Erectile Dysfunction (ED)

Erectile dysfunction (ED) is defined as the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance and/or satisfaction.

This condition is one of the most common sexual problems for men and increases with age. Up to 30 million men in the United States and 150 million men worldwide are estimated to be affected by ED, although not all men are equally distressed by the problem. Because erectile dysfunction is often a symptom of a more serious physical problem, it is extremely important for any man who has trouble achieving or maintaining an erection to see his physician.  Before initiating medical or surgical therapy, it is imperative to explore all aspects of a man’s lifestyle that may be contributing to erectile dysfunction including physical exercise, weight, blood lipids (fats, cholesterol), smoking, alcohol consumption, stress, fatigue, and a busy schedule. Likewise, it is equally important to address potentially reversible causes of erectile dysfunction such as hormonal (testosterone) deficiency and medications that can cause erectile dysfunction as a side effect.

Given the large number of treatment options now available – with more on the way – virtually all men can be successfully treated, regardless of how long they have been sexually inactive.  At the Vantage Urologic Institute, we customize therapies for our patients based on individual medical conditions and personal preferences. Treatment options are applied in a stepwise fashion with increasing invasiveness and risk balanced against the likelihood of success.

Risk Factors

ED can result from health or emotional problems or from both. Lower blood flow or harm to nerves in the penis can lead to erection problems.

Physical Causes of ED

Some things that can increase the chances of getting ED (known as risk factors) are:

• Age over 50
• High blood sugar (diabetes)
• High blood pressure
• High cholesterol
• Smoking
• Cardiovascular disease
• Drug or alcohol abuse
• Obesity
• Lack of exercise

Even though ED becomes more common as men age, growing old is not the cause of the problem. ED can be an early sign of a more serious health problem. Finding and treating the cause(s) of your ED can improve your overall health and well-being.

ED may happen because:

• Not enough blood flows into the penis: Many health issues can reduce blood flow into the penis, such as heart disease, high blood sugar (diabetes), and smoking.
• The penis cannot store blood during an erection: A man with this problem cannot keep an erection because blood does not stay trapped in the penis. This condition can occur in men of any age.
• Nerve signals from the brain or spinal cord do not reach the penis: Certain diseases, injury or surgery in the pelvic area can harm nerves in the penis.

Emotional Causes of ED

Sex activity needs the mind and body to work together. Emotional or relationship problems can cause or worsen ED.

Some emotional issues that can cause ED are:

• Depression
• Relationship conflicts
• Stress at home or work
• Worry about sexual performance

Symptoms

When you have ED, it is hard to get or keep an erection that is firm enough for sex. Most men have trouble with erections from time to time, but in some men, it is a regular and more bothersome problem. ED can cause:

• Low self-esteem
• Performance anxiety
• Depression
• Stress

ED may affect the quality of a marriage or intimate relationships.

Evaluation and Diagnosis

Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history along with a physical examination and selective laboratory testing.

Medical, Sexual, and Psychosocial History

The etiology of ED is often multifactorial. General medical history factors to consider when a man presents with ED are age, comorbid medical and psychological conditions, prior surgeries, medications, family history of vascular disease, and substance use.

Common risk factors for ED include vascular disease, tobacco use, neurologic disease, endocrinopathies, medication-related side effects, and psychosocial issues. Vascular issues are particularly important because in some cases they can be improved with lifestyle interventions, such as dietary changes, weight loss, and increased physical activity.

Key questions regarding ED include identifying the onset of symptoms, symptom severity, degree of bother, specification of whether the problem involves attaining and/or maintaining an erection, situational factors (e.g., occurring only in specific contexts, only when with a partner, only with specific partners), the presence of nocturnal and/or morning erections, the presence of masturbatory erections, and prior use of ED therapy. The presence of nocturnal and/or morning erections suggests (but does not confirm) a psychogenic component to ED symptoms that would benefit from further investigation. Additional important information includes whether symptoms have been stable or are progressive; worsening symptoms may suggest the presence of progressive underlying comorbidities, particularly cardiovascular comorbidities, that need to be definitively addressed.

It is important to define which sexual dysfunction the patient is complaining of. It is not uncommon for patients to confuse ED with other sexual dysfunctions such as premature ejaculation, delayed ejaculation, or even retrograde ejaculation. Information about changes in libido, orgasm, and penile morphology (e.g., the possible presence of Peyronie’s disease) also is needed. The timing of specific symptoms should be ascertained in relation to the onset of ED as these symptoms may be primary causes of ED or secondary effects of the ED condition.

