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Impotence/Erectile Dysfunction (cont.)

Impotence/Erectile Dysfunction Treatment and Medications

Currently, virtually any man who wishes to have erectile function may obtain it, regardless of the underlying cause of his problem. Many treatment options exist, which we will now cover. Your first step is to find a well-trained, experienced, and compassionate doctor, typically a urologist with a focus on erectile dysfunction, who is willing to take the time to understand you and fully discuss the treatments available to you. As mentioned earlier, involvement of a sexologist may also be considered for psychogenic and relationship troubles.

Sexual counseling is an important part of erectile dysfunction management. Many professional sex counselors are skilled in working with patients with ED, but your primary-care doctor and urologist may also serve in this capacity to some degree. These are usually the first professionals to learn about the problem. Men are frequently reluctant to discuss their sexual problems and need to be specifically asked. Opening a dialogue allows your doctor to begin the investigation or refer you to a consultant. After testing is completed, your doctor can then discuss your particular situation, the most likely cause, and reasonable treatment options.

Corrective measures of laboratory abnormalities (blood pressure control, glycemic control of diabetes, cholesterol, low testosterone), coupled with behavioral and/or lifestyle changes (cardiovascular conditioning, weight loss, stress reduction), should always be addressed initially. Psychosexual treatment can also be offered if needed by a sex counselor (sexologist).

Direct medication therapy for erectile function includes the following:

  1. Medical therapy with a class of oral medications called PDE5 inhibitors (sildenafil citrate [Viagra], vardenafil HCl [Levitra], tadalafil [Cialis])
  2. Intraurethral suppository PGE1 medication
  3. Penile injection of vasoactive medications
  4. External vacuum devices: In highly selected cases under the supervision of a urology specialist in ED, combination therapy using several of these methods together can be used.
  5. Unapproved and historical medication options
  6. Penile prosthesis implants can be considered if the above therapies are not satisfactory.

1. Oral Medical Therapy: PDE5 Inhibitor Class

PDE5i medications include

  • Viagra 50 mg, 100 mg,
  • Cialis 5 mg, 20 mg,
  • Levitra 10 mg, 20 mg.

PDE5i medications work by blocking an enzyme that normally promotes detumescence of the penis. This enzyme found in the penis helps breaks down a chemical produced during stimulation that normally produces erections. PDE5i allows this chemical of arousal to survive longer and improves erection function. That is also why sexual stimulation is necessary for Viagra to work.

In general, PDE5i works successfully in about 65%-70% of all impotent men. The greater the degree of damage to the normal erection mechanism, the lower the overall success rate. Men with diabetes and those with spinal cord injury reported between 50%-60% responding successfully to treatment with oral PDE5i medications. The worst response rate has been in men who became impotent after radical prostate cancer surgery where the nerves from the spine to the penis have been injured. Nevertheless, 43% of men reported improved erections particularly if they had the "nerve-sparing" type of prostate surgery.

Viagra, Cialis, and Levitra are prescription ED medications for the treatment of erectile dysfunction. Typically, they are taken 30-60 minutes prior to engaging in sexual activity. 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 hours).

Recently, daily dosing of Cialis 5 mg and vardenafil HCl (Staxyn) 10 mg or Levitra 10 mg have been available to avoid the timing factor planned around sexual activity.

Viagra was the first oral medicine (a pill taken by mouth) available that has been proven to improve erections in most men with impotence. Since its introduction in March 1998, no other therapy for ED has achieved such wide public recognition.

All PDE5i medication does not improve erections in normal men, only in those with difficulty in achieving or maintaining erections sufficient for sexual intercourse due to a true medical problem.

PDE5i medications do not work like an aphrodisiac and will not increase desire or libido.

Unlike other treatments for erectile dysfunction, PDE5i medications requires sexual stimulation to function. Without stimulation, these medications will not provide any effect.

Sildenafil is available in three doses: 25 mg, 50 mg, and 100 mg. Cialis is available in 2.5 mg, 5 mg, 10 mg, and 20 mg. The starting dose depends on the clinical situation. A man in his 50s with mild sexual dysfunction that is probably related to psychological factors can start at the lower dose. Men with moderate-to-severe ED can begin at the higher dose, and after testing the effect of the drug on at least three occasions, the dose can be modified. Men with severe ED may need to quickly move up to the highest. These men are less likely to achieve a satisfactory response, but they should make at least three to four attempts with the drug before considering another form of therapy.

Sildenafil should be taken on an empty stomach about 45-60 minutes prior to sexual intercourse. Cialis, on the other hand, is not affected by food intake.

