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Erectile Dysfunction.docx - Lakeview Center for Urology

  1. 1. Erectile Dysfunction Quick Facts|Overview|ED - Myth vs. Fact|Causes of ED|Diagnosing ED|Treatment Options|ED LinksQuick Facts about Erectile Dysfunction, Impotence, or ED:Erectile Dysfunction (ED) is another word for ImpotenceImpotence, also known as Erectile Dysfunction, or "ED," is the inability to achieve and maintain an erection suitable for intercourse. Erectile Dysfunction affects MANY men - about 50% over the age of 50Estimates suggest that as many as 30 million men in the United States alone may suffer from Erectile Dysfunction. Most don’t seek help with a doctor, deciding instead to either live with it, or seek help though a variety of unproven, ineffective treatments. There are many causes Of Erectile DysfunctionED is often associated with smoking, alcohol, trauma, and underlying medical conditions such as diabetes or vascular disease. It can also be a side effect of certain medications. It is important to have a physician determine the cause so that the appropriate treatment can be prescribed. Erectile Dysfunction Can Be Successfully TreatedThe vast majority of cases of impotence can be successfully treated, regardless of cause and regardless of age. Even if one treatment is not effective, there are other alternative therapies that may work. <br />A Variety of Treatment Options Are AvailableThose experiencing Erectile Dysfunction can work with their doctor in selecting the treatment option that is best for them. The following section will go over many such options.  <br />Overview - Erectile Dysfunction:<br />Definition:<br />Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his sexual needs or the needs of his partner. Most men experience this inability from time to time, often caused by fatigue, medications, alcohol, or other issues. Once a man experiences erection troubles for greater than 6 months, it is considered a medical condition. Left untreated, erection problems can cause emotional and relationship problems, and often leads to diminished self-esteem. It can affect men in many areas of their lives, not just in the bedroom. It has many causes, and is very treatable<br />How often does it occur? An estimated 30 million men in the United States experience chronic erection problems, but only 10-15% seek treatment. It may affect up to 50% of men between the ages of 40 and 70. <br />Anatomy of the Penis The internal structure of the penis consists of two cylinder-shaped rods of muscle tissue called the corpora cavernosa. These run through the left and right sides of the penis. The urethra is a tube on the underside of the penis that expels urine and ejaculate. The two corpora each have an artery carrying blood into the penis called the cavernosal artery. They are very small, about as wide as the lead in a pencil. Under the surface of the penis are thousands of tiny veins, or venules. These lie sandwiched between a tough fiber layer of the penis caused the tunica albuginea and the spongy corpora.<br />Physical Mechanism of an Erection The process of erection begins in the brain and involves the nervous and vascular (blood vessel) systems. Sexual stimulation causes nerves to fire, transmitting a signal down from the brain to the penis. This nerve signal tells the normally tight spongy muscular tissue in the penis to relax, and the two cavernosal arteries to expand. As blood rushes into the penis, it swells, squeezing the veins between the tough tunica and muscular corpora. As the veins are compressed, they flatten, stopping the outflow of blood. Blood continues to rush in, but can’t leave. Pressure rises in the penis and it becomes rigid Any condition that causes blood to come into the penis more slowly, or causes blood to leak out, will lead to a poor erection. When stimulation ends, or following ejaculation, the body releases chemicals to tighten up the penile arteries and the spongy tissue. This puts less pressure on the veins, and they open. Blood leaves the penis, and the pressure drops. Finally, the penis resumes its normal shape and size. <br />Myths and Facts about Erectile Dysfunction (ED):<br />Myths:<br />1) Few men suffer from ED<br />2) "Nothing can be done about ED" or "Viagra didn't work - so nothing will!"<br />3) "It's all in my head."<br />4) Most men with ED seek help with a doctor<br />5) ED is a natural part of Aging<br />6) Herbal over-the-counter treatments can help<br />7) Erection problems are only "man" problems<br /> <br />Facts:<br />1) Approximately 50% of men over the age of 40 have some degree of ED - some mild, some severe. That’s around 30 million men in the US, and millions more overseas. ED is COMMON.