Overview
The treatments for sexual dysfunction are largely empiric therapies. That is, there is an algorithm for treatments that can be initiated based solely on a history and physical. There is testing that is commonly used with sexual dysfunction such as blood tests including a serum testosterone or a serum testosterone panel and perhaps even a prolactin level, but oftentimes therapy can be initiated without any testing whatsoever. There is also radiologic testing that can be performed on the phallus to evaluate male sexual dysfunction. This would include ultrasonography studies directed at evaluating the arterial blood flow into the penis and the ability of the penis to trap blood to create a good firm erection. However, with the advent of oral agents such as Staxyn, Viagra, Cialis, and Levitra, the management of erectile dysfunction is not appreciably altered by radiographic studies such as the duplex Doppler ultrasound of the penis. Therefore, these radiologic studies are not very often used in the management of erectile dysfunction. Testosterone sampling and prolactin sampling can be useful in the evaluation of erectile dysfunction depending on the age and history of the patient.
As regards to the history of the patient the risk factors for erectile dysfunction include advanced age, cigarette smoking, diabetes, elevated lipid levels, hypertension, elevated cholesterol levels, poor physical conditioning, obesity, and essentially any risk factor for cardiac disease. That is, the vascular health of the penis and the vascular health of the heart are closely related. That is because good quality erections are dependent on healthy arterial blood supply similar to the arterial blood supply in the heart. These are small arteries that are affected by such things as high cholesterol levels, cigarette smoking, and diabetes. Also, neurologic deficits such as can occur with diabetes and pelvic surgery and radiation can impair erectile performance. Surprisingly, patients with none of these risk factors can have erectile dysfunction even at a rather young age. Approximately 40% to 70% of men over the age of 40 will have a decrease in the quality and frequency of their erections and this can include men with none of the above risk factors.
Another possible cause of erectile dysfunction is stress. The sympathetic nervous system is responsible for the flight or fight response when we feel threatened. The sympathetic nervous system, in response to any threat or stress, will increase the heart rate, increase blood pressure, and redirect blood flow to the legs and arms to deal with the perceived threat. The sympathetic nervous system, in response to a perceived threat, will also shut down the functions that are not helpful in dealing with the perceived threat such as the ability to empty your bladder and the ability to have good quality erections. The sympathetic nervous system does not differentiate between a stress from a true physical threat or other types of stress such as marital or relationship discord or work-related stress. Therefore, discord in your relationship including past difficulties with sexual function can lead to stress that further inhibits sexual performance thus creating a cycle of sexual failure.
After a history and physical, and perhaps serum testosterone sampling, therapy may be initiated for your erectile dysfunction. The standard first line of treatment for erectile dysfunction is oral phosphodiesterase inhibitors such as Staxyn, Viagra, Levitra, and Cialis. These medications all work in a similar fashion by decreasing the body's physiologic attempt to terminate an erection. By “turning off the off switch” these oral agents can provide greater rigidity and duration of your erection. These oral agents do not create an erection without some native ability to obtain an erection. Therefore, the use of these agents is best applied to patients with partial erectile function and these agents are best used in a setting that maximizes your own native ability to create an erection. These agents can also be supplemented with other therapies such as testosterone replacement or the use of vacuum erection devices. The duration of action of these agents is variable. Viagra generally has an 8 hour duration while Levitra and Staxyn have a 12 hour duration and Cialis has a 36 hour duration. These agents are contraindicated in patients who need nitroglycerin for chest pain. The use of nitroglycerin and these oral agents together can lead to a precipitous drop in cardiac blood pressure and initiate a cardiac event such as a heart attack. These agents can also create an increased risk when used in combination with alpha blockers such as Hytrin, Cardura, Flomax and Uroxatrol. These alpha blockers are sometimes used in the treatment of hypertension and are sometimes used in the treatment of male voiding dysfunction.
Another treatment option for erectile dysfunction includes a vacuum erection device with a penile occlusive device. A vacuum erection device or penile pump can draw more blood into the penis for erection. After more blood is drawn into the penis with this vacuum erection device a penile occlusive device is placed at the base of the penis trapping this blood into the penis for a good solid erection. A penile occlusive device can also be used alone or in combination with most other therapies for the treatment of erectile dysfunction.
For patients who fail oral phosphodiesterase inhibitors and/or the vacuum erection device, the next line of therapy is usually intracavernosal prostaglandin injections. Intracavernosal prostaglandin therapies (Caverject and Edex) can stimulate erections in more profound cases of erectile dysfunction and in the absence of other stimulation for erections. These agents are injected with a small needle directly into the penis. These agents can cause some dizziness or lightheadedness. These agents are best used initially in our office so that issues regarding safety and the correct administration can be reviewed. This is usually accomplished by a first-time demonstration injection in our office. These agents include a 1% to 2% risk of priapism. Priapism is an unwanted, painful erection that lasts over two hours. Priapism in the face of a prostaglandin injection is essentially an overdose of the medication. If your body has a very vigorous response to caverject and the erection is maintained beyond two hours the blood in the penis is not returning to the heart. Therefore, a lack of oxygen supply can lead to pain and even damage to the penis. Priapism needs to be treated rapidly to reverse the erectile process. This can be done in our office or in the emergency room. If you experience priapism you should immediately report to our office or the emergency room for prompt therapy. If priapism remains untreated for six hours it can cause permanent damage to the penis and further decrease your erectile performance.
Testosterone replacement can also be used effectively for the treatment of erectile dysfunction with low Testosterone levels. Testosterone replacement is generally used in patients who have demonstrated a low total testosterone or a low free testosterone on testosterone serum sampling and are symptomatic. Symptoms of a low testosterone include low sexual interest or energy (libido), low overall energy, poor concentration and difficulty sleeping. Testosterone replacement can result in improved sexual desire, improved erections, and improved vigor for daily activities. Some patients will feel more overall energy level while on testosterone. For further details on treating low testosterone please see our brochure on that topic.
Another avenue for treatment of erectile dysfunction is behavioral therapy with a psychologist. When stress is a possible causative factor in erectile dysfunction a behavioral therapist can use cognitive therapies to work through relationship or stress issues with men who have erectile dysfunction. These treatment modalities may be best used by the couple jointly working together with a behavioral therapist.
For patients who fail all of the above therapies surgical implantation of an inflatable penile prosthesis can be considered. This is a dramatic choice to make and generally is to be considered an option of last resort. A surgically implantable inflatable penile prosthesis has the capability of providing erections at any time to even the most profound cases of erectile dysfunction. However, these devices require surgical implantation which might be associated with significant postoperative discomfort. Many patients who undergo implantation of an inflatable penile prosthesis are quite satisfied with their outcome and happy that they underwent such treatment. In fact, studies show patient satisfaction rates in excess of 80% for this treatment. However, once a patient elects this treatment modality the other available treatment modalities (with the exception of sexual therapy with a psychologist) are unlikely be effective. This, in effect, creates a permanent change in erectile tissues in the penis and so it should be considered as the treatment of last resort.