The man’s sexual partner(s) plays a key role in determining the appropriateness and efficacy of any intervention. The ideal clinical situation is one in which the assessments and treatment discussions include the partner. If the man has a partner, then the partner’s views on ED and treatment should be assessed, when possible. Additional details, such as the partner’s gender, the duration of the relationship, ongoing or unresolved interpersonal/relationship issues, the partner’s views on sexuality, and the partner’s personal health/sexual issues, are useful to support a man in the evaluation of ED and to select an appropriate management strategy.

Standardized, validated survey instruments such as the Sexual Health Inventory for Men (SHIM) are now available to assess erectile dysfunction. The SHIM is comprised of five questions scored from 1 to 5; total scores of 22-25 are interpreted as no ED, 17-21 as mild ED, 12-16 as mild-to-moderate ED, 8-11 as moderate ED, and 5-7 as severe ED. These instruments are useful to measure treatment effectiveness and to adjust management plans based on outcomes over time. Questionnaires also can provide an opportunity to initiate a conversation about ED when sexual concerns are not the presenting issue.

Physical Examination

A physical examination is necessary for every patient, with particular emphasis on the genitourinary, vascular, and neurologic systems. A focused physical examination entails an evaluation of the following:

• Blood pressure
• Peripheral pulses
• Sensation
• Status of the genitalia and prostate
• Size and texture of the testes
• Presence of the epididymis and vas deferens
• Any penile abnormalities, such as hypospadias and Peyronie’s plaques

The physical examination may corroborate history findings or may reveal unsuspected physical findings, such as penile plaques, small testes, evidence of possible prostate cancer, prostate infections, or hypertension.

Several studies have found a strong correlation between hypertension and ED—not surprisingly, given that both are manifestations of a vascular disorder. In a large hypertension clinic, men who also demonstrated ED had a much higher prevalence of complications related to high blood pressure. It has been suggested that hypertensive patients with ED and poor cavernosal artery blood flow as measured during duplex ultrasonography studies should proceed to a full cardiac evaluation because of the high prevalence of associated problems.

A number of studies have shown a correlation between benign prostatic hyperplasia and ED. The cause of this correlation is not yet clear.

Laboratory Tests

The laboratory evaluation should include a lipid panel to assess for elevated cholesterol levels and serum glucose estimation in an effort to rule out the presence of diabetes. A serum testosterone level, although not imperative, is often also measured. Assessment of liver function tests and thyroid function tests are best reserved for those patients who manifest symptoms and/or signs suggestive of hepatic or thyroid dysfunction.

ED is now recognized as a warning sign of silent cardiovascular disease. Certain at-risk patients should be considered for additional testing of cardiac status with an EKG, echocardiogram, or stress test.

Specialized Testing

For some men with ED, generally those who present with complex histories, specialized testing and evaluation may be necessary. Situations that may require more detailed evaluation include men with ED who are 1) young, 2) have a strong family history of cardiac illness, 3) have a history of pelvic trauma, 4) have failed prior ED therapies, 5) have a strong likelihood of primary psychogenic etiology, 6) have concomitant PD, and 7) have had lifelong ED.

Such investigations include:

Nocturnal penile tumescence and rigidity testing — Nocturnal penile tumescence testing involves placement of two strain gauges on the penile shaft to measure radial rigidity during sleep. The device is used over several nights’ sleep to quantify the number, rigidity, and duration of nocturnal erections. The test has been used historically to differentiate psychogenic from organic etiologies for ED, with the presumption that men with psychogenic ED would have preservation of nocturnal penile erections.

Intracavernosal injections (ICI) — Intracavernosal injections testing assesses veno-occlusive function of penis. In ICI testing, an erectogenic agent (e.g., prostaglandin E1, papaverine, and/or phentolamine) is injected into the corpora cavernosa of the penis. Erectile response is assessed 5-10 minutes post injection and typically after sexual stimulation (e.g., exposure to audiovisual sexual stimulation). In addition to providing information on penile vascular status, in office erectile function testing may be useful to assess for penile deformities such as Peyronie’s disease.

Penile duplex ultrasound (DUS) — Penile duplex ultrasound may be combined with ICI to produce a more detailed and quantitative assessment of penile vascular response, including arterial sufficiency. DUS also permits observation of plaques and/or fibrosis of the tunica and corporal bodies.

