Nonsurgical Treatment of Erectile Dysfunction

• Most men with erectile dysfunction, troubles achieving and/or maintaining an erection satisfactory for sexual intercourse, can achieve an erection with medical or surgical erectile dysfunction treatment(s), regardless of the cause of the erectile dysfunction.
• Many reasonable nonsurgical erectile dysfunction (impotence) treatment options exist, including external vacuum devices, medications (oral and topical), hormonal therapy, penile injection therapy, and intraurethral pellet therapy. Sex counseling to further improve one's sexual health and sex life is another option and is discussed in Living With Erectile Dysfunction.
• In selected cases and under the supervision of an experienced urologist who treats impotence, therapy combining several of these methods can be used. If none of these therapies is satisfactory, surgical treatment, such as a penile prosthesis, can be considered.
• Erectile dysfunction may be the result of arterial and non-arteritic causes. Hardening of the arteries that bring blood into the penis, atherosclerosis, is a common cause of erectile dysfunction, particularly in men with cardiovascular disease. However, problems with the nerves that supply the penis as well as the veins that drain blood out of the penis can also cause troubles with erection. Erectile dysfunction may also have a psychological cause.

Male reproductive system

Common medical conditions such as diabetes, heart disease, and high blood pressure are associated with an increased risk of developing erectile dysfunction. Thus, optimal management of these diseases may help prevent the development or progression of erectile dysfunction. Lifestyle modifications to improve vascular function, including smoking cessation, losing weight if overweight, and exercising regularly, may be helpful.

Specially designed vacuum devices to produce erections have been used successfully for many years. Vacuum devices are safe, relatively inexpensive, and reliable. Vacuum devices do not require surgery. Vacuum devices are available over the counter or by prescription. It is important to make sure that the vacuum device have a mechanism to prevent too high of a vacuum (negative pressure).

The typical vacuum device consists of a plastic cylinder that is placed over the penis, tension rings of various sizes, and a small hand or battery operated pump. Air is pumped out of the cylinder, causing a partial vacuum (negative pressure), which increases blood flow into the penis and creates the erection.

Once an erection is obtained, a tension ring that is usually preloaded onto the bottom of the cylinder is placed at the base of the penis. The ring acts like a tourniquet to keep the blood in the penis and to maintain an erection.

Using the correct size of tension ring is critical in obtaining the best possible result from this type of treatment. If the ring is too tight, it can be uncomfortable. If too large a ring is used, the erection may not last. The tension ring should not be left in place longer than 30 minutes. Leaving the ring in place for longer than 30 minutes can cause damage to the penis and further aggravate the cause of the erectile dysfunction.

Although these devices are generally safe, bruising can occur and the erect penis may lack some support. Other possible side effects include the following:

• Pain
• Lower penile temperature (coolness to the penis)
• Numbness
• No or painful ejaculation when using the device
• Pulling of scrotal tissue into the cylinder
• Blood in the urine or ejaculate after use
• Injury to the penis with extremely high negative pressure

Many of these side effects can be helped by proper selection of the tension rings and cylinder size, use of adequate lubrication, adequate practice with the device, and proper technique.

Vacuum pumps are effective in most men. Successful erections are achieved in up to 90% of men using the vacuum device, however only about 69% men continue to use the device for two years or longer. The most common cause of failure is improper use of or unfamiliarity with the device. Other drawbacks to the use of vacuum devices include the need to assemble the equipment and the difficulty in transporting it. Many men also lose interest in the device because of

• necessary preparations (may need to interrupt foreplay),
• inability to hide the tension ring,
• relative lack of spontaneity, and
• lack of partner support or concerns by partner about the discoloration and temperature change in the penis.

Men with significant penile curvature (Peyronie's disease) may not be good candidates for using a vacuum device and should consult with their doctor prior to its use. Similarly, men who take blood thinners should also be careful with the use of the vacuum device.

The vacuum device has been used in men after removal of an infected or malfunctioning penile prosthesis to increase blood flow to the penis and decrease the risk of scarring.

An external vacuum device can be used to produce an erection. The typical vacuum device consists of a plastic cylinder, a tension ring, and a small hand pump.

The external vacuum device is shown placed over the penis. Note that, after an erection is obtained, the tension ring is placed at the base of the penis to help maintain the erection.

The venous constriction device is a device designed to compress the veins that drain blood flow out of the penis to keep blood in the penis. These devices may help individuals who have a "venous leak." In these individuals, although blood flow is coming into the penis, it is draining out at the same time and this persistent drainage prevents a fully rigid erection. These devices may be used with other forms of medical therapy, such as medications, injection therapy, or the vacuum device.

Medications can be used to treat impotence, some of which are discussed below. For a more complete discussion, see Erectile Dysfunction Medications. Currently, oral medical therapy is considered the first line therapy in men with erectile dysfunction who have no contraindications to its use.

