My Penis Stuff

Examples

Depo-Testosterone/Virilon IM (testosterone cypionate), Andryl/Arderone (testosterone enanthate), Androderm/AndroGel/Testoderm transdermal (testosterone), Parlodel (bromocriptine mesylate), Dostinex (cabergoline).

These medications can be used to treat men who have high prolactin levels, which can reduce the amount of testosterone produced by the body and may lead to problems such as infertility or erection problems. Bromocriptine and cabergoline are taken by mouth.

What To Think About

When considering hormonal therapy for erection problems, it is important to include your partner in your decision.

During the first year of testosterone therapy, you should receive a prostate examination, a PSA blood test, a complete blood count, and a liver function test every 3 to 6 months.

Although replacement of testosterone through injections or patches can improve a man’s libido, it does not always improve a man’s ability to have an erection.

Cabergoline given weekly is as effective as daily doses of bromocriptine and may be associated with fewer side effects. Prolactin levels should be monitored monthly.

Tests for erection problems can help find a cause for a man’s problem in having or maintaining an erection (erectile dysfunction or impotence). Erectile dysfunction is a common male problem. Most erection problems are caused by a combination of blood vessel, nerve, or psychological issues.

Physical conditions that may cause erection problems include:

• Problems with the nerves of the penis. Conditions such as multiple sclerosis or diabetes may cause nerve damage that affects a man’s ability to have an erection. Also, surgery, injury, or radiation treatment to the pelvic area may cause damage to the nerves of the penis.
• Problems with the blood vessels that supply blood to the penis. Conditions such as hardening of the arteries (atherosclerosis) may make it difficult for a man to have an erection. Activities such as long-distance bicycle riding on a hard, narrow saddle may increase a man’s risk for having an erection problem. See an illustration of blood supply to the penis.
• Low levels of hormones, such as testosterone or thyroid hormones.
• Side effects of medicines, such as medicines taken for high blood pressure (hypertension) or depression.
• The use of tobacco, alcohol, or illegal drugs.

Psychological tests may be needed if no physical cause is found for an erection problem. Psychological causes of erection problems may include:

• Anxiety about sexual performance.
• Relationship problems.
• Stress.
• Depression or grief.

Tests for erection problems includes a sexual history and physical examination. A physical examination includes checking your blood pressure. Your penis and testicles are also checked for any problems. Blood tests for testosterone, luteinizing hormone (LH), prolactin, and thyroid hormone levels are usually done. Other blood tests that may be done include a complete blood count (CBC), blood glucose, cholesterol, and triglyceride. A urine test may also be done. If these results are normal, many doctors will have you try a medicine, such as sildenafil citrate (Viagra), tadalafil (Cialis), or vardenafil (Levitra), before doing more tests.

More tests for erection problems may include a nocturnal penile tumescence (NPT) test or an intracavernosal injection test.

Nocturnal penile tumescence (NPT) test

The NPT test may also be called the stamp test or the rigidity test.

Most men have 3 to 5 full erections during deep (rapid eye movement or REM) sleep. Men who do not have erections because of psychological problems can still have erections during deep sleep. Occasionally, some sleep problems or serious depression can prevent these normal nighttime (nocturnal) erections.

The NPT test sees whether a man is having normal erections during sleep. This test can be done at home or in a special sleep lab. One of two ways may be used.

• A simple ringlike device called a snap gauge made up of plastic films is fitted around the penis. The films break at certain pressures. So an erection during sleep will cause the film to snap.
• An electronic monitoring device is more expensive than using the snap gauge, but it is more accurate and gives more detailed information about erections during sleep. This device records how many, how long, and how rigid the erections are during sleep.

Tests are usually done for at least two nights in a row. If good erections occur during sleep, the cause of the erection problems probably is not physical.

Intracavernosal injection test

During this test, the doctor injects a medicine (usually prostaglandin E1) into the base of the penis to make an erection. This is called an intracavernosal injection. A similar medicine may also be placed into the urethra, the tube through which urine leaves the penis. This is called an intraurethral injection. The fullness and how long the erection lasts is measured.

Doppler ultrasound test

Doppler ultrasound (also called color duplex Doppler) uses a handheld tool passed lightly over the penis. The tool uses reflected sound waves to estimate the speed and direction of blood as it flows through a blood vessel. The sound waves go to a computer that changes the sounds to colors that are overlaid on a picture of the blood vessel. This shows the speed and direction of blood flow.

