Erectile dysfunction (also known as impotence, or ED) is the inability to get and keep an erection firm enough for sex. A practical approach to treating ED —similar to the strategy for most medical issues — starts with a medical history, physical examination and basic lab tests. More extensive testing may be suggested depending on the individual.
If the evaluation indicates that the ED is psychological or emotional in origin, referral to a qualified psychologist, psychiatrist or sexual counselor will be the next step. If the lab results indicate low testosterone, additional hormone tests will be done to determine the precise cause of the low testosterone, then a treatment aimed at normalizing the levels will be suggested. If testing shows undiagnosed or poorly controlled diabetes or a risky lipid and cholesterol profile, a referral to another medical professional will be necessary.
Although ED treatment is tailored to the individual patient, there are four general paths of treatment for ED:
1. Lifestyle makeover. A healthy lifestyle can “reverse” ED naturally, as opposed to “managing” it. Since ED can often be considered a “chronic disease,” healthy lifestyle choices can reverse it, prevent it from getting worse, or even prevent it altogether.
Since sexual function is based on many body parts working together, this approach is to nurture every cell, tissue and organ in the body.The goal is to achieve a healthy weight, adopt a healthy diet, exercise regularly, get enough good quality sleep, stop using tobacco, consume alcohol in moderation, and reduce stress.
Aside from general cardio and strength exercises, specific pelvic floor muscle exercises (“man-Kegels”) are beneficial to improve the strength, power and endurance of the penile “rigidity” muscles.
If a healthy lifestyle can be adopted, sexual function will often improve dramatically, as well as overall health improvements. Since many medications have side effects that negatively impact sexual function, a bonus of lifestyle improvement is potentially needing lower dosages or perhaps eliminating medications (blood pressure, cholesterol, diabetes), which can result in further improving sexual function.
2. ED pills and mechanical devices. It’s my opinion that oral ED medications should be reserved for when lifestyle optimization fails to improve sexual issues. This may be at odds with some physicians who find it convenient to simply prescribe meds, and with some patients who want a quick and easy fix. However, as good as Viagra, Levitra, Cialis and Stendra may be, they are expensive, have side effects, are not effective for every patient and cannot be used by everyone, as there are medical situations and certain medications that may prevent their use.
In this category, I also include mechanical, non-pharmacological, non-surgical devices, including low-intensity penile shockwave therapy, vacuum suction devices, vibration devices and penile traction devices.
- Low-intensity shockwave therapy is an exciting new treatment option that uses acoustic energy to cause mechanical stress and microtrauma to erectile tissues. This stimulates the growth of new blood vessels and nerve fibers and potentially enables penile tissue to regain the ability for spontaneous erection.
- Vacuum suction devices are mechanical means of producing an erection in which the penis is placed within a plastic cylinder that is connected to a manual or battery-powered vacuum. Negative pressure engorges the penis with blood and a constriction band is temporarily placed around the base of the penis to maintain the erection. 80% of men can achieve good rigidity, but many do not continue using the device because of its cumbersome nature.
- Venous constriction devices are used in conjunction with the vacuum suction devices to trap blood in the penis and help maintain the erection. They also can be used without the suction devices in certain circumstances. Men who find these beneficial are usually able to obtain a reasonable quality rigid erection but tend to lose it prematurely.
- Vibration devices were traditionally employed to provoke ejaculation in men with spinal cord injuries who desired to father children. Subsequently, they have achieved broader utility and are now also used to facilitate erections in men with ED. Dual-armed vibratory stimulation of the penile shaft is capable of inducing an erection and ultimately ejaculation.
- Penile traction devices use mechanical pulling forces to lengthen and/or straighten the penis to manage or prevent penile shortening and angulation.
3. Vasodilator urethral suppositories and penile injections. These are suppositories and injections that increase penile blood flow and induce erections.
- M.U.S.E. (Medical urethral system for erection) is a small medicated vasodilator pellet available in a variety of different dosages that is placed within the urinary channel of the penis after urinating. Absorption occurs through the urethra into the adjacent erectile chambers, inducing increased penile blood flow and potentially an erection. About 40% of men can achieve rigidity, but it is often inconsistent.
- Prostaglandin E1 is injected directly into one of the erectile chambers of the penis, resulting in increased blood flow and erectile rigidity. After being taught the technique of self-injection, vasodilator medications can be used on demand, resulting in rigid and durable erections. A combination of medications can be used for optimal results—one such popularly used combination consists of papaverine, phentolamine and alprostadil, known as “Trimix.” 90% or so of men achieve an excellent response, although many men are reluctant to put a needle into their penis.
4. Penile prostheses. Penile prostheses can be life changers for men who cannot achieve a sustainable erection. Surgically implanted under anesthesia on an outpatient basis, they provide the necessary penile rigidity to have intercourse whenever and for however long desirable.
- The semi-rigid device is a simple one-piece flexible rod, one of which is implanted within each of the paired erectile chambers. The penis is bent up for sexual intercourse and down for concealment.
- The inflatable device is a three-piece unit that is capable of inflation and deflation. Inflatable inner tubes are implanted within the erectile chambers, a fluid reservoir is implanted behind the pubic bone or abdominal muscles and a control pump in the scrotum, adjacent to the testes. When the patient desires an erection, he pumps the control pump several times, which transfers fluid from the reservoir to the inflatable inner tubes, creating a hydraulic erection that can be used for as long as desired. When the sexual act is completed, the device is deflated via the control pump, transferring fluid back to the reservoir and restoring a flaccid state.