Impotence/Erectile Dysfunction (cont.)
Impotence/Erectile Dysfunction Treatment: Part 1
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 30minutes.
- 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.
Stephen W Leslie, MD, FACS
Joseph A Salomone III, MD
Francisco Talavera, PharmD, PhD
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