PDE5i medications work best if taken about one hour before sexual activity. Only one tablet should be taken per day. Specifically for Cialis, the duration is 36 hours, and as such, would only need to be taken every second day, if needed. The pill can be taken on an empty stomach. Increasing the dosage of Viagra, Levitra, or Cialis beyond the recommended maximal dosage will not improve the response and will only result in greater side effects.

The most common side effect of Viagra is headache, affecting about 16% of users. A drop in blood pressure, transient dizziness, and facial flushing are reported in 10%. Indigestion occurs in 7%, and nasal congestion in 4%. Between 3%-11% of users report some visual disturbances while on Viagra. This visual disturbance is described as either blurred vision, increased light sensitivity, persistence of a bluish tinge, or temporary loss of the ability to distinguish between blue and green.

The most common side effect of Cialis is headache, facial flushing, and dizziness. More specific to Cialis are the muscle aches of the legs and lower back that result from venous congestion. This discomfort is self-limited and is relieved with common anti-inflammatory medication.

None of these side effects is severe in nature, and most are described as mild. Very few users stop taking the medication because of side effects.

Contraindications to PDE5i Medications

PDE5i medications are absolutely not to be taken by men with heart conditions who are taking nitrates such as nitroglycerine or isosorbide (Isordil, Ismo, Imdur). Those with serious heart disease, exertional angina (chest pain), and those taking multiple drugs for high blood pressure are advised to seek the advice of a heart specialist before beginning therapy with sildenafil.

No nitrate-based drugs should be given to men with suspected heart attacks if they have taken PDE5i medications within 24 hours. Combining PDE5i with nitrate-based medications can cause a severe and dramatic drop in blood pressure with potentially very dangerous consequences. This is also why someone should absolutely never share PDE5i medications with anyone else. If they happen to be taking one of the drugs that interacts dangerously with PDE5i medications, the results could be very serious. If there is any question about possible drug interactions, always check with a doctor or pharmacist.

Certain street drugs such as "poppers" also can cause serious problems if taken with PDE5i medications. Ecstasy is a street drug that may increase sexual desire but interferes with performance. This has prompted some men to combine ecstasy with PDE5i medications. This mixture (a combination sometimes called "sextasy") can improve erection ability but also causes severe headache and priapism. (Priapism is an abnormally prolonged erection that becomes extremely painful and may result in permanent damage to the erection mechanism.) There are also potentially dangerous effects to your heart from mixing PDE5i medications with various other street drugs.

Several medications can interfere with the chemical processing of PDE5i medications by the liver. These can include ketoconazole (an antifungal medication known by the brand name Nizoral), erythromycin (an antibiotic), and cimetidine (also known as Tagamet, for reducing stomach acid). A lower dose of PDE5i medications should be used if one is taking any of these medications.

2. Intraurethral Suppository PGE1 Medication

Intraurethral therapy (Medicated Urethral System for Erections, or MUSE): Alprostadil (PGE1) has been formulated into a small suppository that can be inserted into the urethra (the canal through which urine and semen are excreted). In a selected group of men, the drug was effective in 65%. This drug may be effective in men with vascular disease, diabetes, and following prostate surgery. This is a useful alternative for men who do not want to use self-injections or for men in whom oral medications have failed. It has been quite successful when used together with sildenafil (Viagra) in cases where each drug alone has failed. This type of combination treatment should only be done under the supervision of a urologist experienced in ED. Few side effects occur. The most common is pain at the site where the pellet is deposited. There may also be a small amount of bleeding. It is important for the user to urinate immediately before using the MUSE system. A temporary tourniquet is often helpful in allowing the medication to stay in the erectile tissue a little longer and seems to give a somewhat better response.

3. Penile Injection of Vasoactive Medications

Injection therapy: The modern age of such drug therapies began in 1993 when the injection of papaverine (Pavabid), an alpha-blocker that produces vasodilatation (widening of the blood vessels), was shown to produce erections when injected directly into the penis. Soon afterward, other vasodilators, such as PGE1 and phentolamine (Regitine), were demonstrated to be effective either as single drugs or in combination. The benefit of combination therapy is the decreased dosing of each with less side effects. Most important is the reduction of the prostaglandin PGE1 dosing, which is associated to the localized pain.

