Treatment of erectile dysfunction currently ranges from lifestyle changes to penile inserts and vacuum devices and has undergone many changes. Only a decade ago we thought that 98% of men with sexual dysfunction had a psychological problem and that counseling was the most important therapy. We now know that the primary cause of sexual dysfunction in men is not psychological, but rather "equipment failure" having to do with blood flow and many of the factors that we discuss in this center.
Lifestyle changes as treatment for erectile dysfunction
Of course, lifestyle modification to treat erectile dysfunction is important. It's been well documented that weight loss, smoking cessation, exercise and diet can improve erections. We've discussed this in great detail in other articles at this Center.
Smoking cessation cannot be emphasized enough. Smoking is one of the biggest risk factors we see; it's actually a compounding risk factor when added with age and other comorbidities. It has been well-documented that stopping smoking will improve erections in most cases.
Exercise is always important. Most experts agree that exercise 3 times a week/30 minutes per day to get your heart rate to within 70% of the target range is probably appropriate. This level of exercise will have benefits over the entire body.
Of course, a healthy diet is always important. The diet that contributes the most to our clogging arteries is the atherogenic diet. This diet is rich in saturated fats and high in carbohydrates and trans fatty acids and unfortunately, this is the diet that most of us baby boomers grew up on. Of course, it's important to change this diet to a healthier diet, more like the Mediterranean diet, where appropriate. While it's difficult sometimes to avoid fast foods especially with our busy lifestyles, even the fast food chains have changed their menus to healthier foods in recent years. It's now possible to make healthier menu choices in a fast-food restaurant. Refer also to Good Food, Good Living and Good Loving in this Center.
With regards to medications, the terms Viagra®, Levitra® and Cialis® are not news to any American or, for that matter, anybody in the world. These are probably the most recognized brand names that have ever been on the planet, mostly because of the intensive advertisement campaigns that have taken place. We will collectively call these medications the PDE-5 inhibitors. They all have unique individual properties and specific pharmacologic roles. Generally, when we prescribe these medications, we try all three medications and we then work through our patients' responses and make changes appropriately based on the pharmacologic results. In other words, we stick with the medication which produces the best erection, the longest duration and with the least side effects.
We think it's extremely important that men have multiple opportunities to try these medications. Several studies have shown that when a man fails treatment with a PDE-5 inhibitor, generally it either was not dosed properly or dosed long enough. In a man with significant medical conditions, such as diabetes, or in a man who smokes, it may take daily treatment with these medications for up to two weeks before we begin to see success. Most of the drug studies for the approval of the PDE-5 inhibitors were done in men who had mild to moderate erectile dysfunction, not the group of "hard to treat" men. Men with prostate cancer who've had various surgical treatments or men who have significant diabetes, hypertension and various medications related to this may need different doses, different drug options or longer periods of treatment before seeing results.
When PDE-5 inhibitors don't work, other treatments for erectile dysfunction include intracavernosal penile injections. This concept has been around since the mid 1970s. Prior to the advent of intracorporal pharmacotherapy (penile injections), penile prosthesis or implant was the only option other than drugs.
The initial drug used to treat erectile dysfunction was papaverine mixed with a drug called phentolamine. Papaverine was originally marketed for use in vascular surgery to dilate blood vessels. It was also taken as an oral medication to act a vasodilator in people with low extremity claudication and in people with vascular disease in the legs. The off-label use for erectile dysfunction was so widespread throughout the 1980's that more papaverine was sold in the first year that this usage was discovered than was sold in the prior 30 years. Alprostadil, the manufactured version of prostaglandin, proved to be effective as well. The drug was used for babies with heart abnormalities but it was discovered that it caused relaxation in the corporal smooth muscle, produced an erection and was well-tolerated by men. In 1995, the Upjohn Company, which was subsequently bought by Pfizer, had alprostadil powder approved for use as a penile injection. This product, Caverject®, comes as a dry powder. Liquid is added to it at the time of use in a unique self-dosing syringe.
There are multiple other medications that can be mixed as well for men who have a poor response to the FDA-approved standard dosage regimens. While each of these medications is FDA-approved for other uses, their use for erectile dysfunction, either singularly or in combination, has not been approved so their use is considered "off-label". It's important to notify patients that these drugs are being used off-label. We generally reserve the more exotic mixtures for patients for whom the standard regimens have failed.
