but not rigid.

Priapism can happen in young boys (age 5-10), young adults (around age 20) and mature men (over age 50).

Priapism happens when blood flow to the penis doesn’t work correctly. Some things that could cause this are:

• Blood disorders, like sickle cell anemia and leukemia
• Prescription drugs, like some ED drugs, e.g. Sildenafil (Viagra), Tadalafil, mental health drugs, e.g. Fluoxetine, Bupropion, Risperidone and Olanzapine and blood thinners, e.g. Warfarin and Heparin
• Alcohol and drug use
• Injury to your genitals, pelvis or the area between the penis and the anus; or to the spinal cord
• Tumours

WHY IS TREATMENT IMPORTANT?

When an erection lasts for too long, the blood becomes trapped in the penis. The blood trapped in the penis is unable to go to other parts of the body. The lack of oxygen can damage or destroy tissue in the penis. This can disfigure the penis. It may also cause problems like erectile dysfunction (when the penis cannot become erect) in the future.

Treatment:

Ischemic priapism (most common, 95%) calls for emergency care. Blood must be drained from the penis. There are several ways to do this:

• Aspiration (when a surgical needle and syringe is used) to drain excess blood
• Medicine or a saline mix may be injected into penile veins to improve blood flow. The veins are flushed to relieve pain, remove oxygen-poor blood and stop the erection
• A surgeon may perform a “shunt” to vent blood from the penis or penile implant surgery if presented beyond 36 hours of having priapism.

Nonischemic priapism (less common, 5%) often goes away without treatment. Simple ice and pressure on the perineum may help end the erection. A watch and wait approach is used before surgery.