Why It Is Done

Tests for erection problems are done to help find whether the cause of an erection problem is physical, psychological, or a combination of both.

Scientists once believed erectile dysfunction (ED)—was a problem only of the mind and not of the body. But recent data suggest a physical (or organic) cause in more than half of all cases, especially those involving older men. In any case, experts believe it affects up to 30 million American men. But what is involved in impotence and what is available to correct it? The following information should help you talk to your urologist about this frustrating issue, and some of the options—including vascular surgery—that may help solve it.

What happens under normal conditions?

The internal structure of the penis includes two cylinder-shaped chambers, the corpora cavernosa. Filled with spongy tissue containing smooth muscles, fibrous tissue, veins and arteries, these chambers run the length of the organ and are surrounded by a membrane cover, called the tunica albuginea. The urethra, the channel through which urine and semen exit the body, is located on the underside of the corpora cavernosa and is surrounded by spongy tissue. The longest part of the penis is the shaft, which ends in the glans. The meatus is the opening at the end of the urethra.

Erection is the culmination of a complex set of physical, sensory and mental events, involving both the nervous and vascular systems. It begins when physical or psychological stimulation (arousal) causes neurotransmitters or impulses in the brain (chemicals such as dopamine, acetylcholine and nitric oxide) to tell the muscles of the corpora cavernosa to relax, allowing blood to fill the organ’s tiny open spaces. As the tunica’s fibrous or elastic tissues trap the blood, the penis engorges, or increases, in an erection. When stimulation finally ends, usually after ejaculation, pressure inside the organ decreases, as the muscles contract. Blood then flows from the penis and the penis returns to its normal shape and size.

What is erectile dysfunction (ED)?

Erectile dysfunction refers to the inability of a man to attain and maintain an erection sufficient for intercourse. It occurs when there is reduced blood flow to the penis or nerve damage, both of which can be triggered by a variety of factors. Scientists once believed that ED was an emotional issue alone. But today they know that physical factors are just as important as psychological triggers—stress, marital/family discord, job instability, depression and performance anxiety—in provoking this problem. It is important to note that hundreds of medications can also contribute to impotence while they fight allergic reactions, high blood pressure, ulcers, fungal infections, anxiety, depression and psychoses.

Who is at risk for erectile dysfunction (ED)?

A man is at risk if they suffer from:

Vascular diseases: Hardening or narrowing of arteries, often associated with high cholesterol, can also restrict blood flow to the penis, particularly if you are over 60. Because smoking can lead to any of the factors responsible for vascular problems—such as high blood pressure—it is probably an important factor in both arterial disease (atherosclerosis) and ED.

Neurologic disorders: Spinal cord diseases or injuries, brain injuries, multiple sclerosis, Parkinson’s disease and other progressive diseases can interrupt nerve impulses to and from the brain. Diabetes poses both neurological and vascular problems because it damages small blood vessels and nerves throughout the body, impairing the impulses and blood flow necessary for an erection.

Other conditions/illnesses: In addition, other chronic illnesses such as cancer and well as hormonal imbalances and penile disorders can disrupt the nerve impulses and blood flow necessary for normal erections.

What are the symptoms of erectile dysfunction (ED)?

Failing to achieve and/or sustain an erection is the primary sign of ED. But diagnosing the specific cause and prescribing appropriate treatment usually require a variety of tests, beginning with a complete history and physical examination.

Your doctor may order additional laboratory tests to assess any conditions that may be interfering with normal erectile function, particularly arterial flow to the penis. A blood test, for instance, is normally used to reveal blood lipids and triglycerides, both of which indicate atherosclerosis if elevated. A urinalysis identifies protein and glucose levels that can suggest diabetes.

While these analyses focus on your chemical status, erectile function tests are the principal tools your doctor will use to tell how the blood vessels, nerves, muscles and other tissues of your penis and pelvic region are working. Among them, penile nerve function tests—squeezing the head of the penis and measuring various responses—can determine if there is sufficient sensation in the penis. Nocturnal penile tumescence (NPT), or healthy involuntary erections during sleep, may rule out psychological issues and instead suggest nerve function or blood supply problems.

An imaging technique called duplex ultrasound may also be used. It monitors the behavior of moving structures and might provide some of the best data since it can evaluate blood flow, vein leaks, scarring of erectile tissue and some signs of atherosclerosis. During the test, an erection may be produced by injecting the stimulator prostaglandin into the body and then measuring vessel expansion and penile blood pressures, both of which are compared to the limp penis. In either case, duplex ultrasound can illustrate a specific blood vessel disease that may rule out a need for vascular surgery.

