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Erectile Dysfunction

Approximately 1 - 10% of men aged 40 to 59 years of age have ED compared to 20 - 30% of men greater than 60 years of age.  Erectile dysfunction is increasingly being recognized as an early marker for systemic vascular and coronary disease.  Systemic vascular disease, coronary artery disease and ED share many risk factors.  Medications useful in treatment of these risk factors and medical conditions may further exacerbate or cause ED.  With the introduction of oral treatment for ED, public awareness and the number of men seeking treatment have risen.  The initiation of medical therapy for ED is increasingly being administered in the primary care physician’s office, with those patients failing oral therapy obtaining specialist referral.  

What treatment is available?

After treating reversible causes, first line therapy involves treatment with phosphodiesterase type-5 inhibitors (PDE5-i).  These medications will not lead to erection without sexual stimulation.  Medications in this class include sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis).  These medications act in a similar fashion and are all contraindicated currently in patients taking nitrates or nitric oxide donors.  When these medications are not effective, other options include penile injections, vacuum erection devices and penile prosthesis placement.  Many men respond well to penile injection therapy once they overcome the anxiety of a small needle.  It is also important to assess a man’s testosterone level, as this can lead to ED and limit the effectiveness of PDE5-i.  

Erectile dysfunction is a medical condition that affects more than 30 million men in the United States.  Erectile dysfunction is the inability to get an erection, keep an erection, or less rigidity of the erection.  Over 85% of cases of erectile dysfunction are caused by a medical condition.  Vascular diseases, such as peripheral vascular disease or coronary artery disease (heart attack), make up 40% of cases.  Men with diabetes have a high risk for erectile dysfunction and diabetes causes 30% of cases.  Other causes of erectile dysfunction include prostate surgery, prostate radiation, pelvic surgery, pelvic trauma, medications, recreational drugs, low testosterone, smoking, thyroid disorders, high blood pressure, high cholesterol and neurologic disorders.   Peyronie’s disease is often associated with erectile dysfunction and may alter the treatment plan.  Approximately 10% of cases are due to psychological factors including stress and anxiety.  Thankfully we have many treatments for erectile dysfunction, but the first step should be to attempt to identify reversible causes.  A men's sexual medicine specialist can facilitate this process.  

Erections result from a combination of nerve input, muscle relaxation, improved arterial blood flow into the penis and prevention of blood from flowing out of the penis too quickly.   A problem in any of these areas can cause erectile dysfunction.  For example, diabetes can affect the nerves and arterial blood flow.  Prostate cancer treatments with radiation or surgery can affect the nerves, blood flow in and decrease the ability to keep blood in the penis to maintain the erection.  For the best treatment, identification of the problem area can facilitate a quicker return to normal erections.  Testosterone treatment alone rarely improves erections to the point the patient feels it is normal again.  However testosterone replacement can make other erection treatments more effective and improve results in cases where the pill medication has not been effective previously.  Replacement of testosterone can also improve sexual desire and overall energy.  

Testing commonly undertaken to identify the cause of erectile dysfunction may be based on the patient’s history.  The history is an important first step.  Some men presenting for evaluation of erectile dysfunction may be unaware they have diabetes or vascular disease.  These men may experience other issues such as frequent urination, frequent thirst, or cramping of the legs with walking.  Erectile dysfunction is now seen as a predictor of increased risk of future heart attack or stroke, due to the common pathway of narrowing of the blood vessels.  A physical exam may identify poor blood flow in the legs, a plaque consistent with Peyronie’s disease, or atrophic (small) testicles suggesting low testosterone.  Laboratory testing is often directed based on the history and physical exam, but may include evaluation of testosterone, prolactin, estradiol, LH, a cholesterol panel and even PSA testing.  

Most patients will begin treatment with phosphodiesterase inhibitors such as Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), Stendra (avanafil) or Staxyn (vardenafil).  This may occur before any further testing is undertaken. These are safe and effective medications for men when the nerves are still functional.  If the nerves are not present such as after prostate cancer surgery, these medications are unlikely to work.  You can find more information about these medications here.  It is important to ensure that these medications are taken in the correct way.  These medications require between 60-120 minutes to begin working, and sexual stimulation is still necessary.  The phosphodiesterase inhibitors work similar to a megaphone- once your body begins the process, these medications will amplify the response to attempt to improve erections.  These medications can be affected by food and alcohol intake, delaying the time until the medication is ready to work and decreasing effectiveness.  These medications are safe for the heart when taken correctly and thankfully it is rare for prolonged erections to occur with these medications alone.  For many men, the cost of these medications are a big concern for men, and I have suggestions to help men work with this problem when the medications do improve erections.  