DUS is currently the gold-standard in penile vascular evaluation as it is minimally invasive and provides robust information about both cavernous arterial inflow and the veno-occlusive capacity of the penis. These data may be useful for the following:

• Differentiation of primary psychogenic versus organic etiology for ED
• Assessment of arterial function in men who may warrant assessment by a cardiologist (i.e., men with predominantly vascular ED)
• Identification of men with severe veno-occlusive dysfunction resulting in ED who are unlikely to respond to medical therapy
• Identification of young men who may be candidates for penile revascularization procedures

Treatment

After all the information regarding the patient’s status has been gathered, the various options for management of erectile dysfunction (ED) can be discussed. It is best to include the patient’s partner in this discussion.

Erectile dysfunction may be associated with modifiable or reversible risk factors, including lifestyle or drug-related factors. These factors may be modified either before, or at the same time as, specific therapies are used. Likewise, ED may be associated with concomitant and underlying conditions (such as, endocrine disorders and cardiovascular problems) which should always be well-controlled as the first step of any ED treatment.

Lifestyle Modifications

Healthy lifestyle changes like quitting smoking, losing excess weight, gaining better control of diabetes and increasing physical activity may improve overall health and also help some men regain sexual function. Discontinuing drugs with harmful side effects is another effective treatment. If an isolated low testosterone level is found, then testosterone replacement may be the treatment of choice.

Oral Phosphodiesterase Type 5 Inhibitors (PDE5i)

Oral medications are a successful erectile dysfunction treatment for many men. They include:

• Sildenafil (Viagra)
• Tadalafil (Adcirca, Cialis)
• Vardenafil (Levitra, Staxyn)
• Avanafil (Stendra)

All four medications enhance the effects of nitric oxide — a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation.

Taking one of these tablets will not automatically produce an erection. Sexual stimulation is needed first to cause the release of nitric oxide from your penile nerves. These medications amplify that signal, allowing some men to function normally. Oral erectile dysfunction medications are not aphrodisiacs, will not cause excitement and are not needed in men who get normal erections.

The medications vary in dosage, how long they work and side effects. Possible side effects include flushing, nasal congestion, headache, visual changes, backache and stomach upset.

Your doctor will consider your particular situation to determine which medication might work best. These medications might not treat your erectile dysfunction immediately. You might need to work with your doctor to find the right medication and dosage for you.

Before taking any medication for erectile dysfunction, including over-the-counter supplements and herbal remedies, get your doctor’s OK. Medications for erectile dysfunction do not work in all men and might be less effective in certain conditions, such as after prostate surgery or if you have diabetes. Some medications might also be dangerous if you:

• Take nitrate drugs commonly prescribed for chest pain (angina) such as nitroglycerin (Minitran, Nitro-Dur, Nitrostat, others), isosorbide mononitrate (Monoket) and isosorbide dinitrate (Dilatrate-SR, Isordil)
• Have heart disease or heart failure
• Have very low blood pressure (hypotension)

Vacuum Erection Device

In patients who only have partial erections, and do not respond to other treatments or prefer not to use them, a vacuum device may be helpful. The device consists of a plastic cylinder connected to a pump and a constriction ring. A vacuum pump uses either manual or battery power to create suction around the penis and bring blood into it. A constriction device is then released around the base of the penis to keep blood in the penis and maintain the erection.

A vacuum device can be used safely for up to 30 minutes, which is when the constriction device should be removed. The advantage of a vacuum device is it is relatively inexpensive, easy to use and avoids drug interactions and serious side effects. Potential side effects associated with the vacuum device are temporary and may include penile numbness, trapping the ejaculate and some bruising.

Urethral Suppository (MUSE)

Medicated urethral system for erection (MUSE) is often used when oral medications are not effective. This approach uses a small suppository of medication that is placed in the penile urethra without needles. The suppository is then absorbed and helps to produce an erection.

Large studies conducted in Europe and the United States reported that MUSE was effective in 43 percent of men with impotence of varying causes. The major advantage of the therapy is that is applied locally by patients or their partners and has few side effects. However, the therapy has been shown to cause moderate penile pain and can have inconsistent response rates. Sometimes an adjustable rubber tension ring is applied at the base of the penis and improves results.

Patients using MUSE should have their first application performed in their doctor’s office, to prevent complications such as urethral bleeding, decreased blood pressures, and sustained and prolonged erections. In addition, in rare instances, feelings of lightheadedness or decreased blood pressure may occur.

