Erectile Dysfunction

Click Here to Watch Dr. Engel’s Presentation on Incontinence and ED

Perhaps one of the most common reasons for a visit to the Urologist for men is to discuss Erectile Dysfunction simply because it is so common.  Nearly 50% of men in their fifties will report some degree of erectile dysfunction, which steadily worsens with time.  Erectile dysfunction is simply one example of many of normal aging, and for most, it is a fact of life.  We all recognize that we slow down, have more aches and pains, our hair turns gray, and our bodies may change in many ways as we age.  Men often see erectile dysfunction differently, but it is not.  It is a progressive problem that always worsens with time, as with most other signs of aging.

Managing ED

Dr. Engel Seminar PromoMost men, particularly men in their 50s, do not at all understand this and feel as if they are alone.  Erectile dysfunction affects a man’s self-esteem and the dynamics of their relationship with their partner.  If unaddressed, there is always a psychological component of the problem, and men don’t discuss this topic readily.  Once a man starts to struggle, sex can be more stressful than enjoyable for fear of failure. The relationship is affected because the partner may feel that erectile dysfunction is a sign of a poor relationship, lack of attraction, or even infidelity.   Once this happens, one must reverse both the physical and psychological causes of erectile dysfunction.  This is particularly true of younger men.

Many men in their twenties, thirties, and forties complain of erectile dysfunction.  In these cases, the culprit is almost always psychology, although the treatment is the same.  Here, the key is to let the patient know that they are not alone, that having performance anxiety is typical in this situation, and to try to stress the need to succeed with erections and let the anxiety melt away.  There is often a stigma in a patient’s mind that needing help, such as pills for erections, is a sign of weakness. Or that they may become addicted to the medication.  However, we try to stress that they will hopefully just be a crutch while one regains their confidence or settles more comfortably into their relationship.  In the case of the problem being primarily psychological, in the form of performance anxiety, most of the time, pharmacological help for erections will be temporary until one becomes more confident and comfortable.

The Initial Visit

ED Questions answered bannerMost men initially seek help for their erections, thinking there must be an easily identifiable and reversible cause, a belief only further enforced by the markets created for testosterone supplementation and the information that hopes to link erectile dysfunction with cardiac or other medical concerns.  It is common for a patient to be willing to accept testosterone supplementation but not ready to accept more targeted and efficacious treatments such as Viagra or Cialis due to psychology. Patients often will be more comfortable with the fact that they are having problems performing if they feel it results from a disease rather than aging.  For this reason, the pharmaceutical industry coined the phrase “low T” as a disease state. The reality is that testosterone does not directly mediate the ability to get an erection. Supplementation may affect sexual desire and energy, but not really erections.  The problem with testosterone supplementation is that it is normal for one’s testosterone to drop steadily as one ages. Therefore, nearly everyone has lower testosterone when they are older than when they were younger. It is a normal part of aging, which questions whether this is truly a disease state.  We will supplement a man’s testosterone if they wish, but we will inform them that there is not much science behind it, and it will not likely get them erections.

Shockwave & Alternative Therapies

The most common treatment option that attempts to appeal to a man’s desire not to look at ED as a progressive, standard problem is penile shock wave therapy.  This therapy was created on the concept that ED is a vascular problem.  The thought is that if one breaks up calcifications in the penile arteries or makes tissue damage in the penis, blood flow will improve, and ED will be cured.  There was a flurry of literature about these technologies, with the most hopeful studies showing mild efficacy only in those patients that could already get an adequate erection with pills like Viagra or Cialis.  Unfortunately, these costly treatments are often offered by cash-pay erection clinics as a miracle cure for all.  It is reasonable to provide this treatment for select patients for which there may be a 50% chance of some benefit and where the cost of $3000 to $6000 or more can be afforded.  However, in practice, this is not often what happens.

When patients seek help for their erections, very few tests will change what we do.  We may seek to rule out extremely low levels of testosterone if suspected by history, and we may ask about one’s cardiovascular status and the medicines they use to treat any conditions they may have.  Patients often point to an anti-hypertensive medication they use, and if they want to switch to one that may have less effect on their erections, they will do so with their internist.  However, the basic fact is that erectile dysfunction can be considered a sign of reduced cardiovascular function or blood flow, which is usually a normal part of aging.   Sometimes ED can be the first sign of a cardiovascular problem, but this is not typical.  It simply makes sense that as we get older, we don’t have the same blood flow we did when we were younger.  Certainly, inactivity, smoking, obesity, and diseases such as heart disease, diabetes, and others contribute, and trying to live a healthier lifestyle designed to reduce these conditions is always good advice and warranted.  But ultimately, the Urologist’s approach is primarily results-based. Far less time is spent on knowing exactly why the problem exists, and most of the effort is spent on achieving success in the easiest way possible.  We help people in many ways, and we will discuss them below in the order we typically offer help to the patient:

