A Guide to Men's Health, Reproductive Medicine, and Microsurgery
The United States Census Bureau reported that in the year 2000 about 14 million men in the U.S. were over the age of 65. This number is expected to reach over 30 million by 2030.
According to the Massachusetts Male Aging Study, over half of men in this age group have at least some degree of erectile dysfunction (ED). 17% of men between the ages of 40 and 70 reported mild ED, 25% reported moderate ED, and 10% reported complete ED.
This high disease prevalence is important because ED affects quality of life, influences general health perception of men, represents an unmet medical need, and may be the first sign of other common and important health disorders.
ED shares many risk factors with cardiovascular disease including hypertension, diabetes, dyslipidemia, depression, tobacco use, obesity, and a sedentary lifestyle.
The common pathway of these conditions is endothelial cell damage secondary to oxidative stress. Endothelial cell injury, in turn, may lead to vasoconstriction, atherosclerosis, thrombosis, and erectile dysfunction. Endothelial cell dysfunction results in decreased endothelium-dependent relaxation and increased adhesion of leukocytes to the endothelium.
Thus, ED may be the first sign of underlying cardiovascular disease, so it is important that men be evaluated by their primary care physician as well as by their urologist.
These medications include:
They work via the nitric oxide pathway that leads to increased penile blood flow, and erection.
Each of these medications carries with it different properties including onset time, duration of action, and side effect profile. When taken in a fasted state, the time to maximum plasma concentration of avanafil is about 30 minutes, about one hour for sildenafil and vardenafil, and about 2 hours for tadalafil. In the presence of a high fat meal, this time for sildenafil and vardenafil increases to about 2 hours, approaching that for tadalafil. The time to eliminate 50% of the administered dose of sildenafil and vardenafil is about 4-5 hours, and about 17 hours for tadalafil.
Numerous studies have examined the efficacy of PDE5i’s, and most use self-administered, standardized questionnaires such as the International Inventory of Erectile Function (IIEF), the Sexual Encounter Profile (SEP), and the Sexual Health Inventory for Men (SHIM).
All four available PDE5i’s have been shown to be effective in the treatment of ED.
Each agent is effective and well tolerated in diabetic men with ED.
Daily use has been reported to improve ED over on-demand use alone.
Studies have shown that all PDE5i’s are efficacious in treating men with ED following radical prostatectomy (RP).
Side effects of PDE5i’s generally are few and well tolerated. These include headache, dyspepsia, rhinitis, flushing, abnormal vision, and dizziness. Rarely do men discontinue their use because of adverse events.
Pertinent safety information that applies to all PDE5i’s is that any use of nitrates is universally and strictly contraindicated.
It is also important to consider the health impact of resuming intercourse in certain populations of at risk men with ED.
Also, patients must be aware of the possible, albeit very rare, complication of priapism, which necessitates prompt medical attention.
Drug-specific safety information includes separating any alpha-blocker by 4 hours with sildenafil use; avoiding vardenafil with anti-arrhythmics; and with tadalafil, not using nitrates for 48 hours, avoiding use with “substantial” alcohol intake, and the fact that the drug may cause back pain and myalgia. A recent concern has been the development of nonarteritic anterior ischemic optic neuropathy (NAION) in patients using PDE5i’s. However, because men with ED frequently have risk factors that may also put them at increased risk for NAION, a direct causal relationship has been difficult to establish.
An unfortunate consequence of the success of these medications is counterfeiting and online internet sales of what are advertized to be authentic products. Avoid counterfeit medications by checking to see if the source has been validated and accredited by clicking here.
If men with erectile dysfunction are found to have low testosterone, testosterone replacement therapy may be recommended.
Four commonly used forms of testosterone replacement exist:
Each treatment carries with it unique advantages and disadvantages, and these should be discussed with your doctor prior to initiation of therapy.
Before initiating therapy, prostate cancer and bladder outlet obstruction should be ruled out.
Once therapy has started, hormone levels should be checked at regular intervals, as should PSA, lipid panels, and hemoglobin and/or hematocrit levels.