How is erectile dysfunction (ED) surgically treated?

The past several decades have ushered in a new treatment era for ED. Because of the advent of many advances, today urologists are helping millions of impotent men perform better and longer.

Penile prostheses: Surgically implanted devices to ensure stiffness have become highly reliable therapeutic solutions. Vacuum erection devices have proven to be safe alternatives in stiffening the penis by drawing blood into the organ with a pump and holding it with an “occluding band.” Penile injection therapy is a relatively quick and effective way to send vasoactive drugs directly into the corpora cavernosa where they expand the vessels, relax the tissue and increase blood flow for an erection. Furthermore, the pills: sildenafil, tadalafil and vardenafil have become the treatments of choice for millions of men who have experienced the drugs’ ability to boost levels of cyclic guanosine monophosphate (cGMP), a chemical factor in metabolism responsible for relaxing blood vessels.

Vascular surgery: Although options are varied, not everything is for everyone. In fact, two vascular approaches developed over past decades to restore penile blood flow disrupted by disease or traumas are useful for only a select few.

Penile arterial revascularization: This procedure is designed to keep blood flowing by rerouting it around a blocked or injured vessel. Indicated only for young men (under 45) with no known risk factors for atherosclerosis, this procedure is aimed at correcting any vessel injury at the base of the penis caused by adverse events such as blunt trauma or pelvic facture. When such an event leaves a penile vessel too injured or blocked to transfer blood, the surgeon may microscopically connect a nearby artery to get around the site, clearing the pathway so enough blood can be supplied to the penis to enable an erection.

Venous ligation surgery: This procedure focuses on binding leaky penile vessels that are causing penile rigidity to diminish during erection. Because venous occlusion, necessary for sufficient firmness, depends on arterial blood flow and relaxation of the spongy tissue in the penis, this approach is designed to intentionally block off problematic veins so that there is enough blood trapped in the penis to create an appropriate erection. Since long-term success rates are less than 50 percent, this technique is rarely a choice for correcting ED.

In fact, you are not a candidate for either penile vascular surgery if you have insulin-dependent diabetes or widespread atherosclerosis. You are also not suited if you still use tobacco or experience consistently high blood serum cholesterol levels. Neither of these surgeries will work if you have injured nerves or diseased and/or generalized damaged blood vessels. Also, if you are a candidate, be aware that vascular surgeries are still considered experimental by some urologists and may also not be covered by your insurance.

What can be expected after surgical treatment for erectile dysfunction (ED)?

Most of the best known treatments for ED have excellent track records for being both effective and safe. But in making your choice, make sure to discuss the potential complications of each option with your doctor.

For instance, the good news about a penile prosthesis is that it does not usually affect urination, sex drive, orgasm or ejaculation. But on rare occasions, these semi-rigid, silicone-covered metal rods or hydraulic devices can cause pain or reduced sensation. While injections can initiate erections within 15 minutes to several hours, be aware that they also can produce prolonged or painful ones, not to mention a scarring of penile connective tissue (fibrosis).

At the same time, a vacuum erection device should take only one to three minutes to give an erection, usually with no serious side effects if used properly. However, the use of the erection device to maintain the erection is limited to 30 minutes.

Sildenafil, tadalafil and vardenafil have 75 percent success rates, primarily because they are a subtle solution that works within the hour. But on rare occasions they can cause headaches, flushing, indigestion or muscle aches. Also, if you have heart disease or low blood pressure, the Food and Drug Administration (FDA) cautions a thorough examination before getting a prescription. You cannot take these drugs if you are taking nitroglycerine or any similar drug.

Penile arterial revascularization can restore function in men, although only a small percentage of them undergo the procedure. While few patients experience postoperative complications, side effects can include penile scarring, numbness and shortening all of which can cause further impotence.

Venous ligation surgery, although rare, is also known to cause penile shortening, along with other problems. Also, improvements with venous ligation surgery may be temporary.

When is venous surgery for erectile dysfunction successful?

It has been most successful in young men with abnormally draining veins since birth who have never had a full erection. It has also been used in some patients with an injury to the covering tunica albuginea or the corpora cavernosa.

I am interested in vascular surgery, what should I be aware of?