<br />2) Twenty years ago, there were few treatments for ED. Now there are MULTIPLE effective and proven ways to improve erection problems, including, but not limited to Viagra. Only by sitting down with a medical professional will you learn which of the many treatments is best for you. Click here for more details on available options.<br />3) Years ago, doctors felt that ED was caused by 90% psychological problem, and 10% by physical problems. Now doctors know the opposite it true. About 90% of Erection problems are caused by physical problems with the blood vessels, veins, or nerves, and only about 10% of cases are due primarily to psychological issues. It is very common to have some degree of anxiousness, stress or even depression relating to having erection problems. But most often these come after a physical problem caused the erection problem, not before.<br />4) Most men don't seek help with a doctor. It's estimated that only about 10-15% of men with Erection problems seek help, despite the fact that effective treatments have been around for years. Embarrassment, fear, and discomfort talking about the subject keep many men from the treatment they need to help themselves and their partners. <br />5) Erections are NOT a natural part of aging. As men get older, many develop medical problems, are put on medicines, or continue to smoke or drink, leading to ED. Some older men will avoid ED, while others may develop the problem in their 40's. Often the difference between these men is in the number of risk factors they have (smoking is one example). Once you and your doctor identify the risk factors causing your ED, changes may help improve erections immediately, or reduce the risk of it getting worse.<br />6) Unfortunately, no herbal or over-the-counter (OTC) products have been shown to be helpful in treating erection problems. Yohimbine, Andro, Enzyte, and other OTC products have never been proven in legitimate medical studies to help obtain, maintain, or enhance erections. The 30% of men who feel these products help experience the "placebo" effect" - a product of increased confidence, not herbs. For success rates that range from 50-95%, you will need a prescription from your doctor.<br />7) Erection problems are sadly not "just a man's problem." ED is a couple's concern. Partners suffer as well. The depression, feelings of lost masculinity, anxiety - these feelings can lead men to "clam up", avoid their partners, sleep separately, and many other negative behaviors that can cause marital difficulties. Because ED affects men and their partners, we do encourage partners to be part of the office visit, so they can be part of the solution.<br />Causes of ED: <br />Causes of erectile dysfunction are physical and psychological. Reduced blood flow to the penis and leakage of blood out of the penis are the most common causes. A partial list of the many causes of ED include the following: <br />Vascular Disease <br />Diabetes <br />Medications / Drug Use<br />Hormone Imbalance <br />Neurologic Causes <br />Pelvic Trauma and Surgery <br />Peyronie's Disease <br />Venous Leak <br />Psychological Causes <br /> <br /> <br />Vascular Disease Arteriosclerosis, the hardening and narrowing of the arteries, causes a reduction in blood flow throughout the body and can lead to impotence. It is associated with age and accounts for 50% to 60% of impotence in men over 60. Risk factors that can speed up the development of arteriosclerosis include: <br />Diabetes mellitus <br />High blood pressure <br />High cholesterol <br />Smoking<br />Alcohol Abuse<br />Diabetes Mellitus High levels of blood sugar associated with diabetes mellitus often damage small blood vessels and nerves throughout the body, which can impair nerve impulses and blood flow necessary for erection. It also damages the veins lying under the skin of the penis, often causing leakage of blood. This venous leak explains why many diabetics will first notice trouble maintaining erections before they notice difficulty getting strong erections. About 60-80% of men with diabetes will experience ED at some point in their lives. <br />Medications There are over 200 prescription drugs that may cause or contribute to impotence, including drugs for high blood pressure, heart medications, antidepressants, tranquilizers, and sedatives. A number of over-the-counter medications also can lead to impotence, especially antihistamines and cold medicines. Long-term use of alcohol and illicit drugs may affect the vascular and nervous systems and is associated with erectile dysfunction. <br />Hormone Imbalances Hormone disorders are the main cause of ED in fewer than 5% of men. It may contribute as one of many factors in a higher percentage. Testosterone is the main male hormone, and when low, can (but does not necessarily result in) a loss of libido (sexual desire), poor erections, fatigue, depression, and diminished strength / endurance. Among other conditions, an excess of the hormone prolactin, caused by pituitary gland tumor, reduces levels of testosterone. Hormonal imbalances can also occur as a result of kidney or liver disease. Low libido is often the presenting symptom of low testosterone, but can also be caused by depression, psychological issues, and marital strife. Testosterone is best tested before 10am, as the level peaks near this time, and drops in the afternoon and evening.