If the pills are not effective, then referral to a specialist is often useful.  The nerves are able to be evaluated with UroVal, an assessment of the bulbocavernosal reflex.  This information may provide evidence of underlying nerve damage, but the cause of the damage may not be easy to identify. This is a newer test and how to use this information is still being evaluated.  Another more common test is a penile doppler ultrasound.  This test evaluates the blood flow to the penis.  For the penile doppler ultrasound, an ultrasound is performed before and after an injection of medication to increase the blood flow to the penis.  Using the ultrasound, the blood flow coming into the penis can be measured and we can measure how quickly the blood leaves the penis.  If blood does not enter the penis rapidly enough or the blood flows out of the penis too quickly, often a penile prosthesis will lead to the highest patient satisfaction to cure the erectile dysfunction.  

There are more options available if the pills (phosphodiesterase inhibitors) do not work to improve erections.  When we consider the secondary treatment options, it is important to find the right treatment for the patient and their partner.  The best treatment is not the same for every couple.  Options to consider at this point include a vacuum erection device (VED), intraurethral suppository (MUSE), intracavernosal injections (ICI) and even experimental options.  Each option will be reviewed here.  Experimental options currently include options of stem cell therapy or growth factor therapy and shock wave therapy.  These have each shown some promise in the lab but not been consistently effective in men.  Additionally, because these are experimental currently, cost is an issue and often the patient is paying out of pocket cash for a procedure that has not been shown to provide benefit.  

Vacuum erection devices (VED) are a one time cost.  These devices go over the penis and creates a suction. The suction causes the penis to fill with blood.  Once the penis fills with blood, a tight band can be applied to the base of the penis to try to keep blood in the penis.  This is done prior to the suction being released.  Patients will then often have 20-30 minutes to have sex prior to the blood naturally draining out of the penis.  The tighter the band to hold blood in, the more decrease in penis sensation patients will often experience.  This is not the most common choice for most patients but can provide benefit.  The VED is also able to help after a prior prostatectomy.  After the prostatectomy, many patients will notice loss of penis length.  Using a VED after surgery can help protect penis length.  When used for penile rehabilitation, it should be used twice daily with holding a full stretch on the penis for at least 120 seconds.  

Another option is an intraurethral suppository.  This is a medication that is absorbed through the lining of the urinary tract and allows blood to come into the penis. This will bypass the need for the nerves to work.  As blood comes into the penis, an erection can occur. This medication works in approximately 70% of patients but can cause a decrease in blood pressure.  For patients using this medication, there is a 30% risk of pain in the penis.  This pain is usually an achy sensation but can be enough for patients to avoid sexual activity.  The cost of the medication is also an issue and concern for many patients,  

One of the best options for patients to improve erections are intracavernosal injections (ICI).  This in an injection into the penis.  I recognize that it so I would not be lying to patients.  You feel a small poke as the needle goes in, but beyond that there is very little discomfort.  The injections work by improving blood flow directly into the penis.  This medication does not require the nerves to be present to cause the erection to occur, and therefore can work well following prostate cancer surgery or radiation therapy.  The medication brings blood into the penis.  As the penis fills with blood, and erection should occur.  This will allow many patients to get an erection and keep the erection well.  In fact, the medication will work well enough that we need to monitor to prevent erections that are fully erect for too long.  An erection lasting for more than 2 hours fully erect can become a problem.  It is around 4-6 hours fully erect that more permanent damage can occur, but pain may be present earlier than 4 hours because the penis is not getting new blood with fresh oxygen.  Although we have some concern on how the medication works (too much), it can provide a very good erection.  The medication should not cost too much medication as well, usually around $5-7 per injection in many cases.  There are multiple pharmacies in Columbus that can create this medication for patients.  unds scary to inject the penis with medication, and therefore I tried it 

Typically when these mediations and devices do not work, a penile prosthetic is the best option.  A penile prosthesis is an excellent option for many patients and their partners.  Satisfaction rates are very high following penile prosthesis placement.  

