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Male Erectile Dysfunction - Treatment Options

Lorraine Benuto, Ph.D., edited by C. E. Zupanick, Psy.D.

a) Medications (a.k.a., Viagra ©) The dawn of oral medications has truly revolutionized the treatment of erectile dysfunction. If you recall, we stressed the importance of the neurotransmitter nitric oxide in the development of an erection. Oral Phosphodiesterase Type 5 (PDE-5) inhibitors work by stopping Phosphodiesterase Type 5 (an enzyme) from blocking the biochemical changes necessary for an erection to occur (i.e., the production of nitric oxide, which allows for smooth muscle relaxation). Basically, PDE-5 inhibitors don't cause an erection, but rather block what prevents the erection. Thus in response to sexual stimulation, veins dilate and blood fills the corpus cavernosum applying pressure to the veins in the penis, keeping the blood trapped inside. It is important to note that PDE-5 inhibitors are not aphrodisiacs nor will they produce a spontaneous erection. They require sexual stimulation to be effective.

PDE-5 inhibitors remain the first-line of therapy for the treatment of erectile dysfunction for many men (although not all men are candidates for this type of medication). Since the development of Sildenafil Citrate (a.k.a. Viagra ©) and its approval by the Food and Drug Administration in 1998, two additional PDE-5 inhibitors have been approved for the treatment of erectile dysfunction: Vardenafil (a.k.a. Levitra ©) and Taladafil (a.k.a. Cyalis ©). While there are subtle differences in these 3 medications, they are similar in the mechanism of action and efficacy. In fact, chemically speaking, Viagra © and Levitra © are practically identical and both remain in the body approximately 4-6 hours. Cyalis © on the other hand, remains in the body much longer (approximately 17-36 hours). All three medications must be metabolized before they are effective (they each take approximately 1 hour to make their way into the body); generally this means that sexual activity must be planned. From the perspective of a clinician or a therapist, Cyalis' © long life has its benefits. Many couples have a difficult time adjusting to the need to plan for sexual activity. Because Cyalis © remains in the body for 17-36 hours, there is larger window of time during which sexual activity can "spontaneously" occur. But, not all couples are bothered by the need to plan for sex. On the contrary, some couples are quite pleased to plan for sexual activity because they find it increases the chance that sexual activity will actually occur. Considering that Americans lead quite busy lives, sometimes planning sexual activity becomes the only way to make it happen! On the downside, because all three medications cannot be taken with certain other medications (i.e., nitrates) the long life of Cyalis © can be problematic. Imagine if you had to be rushed to the hospital and needed a dose of nitrates to survive (i.e., in the event of a heart attack). If Cyalis © is still in your system, taking nitrates could be fatal whereas the shorter life of Levitra © and Viagra © would make it less likely that you would encounter this situation.

The effectiveness of these medications has been studied in the general population as well as in special populations. PDE-5 inhibitors have been found to be effective with men who have diabetes, spinal cord injury, radical prosectomy, multiple sclerosis, post-radiation therapy for prostate cancer, and depression. It is important to remember that there are many factors that can impact the effectiveness of the PDE-5 inhibitors. For example, having a poor relationship with your physician can affect whether or not you: 1) choose to ask questions, 2) understand how you are supposed to take the medication, and 3) return for follow-up appointments. Because proper dose optimization and follow-up are necessary for the treatment to be successful (Ellsworth& Kirshenbaum, 2008), it is important that you seek out a physician that you are comfortable with, and that you ask any questions that you might have. An additional relationship that can impact the effectiveness of the PDE-5 inhibitors is the relationship you have with your partner. As mentioned above, in order for PDE-5 inhibitors to work, sexual stimulation is necessary. Having a good relationship with your partner can facilitate that you engage in sexual activity that promotes good sexual stimulation. Finally, disease and drug-use can also impact the effectiveness of the PDE-5 inhibitors.