<br />Neurologic Causes Spinal cord and brain injuries (e.g., paraplegia and stroke) can cause impotence when they interrupt the transfer of nerve impulses from the brain to the penis. Other nerve disorders, such as multiple sclerosis, Parkinson's disease, and Alzheimer's disease, may also result in impotence. <br />Pelvic Trauma and Surgery Trauma to the pelvic region or spinal cord can damage veins and nerves needed for erection. Surgery of the colon, prostate, bladder, or rectum may damage the nerves and blood vessels involved in erection. Cancer surgery, in particular, often requires removing extra tissue and nerves surrounding the affected area, which increases the chances for impotence. Removal of the prostate or bladder often results in impotence. New nerve-sparing techniques aimed at lowering the incidence of impotence are now being developed and used in these surgeries. It can take as long as 6 to 18 months for erections to return, though partial erections may be possible earlier. Even with nerve-sparing procedures, many men still have mild to moderate ED. Nerve-sparing is no guarantee that potency will be spared.<br />Radical cystectomy (for bladder cancer) and prostatectomy (for prostate cancer) require cutting or removing the nerves that control penile blood flow. These nerves can also be permanently damaged in men who have undergone radiation therapy for prostate or bladder cancer. These nerves do not control sensation in the penis and are not responsible for orgasms; only erectile ability is affected by these procedures.<br />Peyronie's Disease Peyronie's disease is a fairly common inflammatory condition that causes scar tissue to form within the fibrous layer of the penis, just under the surface. It occurs in about 1-3% of men during their lifetime and can be caused by trauma to the penis (50% of patients) or may occur without any reason (the other 50%). This scarring can (but doesn't necessarily) produce a curvature of the penis, pain, and difficulty getting or keeping erections. Curvature can be severe enough to stop penetration, or may be mild and cause no difficulties at all. It is not related to cancer, and if doesn't bother you, no treatment is necessary. There are several treatments for those whose Peyronie's does cause them difficulty. These can include oral medications, topical creams, and surgery as a last resort.<br />Venous Leak If the veins in the penis cannot prevent blood from leaving the penis during erection, an erection cannot be maintained. Venous leak can be a result of injury, disease, or damage to the veins in the penis. Frequent causes include Diabetes, Peyronie's, High Blood Pressure, Elevated cholesterol, alcohol abuse, and smoking.<br />Psychological Causes Depression, guilt, worry, stress, and anxiety all contribute to loss of libido and erectile dysfunction. If a man experiences loss of erection, he may worry that it will happen again. This can produce anxiety associated with performance and may lead to chronic problems during sex. If the cycle is inescapable, it can result in impotence. Psychological factors in impotence are often secondary to physical causes and they magnify their significance. Breaking the cycle of failure is often the key to improving Psychological ED.<br />Diagnosis: <br />A medical history and physical examination is the best way to initially diagnose ED. A thorough history can identify the risk factors (like smoking, cholesterol, medications, etc) that may have led to Impotence. The history alone will be sufficient to explain over 80% of the cases of ED. Laboratory tests may be performed to rule out other less obvious causes in those remaining 20%, or to confirm the diagnosis. These can include: <br />Blood Tests and Urinalysis Blood tests can indicate conditions that may interfere with normal erectile functioning. These tests measure hormone levels, cholesterol, blood sugar, liver and kidney function, and thyroid function. Excess prolactin (hyperprolactinemea) can lower testosterone levels, which can diminish libido. Both of these levels may be measured, as well as levels of other sex hormones. If they are persistently low, an endocrinologist (hormone specialist) should be consulted. <br />Lipid Profile / Cholesterol tests: The level of blood lipids (fats) such as cholesterol and triglycerides may indicate arteriosclerosis, which can reduce blood flow to the penis, and may make it more difficult for tiny veins in the penis to close easily (makes them less elastic).