Erectile Dysfunction

     Erectile dysfunction (impotence) affects millions of men. Unfortunately, many men are embarrassed and do not seek treatment. There is a social stigma attached to this problem, and in fact less than 15 to 20 years ago it was commonly believed that psychiatric causes were at the root of the problem in most patients. We now know that over 80% of cases have medical causes. There is no area in all of medicine that has seen as man advances in treatment, as has impotency over the past 10 years. Effective, minimally invasive treatment exists.

Normal Erectile Physiology

     In order to understand the causes of impotence, one must first recognize the way erections are formed. An erection occurs when blood flow is increased to the penis and blood outflow from the penis is decreased. As the penis becomes engorged with blood, it enlarges and hardens. This process is extremely complex, and our understanding of it is far from complete. It involves the interaction of cognitive factors (thoughts), hormonal factors, vascular factors, and neurological factors. Problems with any of these symptoms can result in impotence.

Common Causes of Erectile Dysfunction

     Organic impotence (erectile dysfunction) that is not psychiatric in nature has many causes. One common cause is medication; particularly psychiatric and anti-hypertensive medications can affect potency. Alcohol and drug use can also cause problems with erections. Diabetes is the most common disease associated with erectile dysfunction; it causes nerve damage as well as vascular disease, both of which play a role in erections. Vascular disease is also very common with aging and arteriosclerosis (hardening of the arteries) is prevalent in many impotent men. Hormonal causes of impotence are less common but must be explored, particularly in men with decreased libido (sexual desire). Lastly, neurological problems resulting from pelvic surgery can also lead to impotence.

Evaluation of Erectile Dysfunction

     A thorough history and limited physical exam will often reveal the cause of the problem. There are many tests available. In many patients, a lab test will be drawn to evaluate hormone levels to rule out hormonal imbalance. The patient can also perform nocturnal erection tests in the privacy of home to determine the presence of nighttime erections. In addition, a trial injection of a vasoactive medication may be both diagnostic and therapeutic. After an injection is performed, an ultrasound test is often used to measure blood flow into and out of the penis.

Treatment

     If behavioral problems such as excessive alcohol use are contributing to the problem, these should be corrected. If medications are causing the problem, they can often be changed. If these measures are unsuccessful, treatment must be instituted.

Oral Medications: Viagra, Cialis, Levitra

     The emergence of this class of medications has revolutionized both the diagnosis and treatment of erectile dysfunction. These agents act to potentiate the arterial dilation and subsequent increase in blood flow to the penis that normally occurs in a state of arousal. It is effective in many patients regardless of the cause of erectile failure, but does not work in all cases. It often fails in cases caused by inability to store blood in the erectile bodies, and can’t be taken by patients who are on any nitroglycerin containing medications, which are common among patients with vascular disorders. One potential problem is that many patients who do not have an organic dysfunction will be placed on this medication, which is not risk free. Rarely, patients have died as a result of taking these medications, particularly if they are taking nitroglycerin-containing medication. While minor temporary visual changes are not rare, (especially seeing a blue haze), blindness has been reported in extremely rare cases (less than one in one million).

Vacuum Erection Devices

     Another minimally invasive treatment is a vacuum-erection device. These are placed over the penis as a cylinder. When air is pumped out of the cylinder, erection occurs. A constricting ring is utilized to keep the blood in the penis. Why these devices may be regarded as too cumbersome for some patients, most patients are pleased with them and can be an excellent choice for some men.

Non-oral medications

     Penile injections are widely utilized and often work when oral medications fail. This involves the patient giving himself a shot in the penis, the injected medication causes an increased blood flow and erection occurs. Although some patients cannot stand the thought of self-injection, most patients are pleased with the results.

Surgical Therapies

     A penile prosthesis is an artificial implant that is placed surgically. There are several models, the most simple being the semi-rigid prosthesis, a one piece device that is firm enough to use but can be bent out of the way. These have no working parts and do not breakdown. Mechanical prostheses, on the other hand, have a pump mechanism that creates an erection. In most cases the pump is kept in the scrotum. These devices are more costly and can break down over time, but imitate a more natural erection. Surgery should be used as a last resort and patients should attempt to use other treatment modalities first. Once a penile prosthesis is placed, there is no returning to other treatment forms.