treatments for erectile dysfunction

director: Chris Steidle, MD

The most important part of the treatment for ED is to address the cause. We must address the cause and not just hand out medication. For any treatment to be effective, the patient must adjust any contributing lifestyle factors; therefore, lifestyle modification is a corner stone to treatment. Also, the patient must have any contributing disease process such as diabetes, HTN or elevated cholesterol levels under control.

After we complete a history, physical examination, and laboratory investigation, and have a good handle on the diagnosis, we talk with the patient about treatment options. There are so many options available; the question becomes which of the many is best for each patient: vacuum pumps, intraurethral medications, venous constriction devices, penile injections, penile prostheses or oral therapy?

The best treatment is goal-directed so that the options are specific to the needs of the patient and his partner, and will be based on how much the patient wants to do about his current problem.

Some of the factors to consider:

The patient’s age.
His total health status.
Does the patient have good functioning of his lower and upper extremities?
Does he have a very willing and active sexual partner?
Does the patient have numerous sexual partners?
Is the patient’s partner involved in the decision making process?
What are the goals of therapy?

A great deal of effort goes into educating the patient so he can make an informed decision and we also tailor the workup and treatment to the patient’s specific needs.

The patient is first instructed in the use of oral therapy and then, if a trial of oral therapy is successful, we stop at this point. Today there are many options for oral therapy: Viagra®, Levitra ®, or Cialis ® can be used in most patients.

If the patient continues to have problems (a fair percentage of men will), we then proceed to educate the patient about the variety of other therapies. He may choose one of the many minimally invasive therapies, such as a vacuum erection device that can be very attractive for an older patient concerned about cost, or he may choose a penile injection program. Once oral therapy is proven ineffective, we educate the patient next about multiple agents and combinations of them that are currently available for penile injection including Papaverine, papaverine with phentolamine, papaverine with phentolamine and prostaglandin, or prostaglandin alone in the form of Caverject or Edex. Information about the cost of each type of injection and their proper use is shared in detail. Many men are somewhat hesitant about the use of penile injections and it often takes a long period of discussion and counseling to ease their minds. They have to understand that sticking a needle into their penis is not nearly as painful an event as one would imagine.

Penile Implants
Penile implants are another option. The latest penile implant technology is a dramatic improvement over what was available in the past. The newest devices are much more reliable and have a much lower incidence of infection, especially since they are now combined with antibiotic coatings to prevent infection. Before proceeding with an implant, we conduct a full investigation to be sure that no other less-invasive treatment alternatives are available or appropriate. At that point, we explain the details of vascular surgery as well as some of the diagnostic imaging modalities available to insure successful surgery, including color duplex ultra-sound evaluation.

Vacuum Erection Devices
The vacuum erection device is a plastic cylinder that is placed around the penis. When negative pressure is applied the penis becomes rigid. A rubber ring traps the blood in the penis and keeps the penis rigid for periods of up to thirty minutes. Ejaculation is possible while using the device. These devices are made by a number of manufacturers and are available at several levels of sophistication, from manual pumps to battery-operated devices. The devices are reusable and have a very high satisfaction rate. The major drawback is that the cumbersome device is likely to cause loss of sexual spontaneity. One of the more common partner complaints is that the penis is cold and the rigidity is less than a normal erection. In older female partners, vaginal dryness and stenosis (narrowing) may make penetration difficult. Overall, however, these devices are excellent and are widely used. Most insurance companies will reimburse patients for them.