<br />PSA: Most physicians agree that men over the age of 50 and men after 40 with relatives with Prostate cancer should be screened for prostate cancer with a PSA blood test. PSA is a naturally occurring chemical released by the prostate. Prostate cancer and prostate infections might be found, both of which can cause ED.<br />Liver and Kidney Function Tests Liver and kidney disease can create hormonal imbalances. Blood tests for liver function and kidney function will measure levels of normal enzymes and levels of waste products in the bloodstream. <br />Thyroid Function Tests Thyroid hormones regulate metabolism and the production of sex hormones; a deficiency may contribute to impotence. <br />Urinalysis Urine analysis will typically look for signs of elevated protein, sugar, or the presence of blood. (prostate disease or cancer) levels that may indicate diabetes mellitus, testosterone deficiency, and kidney dysfunction. <br />Erectile Function Tests The following tests assess erectile function by examining the blood vessels, nerves, muscles, and other tissues of the penis and pelvic region. <br />Duplex Ultrasound Duplex ultrasound is used to evaluate blood flow, venous leak, signs of artherosclerosis (hardening of the arteries), and scarring of erectile tissue. Erection is induced by a penile injection with medicines designed to stimulate bloodflow. Ultrasound (imaging with sound waves) is then used to see how quickly the blood moves through the cavernosal arteries, and to check for leakage of blood out of the penis. Scar tissue and penile curvature can also be detected and examined. <br />Prostate Examination An enlarged prostate, which can be detected with a digital rectal examination (DRE), can interfere with blood flow and nerve impulses in the penis. <br />Nerve Testing: Specific nerve tests are used in patients with suspected nerve damage as a result of diabetes or nerve disease. These specialized tests are often done with a neurologist. Penile biothesiometry may be used, but is becoming less common. This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glands and shaft of the penis. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence. <br />Nocturnal Penile Tumescence (NPT) Normal men will typically have four to six erections during sleep. The final erection often is underway when men awaken, explaining why men often wake with AM erections. This is how the body maintains healthy blood flow to the penis, even when sex is not occurring. Few or poor erections may indicate organic, physical problems in the penis, but may also be a sign of depression. If erections are normal during sleep, but poor when awake, this raises the suspicion that psychological and not physical disease is likely present. If erections are poor during sleep and while awake, the chance of physical disease is much greater. This is usually tested with a Rigiscan device, which measures penile rigidity, circumference, and duration, and can be downloaded to a computer for analysis. A snap-gauge can also be used, but provides less information.<br />Penile Injection When injected into the penis, certain solutions cause erection by dilating blood vessels in erectile tissue. Time to obtain an erection, rigidity, curvature, and maintenance time can all be evaluated. Abnormalities can give clues to arterial or venous problems, as well as help quantify the degree of Peyronie’s Disease (scar tissue in the penis). <br />Treatment: <br />Sex Therapy A significant 20% of ED is believed to be primarily psychological. Many others develop psychological and relationship issues following physically caused ED. Often these can be overcome. Even when the problem began as a problem with blood vessels or nerves, the psychological effects will occasionally not resolve even when the erection problem is fixed. Qualified therapists (e.g., sex therapists / counselors, psychotherapists) work with couples to reduce tension, improve sexual communication, and create realistic expectations for sex, all of which can improve erectile function. <br />Sex therapists emphasize the need for men and their partners to communicate, restoring the intimacy often lost during long periods of sexual dysfunction. As intimacy and communication improve, anxiety and depression lessen, and the psychological side of the relationship is helped. This frees the Urologist to concentrate on the physical side of the dysfunction. <br />Medical Treatment <br />Oral Medication <br />There are four current oral prescriptions for Erectile Dysfunction (ED) - Sildenafil (Viagra®),  Vardenafil (Levitra),  