Impotence/Erectile Dysfunction Treatment

Currently, virtually any man who wishes to have erectile function can obtain it, regardless of the underlying cause of his problem. Many reasonable treatment options exist. Your first step is to find a well-trained, experienced, and compassionate doctor who is willing to take the time to understand you and fully discuss the treatments available to you.

Sex 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.

Options include sex counseling, medications, external vacuum devices, hormonal therapy, penile injections or intraurethral suppositories. In highly selected cases under the supervision of a urology specialist in ED, combination therapy using several of these methods together can be used. If none of these therapies is satisfactory, penile prosthesis implants can be considered.

• 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.
  
  
• Sildenafil citrate (Viagra): Viagra is a prescription medication for the treatment of erectile dysfunction. It's the first oral medicine (a pill you take by mouth) available that's 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. Viagra doesn't 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. It is not an aphrodisiac and will not increase desire. Unlike other treatments for erectile dysfunction, Viagra requires sexual stimulation to function. Without this stimulation, Viagra won't have any effect.
  
  
  • Viagra works by blocking an enzyme found mainly in the penis that breaks down a chemical produced during stimulation that normally produces erections. Viagra 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, Viagra 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 Viagra. The worst response rate was in men who became impotent after radical prostate cancer surgery. But even in this hard-to-treat group, 43% reported improved erections particularly if they had the "nerve-sparing" type of prostate surgery.
    
    
  • Viagra works best if taken about 1 hour before sexual activity. Only 1 tablet should be taken per day. It should be taken on an empty stomach. Increasing the dosage of Viagra beyond the recommended amounts will not improve the response and will only result in greater side effects.
    
    
    • The most common side effect of Viagra use 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% and 11% of users report some visual problems 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.
      
      
    • None of these side effects is severe and most are described as mild. Very few users stop taking the medication because of side effects.
    
    
  • Viagra is 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 Viagra within 24 hours. Combining Viagra with nitrate-based medications can cause a severe and dramatic drop in blood pressure with potentially very dangerous consequences. This is also why you should absolutely never share your Viagra prescription with anyone else. If they happen to be taking one of the drugs that interacts dangerously with Viagra, the results could be very serious. If there is any question about possible drug interactions, always check with your doctor or pharmacist.
    
    
  • Certain street drugs such as "poppers" also can cause serious problems if taken with Viagra. Ecstasy is a street drug that may increase sexual desire but interferes with performance. This has prompted some men to combine ecstasy with Viagra. 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 Viagra with various other street drugs.
    
    
  • Several medications can interfere with the chemical processing of Viagra 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 Viagra should be used if you are taking any of these medications.
    
    
  • Sildenafil is available in 3 doses: 25 mg, 50 mg, and 100 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 on the 25 mg dose. Men with moderate-to-severe ED can begin at the 50 mg dose, and, after testing the effect of the drug on at least 3 occasions, the dose can be modified. Men with severe ED may need to quickly move up to the 100 mg dose. These men are less likely to achieve a satisfactory response, but they should make at least 3-4 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. Stimulation is necessary to produce an erection. An increased ability to achieve good erections can last up to 24 hours but usually only about 4 hours. The drug should not be taken daily.
    
    
  • Several drugs very similar to Viagra have recently been approved by the FDA.  These drugs, called vardenafil (Levitra) and tadalafil (Cialis), have essentially the same activity and general precautions 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 4 hours).

• 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 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 3 times a day.
  
  
• Apomorphine (Uprima): Apomorphine is a medication that dissolves under your 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.
  
  
• Testosterone: Men with low sex drive and ED may be found to have low testosterone levels. Hormone replacement may be of benefit by itself or as a complementary therapy used with other treatments. Libido and an overall sense of well-being are likely to improve when serum testosterone levels are restored.
  
  
  • Replacement testosterone is available as pills, injections, patches, and a gel that is rubbed into the skin. Men with low sexual desire and ED may have low testosterone (male hormone) levels. Hormone replacement may occasionally be of some benefit, especially when used in combination with other therapies. Testosterone supplementation alone is not particularly effective in treating erectile dysfunction. Sexual desire and an overall sense of well-being are likely to improve when serum testosterone levels (the levels in the blood) are restored.
    
    
  • As a general guideline, testosterone levels of 300 or less is considered low, but this varies depending on the laboratory that does the testing.
    
    
  • Oral therapy (pills) is the least effective and the most likely to be associated with liver problems, even though this is a small risk. Injections are most likely to restore testosterone levels, but this therapy requires periodic injections, usually every 2 weeks, to sustain an effective level. Skin patches and gels deliver a sustained dose and generally are well accepted.
    
    
  • Follow-up testosterone (hormone) levels and periodic blood counts and prostate checks are necessary for all men on long-term testosterone replacement therapy.
  
  
• Injection therapy: Although many substances are touted as aphrodisiacs (meant to arouse sexual desire), the modern age of such drug therapies began in 1993 when the injection of papaverine, 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 Regitine, were demonstrated to be effective either as single drugs or in combination.
  
  
  • 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.
    
    
  • If the structure of the penis is healthy, the use of injectable drugs is almost always effective. If you choose this therapy, your doctor will teach you 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 alprostadil (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 3 times a week. Men on anticoagulant medications (blood thinners) should probably choose an alternate therapy.
  
  
• Intraurethral therapy (Medicated Urethral System for Erections, 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.
  
  

Types of Medical Therapy Available to Manage Erectile Dysfunction