Realize this is not a surgery for everyone. If you meet the criteria mentioned previously, you will want to find a specialist with a track record of having done these microsurgical techniques. Be aware, however, that penile vascular solutions are still experimental; few specialized urologists or vascular surgeons are trained to do either procedure. If your doctor is not one of them, you will need to ask for a referral. You will also want to get a second opinion if this treatment option is recommended, given that there are few patients who are good candidates.

If I choose vascular surgery, what should I ask my surgeon?

Once you have found a surgeon, ask about his or her experience and outcome record with penile arterial revascularization. Make sure that you understand the potential outcomes and possible complications. Also, ask how the particular approach stacks up against other treatment choices for you. For instance, vacuum devices and oral or injection therapies still work for some people. Penile prostheses, the most widely used surgical technique for ED, usually have a more favorable outcome than vascular techniques.

Is age a factor in impotence?

Yes. Data suggest that while not an inevitable part of aging, the risk of impotence increases as we grow older. About 5 percent of men at age 40 complain of the problem, while between 15 and 25 percent at age 65 experience it. Some experts suggest the numbers may be underreported since men are still embarrassed by this physical and psychological issue. However, the reassuring news is that it is treatable in all age groups.

What should I remember about erectile dysfunction?

Also called impotence, ED is the consistent inability to sustain and maintain an erection, is a widespread problem. It may affect as many as 50 percent of men between ages 40 and 70. Luckily, doctors can identify physical causes involving blood flow, nerves or other mechanical issues involving the penis, which can also be addressed with modern technology. In fact, oral drugs, vacuum devices, injectable medications, psychotherapy and even surgery have made impotence very treatable. The promising news is that new drugs are sure to join existing non-invasive treatments while other experimental options, such as gene therapy, are on the horizon. In addition, ongoing modifications of today’s standard treatments will eventually improve the picture for impotent men.

Erectile dysfunction (ED) is the inability of a man to attain and/or maintain an erection sufficient for sexual activity. Fortunately, most men who have ED only lose the ability to have satisfactory erections. In other words, for most of these men, penile sensation is normal and the ability to have an orgasm and ejaculate (The fluid that is expelled from a man’s penis during sexual climax (orgasm). To release semen from the penis during an orgasm.) remains. Today, there are several treatment options available to men suffering from this disorder. Lifestyle changes are the first line of treatment with weight loss, smoking cessation and exercise associated with improved erections. For most men, the initial medical treatment will be an oral medication such as sildenafil citrate. If this treatment is unsuccessful, second-line treatment options are ordinarily considered. These include using a vacuum erection device (A device used for treatment of impotence that features a pump that draws air from a plastic cylinder placed over the penis and creates a vacuum that allows increased blood flow to the penis which causes and erection.), intraurethral medication (Medication administered via the urethra, the tube that carries urine outside the body from the bladder.) or penile injection therapy (Treatment for impotence that utilizes a combination of drugs that are injected into the side of the penis. The drugs relax the muscles and increase blood flow to create an erection.). If these second-line treatments fail or if the patient and his partner reject them, then the third-line treatment option, penile prosthesis implantation, is considered.

What are penile prostheses?

Penile prostheses are devices that are implanted completely within the body. They produce an erection-like state that enables the man who has one of these implants to have normal sexual intercourse. Neither the operation to implant a prosthesis nor the device itself will interfere with sensation, orgasm, ejaculation or urination. What are the different types of penile prostheses?

There are two erection chambers (corpora cavernosa) in the penis. All penile prostheses have a pair of components that are implanted within both of these erection chambers. The simplest penile prostheses consist simply of paired flexible rods that are usually made of medical-grade silicone, and produce a degree of permanent penile rigidity or firmness that enables the man to have sexual intercourse. These devices are either malleable (Able to be shaped or bent.) or inflatable. A malleable rod prosthesis can be bent downward for urination or upward for intercourse. Inflatable penile prostheses are fluid-filled devices that can be inflated for erection. They are the most natural feeling of the penile implants, as they allow for control of rigidity and size.

The inflatable devices have fluid-filled cylinders that are implanted within the erection chambers. Tubing connects these cylinders to a pump that is implanted inside the scrotum (Also referred to as the scrotal sac. The sac of tissue that hangs below the penis and contains the testicles.), the sac that contains the testicles (Also known as testis. Either of the paired, egg-shaped glands contained in a pouch (scrotum) below the penis. They produce sperm and the male hormone testosterone.). In the simplest of these inflatable devices, the pump transfers a small amount of fluid into the cylinders for erection, which then transfers out of the cylinders when erection is no longer needed. These devices are often referred to as two-component penile prostheses. One component is the paired cylinders and the second component is the scrotal pump.

