Erectile dysfunction (aka impotence) is defined as “the persistent inability to achieve or sustain and erection sufficient for satisfactory sexual intercourse.” This can be a total inability or inconsistent ability, or a tendency to sustain only brief erections.
Although it is common (at least 50% of men over 50 year old have some loss of function), it is NOT normal, no matter what the patient age. Unfortunately, only 10% of men seek treatment and many (50%) discontinue treatment once they start it. This is because they are understandably embarrassed to raise this issue with their physicians and they may get inadequate information about the many treatments that are available to them.
It is even more unfortunate when you consider that it 1) affects the quality of life 2) makes men feel worse about their general health and 3) may be a symptom of an underlying disorder (for example, diabetes, cardiovascular disease, etc). Men do not realize that there are a variety of very satisfying treatments and there is no need to suffer in silence.
What are the causes?
In the most basic analysis, an erection consists of blood flowing into the corpora cavernosa (AKA erection bodies) and being trapped there. A problem with either blood getting in or staying in causes ED.
Potential causes are many and include: vascular (high blood pressure, elevated cholesterol, diabetes, cardiovascular disease), diabetes, trauma (spinal cord injury or injury to the pelvis), neurologic disease (stroke, Parkinson’s disease), radiation to the pelvis (for prostate or rectal cancer), endocrine disease, surgery in the pelvis (radical prostatectomy, surgeries for rectal cancer or bladder cancer), medication side effects (especially medications used for high blood pressure), alcohol, tobacco, cocaine, etc. Is this just the man’s problem?
This is a “couples disease”. Even though the problem is not Psychologic (i.e. it’s not “all in your head”), ED causes depression, anxiety, loss of feelings of masculinity and self-esteem. This of course affects relationships and may set up a “vicious cycle” where the partner feels unattractive and so stops initiating intimacy, the man then feels unattractive, etc. This can be devastating to the couple. Very few couples can or want to give up their physical intimacy without any problems!
Luckily, there are treatments. These include pills, injections, penile suppositories, vacuum devices, and surgery.
What about pills?
Phosphodiesterase inhibitors are the name of the oral drugs used to treat erectile dysfunction. The most common medications are sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra). They work by blocking a chemical that stops erections. Viagra was introduced in 1998 (the others in 2003) and revolutionized the way that men and their partners were treated for erectile dysfunction.
Keys to using pills successfully
Generally these medications are safe. Side effects are common (around 30% of men have them) and include: headache, flushing (feeling hot), upset stomach, stuffy or runny nose, and back pain (especially Cialis).
These medications should NOT be used if you are taking (or have at home) nitroglycerin or medications containing nitrates (ask your doctor or pharmacist if you have a question about this), as the combination may cause a dangerous drop in blood pressure.
These medications should be used with caution if you are taking medications for enlarged prostate (BPH) such as flomax/tamsulosin, hytrin/terazosin, etc. Again, ask your doctor or pharmacist if you have questions about this or if you have any other less common medical conditions that would make you change the dosage of the pills.
If pills don’t work or if the patient cannot tolerate them, alternatives include injections, suppositories, vacuum devices, or surgery.
A vacuum device (VED) is an external device (not a drug) that goes over the penis. When pumped, it pulls blood into the penis then a special ring is placed over the base of the penis to keep it erect.
VEDs are generally safe (although there have been some very rare but serious complications) but unfortunately many men simply do not like them. They can only work well in the setting of a stable relationship and many men simply stop using them.
Benefits of VEDs are that they are inexpensive with limited side effects; however, the VED also has many drawbacks. Notable drawbacks include: penile pain, numbness, pain with ejaculation, decreased satisfaction, unnatural erection, and cumbersome sensation.
Drugs may be injected directly (using a tiny needle) into the penis. Several drugs and drug combinations are available, including alprostadil (Edex, Caverject), phentolamine, and papavarine (usually given in combination as Bimix or Trimix). The patient can usually get an erection within 5-10 minutes, and it should last between 20 minutes to an hour.
Injections do require training and may take time/effort to get the correct dose. We always do the first injection in clinic, which helps the patient learn technique and also provides information about the dosing. Patients are usually anxious about penile injections but are almost always surprised that the injection can be painless. The patient will be observed in clinic to make sure the erection resolves. They will be provided instruction on how to slowly titrate the injection for best effect, being cautious to avoid potential side effects (aka, priapism).
It is very important to alternate injecting the left and right side of the penis [link to diagram and info sheet] and to not use injections more than 3 times per week.