  • Self-injection of these agents has been of enormous benefit because they represent the most effective way to achieve erections in a wide variety of men who otherwise would be unable to achieve adequate rigid erections. The need for intact nerve pathways to the penile tissue is not needed. The locally injected medication directly relaxes the arteriole vessels and penile cavernosal tissue, thus directly causing male erection.
  • If the structure of the penis is healthy (not fibrosed or scarred), the use of injectable drugs is almost always effective. If one chooses this therapy, a doctor will teach the individual how to perform the injections, and the urologist (specialist) must determine the appropriate dose. The dosage is adjusted to achieve an erection with adequate rigidity for no more than 90 minutes.
  • Alprostadil, a synthetic PGE1, is the most commonly used single drug for injections into the penis as a treatment for ED. It works well in the majority of men who try it. In one study of 683 men with ED, 94% reported having erections suitable for penetration after PGE1 injections. When PGE1 is used in combination with papaverine and Regitine, the mixture is called TriMix, which has roughly twice the effectiveness of alprostadil alone. However, TriMix is quite expensive and is usually not covered by insurance, while PGE1 is often a covered benefit in most insurance medication plans. The main side effects are pain from the medication (not from the injection), priapism (persistent or abnormally prolonged erection), and scarring at the site of the injection. Many men are uncomfortable with penile injection therapy even though the injection itself is painless. The injection cannot be done more often than three times a week. Men on anticoagulant medications (blood thinners) should probably choose an alternative therapy.

4. External Vacuum Devices

  • Vacuum devices: Specially designed vacuum devices to produce erections have been used successfully for many years. They are safe and relatively inexpensive. They work by using a manually generated vacuum to draw blood into the penis to create the erection. When used successfully, their other significant benefit is a high degree of reliability compared to drug treatments, which tend to be less predictable.
  • The typical vacuum device consists of a plastic cylinder that is placed over the penis, tension rings of various sizes, and a small hand pump. Air is pumped out, causing a partial vacuum, which creates the erection. Once an erection is obtained, a tension ring, which acts like a tourniquet to keep the blood in the penis and maintain an erection, is placed at the base of the penis. This technique is effective in 60%-90% of men. It is not recommended to leave the tension ring in place longer than 30 minutes.
    • These devices are generally safe, but bruising can occur. Other unwanted effects include pain, lower penile temperature, numbness, no or painful ejaculation, and pulling of scrotal tissue into the cylinder. Many of these problems can be helped by proper selection of the tension rings and cylinder, use of adequate lubrication, and proper technique.
    • The devices are very reliable and seem to work better with increased use and practice. They can be operated and used quickly with experience but still are perceived to be less romantic than other options.
    • One drawback to the use of these external vacuum devices is the need to assemble the equipment and the difficulty in transporting it. Many men lose interest in using the device because of the preparations that are necessary, lack of easy transportability, inability to hide the tension ring, and the relative lack of spontaneity.
    • About half the men who use a vacuum device obtain good or excellent erections with them, but only half of these men consistently use the device over long periods of time.

5. Unapproved and Historical Medications

  • Historically, the option of local vasodilators (nitroglycerine) as well as oral apomorphine have been described in the literature with questionable success. Given the larger variety of medical treatments, particularly with oral PDE5i and the vast amount of published, peer-reviewed research on the safety and efficacy of Viagra, Levitra, and Cialis, most physicians will not offer such unapproved drugs. Similarly, historic medications such as yohimbine (Yocon), pentoxifylline (Trental), and trazodone (Desyrel), with high failure rates and substantial side effects, are summarized and included in the summary table. They, too, are not commonly used given the options currently available. The two most important historical ED drugs are described below:
    • Yohimbine: This herbal product has been available for many years. It comes from the bark of a West African tree. Its use has been questioned because, even in good, well-controlled studies, yohimbine is only slightly better than a placebo (no drug at all). A renewed interest in this agent has occurred, particularly when combined with sildenafil or some of the other oral drugs. Yohimbine is safe with few known adverse effects. The customary daily dose is one tablet of 5.4 mg taken three times a day. Given the current availability of targeted oral PDE5i medical therapy, yohimbine is not a current standard of care therapy for ED.
    • Apomorphine (Uprima): Apomorphine is a medication that dissolves under the tongue. It is not yet approved by the Food and Drug Administration (FDA). Apomorphine has a central effect on the hypothalamus, which is an area in the brain known to involve erections. Side effects are nausea, sweating, dizziness, drowsiness, vomiting, yawning, and weakness. Most of these were considered mild to moderate. Given the current availability of targeted oral PDE5i medical therapy, apomorphine is not a current standard of care therapy for ED.