Three-component inflatable penile prostheses have paired cylinders, a scrotal pump and an abdominal fluid reservoir. With these three-component devices, a larger volume of fluid is pumped into the cylinders for erection and out of the cylinders when erection is no longer needed.

What does penile prosthesis implantation involve?

Penile prostheses are usually implanted under anesthesia. Usually one small surgical cut is made either above the penis where it joins the abdomen or under the penis where it joins the scrotum. No tissue is removed, blood loss is small and blood transfusion (The transfer of blood from a healthy donor into the bloodstream of somebody who has lost blood or has a blood disorder.) is almost never required. A patient will typically spend one night in the hospital.

Most men have pain after penile prosthesis implantation for about four weeks. Initially, oral narcotic pain medication is required and driving is prohibited. If men limit their physical activity while pain is present, it usually resolves sooner. Men can often be instructed in using the prosthesis for sexual activity one month after surgery, but if pain and tenderness are still present, this is sometimes delayed for another month.

What are the complications of penile prosthesis surgery?

Infection occurs in 1 to 5 percent of cases. This is a significant complication because in order to eliminate the infection, it is almost always necessary to remove the prosthesis. In 1 to 3 percent of cases, erosion (The wearing away of surface tissue by disease, ulceration, cancer or the chemical processes associated with inflammation.) occurs when some part of the prosthesis protrudes outside the body. Erosion often is associated with infection and removal of the device is frequently necessary.

Mechanical failure is more likely to occur with inflatable than with rod prostheses. The fluid present inside the inflatable prosthesis leaks into the body; however, these prostheses contain normal saline (Containing salt.) that is absorbed without harm. After mechanical failure, another operation for prosthesis replacement or repair is necessary if the man wants to remain sexually active. Today’s three-component inflatable penile prostheses have about a 10 to 15 percent likelihood of failure in the first five years following their implantation.

Frequently asked questions:

Is penile prosthesis implantation covered by insurance?

Although all third-party payers do not cover penile prosthesis implantation, most including Medicare do if the prosthesis is implanted to treat erectile dysfunction caused by an organic disorder.

Will a penile prosthesis interfere with urination?

It normally does not.

Erectile dysfunction (ED) is a medical term that describes the inability to achieve and or maintain an erect penis adequate for sexual function. This condition is one of the most common sexual problems for men and the number of men suffering from ED increases with age. Approximately 25 million American men suffer from ED, although not all men are equally distressed by the problem.

What happens under normal conditions?

Achieving a normal erection is a complex process involving psychological impulses from the brain, adequate levels of the male sex hormone testosterone (Male hormone responsible for sexual desire and for regulating a number of body functions.), a functioning nervous system, and adequate and healthy vascular tissue in the penis. The simplest way to describe the process of erection is to think of a washing machine. The “on-off” switch (the brain) initiates the process; the wires in the washing machine (the nerves) carry the electrical signal to the pipes (the blood vessels), when an appropriate signal arrives a valve opens to allow water to flow in (the arteries carry blood into the penis) and the drain shuts (the penile veins close). Water flows in and fills the tank (the penis fills with blood and becomes erect) and the wash cycle begins (enjoys sexual activity). At the end of the wash cycle this process reverses, the switch goes to the off position (the brain terminates erection), the valve closes (the arteries markedly decrease blood inflow) and the drain opens draining the wash tank of water (the veins open, blood leaves the penis and erection subsides).

What are the risk factors for ED?

There are risk factors for the development of ED. As men age, the level of circulating testosterone decreases, which may interfere with normal erection. While a low testosterone level itself is rarely the cause of ED (5 percent or less), low testosterone can be an additional contributing factor in many men who have other risk factors for ED. Low levels of sexual desire, lack of energy, mood disturbances and depression can all be symptoms of low testosterone. A simple blood test can determine if the testosterone level is abnormally low, and testosterone can be replaced using a number of different delivery systems (e.g., shots, skin patches, gels, pills placed under the tongue).

What are some causes of ED?