Evidence supporting the role of testosterone replacement in ED includes the fact that hypogonadal men have a diminished response to oral medication, the nitric oxide pathway is testosterone dependent, and treating men with hypogonadism has resulted in improved response rates with oral medications.
Click here for more information about low testosterone and testosterone replacement therapy
This therapy involves delivery of vasoactive agents directly into the erectile tissue of the penis.
Commonly used agents include alprostadil (prostaglandin E1), phentolamine, and papaverine. These agents are packaged and commonly sold under the names of Caverject, Edex, Trimix, Super-Trimix, and Quadmix.
Currently, the only FDA-approved products are Caverject and Edex, however, the are expensive and often painful for many patients.
Trimix is a combination of papaverine, PGE-1, and phentolamine that must be compounded by an approved facility. Its advantages include minimal pain, improved efficacy, and a synergistic effect of its components. Additionally, it is inexpensive and available in generic form.
As with other medical treatments for ED, a risk of priapism exists when performing penile injections.
Intraurethral suppositories (MUSE) allow for the delivery of alprostadil into the corporal bodies via direct urethral absorption.
This system obviates the use of needles, however, it has not been as effective as originally predicted and in its current form is expensive.
Furthermore, erections may be painful secondary to the prostaglandin effect. However, in combination with oral medications, the MUSE has shown better efficacy than oral agents alone in a subset of patients.
As with other medical treatments for ED, a risk of priapism exists when using intraurethral suppositories.
VED’s are non-invasive manual devices that pull blood into the corporal bodies via a negative pressure gradient. Once an erection is obtained, a constricting band is placed around the base of the penis to create venous occlusion and maintain the erection after releasing the vacuum pressure.
These devices require minimal manual dexterity.
Current uses of VED’s also include therapeutic exercises post radical prostatectomy. Engorgement of the corporal bodies results in improved oxygen delivery, stretches the erectile tissue, and allows for early functional use post-operatively.
VED’s are often used when other treatment modalities fail or when a penile prosthesis is not an acceptable or desirable option.
VED's are also used prior to penile prosthesis surgery in order to regain penile length that has been lost due to years of poor blood supply and tissue atrophy.
VED's may also be used as part of a treatment program for Peyronie's Disease.
A number of companies make vacuum erection devices including:
Click here for Dr. Williams' vacuum erection device protocol
Venoconstrictive bands are designed to help treat a phenomenon called veno-occlusive disease, or "venous leak". A venous leak occurs when blood enters the penis through the arteries but does not stay trapped in the penis. A variety of conditions, including Peyronie's Disease, can cause venous leaks and result in erectile dysfunction.
Venoconstrictive bands such as those made by Vivus can be used either alone or in combination with other therapies.
Two general types of penile prostheses exist—the malleable and inflatable.
Placement of penile prostheses requires surgery with strict adherence to proper technique.
Generally, the devices may be activated once patients have recovered from surgery and may be used starting 4-6 weeks post-operatively.
Patient/partner satisfaction with penile prostheses is over 90%.
Patients reports better erectile function and higher treatment satisfaction rates with penile implants than with oral medications or penile injections.
These devices are made by American Medical Systems and Coloplast.
Read more about penile prostheses at urologyhealth.org.
Listen to patient testamonials at EDcure.org
Click here for an online tutorial about penile implants.
Click here to watch Dr. Williams perform placement of a 3-piece inflatable penile prosthesis via a peno-scrotal approach
American Urological Association Guidelines for the Management of Erectile Dysfunction
urologyhealth.org - Medical Management of ED
urologyhealth.org - Surgical Management of ED
Sexual Medicine Society of North America
Erectile Dysfunction Institute
Higher patient satisfaction with penile implants than with oral or injectable medications
AAFP Review of Erectile Dysfunction
JAMA Patient Page on Erectile Dysfunciton
Other Male Sexual Health Resources
Midwest Center for Sex Therapy
Vacuum Erection Device Protocol
International Society for Sexual Medicine
American Urological Association Guidelines for the Management of Premature Ejaculation
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