Oral Medications

It would be tough to find an adult that does not know what Viagra (sildenafil) or Cialis (tadalafil) is, as they are one of the most commonly used classes of drugs.  The term “erectile dysfunction” was primarily created by the makers of these drugs so that their usage would not just be applied to patients with severe erectile dysfunction or impotence.  Others on the market are less well known, such as Levitra (vardenafil) and Stendra (avanafil), but all of these pills are PDE-5 inhibitors.  All have slight marketing differences and slightly different side-effect profiles or instructions. However, they all work by amplifying the signal from the nerves that control erection by causing arteries to dilate in the penis. Pills are usually first offered because they are the simplest thing to try.  And, now that most are generic and inexpensive, the barrier of extremely high cost that used to exist is no longer present.  Some will take Cialis daily, but they usually are best used as on-demand pills utilizing the lowest dose necessary to produce a satisfactory erection.  Pills certainly do not work for everyone, and almost always erectile dysfunction will eventually progress with time such that they become less effective over time.  They are also rarely beneficial for the man that gets no erection at all.  Instead, they are best for the most common presentation of ED – the patient who is just starting to have problems maintaining an erection to finish or the man who intermittently has issues. This probably constitutes at least 80% of all men who first seek help.

There are herbal remedies marketed as supplements for this problem, but as is true usually with such remedies, there is usually no placebo-controlled data proving efficacy.  However, the placebo or “sugar pill” effect for this often primarily psychological problem is strong, so we do not discourage their use if they are safe and economical.

Intra-urethral Suppositories or Gels

Historically, urologists used to offer intra-urethral suppositories of a drug called Alprostadil as the next step after pills are no longer effective. The patented trade name of this drug is MUSE, or medicated urethral suppository for erection.  In the past, Dr. Engel was a major author and contributor to the most significant American study testing the concept of penile rehabilitation after prostatectomy, comparing Muse to Viagra in patients suffering erectile function after prostatectomy.  Muse can be an excellent solution for some men. However, Dr. Engel found the cost (approximately $50 a dose) and the common complaint of pain and lack of efficacy (only reliable in about 25% of men) to limit its utility.   Muse is very rarely used today but is still available.   However, recently some compounding pharmacies, including the one that Urologic Surgeons of Washington works closely with, are beginning to offer a similar medicine called Tri-Mix (see discussion of injections below) in a gel form.  Here, a man is sold 1cc of the gel in a syringe, with the standard dose being .1cc.  The dose is injected into the urethra, costing closer to $5 a dose. As with Muse, the medicine must be kept refrigerated, but unlike Muse, the syringe will be reused for several doses. Urologists, particularly Dr. Engel, are waiting to see if the efficacy of gel using Tri-Mix, which uses alprostadil as one of three components, will have more efficacy with less pain than Muse.  However, it is another possible solution that some patients may be interested in before turning to vacuum erection devices or injection therapy.

Vacuum Erection Devices

If erectile dysfunction has progressed beyond the point that pills will work sufficiently at their highest dose, then what is offered to our patients at that point will be something that forces an erection.  A vacuum erection device is a device that will force venous blood into the penis that must then be captured in the penis by also wearing a constrictive band around the base.  Some married couples will find this useful, as will the man unwilling to self-inject (see below).  Patients interested in moving to a vacuum erection device can purchase one online.  Amazon will display many, and our patients are encouraged to buy a medical-grade device, usually priced around $150, with bands and instructions, and a phone number for support and usage device.  Vacuum erection devices have been marketed to help with post-prostatectomy impotence. However, Dr. Engel and others have, and the data is not particularly convincing that they help as a treatment measure.   Partners can complain that the erection is colder than they might be used to, and patients may not like the lack of spontaneity or the need for a constriction band that may cause pain.  For these reasons, we recommend vacuum erection devices rarely and usually ask patients to strongly consider injection therapy once pills fail them.

Injection Therapy

Almost all patients will be willing to try pills for their erections, but a smaller subset will have the motivation level to try injections.  However, they are the next solution in our practice when pills fail. ED injections are safe, almost always effective, and not nearly as painful as one would think.  The most used medicine is a mixture of three medicines, which will potently and directly dilate arteries to cause blood to rush into the penis to give an erection. The reason for the mixture is to get each medicine’s specific positive attributes and lessen the potential for each drug’s specific drawback.  For example, alprostadil rarely causes priapism (erections that will not go down) and is thus the safest ingredient, but it can cause pain. Papaverine and phentolamine rarely cause pain but can cause priapism. Thus, an adjustable mixture called Tri-Mix is used, and we sometimes add another ingredient, Atropine, making it Quad-Mix.