Summary of Various Medical Therapies

Types of Medical Therapy Available to Manage Erectile Dysfunction
Hormonal (Testosterone) TherapyNo surgery required
May restore sexual desire
If unsuccessful, does not interfere with other treatments
Patches and gel now available
Inexpensive (injections)
Useful only in the few men with abnormal hormone levels
Need to take medications regularly
Significant side effects (such as fluid retention, liver damage)
Limited effectiveness
Highly variable blood levels when injections used
Absorption may be unreliable with patches and gels
Expensive (patches and gel)
PDE5 Inhibitor Medical Therapy
Sildenafil (Viagra)
Vardenafil (Levitra)
Tadalafil (Cialis)
No surgery required
May use treatment only when desired
Easily hidden and transportable
If unsuccessful, does not interfere with other treatments
Can be used in combination with other therapies under proper supervision
Maximum use is once per day
Benefit lasts between four to six hours (Viagra) or up to 36 hours (Cialis)
Side effects, if present, usually quite mild
Very effective with overall success rate of 65%-70%
Frequent side effects (40%) include headache, indigestion, facial flushing, nasal stuffiness, and rarely visual changes (temporary blue tint)
Potentially lethal interaction when used together with nitrate medications such as nitroglycerin, isosorbide mononitrate (Imdur), isosorbide dinitrate (Isordil)
Risk of an interaction is present for 24 hours after taking sildenafil
Must be taken on an empty stomach
Maximum effect takes 45-60 minutes
Does not "cure" underlying problem
No effect on libido (desire) or sensation
Vasodilators (Nitroglycerin)Historical
No surgery required
May use treatment only when desired
If unsuccessful, does not interfere with other treatments
Condom use required
No reports on long-term use
Possibly common side effects (headaches)
Lack of scientific studies on effectiveness
Very high failure rate
Very limited effectiveness
Very dangerous if used with sildenafil (Viagra)
No longer in general clinical use for ED
Yohimbine (Yocon)Historical
No surgery required
Side effects uncommon
May increase sexual desire
If unsuccessful, does not interfere with other treatments
20%-25% success rate
May be of some use in combination with sildenafil (Viagra)
Need to take medication every day
No reports on long-term use
Side effects, including nervousness, headache, dizziness, and nausea
75%-80% failure rate
Limited effectiveness
Pentoxifylline (Trental)Safe
No surgery required
Side effects uncommon
If unsuccessful, does not interfere with other treatments
50% success rate in selected patients
Need to take medication every day
No reports on long-term use
Side effects, including headache, dizziness, and stomach upset
May only help with marginal penile blood
50% failure rate
Trazodone (Desyrel)Safe
No surgery required
Side effects uncommon
May improve success and reduce side effects of yohimbine
If unsuccessful, does not interfere with other treatments
25% estimated success rate
Need to take medication every day
No reports proving benefit
No reports on long-term use
Side effects, including lethargy and drowsiness
Optimal dosage unknown
75% failure rate
Limited effectiveness
Penile Injection TherapyNo surgery required
Usually painless
May use treatment only when desired
Newer medications may reduce risks
Easily hidden and transportable
Refrigeration not required
If unsuccessful, does not interfere with other treatments
70%-75% success rate
Highly effective
Can be used in combination with other treatments such as sildenafil (Viagra)
Requires injections directly into the penis
Risk of infection, bruises, pain, and permanent scarring inside the penis
Possible painful permanent erection (priapism)
No completely acceptable medication currently available
Optimal combination of drugs not known
Lacks formal FDA approval (except for prostaglandin [Caverject, Edex])
May not be covered by some insurance companies
Usually not effective in men with blood flow problems or vascular disease
Most effective form (TriMix) not covered by most insurance plans and may be quite expensive
Cannot be used by patients on MAOIs* or blood thinners
Intraurethral Pellet Therapy (MUSE)No surgery required
May use treatment only when desired
Easily hidden and transportable
If unsuccessful, does not interfere with other treatments
Maximum usage up to two times per day
No needles, injections, or scarring
Approved by FDA
45% success rate
Reasonably effective
45%-65% success rate
Can be part of a combination therapy plan if properly supervised
Pellet must be inserted directly into penis through urethral opening
Requires refrigeration
Mild occasional burning or discomfort (experienced by about one-third of uses)
Possible priapism (rare <1%)
Can cause mild dizziness, faintness, or low blood pressure
Only four dosages are available
May require a tension ring or penile tourniquet for best results
External Vacuum TherapySafe
No surgery required
May use treatment only when desired
May improve natural erections in some users
If unsuccessful, does not interfere with other treatments
75%-85% success rate
Highly effective
Requires some manual dexterity and strength
Not easily hidden
Somewhat bulky to transport
Removing tension ring within 30 minutes recommended
Tension ring necessary to maintain erection
Possibly uncomfortable ejaculation
May need to interrupt foreplay
Proper tension ring size crucial for best results
Requires practice

*Monoamine oxidase inhibitors

Medically Reviewed by a Doctor on 7/29/2015

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