Erectile dysfunction (ED) is the inability to get or keep an erection firm enough for sexual intercourse. ED can be a total inability to achieve an erection, an inconsistent ability to do so, or a tendency to sustain only brief erections.
ED is a very common problem in older men. It affects about 30 million men in the US. Based on a large population study, some degree of ED was noted in 48% of men in their 50’s, 57% of men in their 60’s and 67% of men in their 70’s.
What causes erectile dysfunction?
Erectile dysfunction can have a psychologic or physical cause. Most men under 40 have psychologic ED caused by stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure. Although, medications may be helpful in this scenario, psychologic ED is best managed with use of psychotherapy using psychologists who use techniques that decrease anxiety associated with intercourse. Such techniques may also help relieve anxiety during treatment for ED from physical causes.
In older men, erectile dysfunction usually has a physical cause. An erection requires a precise sequence of events including nerve impulses in the brain, spinal column, and pelvis and appropriate response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa. Any disease, injury, or drug that affects the nerves or impairs blood flow in the penis has the potential to cause ED.
The most common cause of erectile dysfunction is from vascular disease. Aging and chronic medical diseases, such as diabetes, high blood pressure, and high cholesterol disease lead to atherosclerosis (deposition of cholesterol deposits) in penile blood vessels, which in turn limits flow during an erection. Lifestyle choices that contribute to vascular disease include smoking, excessive alcohol intake, obesity, and lack of exercise.
The second most common cause of erectile dysfunction is from nerve damage. This could be from chronic diseases (e.g., diabetes, multiple sclerosis) or from radical pelvic surgery (e.g., prostate, bladder, or colon/rectum removal).
In addition, ED can be a side effect of many common medicines, such as blood pressure medications, antihistamines, antidepressants, tranquilizers, and appetite suppressants.
Hormonal abnormalities, such as low levels of testosterone, are a less frequent cause of erectile dysfunction.
How is it treated?
The treatment depends on the cause and severity of the disease. Lifestyle changes, medication adjustment and psychotherapy/behavior modification should be utilized, along with standard medical therapy.
Oral medications using phosphodiesterase inhibitors (e.g., Viagra, Levitra, Cialis, and Stendra) are first-line therapy for management of ED. These medications have to be taken a few minutes to an hour prior to sexual activity and require sexual stimulation to be effective. They work by increasing the blood flow by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis. 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 these drugs because the combination can cause a sudden drop in blood pressure. The common side effects include headache, back pain, facial flushing, and vision changes.
In patients who do not respond to oral medication, second-line therapies include vacuum erection devices, intraurethral suppositories, and injectable medications.
Vacuum erection devices cause an erection by creating a partial vacuum around the penis, which draws blood into the corpora cavernosa, engorging and expanding the penis. An elastic ring is applied at the base of the penis after the erection is obtained to prevent the blood from flowing back into the body. The elastic ring should be removed within 30 minutes to restore normal circulation. Couples may find using a vacuum device to be cumbersome and the erection achieved may not feel like a natural erection. The penis may feel cold or numb and have bruising. 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.
Injectable medications that increase the blood flow can be injected into the penis using a tiny needle. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. Many men achieve stronger erections using injectable medications.
The injectable form of alprostadil is marketed as Caverject or Edex. These are expensive and may cause burning penile pain in up to 20% of patients. Trimix is a commonly utilized combination of 3 medications (papaverine, phentolamine and alprostadil) that can be compounded by a special pharmacy. It is cost-effective and has a lower incidence of penile pain after injection. However, it needs to be refrigerated after compounding.
All injectable medications can cause priapism (prolonged erections) and scarring of the penis with prolonged use (years). Priapism is reported in <1% of patients using penile injections and requires immediate medical attention to prevent permanent loss of erectile function.
MUSE is a system for inserting a pellet of alprostadil into the urethra. An erection will begin within 10 to 20 minutes and may last 30 to 60 minutes. The most common side effects are bleeding from the urethra and burning pain in the penis and testicles in up to a third of patients. The erection obtained is usually weaker than one obtained from penile injections.
What is penile implant surgery?
In patients with severe ED who do not respond to medical therapy, a penile implant (also called as penile prosthesis) is surgically placed inside the penis. These devices have been shown to have good satisfaction rates in patients and partners and can restore intimacy and a sexual life to many patients with ED. These implants are placed in an ambulatory setting (overnight stay) using a tiny incision (1”) in the scrotum.
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 the adjustment does not affect the width or length of the penis.
Inflatable implants consist of paired empty cylinders that are surgically inserted inside the penis. 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 when inflated and leave the penis in a more natural state when flaccid.
Once a man has either a malleable or inflatable implant, he must use the device to have an erection, as natural or medication-assisted erections will not be possible. Complications with implants include mechanical failure (<10%), deformity (<10%), infection (2-3%), and chronic pain (1%).
The urologists at Medstar Health provide the whole range of medical and prosthetic surgical therapies for treatment of ED.