Phosphodiesterase type V inhibitors (PDE-5 inhibitors) are the most commonly used therapy for erectile dysfunction. These medications work by preventing the breakdown of chemicals that stimulate increased blood flow into the penis. Several different PDE-5 inhibitors are available, which differ slightly in how to use them and their side effects. They appear to be equally effective in the treatment of erectile dysfunction in general, but some individuals may respond to one of these medications more effectively than another.

Although these medications are the most commonly used for erectile dysfunction treatment, there are some individuals in whom these medications should not be used:

PDE-5 inhibitors are contraindicated in men taking any form of nitrates, such as nitroglycerin and in men taking guanylate cyclase inhibitors.

These medications should not be used in individuals with a condition called retinitis pigmentosa.

Caution is recommended regarding the use of PDE-5 inhibitors and alpha-blockers (for example, Hytrin, Cardura, Uroxatral, Flomax, Rapaflo), medications commonly used to treat benign prostate enlargement (BPH). The combination of these medications can cause lowering of the blood pressure. Stable use of one therapy should occur prior to the addition of the other therapy, which should start at a low dose.

Currently, there are four different PDE-5 inhibitors available, sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra). All of these medications require sexual stimulation to achieve an erection. None of these medications will improve sexual desire, nor will they improve normal erections.

• Levitra, Cialis, and Stendra have essentially the same activity as Viagra.
• Cialis has a longer duration of increased sensitivity to develop an erection (up to 24-36 hours) compared with Viagra and Levitra (up to four to 16 hours) and is the only medication that can be taken daily. Stendra can work as rapidly as 15-30 minutes and can be taken with alcohol.
• Viagra, Levitra, Stendra, and Cialis work successfully in a majority of all men with erectile dysfunction.
• Of those men with diabetes or with spinal cord injury, a majority reported being successfully treated with these medications.
• In men who became impotent after radical prostate cancer surgery, almost half reported improved erections with sildenafil, particularly if they had the "nerve-sparing" type of prostate surgery. These medications are most effective if there is some erectile function; if there is no erectile function, these medications are not usually beneficial.

Viagra is available in three strengths: 25 mg, 50 mg, and 100 mg. Viagra works best if taken on an empty stomach about 30-45 minutes before sexual activity. Optimal results may not be realized until the medication has been tried six to eight times. Viagra may be used cautiously with alpha-blocker medications as long as sufficient time has passed between their dosing.

Levitra is available in two strengths: 10 mg and 20 mg. It is not necessary to take it on an empty stomach. Levitra should be started at low dose in men taking certain medications called CYP3A4 inhibitors (ketoconazole, medications for HIV, and clarithromycin) and should be not be used in individuals with a known heart problem called prolonged QT interval or with medications that prolong the QT interval.

Cialis is available in three strengths: 5mg, 10 mg, and 20 mg. Cialis can work in 30 minutes, but peak results usually take longer. Cialis has the advantage of a much longer period (24-36 hours) during which sexual ability is increased. The newest formulation of Cialis is the 5 mg dosage for daily use. The major advantage of daily dosing is that it allows for spontaneous sexual activity.

Stendra is available in three strengths: 50mg, 100 mg, and 200 mg. Stendra can work as rapidly as 15-30 minutes and can be taken with food or alcohol.

Side effects of Viagra, Levitra, Stendra, and Cialis include the following:

• Headache
• Hypotension (a drop in blood pressure)
• Transient dizziness
• Facial flushing
• Indigestion
• Nasal congestion
• Lower back pain (unique to Cialis)
• Visual disturbance (for example, blurred vision, increased light sensitivity, persistence of a bluish tinge, temporary loss of the ability to distinguish between blue and green)
• Priapism is a painful erection lasting six or more hours (a urologic emergency that requires you to call your doctor or go to an emergency department).
• Sudden decrease or loss of hearing
• Sudden loss of vision in one or both eyes

Your physician will determine which of these medications is most appropriate for you and the optimal dosage, which may vary with other health problems that you may have. Never give any of these medications to anyone else as they can cause serious problems due to drug interactions if not monitored by a physician.

Certain street drugs (for example, ecstasy) can also cause serious problems if taken with Viagra, Levitra, Stendra, or Cialis.

Penile injection therapy, intracavernous injection, involves the injection of a vasodilator (a chemical that relaxes arteries to increase blood flow) into the penis. Penile injected therapy is recognized as the most effective nonsurgical treatment for erectile dysfunction. However, due to the invasive nature, it is often used in men who have failed or have contraindications to other treatments such as oral therapies.

Papaverine, a drug that produces vasodilatation (widening of the blood vessels), was shown to produce erections when injected directly into the penis. Soon afterward, other vasodilators were demonstrated to be effective as an erectile dysfunction treatment.

• Alprostadil (prostaglandin E1) is currently the most commonly used drug for injections into the penis. Alprostadil works well in most men who try it, however it may be associated with penile pain.
• Bimix and Trimix (combinations of alprostadil, phentolamine, and papaverine) are generally more effective than alprostadil alone and have less risk of penile pain. However, combination therapy is not readily available and often requires a compounding pharmacy and may not be covered by insurance plans.

