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Erectile Dysfunction is a common occurrence that affects some 50% of men over the age of 40. For healthy men who want to continue an active sex life, treatments are available.
Mr. E is a 53-year-old corporate executive. Married to his college sweetheart, they are beginning to really enjoy their time together, now that their two children are grown and out of the house and they are financially stable. Recently, Mr. E experienced difficulty achieving an erection when he and his wife were intimate. While he has noted that his erections have been less strong of late, he had attributed the problem to fatigue and career stress. Now with difficulty on vacation, he is increasingly concerned. Since their vacation, he has not been able to achieve an erection and is now deeply concerned. He has not discussed recent events with his wife as he doesn’t want to worry her, but he has been avoiding intimacy for the past several weeks. Mr. E wants treatment so that he may resume sexual relations with his wife and has scheduled an appointment with his internist.
Erectile Dysfunction (ED) is defined as the inability to achieve and sustain an erection sufficient for satisfactory intercourse. ED will affect nearly 50% of men over the age of 40 and its prevalence increases with age. Additional risk factors include:
• Hypertension and antihypertensive medication
• Diabetes Mellitus and other microvascular disease
• Prostate surgery for prostate cancer
• Smoking which leads to blood vessel constriction and microvascular disease
• Substance abuse, including excessive alcohol consumption
• Peyronie’s Disease
“There is still some reluctance among men to talk about Erectile Dysfunction (ED),” says David Phillips, MD, urologist with Urology Austin. “It’s still an embarrassing subject.”
Phillips tries to provide his patients ample opportunity to discuss ED. He asks his patients if there is anything that they want to discuss and finds that it’s often not until he’s ready to leave, that the topic of ED comes up.
“Often a patient will come in with another urological problem and near the end of the visit, will ask about treatment for his ED. Sometimes it’s the spouse who brings up the topic. But it’s important that there be open communication in a calm, non-threatening or blaming atmosphere. Many men with ED are already upset about the situation. It’s not helpful if his spouse is accusing or makes him feel ashamed about what is happening.
Elizabeth Houser, MD, urologist with the urology team finds that most men do want to do something about their ED and many aren’t afraid to talk about it.
“I find that younger men, say in their 30s, may be a bit more embarrassed if they are experiencing ED,” says Houser. “But men in their 40s and 50s want treatment and so do their wives. I find that men in my practice who are healthy and able-bodied want to maintain their sex lives. The oldest patient that I’ve treated for ED is 98 years old. An 86- year-old patient told me, “I still enjoy chasing the girls!”
So what are a man’s options for treatment? Most of us are aware of “the little blue pills” (Viagra), but what else is available to men with ED? Dr. Houser and Dr. Phillips both provide a comprehensive overview of ED treatments and they are presented here from the least invasive to the most invasive treatment modalities.
Pumps and Vacuum Devices
The Penile Pump or Vacuum device is a non-invasive treatment for erectile dysfunction. The device consists of a cylinder that fits over the penis with an attached pump (manual or motor operated). Using vacuum suction the pump draws blood into the penis and when there is a sufficient erection, a rubber ring is placed at the base of the penis near the pubic bone to hold the blood in and maintain the erection. After intercourse, the ring is removed and the blood is allowed to flow out of the penis. There are few if any side effects and most men can use this device successfully.
Oral Medications
These are the pills that we have all seen advertised on television and in magazines, Viagra, Cialis and Levitra. They belong to a class of medications called phosphodiesterase inhibitors and they work by increasing blood flow to the penis. When a man is ready to have intercourse, he takes one of the pills and typically, within 15 minutes to one hour, they are able to achieve an erection that is sustainable for intercourse. The effects of the pills generally last for about 45 minutes to one hour. Sustained release formulations (Cialis) work for 36 hours.
The oral medications are not without risks. Men who take nitrates (nitroglycerine and others) for heart disease cannot take oral medications for ED. Men should discuss if it is safe for them to take oral medications for ED if they are on blood pressure medications and certain medications for diabetes. Oral medications for ED may cause blurred or double vision, ringing in the ears, headaches and/or flushing. Although rare, the medications can cause priapism, an erection lasting for more than four hours.
Penile Suppositories
MUSE stands for Medicated Urethral System for Erection. The active ingredient in MUSE is alprostadil. At the time of intercourse, a man (or his partner) inserts a MUSE tablet into the urethra and advances it using a small plunger. For maximum absorption, the penis should be massaged for approximately 90 seconds. Some men report that walking for about 10 minutes aids with absorption of the medication. An erection typically occurs within 15-30 minutes.
Side effects of MUSE are priapism and sometimes urethral irritation from the alprostadil. MUSE tablets are also expensive and some men report that they are not as effective as penile injections.
Penile Injections
Penile injections work by injecting medication (alprostadil) directly into the side of the penis prior to intercourse. The medication relaxes the blood vessels allowing blood to flow in and an erection to occur. Erections typically occur within 10-20 minutes of the injection and last long enough for intercourse and sometimes longer. Erections lasting longer than 4 hours should be evaluated by a physician.
Many men are put-off at the thought of an injection directly into the penis. However, the injections are highly effective, use very small insulin needles and cost less than the MUSE tablets. There can be some stinging and bruising at the injection site, but men who follow proper injection technique seldom experience problems.
Penile Implants
Penile implants are devices that are implanted within a man’s body. Two or three soft rods are placed within the shaft of the penis. A small pump is placed within the scrotum and a sterile fluid filled receptacle is placed in the lower abdomen just above the pelvis. When a man is ready to have intercourse, he pumps the fluid from the receptacle into the rods using the pump device in the scrotum. When intercourse is complete, there is a release valve on the pump that he turns and simply lets the fluid flow back into the receptacle.
Although there is some risk with the placement of the implants (it’s a surgical procedure so all of the risks of surgery including anesthesia and wound infection come into play) many men are very satisfied with the implants. For men whom the oral pills are contraindicated, cannot tolerate the alprostadil or injections, a penile implant is a very good option.
Common Causes of Erectile Dysfunction
• Hypertension and antihypertensive medication
• Diabetes Mellitus and other microvascular disease
• Prostate surgery for prostate cancer
• Smoking which leads to blood vessel constriction and microvascular disease
• Substance abuse, including excessive alcohol consumption
• Peyronie’s Disease
Special thanks to Dr. Elizabeth Houser and Dr. David Phillips for contributing to this article.
MORE INFO
Elizabeth Houser, MD
The Urology Team
3 Locations in Austin
www.urologyteam.com
David Phillips, MD
Urology Austin
13 Central Texas Locations
www.urologyaustin.com