Tadalafil (Cialis), and Yohimbine (Yohimbine®, Yocon®). <br />Viagra improves erections by inhibiting natural chemicals in the body that normally makes erections disappear after ejaculation. It increases levels of cyclic GMP (cGMP), which causes the smooth muscle and arteries of the penis to relax. When relaxed, extra blood flows into the two muscular bodies of the penis, the corpora cavernosa, often causing better erections. Viagra works best if taken about 45 min to 1 hour prior to intercourse, and is often helped by taking it on an empty stomach. Sexual stimulation is necessary for it to work. Results vary depending on the cause of erectile dysfunction - from as low as 30% successful in those having a history of prostate surgery, to as high as 85% in psychological ED. Common side effects include headache, flushing, and indigestion. Rare side effects include palpitations and changes in color vision. All Side Effects are temporary. Viagra should not be taken more than once a day and is not suitable for men using Nitrites medications taken for chest pain from heart disease. Despite information in the public press, Viagra does not cause or worsen heart disease. Many men with multiple medical problems have safely taken Viagra, as long as Nitrates were not used. If you carry Nitro, some doctors will not feel comfortable prescribing Viagra until they discuss the issue with your Cardiologist. <br />Levitra and Cialis work by the same chemical mechanism seen above for Viagra.  These drugs often offer substantial benefits for some patients, explaining their growing popularity. Both newer drugs target the same chemical that Viagra does to stop erections. But both Cialis and Levitra have less effect on other chemical systems, making side effects less likely. Comparing all three drugs, Levitra may work the quickest, and some patients fell that it may be the strongest. Cialis has the longest life in the body, and is completely unaffected by food. Cialis may improve the potential of having an erection for up to 36 (or more) hours, but very rarely causes prolonged erections mentioned in television advertisements. At Metro Urology, we often encourage our patients to try samples of all three drugs. Whichever drug works the best with the least side effects is usually prescribed. Of note, men who take prostate relaxing alpha blockers should not take Levitra. Of these drugs, only Flomax can be used safely with Cialis.<br />Some men who have had less adequate success with Viagra have been successfully treated with Cialis and Levitra. Please consider an appointment to discuss the newer medications and obtain samples. <br />Yohimbine improves erections in only a small percentage of men, about 20-30%. Studies have shown it is only marginally better than a placebo (sugar pill). It can stimulate the parasympathetic nervous system, which has been linked to erections, and it may increase libido. It is necessary to take the medication for 6 to 8 weeks before determining whether it will work or not, and has to be taken three times per day. Side effects can include elevated heart rate and blood pressure, mild dizziness, nervousness, and irritability. For these reasons, it is not recommended in those with heart disease or high blood pressure. As many men with ED have risks for heart disease, stroke, or high blood pressure, Yohimbine is being used less and less. It is a common component of many OTC products.<br />Urethral suppositories <br />A device containing prostaglandin (Alprostadil), like Muse® (Medicated Urethral System for Erections), may be an alternative to injection. Using a small plastic delivery system, a man inserts a prostaglandin pellet down the end of the penis into the urethra. The medication is absorbed through the urethra into the erectile tissue of the penis within 15-20 minutes. It is available with a prescription, is well tolerated, and may improve erections in about 40-50% of men. Common side effects include short-term mild soreness, aching or tingling in the penis. Rarely we see feelings of lightheadedness, dizziness, or see prolonged erections. <br />Penile Self-Injection Self-injection involves using a short, thin needle (smaller than a diabetic needle) to inject medication through the side of the penis directly into the spongy muscle of the penis. This produces an erection that can last briefly or several hours in about 80% of men. Current medications include: Alprostadil (Caverject®, Edex®), Papaverine, Phentolamine (Regitine®), Forskolin, and VIP. Of these medications, only Alprostadil has been approved by the FDA for use in penile injection. The others have been tested elsewhere in the body and found to be safe, but not approved for use in the penis. These medications dilate blood vessels in the penis and relax muscle tissue, causing