It also is important to note that after inserting the suppository into the penile urethra, sexual stimulation is required to increase blood flow to the penis. Medication should be refrigerated, and maximum use is limited to one suppository per day.

Penile Injections

Penile injections are another treatment option for ED when oral medications are ineffective. Although the idea of inserting something into your penis is probably unappealing, thousands of men will testify to the effectiveness and ease of the injections.

In addition to two FDA approved medications called Caverject and Edex, urologists also use a combination of drugs, including papaverine, phentolamine and alprostadil. In most cases, a combination of two or three medications is used for injection. This combination, known as Trimix, allows for a synergistic effect of the three medications, while keeping the dose of each drug low enough to prevent side effects. In addition, the response rate of the Trimix solution is as high as 90 percent.

Men must receive appropriate training and education by their doctor before beginning home injection therapy. The goal of the injection medicine is to achieve an erection that is sustained for sexual intercourse, but not prolonged or painful. The injections must be given in proper amounts with the appropriate technique to minimize the risk of scarring the penis or developing priapism.

Penile Implant (Prosthesis) Surgery

For men with erectile dysfunction who do not tolerate or respond to other treatments, a penile prosthesis offers an effective, yet more invasive alternative because it requires surgery. Prostheses come in either a semi-rigid form or as an inflatable device. Most men prefer the placement of the inflatable penile prosthesis, which consists of a pump that contains the inflation and deflation mechanism.

Although the placement of the penile prosthesis requires surgery, patient and partner satisfaction rates are as high as 85 percent. However, it is important to note that full penile length might not be restored to the patient’s natural erect status.

Placing the prosthesis within the penis requires the use of an anesthetic. A skin incision is made either at the junction of the penis and scrotum, or just above the penis, depending on which prosthesis and technique is used. The spongy tissue of the penis is exposed and dilated; the prosthesis is then sized, and the proper device is placed. The inflatable device is placed is the scrotum. The patient can control his erection at will by pushing a button under the skin.

Side effects associated with penile prosthesis include infection, pain and device malfunction or failure. As the nerves that control sensation are not injured, the penile sensation and the ability have an orgasm should be maintained.

New and Emerging Therapies

Low-intensity extracorporeal shock wave therapy (Li-ESWT) — Low-intensity extracorporeal shock wave therapy, uses energy from acoustic waves to trigger a process called neovascularization in the penis.

When LI-ESWT is applied to an organ, the relatively weak yet focused shock waves interact with the targeted deep tissues where they cause mechanical stress and microtrauma, also known as shear stress. This shear force then triggers a chain of events that cause the release of angiogenic factors inducing neovascularization of the affected tissues and enhancing the blood flow. Extrapolation of these findings to ED has led to the assumption that if applied to the corpora cavernosa, LI-ESWT could improve penile blood flow and endothelial function by stimulating angiogenesis in the penis.

LI-ESWT is a simple relatively painless in-office procedure which is usually completed in 20 – 30 minutes. The shock waves are delivered to the corpora cavernosa of the penis along the penile shaft and the crura using a special probe attached to an electrohydraulic unit with a focused shock wave source. Typical treatment protocols consist of 2 treatments per week for 3 weeks.

Platelet-rich plasma (PRP) — Platelet-rich plasma therapy is a relatively new treatment for erectile dysfunction that uses a patient’s own plasma that is highly concentrated with platelets.
To prepare PRP therapy, a small sample of blood is drawn (similar to a lab test sample) and placed in a centrifuge that spins the blood at high speeds, separating the platelets from the other components. The concentrated platelet-rich component is then injected into specific areas of the penis to restore erectile function.

Where PRP seems most promising is in combination with low-intensity extracorporeal shock wave therapy (LI-ESWT). Although the exact science behind the effects of PRP is still not precisely understood, it is theorized that the growth factors present in platelets promote tissue recovery and healing. PRP used in conjunction with a neovascularization therapy, such as LI-ESWT, could result in greater improvements, likely due to additional tissue renewal, stimulated by the addition of platelets to the neovascularization process. Since the combined therapies are regenerative, PRP and LI-ESWT may produce long lasting results.

While research into the effectiveness of PRP therapy remains ongoing, it’s clear that the therapy itself carries minimal risk. Treatments may irritate tissue near the injection site, much like any use of hypodermic needles might. Typical complications from injections, such as infection, and or tissue damage, are no different than with other injection procedures. Risk of allergic reaction is minimal, given that the plasma is derived from the individual’s own blood.