Benefits of injections include: effective, mimics normal erection, normal sensation, discreet. Risks of injection include: prolonged erection (priapism), penile scarring causing penile curvature, pain with injection, bruising, and decreased long-term satisfaction.
Although, penile injections work well, there is a high drop off in use over time due to the above risks with injections.
Urethral suppositories (aka, MUSE) contain alprostadil (see “Injections”). The pellet is given via a delivery system into the urethra (urinary channel) and dissolves in the urethra. Advantages of urethral suppositories include: no needle, mimics normal erection, normal sensation, discreet, rare scarring or prolonged erection (aka, priapism). Disadvantages include cost, burning with urination, penile pain, expensive, decreased reliability, urethral bleeding, and poor long-term satisfaction.
A penile implant is the most efficacious method to treat erectile dysfunction. Satisfaction rates are high (> 90%). They allow the patient to have an erection at any time in a reliable manner. Penile implants are inserted in the operating room through a small opening in the skin. There are three components to the penile prosthesis, which are all connected. The first component are the inflatable cylinders that are inserted into the shaft of the penis. The cylinders become filled with sterile saline when the scrotal pump (second component) is manually compressed. This cycles saline from a reservoir (third component) into the cylinders in the penis. The pump is compressed at the completion of sexual activity, the deflate the penile cylinders and discontinue the erection. All components of the device are underneath of the skin are well concealed.
Some surgeons will recommend using a VED before surgery to stretch the corporal bodies to allow a longer penile implant.
To help you prepare for surgery, you will need the following appointments:
Appointment with the Preoperative Center
At the Preoperative Center, you will have routine tests that you will need for your surgery (like blood tests, X-rays and EKGs). You will also meet with a nurse who will review specific instructions that you should follow before your surgery. For example, they will tell you which medicines and foods you may need to avoid before surgery.
Wear loose fitting clothing on the day of surgery.
When you arrive at the Hospital Admissions Department.
After registering, you will go to Ambulatory Surgery and then change into a hospital gown.
Then you will be brought to the “pre-op hold and prep” area.
Next, you will be taken to the operating room.
The anesthesiologist will attach you to various monitors. They will also give you oxygen through a small mask placed over your nose and mouth. Soon after this, you will drift off to sleep.
When the surgery is over, you will be taken to the recovery room.
You will have an incision (wound) either over the upper scrotum (penoscrotal) or above the penis (infrapubic). You may have a second incision over the right or left lower abdomen that can be used to place the pressure regulating balloon.
You will receive pain medicines and other medicines.
Most people have some pain for the first couple of weeks after surgery, but the pain is usually not very bad. Your surgeon will prescribe pain medications and discuss use of Tylenol and/or ibuprofen to take on a scheduled manner to reduce the need for narcotic pain medications.
You will slowly introduce foods to your diet.
Most patients start eating again the day of surgery. Advance your diet as able.
You will recover quicker by doing certain activities.
You may start walking the day of your surgery.
Walking is very important since it helps to prevent blood clots (clumps that form when your blood thickens) in your legs. Even a short walk will help a lot.
Postoperative Day 1:
You may have an appointment with your surgeon the following day for removal of the penoscrotal bandages, drain, and/or urethral catheter. You may have been asked to keep track of output from the drain.
The penile implant will be left partially inflated for the next two weeks. The surgeon will instruct you on the location of the control pump in the scrotum. You should feel for this scrotal pump daily and ensure that the pump remains in the scrotum.
Postoperative Day 14:
A member of your surgery team will meet with you to deflate the penile prosthesis. You will be given instructions on how to inflate and deflate the penile prosthesis. Some patients may need to wait an additional two weeks if there is persistent swelling that precludes the ability to inflate/deflate the penile prosthesis.
Once you are able to demonstrate how to use the device, you will be provided instructions on a protocol to inflate/deflate the penile prosthesis. Most patients can use the penile implant 4-6 weeks after surgery.
The penile implant acts as a tissue expander. Your surgeon may recommend inflating and deflating the device daily for the first 3-6 months after surgery. This will serve many purposes such as making the patient more familiar with the device and continuing to passively expand the corpora to gain potential penile length.
Here are some tips for caring for yourself at home. We will give you more detailed instructions before you leave the hospital.
Eating and drinking
Anesthesia and pain medicine can affect your bowel movements. It will take time for your bowel movements to be normal. To prevent constipation:
Bathing/Caring for Your Incision
Returning to work
Call your surgeon if you have any of the following:
• Every day things usually get a little easier.
• Do not be afraid to take pain medicine when you are uncomfortable.
• Walk, walk and walk some more. It will help speed your recovery.
• Ask us about anything that concerns you.