Injections for erections are far more common than most people realize.  They are generic medicines typically provided by a compounding pharmacy.  There are compounding pharmacies that are somewhat disguised as clinics and heavily advertised on the radio and newspaper that are essentially just selling injections for erections at a price usually nearly ten times compared to if prescribed by a Urologist.  These clinics utilize the embarrassment and desire for privacy that patients with ED have and fail to tell them of all their options. We, therefore, strongly discourage our patients from being taken advantage of in this way. If a patient seeks injection therapy, we urge them to read our tutorial,  We order the medicine for them that gets shipped directly to the patient, and then we teach the patient in the office how to perform the injection and recommend a starting dose after we see how efficacious a low dose in the office is.  The patient will inject himself when he desires an erection at home and slowly increase the dose each time until the perfect dose is found.  Erections have few risks, but among them would be rare penile scarring and priapism (an erection that will not go down), which is almost always avoided by titrating the dose up slowly.

Ultrasonic Wave Therapy

Whereas in the past, the marketing push for the “Men’s Health Clinics” mentioned above was a disguised description of injections with guaranteed results, now the most heavily marketed treatment offered at these facilities is Ultrasonic Wave Therapy.  Here, pulsed sound waves, or mechanically produced shock waves, are applied directly to the penis.  This simple and relatively painless treatment is theoretically designed to shock the arteries to the penis, hopefully, break up microcalcifications within them, and improve blood flow.   There have been a few placebo-controlled trials with these modalities, and some have demonstrated some efficacy.  However, it is very difficult to perform these studies as patients will generally know if they are receiving therapy. Therefore it is largely impossible to tell whether any perceived benefit is a placebo effect.  Insurance does not cover these treatments because of the lack of convincing data.  Clinics will perform a blood flow study at a cost and will generally prescribe a certain number of treatments based on the results of that study.  This is not a protocol generally established by any published study.  The cost of this treatment at Men’s Health Clinics is typically close to $6000.  Urologists tend to offer this at a lower price, closer to $3000, for the series of treatments.

Urologic Surgeons of Washington can and does offer this therapy on a limited basis in our office.  The right patient for this would be the patient that has erections and might even have success with pills but seeks a solution that might give him just enough improvement not to need the drugs. Another person that this might make sense to is a man whose erectile dysfunction is likely due to Peyronie’s disease. It was in these patients that this technology was first applied.  The right patient should also be willing to pay for this (although at significantly less cost in a doctor’s office), understanding the experimental nature of it and the distinct possibility that it may not work at all. As we feel there is little chance of success, the wrong patient is the patient with severe erectile dysfunction or the post-prostatectomy patient who has yet to have any partial return of erections. Learn more about shockwave therapy.

Inflatable Penile Prosthesis

When all else fails, or if patients have demonstrated the willingness to try other remedies but are either not happy with them, not happy with the lack of spontaneity they provide, or don’t find them to be a reliable solution, we turn to a penile prosthesis / penile implants. This is a surgery in which three components are surgically implanted into the penis, scrotum, and behind the pubic bone or abdominal muscles.  With a penile prosthesis, we implant two cylinders into the normal anatomy of the penis.  These cylinders will fill with water with the patient squeezing a pump implanted in the scrotum.  The water comes from a water balloon that has been implanted imperceptibly behind the pubic bone.  The penis will get increasingly erect and fully erect after approximately five to ten pumps.  Penile sensation will be the same as before the prosthesis is placed.  When sex is finished, the prosthesis is deflated simply by pressing a button on the scrotal pump.   The penis goes back to the flaccid state.  The entire prosthesis is invisible to the naked eye; no one can tell it is present unless felt.

A prosthesis is the perfect solution for the motivated patient where all else has failed or is unacceptable.   It is, in fact, the standard of care solution for the patient who suffers from severe erectile function and also has moderate to severe Peyronie’s disease, as the prosthesis will address both problems of erections and curvature simultaneously.   A penile prosthesis delivers the highest patient satisfaction rates of all treatments for erectile dysfunction, hopefully reflecting the motivated nature of the patients choosing to have one.  However, we do not recommend a prosthesis lightly as it is a surgery, and all surgeries have risks.  The procedure is relatively simple, but the patient will have two to three weeks of soreness in their penis or scrotum.  There are also relatively rare risks, primarily being infection of any or all parts of the prosthesis requiring removal or erosion through normal tissue, which will also require removal.  These risks are not enough for the right patient to keep them from seeking this durable, dependable solution.  The penile prosthesis can be a life-altering solution for a patient and his partner; seeing this joy is a very gratifying part of Dr. Engel’s practice.


Urologic Surgeons of Washington is a proud member of Privia Medical Group. The best doctors in our community have joined together to form Privia Medical Group (PMG), a multi-specialty, high-performance medical group that puts patients first. Our physicians are united by the mission of providing better, more coordinated care for their patients.

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