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. In fact, nearly 50% of men in their fifties will report some degree of erectile dysfunction, and this steadily worsens with time. Erectile dysfunction is simply one example of many of normal aging, and for most it is simply 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 is true with most other signs of aging.
Most men, particularly men in their 50’s, 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 as well, and men simply don’t talk about this topic readily with others. Once a man starts to struggle, sex can be more stressful than enjoyable for fear or failure. The relationship is affected in that the partner may feel that the erectile dysfunction is a sign of a poor relationship, lack of attraction, or even infidelity. Once this happens, one will have to reverse both the physical and psychological causes of erectile dysfunction. This is particularly true of younger men. In fact, we see many men in their twenties, thirties and forties that complain of erectile dysfunction. Here, the culprit is almost always psychology, although the treatment is the same. Here, the key is for us to let the patient know that they are not alone, that having performance anxiety is normal in this situation, and to try to simply stress the need to succeed with erections and let the anxiety melt away. There can be a stigma in a patient’s mind that to need to use help such as pills for erections is a sign of weakness, or that they may become addictive. However, we try to stress that they will 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 the vast majority of the time the use of pharmacological help for erections will be temporary once one becomes more confident and comfortable.
Most men initially seek help for their erections thinking that there must be an easily identifiable and reversible cause, a belief only further enforced by the markets that have been created for testosterone supplementation and the information that hopes to link erectile dysfunction with cardiac or other medical concerns. It is extremely common for a patient to be willing to accept testosterone supplementation, but not willing to except 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 is a result of a disease rather than aging. It is for this reason that the pharmaceutical industry coined the phrase “low T” as a disease state. The reality is that testosterone does not at all 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 is is simply normal for one’s testosterone to drop steadily as one ages. Therefore, nearly everyone has lower testosterone when they are older compared to when the were younger. It is a normal part of aging, which calls into question whether this is truly a disease state at all. 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.
In fact, when a patient seeks help for their erections, there are very few tests to be gotten that will change what we do in any way. 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 anti-hypertensive medication they use, and if they want to switch to one that may affect them less they will do so with their internist. However, the basic fact is that erectile dysfunction really can be thought of as a sign of reduced cardiovascular function, or blood flow, that usually is a normal part of aging. It is true that sometimes ED can be the first sign of a cardiovascular problem, but this is not at all typical at all. 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, obesity, diseases such as heart disease, diabetes and others contribute. But, ultimately the Urologist’s approach is primarily a results based approach, and 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. There are many ways that we help people, and we will discuss them below in the order we typically offer help to the patient.:
It would be very hard to find an adult that does not know what Viagra or Cialis is, as they are one of the most commonly used classes of drugs out there. In fact the term “erectile dysfunction” was in large part created by the makers of these drugs so that their usage would not just be applied to patients with severe erectile dysfunction, or impotence. There are others on the market that are less well known such as Levitra and Stendra, but all of these pills are called PDE-5 inhibitors. All have their own small 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 the first thing that is offered because it is 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 every day, but normally they are best used as on demand pills utilizing the lowest dose necessary to produce a satisfactory erection. Pills 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 useful 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 be able to finish, or the man who intermittently has problems. This probably constitutes at least 80% of all men who first seek help.
There are herbal remedies that are 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 times largely psychological problem is strong, so we do not discourage their use as long as they are safe and economical to use.
Intra-urethral Suppositories or Gels
Historically, Urologists used to commonly 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 called MUSE, or medicated urethral suppository for erection. In fact, Dr. Engel in the past was a major author and contributor to the largest American study testing the concept of penile rehabilitation after prostatectomy comparing Muse to Viagra in patients suffering erectile function after prostatectomy. Muse can be a great solution for some men, however Dr. Engel found the cost (approximately $50 a dose) and also the very common complaint of pain and lack of efficacy (only reliable in approximately 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 a 1cc syringe of the gel in a syringe, with the standard dose being .1cc. The dose is injected into the urethra, and the cost is 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, and Dr. Engel in particular, 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 did. 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 in essence forces an erection. A vacuum erection device is a a device that will suck venous blood into the penis that must then be captured in the penis by also wearing constrictive band around the base to hold this in. Some married couples will find this to be useful, as will the man that is unwilling to self inject himself (see below). Patients interested in moving to a vacuum erection device are advised to purchase one via the internet. Amazon will display many, and our patients are encouraged to buy a medical grade device, usually priced around $150, that comes with bands and instructions and a phone number for support and usage device. Vacuum erection devices have been marketed for helping with post-prostatectomy impotence and Peyronie’s disease, but Dr. Engel and others have researched this extensively 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 spontaneity or the need for a constriction band that may cause pain. For these reasons, we use these rarely and usually ask patients to consider strongly injection therapy once pills fail them.
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. Shots are safe, and almost always effective, and not nearly as painful as one would think. The medicine that is most commonly used is actually a mixture of three medicines, all of which on their own will potently and directly dilate arteries to cause blood to rush into the penis to give and erection. The reason for the mixture is to get the specific positive attributes of each medicine and to lessen the potential for each drugs specific drawback. For example, alprostadil rarely causes priapism (erections that will not go down) and is thus the safest ingredient but can cause pain. Papaverine and phentolamine rarely cause pain but can cause priapism. Thus an adjustable mixture called Tri-Mix is used, and at times we add another ingredient, Atropine, and use a mixture called 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 that are heavily advertised on the radio and newspaper that in essence are just selling injections for erections at a price usually nearly ten times the price they are readily available at if prescribed by an 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 at that time 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 will 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, which is hopefully avoided by titrating the dose up slowly.
Ultrasonic Wave Therapy
Whereas in the past the marketing push for the “Mens 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 sounds waves, or mechanically produced shock waves are applied directly to the penis. This is a simple and relatively painless treatment that 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 of them have demonstrated some efficacy. However, is very difficult to actually perform these studies as patients will generally know if they are receiving therapy or not and therefore it is largely impossible to know whether any perceived benefit is a placebo affect or not. Because of the lack of convincing data, these treatments are not currently covered by insurance. 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 generally runs between $2500 to $5000.
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 to not need the pills. 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 someone that is 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. Absolutely the wrong patient, as we feel there is little chance of success, is the patient with severe erectile dysfunction or the post-prostatectomy patient who has yet to have any partial return of erections.
Inflatable Penile Prosthesis:
When all else fails, or if patients have demonstrated the willingness to try to other remedies but are either not happy with them, not happy with the lack of spontaneity they provide, or simply don’t find them to be a reliable solution, we turn to a penile prosthesis. This is a surgery in which three components are surgically implanted in to penis, scrotum and behind the pubic bone. With a penile prosthesis, what is done is to implant two cylinders into the normal anatomy of the penis. These cylinders will fill with water by the patient pumping 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 more and more erect, and will be fully erect after approximately five to ten pumps. Penile sensation will be 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, and noone could tell it is present unless actually 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 itself 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. For the right patient, these risks are not enough to keep them from seeking this durable, dependable solution.