A penile prosthetic goes completely under the skin.  It is not noticeable from outside the body.  The penile prosthesis provides patients a normal feeling erection and normal sensation.  The prosthesis is reliable and helps men overcome the worry that they will not be able to perform.  With this treatment, men can still reach orgasm and ejaculate.  If desired, this may help some men achieve a natural pregnancy.  Even for men without a long term partner, the patients comment how their sexual partners do not know about the prosthesis unless they tell their partner.  

Men may worry about many aspects of the penile prosthesis.  It is MRI compatible.  It does not set off alarms at the airport.  The sensation of the penis is normal.  The prosthesis provides good girth and rigidity, the factors that men and women note makes it feel like a normal erection.  The penile prosthesis does not itself lengthen the penis.  

Please see the penile prosthesis section for more information on this excellent treatment option.  



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Causes of ED

  1. Vascular disease
    1. Heart disease such as prior heart attack
      1. The same process that can narrow blood vessels in the heart, can narrow blood vessels in the penis
    2. Prior stroke
    3. Peripheral vascular disease
    4. Pelvic trauma causing damaged blood flow
    5. High blood pressure
    6. High cholesterol
  2. Diabetes
    1. Damages the nerves initiating an erection
    2. May narrow blood vessels limiting blood flow
    3. Having uncontrolled diabetes makes erections worse at that time and increases damage causing patients to move on to more invasive treatments quicker.
      1. Keep your blood sugars under control!
  3. Neurological disease
    1. Many neurologic diseases can cause problems
      1. Multiple sclerosis
      2. Stroke
      3. Parkinson’s disease
      4. Encephalitis
      5. Temporal lobe epilepsy
      6. Tumors
      7. Dementia including Alzheimer’s disease
      8. Shy-Drager syndrome
      9. Head trauma/Traumatic brain injury
      10. Spinal cord injuries
        1. Spina bifida
        2. Spinal disk herniation
        3. Transverse myelitis
    2. Surgical treatments may damage nerves
      1. Prior prostate surgery or prostate radiation therapy
      2. Prior prostate cryotherapy or HIFU
      3. Abdominal perineal resection
      4. Rectal surgery
      5. Colon surgery
    3. Pelvic trauma damaging nerves
  4. Peyronie’s disease
  5. Chronic renal failure
  6. Hormonal disease
    1. Low testosterone
      1. Testosterone may not correct erectile dysfunction, but can allow some medications to be more effective
    2. High or low thyroid levels
    3. High prolactin levels
  7. Smoking
    1. Leads to narrowing of the blood vessels 
      1. Both short term changes and more damaging long term changes
  8. Medications
    1. Blood pressure medications (please do not stop your medication without first speaking with your physician)
      1. Beta blockers
        1. Atenolol, metoprolol
      2. Diuretics
        1. Thiazide
    2. Psychotropic medications
      1. SSRI antidepressants
        1. Citalopram, paroxetine, venlafaxine
      2. Antipsychotics
        1. Risperidone
    3. Antiandrogen medications
      1. Prostate cancer treatments
        1. Bicalutamide, LHRH antagonists
      2. BPH treatments
        1. Finasteride
      3. Antifungal
        1. Ketoconazole
    4. Other medications
      1. Opiates
        1. Oxycodone, Percocet, methadone
      2. Retroviral medications
        1. Ritonavir
      3. Cancer drugs
      4. Alcohol
        1. Particularly in higher amounts or with chronic use
    5. Psychogenic causes
      1. Anxiety
        1. As trouble with erections occurs, most men will begin to worry it may happen again
      2. Stress
      3. Depression


Tests for determining the cause of erectile dysfunction

  1. Blood testing
    1. Hormonal testing for testosterone, thyroid function, prolactin level
    2. HgbA1c to evaluate for previously undiagnosed diabetes
    3. Lipid profile to evaluate cholesterol
  2. Bulbocavernosus reflex latency
    1. UroVal testing
  3. Nocturnal penile tumescence and rigidity testing
  4. Intracavernosal injection pharmacotesting
    1. May also be performed with doppler ultrasound to measure blood flow
      1. Evaluates arterial inflow and vena-occlusive dysfunction (venous leak)
  5. CT angiogram
    1. Limited role for this test

Oral ED Treatments

Oral treatment options for erectile dysfunction

 