By far, the most important cause of the development of ED is the presence of illnesses like high blood pressure, diabetes mellitus (A condition characterized by high blood sugar resulting from the body’s inability to use sugar (glucose) as it should. In type 1 diabetes, the pancreas is not able to make enough insulin; in type 2 diabetes, the body is resistant to using available insulin.), high cholesterol levels and cardiovascular disease. These processes, acting over time, can lead to a degeneration of the penile blood vessels, leading to restriction of blood inflow through the arteries and also to leakage of blood through the veins during erection.

The choices we make in life can lead to degeneration of the erectile tissue and the development of ED. Smoking, drug or alcohol abuse, particularly over a long period of time, will compromise the blood vessels of the penis. Lack of exercise and a sedentary lifestyle will contribute to the development of ED. Correction of these conditions will contribute to overall health and may in some individuals correct mild ED. Treatment of many medical conditions can interfere with normal erections. Drugs used to treat these risk factors listed above may also lead to or worsen ED. Patients undergoing surgery or radiation therapy for cancer of the prostate (In men, a walnut-shaped gland that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.), bladder, colon (Large intestine.) or rectum (The lower part of the large intestine, ending in the anal opening.) are at high risk for the development of ED.

How is ED diagnosed?

For most patients, the diagnosis will require a simple medical history, physical examination and a few routine blood tests. Most patients do not require extensive testing before beginning treatment. The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment like oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied,then further steps may be taken. In general, as more invasive treatment options are chosen, testing may be more complex.

What are some non-surgical treatments?

The first line of therapy for uncomplicated ED is use of oral medications known as phosphodiesterase-5 inhibitors (PDE-5)  - sildenafil citrate, vardenafil HCl or tadalafil. Men with ED take these pills before beginning sexual activity and the drugs boost the natural signals that are generated during sex, thereby improving and prolonging the erection itself. These medications are safe and fairly effective, with improvement in erection in nearly 80 percent of patients using these drugs. Early concerns about possible bad effects on the heart have not proven true; after extensive testing and five years of use, sildenafil citrate can be used safely by all heart patients except those using medications called nitrates because of an interaction between these two classes of drugs. The side effects of PDE-5 inhibitors are mild and usually transient, decreasing in intensity with continued use. The most common side effects are headache, stuffy nose, flushing and muscle aches. In rare cases, sildenafil can cause blue-green shading of vision due to high blood levels of sildenafil exerting a brief effect on the retina of the eye. This is of no long-term risk and is gone within a short time as the amount of sildenafil in the blood decreases. It is important to follow the instructions for using these medications in order to get the best results. Tests have shown that 40 percent of men who do not respond to sildenafil will respond when they receive proper instruction on medication use.

For men who do not respond to oral medications another drug, alprostadil, is approved for use in men with ED. This drug comes in two forms: injections that the patient places directly into the side of the penis and a transurethral suppository. Success rates with self-injection can reach 85 percent. Modifying alprostadil to allow transurethral delivery avoids the need for a shot, but reduces the effectiveness of the agent to 40 percent. The most common adverse effects of alprostadil use are a burning sensation in the penis and the risk of over correcting the problem, resulting in a prolonged erection lasting over four hours and requiring medical intervention to reverse the erection.

For men who cannot or do not wish to use drug therapy, an external vacuum device may be acceptable. This device combines a plastic cylinder or tube that slips over the penis, making a seal with the skin of the body. A pump on the opposite end of the cylinder creates a low-pressure vacuum around the erectile tissue, which results in an erection. To keep the erection once the plastic cylinder is removed a rubber constriction band goes around the base of the penis, which maintains the erection. With proper instruction 75 percent of men can achieve a functional erection using a vacuum erection device.

There are some men who have severe degeneration in the tissues of the penis, which makes them unable to respond to any of the treatments listed above. While this is a small number of men, they usually have the most severe forms of ED. Patients most likely to fall into this group are men with advanced diabetes, men who suffered from ED before undergoing surgical or radiation treatment for prostate or bladder cancer and men with deformities of the penis called Peyronie’s disease (A plaque (hardened area) that forms on the penis, preventing that area from stretching. During erection, the penis bends in the direction of the plaque, or the plaque may lead to indentation and shortening of the penis.). For these patients reconstructive prosthetic surgery (placement of a penile prosthesis or “implant”) will restore erection, with patient satisfaction rates approaching 90 percent. Surgical prosthetic placement normally can be performed in an outpatient setting or with one night of hospital observation. Possible adverse effects include infection of the prosthesis or mechanical failure of the device.

What can be expected after treatment?

