Treatment of erectile dysfunction is usually guided by patient preference for treatment options, not by the underlying disease process. These options include an oral medication, pharmacologic injection therapy, intraurethral medication, vacuum device therapy, a penile implant, or arterial or venous surgery in selected individuals.
Current treatment often begins with a trial of medications such as Viagra, Levitra, or Cialis. These medications cause dilation of the blood vessels which supply the penis, increasing the amount of blood flowing into the erectile bodies of the penis. Individuals who respond to oral medications often opt against further diagnostic workup since the medication is so easily used.
Most individuals can use oral medicaitons. Only those using nitroglycerine or nitroglycerine containing compounds such as Isordil or Imdur cannot try the medication. In general, they must be taken 45 to 60 minutes before intercourse to allow absorption into the blood stream. Once an adequate level of medication is present in the bloodstream, many men experience improved rigidity from sexual stimulation. Depending on the cause of ED, between 40 and 85% of patients will experience improved sexual performance with medications. Some men do experience side effects, however. Headache, nasal stuffiness, blue-green visual hue, and flushing are not uncommonly experienced by some men.
Pharmacologic injection therapy involves the injection of a small quantity of vasoactive substance into the side of the penis to quickly induce a rigid erection. Once the correct dosage is determined and proper technique is mastered, an individual can administer this medication at home. Mastery of the injection technique and determination of the proper dosage requires two to three office visits. Injection therapy produces a rigid erection having adequate duration for intercourse. Many people feel that this method produces the most 'normal' erection.
Less effective than injections, although less invasive, is the technique of intraurethral medication. This method uses a small pellet filled with the same medication used for pharmacologic injection. A specially designed applicator places the pellet into the urethra, or urine tube. Since the medication is not injected into the specific location where the blood vessels enter the penis, the dosage of medication required is far larger than used for injection. Uncommonly, a patient can absorb enough of this medication into the blood stream to lower the blood pressure. About 30% of patients using the intraurethral suppository achieve satisfactory results.
Vacuum device therapy is another option for achieving erection. Using this technique, a plastic cylinder is placed over the penis. A vacuum is created within the cylinder by either a hand pump or a battery-powered pump. T he vacuum causes penile engorgement and rigidity. A rubber band located at the base of the cylinder is rolled onto the base of the penile shaft. Constriction of the penile base by the band prevents the outflow of blood and maintains penile erection. Although the character of erection maintained with this device may not be as complete as that achieved using injection therapy, the vacuum device is attractive for its least invasive nature.
Placement of a penile implant is the fourth treatment option. Penile erection is achieved in the normal state by filling of two cylindrical tubes — called the corpora cavernosa — with blood. In the person unable to achieve erection, the surgical implants are placed inside the same tubes to produce rigid erection. Implantation of a penile prosthesis is a surgical procedure done in an operating room. The two principal types of penile prostheses are semi-rigid devices that remain firm always and inflatable devices that can become flaccid when not in use.
The vast majority of patients in our practice who choose a penile implant opt for an inflatable penile prosthesis. This is due to improved rigidity and flaccidity when compared to semirigid devices. About 90% of patients are very satisfied with their implant. Like all mechanical devices, penile implants can experience mechanical failure. Approximately 90% of implanted devices remain operable after five years. Replacement of a failed device with a new one is successful in most patients. I nsertion of a penile prosthesis should be looked upon as a permanent procedure. When a prosthesis is unsuccessful, replacement with a new prosthesis is required. Intracorporeal injections are no longer an option. Vacuum erection therapy can be used after prosthesis removal although the results are often not as good as can be achieved before implantation.
The condition of certain other individuals is more amenable to primary surgical repair, although they represent the minority of persons having erectile dysfunction. These include young patients whose erectile dysfunction is due to pelvic trauma and a group of people who experience incomplete rigidity due to venous leakage of blood out of the corporal bodies.
Serious pelvic trauma usually involving fracture of the pelvic bones may cause a blockage of the main penile blood supply. The occasional patient may benefit from bypassing the blockage. Unfortunately, this technique has not proven effective for those with an arterial blockage due to vascular disease or diabetes.
Impotence due to venous leak can be found in those individuals experiencing sudden loss of a normal erection and in those who experience incomplete rigidity with injection therapy. The condition occurs from decreased venous resistance allowing too much blood to leave the penis during erection. Persons afflicted with this disorder often benefit from either a constriction band placed at the base of the penis or surgery to remove the leaking veins.
Part of our evaluation may include a blood sample to determine the testosterone, or male hormone, level. Most of the time, the hormone level is normal, and if so, those patients are offered the treatment techniques described above. If, however, the testosterone level is low, then a trial of testosterone replacement may be beneficial. This medicine is best given as an injection every three weeks or through a patch placed on the skin each day. Also, if the hormone level is low, we would perform other blood tests to learn why enough testosterone is not being produced by the body.