  • Levitra (vardenafil), Staxyn (vardenafil), Stendra (avanafil) and Viagra (sildenafil)-
    1. These medications are taken by mouth 30 minutes to one hour before sexual activity.  The medication will not automatically give you an erection but will increase/improve your natural erection.  You must have sexual stimulation to allow the medication to work.  It may take up to 6 tries of the medication for it to begin to work.  These medications may not work as well if taken with fatty food or alcohol, particularly Viagra.
    2. These medications will work for between 4-8 hours.
    3. Do not take this medication with nitrates such as nitroglycerin or isosorbide di-nitrate (Imdur).
  • Cialis (tadalafil) as needed-
    1. This medication is taken by mouth two hours before sexual activity.  The medication will not give you an erection but will increase/improve your natural erection.  You must have sexual stimulation to allow the medication to work.  It may take up to 6 tries of the medication for it to begin to work.  
    2. This medication will work for between 36-48 hours.
    3. Do not take this medication with nitrates such as nitroglycerin or isosorbide di-nitrate (Imdur).
  • Cialis (tadalafil) daily-
    1. This medication works similar to Cialis as described above.  When taking the Cialis daily, the medication does not need to be two hours before sexual activity.  This medication should be taken at the same time each day regardless of sexual activity.  
    2. Another benefit of daily Cialis is that is can improve urination and treat BPH (enlarged prostate).  In many cases, daily Cialis will allow men to urinate less, get up to urinate at night less, improve the strength of their stream and decrease the urgency with which they have to get to the bathroom.  
    3. Do not take this medication with nitrates such as nitroglycerin or isosorbide di-nitrate (Imdur). 
  • Side effects of each of these medications
    1. Headache, dizziness, facial flushing, upset stomach, back ache (tadalafil), blue vision (sildenafil), low blood pressure, hearing changes, vision changes
    2. Overall these medications are very safe when taken appropriately.  I have reviewed the FDA data on these medications in the past and the risks of heart attack or stroke is thankfully low.  
    3. Cost is an issue with many of these medications.  Dr. Lowe can assist in helping patients as they find ways to make this a cost effective treatment for erectile dysfunction.  

 

Treatments to consider if Cialis, Levitra or Viagra are not working:

Please see the section on erectile dysfunction and penile prosthetics

 

Patient Instructions

Pre-Operative Instructions for ED surgery

It is important that patients do not eat or drink anything, even coffee or water, starting at midnight the night before erectile dysfunction (ED) surgery. However, all medications can be taken with a sip of water.

Please stay on low dose aspirin prior to surgery.

Please arrive at the surgery center two hours before your scheduled surgery time. If your scheduled surgery time is the first of the day, please arrive at 6:00am.

Due to rules regarding anesthesia, you will not be able to drive home that day. Please arrange for someone to drive you home, should you be going home the same day as the surgery.
 

Post-Operative Instructions for ED surgery

Keep area clean and dry for 48 hours. After that time, you may shower with NO direct water contact for 5 days. However, after 5 days, hot water soaks are recommended 3 times per day.

Anti-inflammatories, such as ibuprofen, may be used for post-operative discomfort.

Remove dressing after 24 hours.

Apply ice to scrotum 5 times per day, 30 minutes at a time, for 1 week after the procedure.

A pressure bag will be kept on your incision for 2 hours in the recovery room.

Scrotal support should be used for the first 10 days after the procedure.

No sutures will need to be removed.

Ten days after the procedure, please begin to locate the inflate and deflate mechanisms of the pump in the scrotum, but do not use the device. Begin to gently pull down on the pump mechanism and perform deep tissue massage to the pump area.

Inflation and deflation teaching will be done 3-4 weeks after the procedure.

Please call us if:

  • Your temperature is greater than 101.5
  • Your skin appears very red or hot
  • You have difficulty voiding


Dr. Lowe’s Nurse: Julia (614) 788-2878

Dr. Lowe’s MA: Sue (614) 788-2873

Bing office: (614)788-2870

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We will attempt to make the appointment as close to your desired date as possible, but this submission is not a guarantee of an appointment at that time. If an urgent visit is needed to discuss sperm cryopreservation prior to cancer treatment, please call the office directly and be sure to notify the staff of this need.

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OhioHealth Urology Physicians
OhioHealth Riverside Methodist Hospital
Bing Cancer Center
500 Thomas Lane, Suite 3G
Columbus, Ohio 43214

Phone: (614) 788-2870
Fax: (614) 533-0177
 
 

OhioHealth Urology Physicians
OhioHealth Riverside Methodist Hospital
Bing Cancer Center

500 Thomas Lane, Suite 3G
Columbus, Ohio 43214

Phone: (614) 788-2870
Fax: (614) 533-0177