Impotence/Erectile Dysfunction (cont.)
Stephen W Leslie, MD, FACS
Joseph A Salomone III, MD
Francisco Talavera, PharmD, PhD
Impotence/Erectile Dysfunction Treatment: Part 3
- 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 analternate 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 isoften helpful in allowing the medication to stay in the erectile tissue a little longer and seems to give a somewhat better response.
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