Erectile Dysfunction

Erectile dysfunction (ED) is an ailment that traditionally has been thought of as a condition that impacted men who are older.

However, that stereotype has faded away with the advent of the “little blue pill” and the ED dialogue is now openly discussed among men young and old.

Technically, erectile dysfunction is the inability to achieve and/or maintain an erection adequate for sexual intercourse.

A few causes of Erectile Dysfunction:

• Coronary artery disease
• Peripheral vascular disease
• Tobacco use
• Alcohol and substance abuse
• Medications such as anti-psychotics, anti-hypertensive
• Fatigue
• Stress
• Obesity
• Depression
• Thyroid disase
• Diabetes
• Elevated cholesterol
• Neurological disease such as Parkinson’s disease, multiple sclerosis, spinal cord injury
• Peyronie’s disease – development of plaque / scar tissue along the shaft of the penis
• Nerve damage due to pelvic surgery or radiation therapy

Workup for ED includes a detail history and physical examination. In addition, other studies maybe indicated including:

• Laboratory studies may include a check for low testosterone, thyroid disease, and diabetic screening (if suspected)
• Penile doppler study to asses blood flow and also screen for venous leakage; Such a study maybe accompanied by the injection of a medication to induce an erection occasionally
• Nocturnal penile tumescence test (Snap-Gauge band) screening for erection when the individual is asleep

Any hormonal imbalance detected during workup will usually be addressed.

In most cases, patients will also need to either treat any other medical condition that maybe under poor control such as the correction of diabetes or thyroid disease if present.

If an individual continues to experience erectile dysfunction then the use of oral medications is usually preferable. This class of medication is called phosphodiesterase inhibitors (PDEs) and is designed to reduce the break down of nitric oxide in the blood stream leading to greater relaxation of the musculature found in arterial blood vessels.

A few Erectile Dysfunction Medication:

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

Patients who fail oral therapy can also consider the following:

• Penile injection of vasodilating agents (single agent / Trimix / Quadmix) directly into the corpus cavernosum
• Insertion of an intraurethral vasodilation agent called MUSE
• Use of a constriction band in conjunction with medication.
• Use of a vacuum erection device

Surgical correction of erectile dysfunction is certainly another option for men who have failed to respond to more conservative therapies.

Men who suffer primarily from ED but do not have issues with penile curvature will often benefit from the placement of a penile prosthesis.

The two types of penile prosthesis currently available are semi-rigid penile prosthesis and inflatable penile prosthesis.

A semi-rigid penile prosthesis is usually a self-contained pair of malleable rods that are placed in the corpus cavernosum. When the individual is not engage in sexual activity, the penis can be flexed against the pubic symphysis or along the thigh.  However, when engage in sexual activity the individual can bend the penis into an erect position to allow for sexual intercourse.

An inflatable penile prosthesis, on the other hand, is a much more dynamic device.  The basic component of any penile prosthesis involve a reservoir to hold the fluid that provide the erection when moved into the penile cylinders as well as control pump which directs the fluid between the reservoir and cylinders.  When the patient is not in an erect state, the majority of fluid is located in the reservoir.  When the patient is engaged in sexual activity, he will press on the control pump several times to move fluid from the reservoir toward the cylinders that are implanted into the corpus cavernosum.

The risks associated with any implant are mechanical failure and erection. Patients receiving an implant should be counseled carefully on expectation. Quite often despite a successful implantation, most recipients may complain of a loss of length.

Neither implant will enhance the glans penis, which normally becomes engorge during sexual activity.

If an individual receiving an implant also suffers from Peyronie’s disease, we will often perform a procedure to correct the curvature during the same procedure.

Such procedures can include:

• Penile mottling
• Nesbitt plication
• Excision of plaque and placement of tissue graft

For individuals who can achieve an erection but has Peyronie’s disease, a new option for treating the penile curvature is the injection of a collagenase enzyme (Xiaflex) directly into the plaque to try and dissolve it.

Individuals who fail Xiaflex therapy or are not ideal candidates for it can also consider the following options:

• Nesbitt plication
• Excision of plaque and placement of tissue graft

Risks associated with Peyronie’s treatment include but are not limited to:

• Increase risk of penile fracture
• Shortening of penile length
• Loss of tactile sensation
• Deformity of the shaft such as a divot over the sight of repair