The use of injection therapy requires being taught how to properly inject the medication, determination of the best dose, and monitoring for side effects. It is recommended that one inject on the side of the penis at the base and to alternate sides. Injection therapy should be used no more frequently than once every 24 hours. Individuals on blood thinners must be careful with use of injection therapy.

Side effects include the following:

• Pain from the medication (not from the injection), which is more common when alprostadil is used
• Priapism
  • Priapism is a persistent or abnormally prolonged erection that lasts four hours or more.
  • Priapism is a urologic emergency if an erection lasts six hours or more. Prolonged erection is an erection lasting four hours or longer.
  • Priapism/prolonged erection is a urologic emergency. If an erection lasts for four hours or more, you must either contact your urologist or go to an emergency department for immediate treatment.
• Scarring or bleeding at the site of the injection: Gentle compression at the site of injection after removal of the needle may help prevent bleeding/bruising.
• Penile curvature related to the development of scar tissue at the injection site

Intraurethral suppository therapy, also called the medicated urethral system for erections (MUSE), is a useful alternative for men who do not want to use self-injections or for men in whom oral medications have failed.

• Intraurethral pellet therapy is effective in men, although it tends to be less effective than PDE-5 inhibitors.
• Intraurethral pellet therapy has been successful when used together with Viagra; however, this type of combination treatment should only be done under the supervision of a urologist who is experienced in treating erectile dysfunction.

Alprostadil, a drug also discussed in Penile Injection Therapy, has been formulated into a small suppository. This applicator is inserted into the urethra (the canal through which urine and semen are excreted), and with compression of the applicator, the small suppository is released into the urethra. With massage/rubbing of the penis, the suppository dissolves in the urethra and the medication is absorbed into the penis where it acts to increase blood flow into the penis. One cannot use any form of lubricant (for example, K-Y jelly, Vaseline, etc) to help with the insertion of the suppository. Urinating prior to inserting the applicator will help moisten/lubricate the urethra.

A penile constriction device may be helpful in allowing the medication to stay in the erectile tissue a little longer and seems to give a somewhat better response.

Although few side effects occur with intraurethral pellet therapy, it is recommended that the first use be performed in the office as MUSE can cause lowering of the blood pressure (hypotension). The most common side effect is pain in the penis, which is a limiting factor in its use. A small amount of bleeding may also occur.

Intraurethral alprostadil is contraindicated in individuals who have abnormal penile anatomy (for example, urethral stricture, severe hypospadias with penile curvature), patients with acute or chronic irritation/infection of the urethra, individuals prone to priapism such as those with sickle cell anemia, thrombocytopenia, polycythemia, multiple myeloma, or are prone to blood clots. Intraurethral alprostadil should not be used for sexual intercourse with a pregnant woman.

Penile injection therapy can be used to achieve an erection. A vasodilator (a drug to widen the blood vessels) is injected into the penis, and, if the blood vessels are capable of dilating, a strong erection should develop within five minutes.

Intraurethral pellet therapy is also called the medicated urethral system for erections or the MUSE system. With this therapy, a small suppository containing a vasodilator (a drug to widen the blood vessels) is inserted into the urethra, using the device shown, to help achieve an erection.

Men with low sex drive and erectile dysfunction may have low levels of testosterone (the male hormone). As a general guideline, a testosterone level of 300 ng/dL or less is considered low, but this varies depending on the laboratory that does the testing and the time of day the sample is taken.

Hormone replacement may be beneficial for treating other forms of sexual dysfunction such as decreased libido; however, testosterone supplementation alone is not particularly effective in treating erectile dysfunction.

Sexual desire (libido) and an overall sense of well-being are likely to improve when serum testosterone levels (the level of the male hormone in the blood) are restored. However, testosterone therapy should not be started without a proper evaluation as there are risks associated with testosterone therapy.

Replacement testosterone is available in the following forms:

• Injections: Injections are a reliable way to restore testosterone levels, but this therapy requires periodic injections (usually every two weeks) to sustain an effective level. It also causes high hormone levels right after the injection and low hormone levels just before the next shot. This is thought to be slightly more risky than other methods that maintain a moderate hormone level throughout the treatment period.
• Skin patches and gels that are rubbed into the skin deliver a sustained dose and are generally well accepted. A strip that is placed in the mouth on the gums is also available. With the patches and the gels, skin rashes and irritation are the most common problems.
• Injectable pellets (Testopel) are injected under the skin every four to six months. Testosterone levels are maintained at an effective level, but the injection can be uncomfortable and cause bruising.
• Oral therapy (pills): This is the least effective therapy. Pills are also associated with a small risk of liver problems. Testosterone pills are not recommended.
• If your doctor prescribes long-term testosterone replacement therapy, you will have follow-up visits to assess your testosterone levels, to periodically monitor your blood counts, and to undergo regular prostate checks, including digital rectal examinations and prostate specific antigen (PSA) blood tests.