All of the treatments above, with the exception of prosthetic reconstructive surgery, are temporary and meant for use on demand. The treatments compensate for but do not correct the underlying problem in the penis. So it is important to follow-up with your doctor and report on the success of the therapy. If your goals are not reached, if your erection is not of sufficient quality or duration and you are still distressed, you should explore the alternatives with your doctor. Because the medications used are not correcting the problems leading to ED, your response over time may not be what it once was. If such should occur again, have a repeat discussion with your physician about the remaining treatment options.

Frequently Asked Questions

How do I know my ED is not in my head?

Many years ago most men with ED were thought to have psychological problems. This was the result of our ignorance of the normal mechanism of erection and the causes of ED. We now realize that most men have underlying physical causes.

If I worry about my ability to get an erection can I make a bad condition worse?

Nothing happens in the body without the brain; worrying about your ability to get an erection can itself interfere with the process. This condition is called performance anxiety and can be overcome with education and treatment.

Can I combine treatment options?

This is often done but because of the risk of prolonged erections with drug therapy it should only be performed under physician supervision. Ask your doctor for proper instructions.

I was fine until I began taking this new drug, what should I do?

Many drugs can cause ED, but some cannot be changed because the benefits outweigh the adverse effects. If you are fairly certain that a specific drug has caused the problem, discuss the possibility of a medication change with your doctor. If you must remain on the specific medication causing the problem, the treatment options outlined above can still be used in most cases.

Erectile dysfunction (ED), or the inability to get an erection, is a complex condition with many possible causes. The cardiovascular system, specifically the thin layer of cells lining the blood vessels called the endothelium, is believed to play a major role in some cases of ED.

The presence of ED can often be one of the earliest signs of problems in endothelial function that may later progress to heart disease. In such cases of ED, the vascular endothelium loses its capacity to form nitric oxide, which is necessary to dilate the blood vessels in the penis that cause an erection.

If this hypothesis is correct, then a drug designed to treat this damaged vascular endothelium, such as a statin, should help men with ED who do not respond to treatment with Viagra.

One small but promising study involved men who previously failed treatment with Viagra alone. The men were given 80 mg daily of the statin Lipitor or a placebo. Both groups also received 100 mg tablets of Viagra to use for sexual purposes. After 12 weeks, the Viagra-plus-Lipitor group had statistically significant improvement in erectile function, while the placebo group showed no such improvement.

Although the number of men in the study was small, the results nonetheless are promising enough for the authors to call for larger trials to be done.

Other Treatment

Other treatments for erection problems (erectile dysfunction) include vacuum devices, external penile splints, and counseling (psychotherapy).

Other Treatment Choices

• Vacuum devices are useful for all types of erection problems—physical, psychological, or both. The device has a tube you place around the penis. You pump the device to create a vacuum that leads to an erection. Then you place a band around the base of the penis to maintain the erection for up to 30 minutes.
• Counseling (psychotherapy) is recommended for men whose erection problems are caused, at least in part, by psychological factors. It may include sex therapy, which focuses on methods to improve attitudes toward sex and specific sexual techniques. Counseling also may be used with medication treatment or vacuum devices for erection problems that have psychological and physical causes.
• External penile splints may be another nonsurgical option. External penile splints are mechanical supports that “hold up” the penis. Although penile splints have been available for years, they have not often been used because they covered much of the penis or resulted in painful intercourse. Their advantages are that they are noninvasive, inexpensive, and often reusable. More recent penile splints do away with many of the old problems. However, they must be sized to each man and are best used by those who are capable of partial erection.

What To Think About

Some men take the amino acid L-arginine as a dietary supplement to try to treat erection problems. The amino acid increases the amount of nitric oxide, which relaxes blood vessels; theoretically, L-arginine could improve erections. However, there is little scientific evidence that it is effective for this purpose. 

No matter what approach you use to treat an erection problem, including your partner in the decision is helpful and may improve results.

Sex therapy may be helpful for some men who have erection problems (erectile dysfunction). Sex therapy does not involve having sex with or in front of the sex therapist. It is also not long-term or open-ended therapy. It usually involves working with a therapist who recommends gradual steps to change sexual behavior.

Sex therapy helps you understand and accept that emotions (such as anxiety or sadness) can easily become associated with physical factors or reactions. It is based on the following premises:

• Both partners share responsibility for helping solve the problem, even if it is due to physical causes.
• You and your partner receive information and education about sexual techniques.
• It is necessary to change any negative attitudes toward sex.
• It is necessary to open up lines of communication between you and your partner.