Despite the popularity of these new drugs, not all men are candidates for PDE-5 inhibitors. Individuals who take nitrates (i.e., Nitro-Bid, Nitrolingual, Nitrostat) cannot take PDE-5 inhibitors. Because both nitrates and PDE-5 inhibitors relax the vascular muscle and cause the blood pressure to lower, the combination of the two can be fatal. On this note, it is important to be aware that PDE-5 inhibitors do reduce blood pressure. While individuals who take blood pressure medication can take PDE-5 inhibitors, it is recommended that they be taken at least 4 hours apart. Individuals who have liver or kidney problems should only take PDE-5 inhibitors in small doses. Individuals who have had a recent heart attack, unstable angina, uncontrolled blood pressure, or Retinitis Pigmentosa cannot take PDE-5 inhibitors. This is not an exhaustive list of contraindications for PDE-5 inhibitors. It is important that you discuss all physical and psychological conditions you have with your doctor as well as providing a complete list of all medications you are taking (including so-called natural treatments).

As with all medications, PDE-5 inhibitors have side effects. Common side effects include: headache, reddening of the face, changes in vision (i.e., blue tinge) or hearing, reduced blood pressure, and dizziness. Another side effect that can occur with the use of PDE-5 inhibitors is called Priapism. Priapism is an erection, usually painful, lasting more than 4 hours. It is important that you seek out medical treatment immediately if you experience Priapism. This is not an exhaustive list of side effects and if you seek out this medication from your physician it is very important that you discuss potential side effects as well as any other concerns you might have.

When considering PDE-5 inhibitors, remember that other important considerations must be made. Because sexual activity often involves two people, it is very important that you discuss this with your partner. Oftentimes, men seek out Viagra ©, Levitra ©, or Cyalis © without first consulting their partner. They then approach the partner and find themselves rejected. While discussing sexual difficulties can be difficult, a relationship is much more than a successful erection. Communication is very important. You may want to ask your partner their opinion, discuss potential side-effects, and share with them that sexual activity may require planning. You and your partner may want to review the section LINK TO A GUIDE FOR PARTNERS

You may also want to keep in mind that these medications will impact the frequency with which you can engage in sexual activity. For many men, this means an increase from the present, but a decrease from the past. Having realistic expectations of your partner, and yourself, help to prevent unproductive resentments and misunderstandings from developing. Thus, it is often helpful to be reminded that sexual relationships are about quality and not quantity.

b) Vacuum Constriction Device: The Vacuum Constriction Device continues to be an alternative for individuals who are not candidates for other treatment options. It was created by Geddings Osbon in the 1960s to treat his own erectile dysfunction. It essentially allows for passive engorgement of the penis in conjunction with a band that is placed at the base of the penis to retain blood within the corpus cavernosum.

While there are many different types of devices, most consist of a clear plastic cylinder, a manual or battery-operated pump, and tension rings. The device requires the use of water-soluble, alcohol-free lubricant. This can be purchased at most pharmacies. It is important that only the recommended lubricant be used because lubricants that contain alcohol, oil, or petroleum can damage the device. To use the device, the lubricant is placed on the end of the clear plastic cylinder. The tension rings are then slipped on the lubricated end of the clear plastic cylinder. The pump is inserted into the other end of the cylinder. Using lubricant to create a seal, the cylinder (the end with the tension ring) is placed over the penis with the end of the cylinder closely nestled against the pubic region. The pump is then used to remove the air that is inside the plastic cylinder creating a vacuum inside the cylinder, and allowing blood to enter the penis. Once an erection is achieved, the tension ring is slid off of the cylinder and onto the base of the penis where it remains during sexual activity. It is absolutely crucial to be aware that there is a time limit when using this device. Because the tension ring causes constriction it is of utmost importance that it not be left on the penis for longer than 30 minutes.

The vacuum device is quite effective and some men report regaining the ability to have spontaneous erections after using the vacuum device for a long period of time. The vacuum device can also be used to help improve penile health. Normal, nocturnal erections (night-time erections) bring blood to the penis, providing nourishment to the tissue in the penis. With the passage of time and age, many men no longer experience nocturnal erections. The vacuum device artificially brings blood to the penis and some health care providers recommend using the device without the tension rings, a few times a week to provoke an erection, maintain it for about 1 minute, and then release it. If you are interested in obtaining additional information about the vacuum constriction device for sexual or penile health purposes, you should discuss your interest with your health care provider before trying the vacuum constriction device.

