Erectile Dysfunction (ED)
Most doctors suggest that treatments proceed from least to most invasive. Making a few healthy lifestyle changes may solve the problem. Quitting smoking, reducing alcohol consumption, losing excess weight, and increasing physical activity may help some men regain sexual function.
Cutting back on or replacing medicines that could be causing ED is considered next. For example, if a patient thinks a particular blood pressure medicine is causing problems with erection, he should tell his doctor and ask whether he can try a different class of blood pressure medicine.
Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.
Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient’s partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety during treatment for ED from physical causes.
Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis.
Sildenafil (Viagra), vardenafil hydrochloride (Levitra) and tadalafil (Cialis) oral medications that are available to treat ED
Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.
None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin pills for heart problems should not use any of the three drugs because the combination can cause a sudden drop in blood pressure. Also, men should tell their doctor if they take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. The doctor may need to adjust the ED prescription. Taking a PDE inhibitor and an alpha-blocker within 4 hours of each other can cause a sudden drop in blood pressure. A small number of men have experienced vision or hearing loss after taking a PDE inhibitor. Men who experience vision or hearing loss should seek prompt medical attention.
While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. One injectable medication is Edex. These drugs may create unwanted side effects, however, including scarring of the penis and persistent erection, known as priapism. Nitroglycerin ointment, a muscle relaxant, can sometimes enhance an erection when rubbed on the penis.
A system for inserting a pellet of alprostadil into the urethra uses a prefilled applicator to deliver the pellet about an inch into the urethra. The pellet form of alprostadil is marketed as MUSE. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; a warm or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.
Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.
Mechanical vacuum devices cause an erection by creating a partial vacuum, which draws blood into the corpora cavernosa, engorging and expanding the penis. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic ring, which is moved from the end of the cylinder to the base of the penis as the cylinder is removed. The elastic ring maintains the erection during intercourse by preventing blood from flowing back into the body. The elastic ring can remain in place up to 30 minutes. The ring should be removed after that time to restore normal circulation and to avoid skin irritation.
Couples may find that using a vacuum device requires some practice or adjustment. An erection achieved with a vacuum device may not feel like an erection achieved naturally. The penis may feel cold or numb and have a purple color. Bruising on the shaft of the penis may occur, but the bruises are usually painless and disappear in a few days. Ejaculation may be weakened because the elastic ring blocks some of the semen from traveling through the urethra, but the pleasure of orgasm is usually not affected.
Implanted devices, known as prostheses, can restore erection in many men with ED.
- Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.
- Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid. Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. The pump causes fluid to flow from a reservoir residing in the lower pelvis to two cylinders residing in the penis. Inflatable implants can expand the length and width of the penis to some degree. They also leave the penis in a more natural state than malleable implants do when not inflated.
Once a man has either a malleable or inflatable implant, he must use the device to have an erection. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have decreased in recent years because of technological advances.