The technique of penile injections is quite simple and painless. The injection uses a small 30 gauge needle and 1cc syringe, the exact same type of injection and syringe that diabetics use for insulin. The contraindication to treating with pharmacologic intracavernosal injections is patients who are at risk for priapism. Priapism is a painful erection that lasts for four hours or more. This is a relatively common condition but we are very experienced at preventing it. The pain tends to be an aching sensation but most patients are able to tolerate it. Very few patients drop out of a pharmacologic erection program because of pain. However, in the long-term, patients who are on penile injections tend to drop out over time.
Penile implants or prostheses are another alternative for men who choose not to use injections and in whom oral medications fail. In the right patient a penile implant is a blessing; in a poorly selected patient it can be a nightmare. Prosthetic penile implants have been available since the 1970s. Unfortunately, the early devices were plagued with malfunctions, infections and erosions resulting in a bad reputation. Deciding to have a penile implant is a very important decision for a man and there are many factors that need to be considered by both the patient and the implanting surgeon. Our personal feeling is that penile implants are the last resort. Men with erectile dysfunction who are unable to achieve a satisfactory erection or maintain an erection and rigidity required for penetration are candidates but the man should also have tried all other therapeutic options. When these options have failed or the man doesn't feel they are applicable to his lifestyle, a penile implant is indicated.
The candidate for penile implant will have the full diagnostic work, including a color flow Doppler examination. Although many urologists have some working knowledge of penile implants, only a surgeon who regularly performs this procedure has the experience necessary, especially when confronting the difficult situations or complications that may arise during the implantation process. It's also important to ask about the number of devices the surgeon has implanted. At least 25 procedures per year are necessary to maintain clinical competence in this arena. If the surgeon does this procedure only infrequently, the patient should ask for names of other surgeons at a referral center. Many of these names are well-known to the urologic community; some information can be even obtained on the internet.
The next step is deciding what type of device to choose. A wide variety of these devices exists, so a good initial question is whether you want a semi-rigid implant or an inflatable implant. Using a car analogy, we generally look at the 3-piece inflatable device as the gold standard or Cadillac. Nothing else is quite as effective. Again, these are important questions to ask your surgeon before considering these devices.
Vacuum erection devices
Other treatment options include the vacuum erection device. The vacuum erection device is not a new concept; it has been around for many years. A vacuum pump is placed over the penis, negative pressure is applied and blood is pulled into the penis. A rubber ring placed at the base of the penis traps the blood and prevents the blood from escaping. The advantage to this device is that it is non-invasive and relatively simple to perform. The down side is that it produces a fairly swollen penis that tends to be cold to touch.
Before the advent of modern vacuum erection devices, most of these devices were sold from the back of men's magazines as "penis enlargers". Clinicians tended to avoid them because they were not familiar with the devices and because there was little peer-reviewed medical literature on them. It wasn't until the National Institutes of Health Consensus Statement on Impotence (1992) that VEDs became a reasonable option in the treatment of erectile dysfunction. Vacuum erection devices, like many other devices, differ in quality. The basic unit is a cylinder with a clear plastic sleeve that fits over the penis. The adage "you get what you pay for" is true in choosing a vacuum erection device. Other options include devices that can be placed at the base of the penis to act as a venous flow controller to prevent blood loss. The medical version is known as the Actis Ring® but there are many other constrictive devices sold in the back of men's magazines. Many of these have additional parts on them that can act as stimulation devices as well.
Herbal remedies as treatment for erectile dysfunction
It's interesting that more men choose herbal remedies than use standard PDE-5 therapy for the treatment of erectile dysfunction. Herbs have a role which is discussed in Good Food, Good Living and Good Loving. There have been many herbal remedies such as horny goat weed that have applicability in this area. A recent study of herbal medications found that many contain the active ingredient in Viagra®. Many men choose to purchase their medication on the internet, which can be unreliable or sometimes downright dangerous because it's difficult to know that you're getting a quality preparation and not something that's non-standard, unpurified or containing toxins or poisons.
Pellets for erectile dysfunction treatment
Muse® is alprostadil that's been processed into a small pellet. The pellet is placed in the head of the penis, into the urethra of the glans penis and massaged until it dissolves. This device was popular for a period in the 1990s. This medication can produce an erection in a number of men but may cause symptoms such as burning. The major drawback to this medication is the irritation and burning that may result with the use of the device and the cost. But there is still a loyal following of men who are very happy with Muse® therapy. If this works for you, this is certainly a reasonable therapy.
Overall, what's important is goal-directed therapy. Use what you're comfortable with. Use the device or medication that produces an adequate erection for penetration. Be comfortable knowing there are many options available for treatment of erectile dysfunction.
References: See Bibliography
Posted August 2008
Updated March 2012