Erectile Dysfunction (ED)

What causes erectile dysfunction?

Erectile dysfunction is characterized by the inability to achieve or maintain an erection during sexual intercourse. There are numerous factors which affect ED. These include medical issues such as high blood pressure, high cholesterol, diabetes, hormone problems, and treatment for bladder or prostate cancer. Additionally, some medications can cause ED, as can stress/psychologic issues, as well as tobacco, alcohol, and substance use.

How do the common ED medications work?

Tadalafil (Cialis) and sildenafil (Viagra) are the two most common phosphodiesterase type 5 inhibitors (PDE5I) on the market. They inhibit the enzyme phosphodiesterase type 5, ultimately leading to increased cyclic guanosine monophosphate (cGMP) and increased blood flow to the penis. A patient taking these medications will need to consume the medication a few hours prior to intercourse, often on an empty stomach, in order for them to be effective. While sildenafil can be effecrtive up to 4-5 hours, tadalafil can be effective up to 36 hours.

What are the side effects of the ED medications?

Although they are overall well tolerated, common side effects include headaches, flushing, indigestion, nasal congestion, and changes in vision. Phosphodiesterase inhibitors are contraindicated for patients taking nitrates for heart disease, and must be used with caution in patients taking alpha-blockers for benign prostatic hypertrophy, as well as protease inhibitors.

What can I do if medications don’t work for me?

PDEI5 are ineffective for at least 30% of patients, however there are other options available for these patients.

Pulse Wave Therapy

Pulse wave therapy, also known as shockwave therapy, is a non-invasive medical treatment for ED. It involves the use of low-intensity sound waves, which are typically delivered to the penis using a specialized device. It is believed that pulse wave therapy helps to stimulate blood flow to the penis by stimulating the growth of new blood vessels (angiogenesis). Pulse wave therapy is unique because it is considered a restorative treatment for ED, as it helps to address the underlying mechanism causing ED. Pulse wave therapy is typically considered for men with mild to moderate ED, and is currently not covered by insurance. Most patients begin with six weekly sessions, and some may choose to have maintenance sessions depending on the results they experience.

Intracarvernosal Injections (ICI)

During ICI, a patient is taught how to inject a small needle into the base of their penis, which administers a combination of medications that help induce an erection. The injections can cause an erection within 2-15 minutes, much faster than medications can, and can last up to 1 hour. Patients who are taking blood thinners may need to hold pressure on the injection site for a few minutes to ensure that no bruising or swelling occurs. A precaution for patients taking this erection is priapism (an erection lasting greater than 4 hours). If this occurs, patients must seek immediate medical attention to reverse the medications.

Penile Prosthesis

Over 50 years ago, the first penile implant was introduced and these remain a cornerstone of ED therapy today. A penile implant is a silicone device which is placed inside of the muscles of the penis during a surgical procedure to help procedure an erection. There are two types of implants, malleable and inflatable prostheses. After penile implant surgery, a patient will continue to have normal sensation to the penis, however an erection can only occur with the help of the device. Satisfaction with penile implants has been demonstrated to be as high as 98%.

The malleable prosthesis is a pair of bendable rods which can be adjusted into an erect position when desired. Alternatively, the inflatable penile prosthesis (IPP) contains inflatable cylinders and a pump system. The device can come with either two or three pieces, and is designed to help produce a more natural erection. During activation, fluid is moved from the pump system into the inflatable cylinders to produce an erection.

How long does the penile implant last?

Penile implants last on average for 10-15 years, but can last longer in some cases. Penile implants can break with repeated use, and if broken, may require a revision surgery to install a new device.

What are the risks of penile implant surgery?

The risk of infection is about 1% in a healthy patient undergoing a first-time implant. If infected, timely removal of the implant is required to prevent further complications. Other risks associated with surgery include erosion of the implant, bleeding, pain/discomfort, and device malfunction.

After penile implant surgery, will ejaculation be normal?

After penile implant surgery, sensation to the penis, orgasm, and ejaculation should continue to be normal. A patient who undergoes an implant will continue to produce sperm in their ejaculate and can father a child.

How long is the recovery process following surgery?

Most patients go home the same day following surgery. Recovery typically takes several weeks. Most patients experience mild pain or discomfort for the first few weeks following the procedure. Patients are brought back to the office by the fourth week to examine the wound, and following this most patients can resume heavy lifting. If the swelling has improved by the fourth week, patients can start using the implant, however there are some patients who may need another few weeks prior to using the device.

What can patients do to minimize pain/swelling following surgery?

During the procedure, local anesthetic is administered to help minimize pain and discomfort for the first 24 hours. Following surgery, patients will be prescribed a combination of acetaminophen (Tylenol) and an anti-inflammatory, and in some cases a narcotic. The day following surgery, patients are recommended to wear a tight-fitting underwear such as the Under Armour Boxer Jock. Wearing a tight fitting underwear can minimize swelling following the procedure.