How can erectile dysfunction be treated?

Erectile dysfunction is a condition that affects not just the man involved but also his partner. It affects his self-esteem and his relationship with his partner.

The treatment of erectile dysfunction has been evolving over the past 10 years.

From an andrologist's and prosthetic urologist's standpoint, other than a couple counselling, I will focus on what I can do for the patient as a surgeon.

How I treat erectile dysfunction

It used to be the dogma that erectile dysfunction treatment has to follow a step-wise ladder kind of protocol:

1. We start with lifestyle modification,
2. determine if there is an underlying hormonal issue (e.g. testosterone deficiency) or undiagnosed heart disease before we even start prescribing oral medications (most common being the blue pill viagra).
3. If the oral medications fail, we will offer injections and
4. only if all these treatments have been exhausted can we then even mention the placement of a penile implant/prosthesis.

There is a paradigm shift in sexual medicine. The latest consensus and guidelines have mentioned that there is no need to exhaust all options before offering the man a penile implant. The need to have an erection and to be able to perform in the bedroom is different for each man. How fast he wants the treatment to work, the side effects he is able to tolerate and how badly affected the relationship is are also factors we should consider as the patient's doctor.

During the first consult in my clinic for erectile dysfunction, I would explain:

• oral medications (PDE5 inhibitors - e.g. Viagra, Cialis, Levitra) and how to use them effectively,
• penile injections (intracavernosal prostaglandins),
• use of medical-grade vacuum erection devices (as an adjunct to the medications to further improve erections).

Combination of all these different treatments is possible under a urologist's guidance.

Surgical treatment for erectile dysfunction

The true cure for erectile dysfunction would still be the placement of a penile implant/prosthesis [1]. Once the implant is placed, the erections would be guaranteed and would last as long (pun intended) as the man desires it to. It is performed as a day surgical procedure under anaesthesia and the device can be activated 6 weeks after surgery. For the best results, seek medical attention with a prosthetic urologist as not all urologists would perform this procedure.

Non-surgical treatment for erectile dysfunction

The other potential cure of erectile dysfunction would be low-intensity extracorporeal shockwave treatment (LiESWT) where we deliver shocks to the penis to cause the growth of new blood vessels to improve blood circulation to the penis, hence improving the strength of the erections [2]. LiESWT is performed in the urologist's office with minimal discomfort. Not all patients will get good results with this treatment and assessment by a urologist is recommended.

References:

1. Rodriguez KM, Kohn TP, Davis AB, Hakky TS. Penile implants: a look into the future. Translational Andrology and Urology. 2017;6(S5):S860-S866. doi:10.21037/tau.2017.05.28

2. Gruenwald I, Appel B, Kitrey ND, Vardi Y. Shockwave treatment of erectile dysfunction. Therapeutic Advances in Urology. 2013;5(2):95-99. doi:10.1177/1756287212470696

Erectile dysfunction refers to the persistent inability to get and keep an erection firm enough for sex. Problems getting or keeping an erection can also be a sign of an underlying health condition that needs treatment and a risk factor for heart disease.

Erectile dysfunction symptoms might include persistent:

• Trouble getting an erection
• Trouble keeping an erection
• Reduced sexual desire

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels [1]. Erectile dysfunction can result from a problem with any of these. Likewise, stress and mental health concerns can cause or worsen erectile dysfunction. Sometimes a combination of physical and psychological issues causes erectile dysfunction.

Various risk factors can contribute to erectile dysfunction, including [2]:

• Medical conditions, particularly diabetes or heart conditions, high cholesterol, high blood pressure
• Tobacco use, which restricts blood flow to veins and arteries, can — over time — cause chronic health conditions that lead to erectile dysfunction
• Being overweight, especially if you're obese
• Certain medical treatments, such as prostate surgery or radiation treatment for cancer
• Injuries, particularly if they damage the nerves or arteries that control erections
• Medications, including antidepressants, antihistamines and medications to treat high blood pressure, pain or prostate conditions
• Psychological conditions, such as stress, anxiety or depression
• Drug and alcohol use, especially if you're a long-term drug user or heavy drinker

The brain plays a key role in triggering the series of physical events that cause an erection, starting with feelings of sexual excitement. A number of things can interfere with sexual feelings and cause or worsen erectile dysfunction. These include:

• Depression, anxiety or other mental health conditions
• Stress
• Relationship problems due to stress, poor communication or other concerns

The possible nature of the interrelationship between biological and psychological factors was suggested as the following: ‘When any organic factor occurs in isolation, it may serve to make erections more vulnerable to emotional disturbances and sympathetic overactivity, facilitating the vicious circle of performance anxiety that maintains ED.”

Complications resulting from erectile dysfunction can include:

• An unsatisfactory sex life
• Stress or anxiety
• Embarrassment or low self-esteem
• Relationship problems
• The inability to get your partner pregnant

Sex therapy is a short-term form of counselling, generally involving five to twenty sessions with a therapist. During the session, the therapist will give the patient or couple assignments to do at home, such as reading books about sexuality, exercises on sensate focus (designed to take away the pressure to perform during sex) and practising better sexual communication skills.

The following are themes in the treatment of psychogenic ED: information including realistic ideas and expectations concerning sexual performance and satisfaction; performance anxiety relief through us of ‘sensate focus’; attention to relationship issues (e.g., intimacy, control, conflict resolution, trust); relapse prevention.

Sensate focus is a sex therapy technique introduced by the Masters and Johnson team. It works by refocusing the participants on their own sensory perceptions and sensuality, instead of goal-oriented behaviour focused on the genitals and penetrative sex [3]. For men with stress-related erectile dysfunction, having the partner involved in the therapy resolves the problem 60% of the time.

Other forms of treatment for erectile dysfunction include:

• Oral medications like PDE5 inhibitors
• Penile injections
• Transurethral alprostadil
• Vacuum construction devices
• Prosthesis

To add on, the use of prostheses (or implants) in the treatment of men with ED is generally considered a last resort since surgery involves the destruction of structures which are otherwise normally involved in the erectile process.

References:

1. Dean RC, Lue TF. Physiology of Penile Erection and Pathophysiology of Erectile Dysfunction. Urologic Clinics of North America. 2005;32(4):379-395. doi:10.1016/j.ucl.2005.08.007

2. Erectile dysfunction - Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/erectile-dysfunction/symptoms-causes/syc-20355776. Published 2018. Accessed December 17, 2019.

3. Ramage M. ABC of sexual health: Management of sexual problems. BMJ. 1998;317(7171):1509-1512. doi:10.1136/bmj.317.7171.1509