Sex therapy may involve:

• Talking about the multiple causes of sexual problems and how emotions can play a role in physical causes.
• Using a variety of psychological tests.
• Talking about the natural changes in sexual function that occur with aging.
• Offering specific suggestions for enhancing sexual enjoyment (such as altering foreplay, using lubricants, getting enough rest, eliminating distractions).

For many men, psychological issues play a role in erection problems (erectile dysfunction). Careful attention to these issues and attempts to relieve sexual anxieties should be a part of therapy for all men with these problems.

The type of therapy and how long it lasts depends on what type of problem (depression, anxiety disorder, or another mental disorder) you have.

Group or individual therapy may be indicated. Involving your partner in counseling is often helpful.

Psychological treatment is most likely to be helpful for men who:

• Have an erect penis when they wake up in the morning.
• Can get a firm erection when masturbating.
• Have gone through a stressful major life event, such as divorce, separation, death of a loved one, change in job, or moving.
• Grew up in an environment where sex and sexuality were considered negative, wrong, or “bad,” or who were sexually or physically abused as a child.
• Lost their mother or father during early childhood.
• Have a history of serious relationship problems.
• Have a history of anxiety disorders or physical problems that have a psychological component (such as irritable bowel syndrome, migraines, asthma, or nervous bladder).

Treatment Overview

A vacuum device, which is sometimes used to treat erection problems (erectile dysfunction), is a tube made of plastic that fits around the penis. You coat the base of the penis with lubricant and insert it into the tube. Air is pumped out of the tube, which creates a vacuum. The vacuum helps blood flow into the penis, producing an erectionlike state in about 5 minutes. A constrictive band is placed around the base of the penis to maintain the erection, and the tube is removed.

See an illustration of a vacuum device below

The constrictive band may be left in place for up to 30 minutes. If you want the erection to last longer, you may remove the band for a few minutes and then repeat the process.

Vacuum devices block ejaculation. You still have an orgasm but do not ejaculate (release semen).

Some men say the erection is “wobbly” or has a “hingelike” feeling, since the tissues beneath the ring on the base of the penis don’t get hard. A small number of men consider this a major problem, and it may make penetration difficult.

A prescription is not needed to buy these devices. They are reusable and should be cleaned after each use.

What To Expect After Treatment

The device usually produces an erection, which goes away when the constrictive band is removed.

Why It Is Done

Most men who have erection problems from physical causes can use vacuum devices. Men who have erection problems because of psychological causes may also use these devices.

These devices can be used by men who take medications to prevent blood clots (anticoagulants, such as warfarin [Coumadin]).

How Well It Works

Studies indicate that more than 90% of men using these devices are able to get an erection that is satisfactory for sexual intercourse. 

Most men and their partners are satisfied with the device and the quality of the erections. Studies have reported satisfaction rates ranging from 70% to 94%. However, some studies report that only 26% to 30% of men are satisfied with the erections they receive from a vacuum device. 

Most men who stop using the vacuum device do so for a variety of reasons, including inconvenience and interruption of foreplay (the man has to take a brief “time-out” to use the device to get an erection). Your satisfaction with the device may be better if you meet with a representative of the manufacturer who can show you how to use the device correctly. Your doctor can arrange a meeting.

Regular use may improve success and satisfaction. Most men who use the device successfully for 3 months continue to use it. With regular use, the time it takes to get an erection decreases.

Men who have erection problems from psychological factors may regain the ability to have unaided erections after using the device for a time.

The cause of the erection problem (blood vessel, nerve, or psychological) does not appear to affect the results. The device also may produce erections in men who have had a failed penile implant.

Risks

The risk of side effects is low and they are usually minor. Possible problems may include:

• Bruising.
• Pain or discomfort.
• Numbness or loss of sensitivity. This occurs occasionally in about half of men but is a major problem for only a few men.
• A sensation that the penis is cold.
• Pinching scrotal tissue in the device.

No significant side effects or complications have been reported.

What To Think About

Be sure to discuss using a vacuum device with your partner. It is important that both of you have realistic expectations of what the device can do. The vacuum device gives you an erection that may be suitable for sexual intercourse but is not the same as a normal erection.

A trial period at home is helpful. The device can be difficult to learn to use, and about four tries are needed to learn to use it successfully.

Some men find the band around the base of the penis distracting or irritating during sex. Also, the band may prevent ejaculation.