erection. Unlike oral medications, the results are more rapid, and often do not require sexual stimulation. The injections are relatively painless and create an erection that begins about 5 to 10 minutes after the injection. It is recommended that self-injection be performed no more than 3 times per week. Side effects can include infection, bleeding, and bruising at the injection site, dizziness, heart palpitations, and flushing. There is a small risk for priapism (an erection that lasts for more than 4 to 6 hours and requires medical relief). Repeated injection may cause scarring of erectile tissue, which can further impair erection. This is estimated to occur in about 8-10% of men who use injections as long-term therapy.<br />Vacuum Devices Vacuum devices work by manually pulling blood into the penis, creating an erection. The penis is inserted into a plastic tube, which is pressed against the body to form a seal. A hand pump attached to the tube is used to create a vacuum that draws blood into the penis, causing the penis to become engorged. Once created, the erection is maintained by pushing a rubber ring onto the penis base, preventing leakage. The penis is removed from the tube, and the ring left in place for 25 to 30 minutes (no longer!). If one size of ring does not hold the erection up sufficiently, tighter rings can be used. Vacuum pumps are easy to use at home and typically improve erections regardless of the cause of impotence. With practice, use of the pump becomes simple and erections occur quickly. Some men may experience a numbing feeling after placing the O-ring, or experience delayed or weak ejaculation. Side effects may also include a cold penis, discomfort or penile bruising. <br />Surgical Penile Implants Penile implants involve surgical insertion of bendable or inflatable rods into the penis. <br />A one piece penile implant, like the Dura-II, or AMS 600 is a silicon-covered flexible metal rod. One is placed in each side of the penis, within the tube of muscle tissue (corpora) on each side. Once inserted, it provides the rigidity necessary for intercourse and can be bent up or down against the body for concealment. It requires the simplest surgical procedure of all the prostheses, and has the advantage of being the easiest to use (bending it into position), and lasting the longest (usually more than 10 years). Its main disadvantage is that concealment can be difficult with certain types of clothing. <br />An inflatable penile prosthesis like the AMS 700 or Mentor Titan consists of two soft silicone or bioflex (plastic) tubes inserted in the penis, a small reservoir implanted in the abdomen, and a small pump implanted in the scrotum. To produce an erection, a man pumps sterile water from the reservoir into the tubes by squeezing the pump in the scrotum. The tubes expand and may lengthen (depending on the type of implant) to form an erection. When the erection is no longer desired, pushing on a valve in the scrotum allows the water to return to the reservoir. Inflatable prostheses are the most natural feeling of the penile implants and they allow for control of rigidity and size. <br />The surgical procedure to implant the inflatable prosthesis is slightly more complicated than for a single-piece implant. Also, because there are more mechanical parts, there is a higher risk for mechanical failure requiring repair or adjustment. The advantage of the three-piece unit is that the penis can expand in girth and length (unlike the single-piece unit) and can be more easily concealed when not in use (just deflate the unit and the penis returns to normal size). <br />Side effects with any penile implant can include infection (1-2%), prolonged swelling, discomfort, and perceived loss of penis length (erections will not be the same as they were as a young man, but will be the surgeon's best effort to stretch the penis to maximal size).<br />Vascular Reconstructive Surgery A small percentage of men undergo vascular reconstructive surgery to improve blood flow to the penis. Revascularization involves bypassing blocked veins or arteries by transferring a vein from the leg and attaching it so that it creates a path to the penis that bypasses the area of blockage. Young men who experienced local arterial blockage following trauma are the best candidates for this procedure. It may restore function in 50% to 75% of men. It is not useful for the vast majority of men seen for ED, whose blocked arteries are too extensive and too small to be bypassed. Venous ligation has been done in the past to prevent venous leak. Problematic veins are bound (ligated) or removed, which allows an adequate amount of blood to remain in the penis. Poor results led most surgeons to abandon the surgery, and it is rarely performed by credible Urologists.<br />