Erectile Dysfunction Overview
How does an erection develop?
An erection normally develops when blood flows into the erectile chambers of the penis. These chambers, known as the corpora cavernosa, are elastic sleeve like structures which lie in the penis adjacent to the urethra, the urinary channel. Erection develops when there is marked increase of blood flow into the spongy elastic erectile sleeves. Once blood flows in, it should be trapped there so that it does not leak back out. This entire process is under the control of chemical messengers. These events are in turn coordinated through a control center in the brain.
What conditions interfere with the ability to get an erection?
A variety of problems can interfere with the ability of a man to get an erection.
- The most common cause for erectile dysfunction is venous leak. The veins which are responsible for trapping the blood in the erectile chambers leak. In this case blood gets to the proper place but doesn’t stay there.
- The nerves which control the process may not function properly.
- There may be inadequate blood flow secondary to poor circulation either in the major blood vessels which bring blood to the groin area or in the smaller arteries that directly supply the erectile sleeves.
- There may be improper levels of the male hormone testosterone.
- Stress, anxiety or other emotional problems may adversely affect the control center in the brain.
Are there other health conditions with can cause ED?
Many health conditions may interfere with erectile ability. High blood pressure, heart disease, impaired circulation, previous stroke, diabetes, alcoholism and kidney disease all can cause ED. Trauma to the pelvic or groin area may interfere with blood flow. Prescription and non-prescription medications may adversely affect erection. Stress, anxiety, emotions and relationship difficulties also interfere with erection.
What is done to evaluate ED?
Evaluation of erectile dysfunction begins with the medical history. During the history the doctor asks questions to gather information about the above conditions. Subsequently, the doctor examines the abdominal and groin area to search for physical signs of some of the underlying conditions noted above.
Hormone levels of testosterone may be checked with a blood test. If the testosterone level is low, testosterone replacement may help. If the testosterone level is normal, there is no advantage to giving extra testosterone.
In men over the age of 45 the prostate may be checked. The prostate itself does not cause problems related to ED; however, all men are at risk for the development of prostate cancer and with that in mind, the prostate may be checked with a digital rectal exam.
Goal oriented approach to treatment
In the past a variety of diagnostic tests were carried out to pinpoint the cause of erectile difficulty. Some of these tests included sleep lab testing, Doppler study to assess blood flow and tests to check the function of the nerves in the groin area.
Current practice favors a “Goal Oriented” evaluation and treatment strategy. We found that expensive tests did not change eventual treatment recommendation. For that reason, we now approach ED in terms of what can be done to improve sexual function.
What treatments are available?
The first treatment step is typically a trial of an oral medication. Viagra, Levitra and Cialis have worked extremely well for many men. One of these pills is taken several hours before sexual activity. These medications will not cause an erection to develop on its own. However, when sexual stimulation starts, a better erection often develops. They work by affecting one of the chemical messages responsible for controlling the process of blood flow in – blood flow out. The pills amplify whatever chemical message is already present, so that there is better blood flow into the elastic erectile sleeves, and once the blood reaches the erectile sleeves, it is trapped there better so that it is less likely to leak back out. After climax and ejaculation, the penis becomes soft again (known as detumesence) just as it does for an erection not aided by pills. A prolonged erection does not develop from using one of these pills. These pills work best if taken on an empty stomach, 2-3 hours before sexual activity. So, if going out to dinner on a Saturday night, it is best to take the pill before going out, not after coming home with a full stomach. These pills are contraindicated in men with severe heart disease who are using a nitrate-based medication. Side effects can include headache, flushing and rarely stomach upset or increased sensitivity of the eyes to light.
When pills are not effective the next step may be a venous constriction band or a vacuum erection device.
Some men can naturally get an erection but find their erection does not last long enough for satisfactory intercourse. This is often due to a condition known as venous leak. Many of these men can be helped with the use of a venous constriction band (VenoSeal). VenoSeal is an adjustable constriction loop that is placed and tightened at the base of the penis. With proper tension, the VenoSeal device will be comfortable to the user but also provide enough additional pressure to prevent blood from flowing back into the body, thus maintaining the erection.
A vacuum erection device uses a cylinder placed over the penis to create a vacuum that draws blood into the erectile sleeves. A restrictive band is placed at the base of the penis to keep the blood there. This form of therapy is safe and non-invasive. Although it may be awkward to learn at first, many men are quite satisfied with this option. These devices can now be purchased on Amazon.
When simple things do not work, the next choices are penile self-injection and MUSE.
With self-injection therapy the patient learns how to inject the medicine into the elastic erectile sleeve in the penis. This delivers the chemical message directly into the elastic sleeves to start the erectile process of blood flow in and blood flow trapping. After injection, an erection occurs which may last from 30 minutes up to 2 hours. Prostaglandin (Caverject, etc.), phentolamine and papaverine are medicines used for penile self-injection. Direct injection of any of these medications may cause a persistent erection that does not go away spontaneously after ejaculation and may require emergent treatment.
The major limitation to the use of penile self-injection has been the requirement for a man to inject himself with a needle in the side of the penis. An alternative delivery system known as MUSE allows the medication (prostaglandin) to be delivered by inserting a small suppository into the urethra at the tip of the penis. If enough of the medication is absorbed from the urethra (the urinary channel) into the erectile sleeves, an erection can develop.
If a prolonged erection (greater than 2 hours) develops after penile self-injection or the use of MUSE, the patient should take Sudafed 120 mg. If the erection persists despite that, a patient needs to seek emergency treatment.
An option for ED therapy which was popular in the past was the surgical insertion of a penile prosthesis or an implant. With a penile implant, an artificial device is inserted into the erectile sleeves of the penis that can be mechanically inflated to produce an erection. Problems include device failure and infection.
For some men the erectile process works normally but they may have difficulty getting an erection due to emotional stress or anxiety. Counseling works well in this circumstance.
Take Home Message
Overall, a “Goal Oriented” stepwise approach to ED has proved very successful. Counseling where needed may be helpful. Treatment with oral medication is oftentimes very successful. When that fails, therapy with either a vacuum erection device, MUSE or penile injection may produce favorable results.
Erectile Dysfunction Evaluation
Erectile Dysfunction Score Sheet (SHIM)
Low Testosterone Questionnaire
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