Although the vacuum constriction device tends to be a fairly successful means of achieving and maintaining a penile erection, some men do complain of pain, ejaculatory difficulties, bruising, and numbness. Additionally, it may be difficult for a couple to adjust to having to use such a mechanism to engage in sexual activity. If you are considering trying the vacuum constriction device, it is important that you discuss this with your partner. You may find that you are able to incorporate the vacuum constriction device into your foreplay activity.

c) Vascular Penile Surgery: Vascular penile surgery is a relatively delicate procedure that is rarely used. It is similar to a delicate surgery that is performed on the heart. Essentially, special imaging techniques are used to determine whether or not there is an "escape" or obstruction that is not allowing the blood to get to the penis. If an escape route or obstruction is identified, it is repaired through this very delicate procedure. This surgery is quite costly, is temporary, and not very effective among older adults.

d) Penile Prosthetic Implant: The penile prosthetic implant remains a last-resort treatment option for men with erectile dysfunction. There are essentially three types of prosthetic impacts, semi-rigid, multi-component inflatable, and single-component inflatable. The semi-rigid implant consists of a flexible wire covered in silicone that allows the penis to be manually moved so that it is erect if bent up and upon being bent it can be tucked discreetly inside underwear. The inflatable implants utilize a pump (inserted into the scrotum) that when activated causes (by pressing it with the fingers) the prosthetic implant to be filled with saline solution. In all cases, two cylinders made of silicone are surgically inserted in the corpus cavernosum of the penis.

The penile prosthetic implant is a very effective way to treat erectile dysfunction; however, it is very important that the individual who is undergoing the surgery be aware of the permanent and likely irreversible effects of the surgery. Very few men will ever recover their natural erectile abilities after the surgery. The prosthetic implant destroys the corpus cavernosum of the penis, and with that the ability for the man to have natural erections. Thus, it is important that the prosthetic implant be considered only as a last alternative, and not a temporary treatment alternative. It is also important for one's partner to be included in the decision process as adjustments must be made in the sex lives of both people. For example, sexual positions must be chosen that provide the minimum amount of pressure on the prosthetic implant (e.g., the woman on top is not recommended). Recovery time after the surgery is approximately 4-6 weeks for healthy individuals and longer for individuals who have a physical illness (e.g., diabetes). As with all surgeries, there are risks and possible complications. Infections can occur and in some instances the body may reject the prosthetic implant.

e) CaverJect ©: In the early 80s doctors discovered that if certain prostaglandins (substances that act like hormones) are injected directly into the corpus cavernosum of the penis, an erection results. It is important to be aware that this medication should be prescribed by an urologist and the first time the injection occurs should be within the office of the urologist. After that, your or your partner will be responsible for administering the injection. While many men cringe when they hear this, the needle used for the injection is small (the type used for diabetes) and patients don't typically complain of the pain associated with the prick but rather a burning sensation when the medication disperses. The injection must always occur on the lateral areas (sides) of the penis as the urethra runs below and important arteries run above. The site of injection should be alternated so that a callous does not form which could result in painful curvature of the penis. While this treatment method is quite effective, side effects include priapsim, pain, and fibrosis.

f) Intraurethral Alprostadil (MUSE) ©: Intraurethral Alprostadil (MUSE) © provides an alternative to intracavernous injection therapy and can be used by individuals who cannot take PDE-5s because of contraindications and/or because the treatment was not successful. To use the MUSE the male must first urinate to lubricate the urethra. The medication is then inserted through the urethra via a suppository that contains a soft pill. The man is then instructed to hold the penis upward while massaging the penis so that the soft pill can dissolve. The medication is then absorbed by the membranes that line the walls of the urethra. The medication causes the corpus cavernosum to relax thus allowing blood flow to augment and an erection to be produced. It takes approximately 10 minutes for the erection to develop and it can last up to one hour. Potential side effects include pain, a burning/stinging sensation as the medication is absorbed, and laceration of the urethra.