Treatment for Erectile Dysfunction
Men with organic ED can be treated with one or more of the various available therapies (see above). However, if they have lost confidence in their ability to obtain and maintain an erection suitable for penetration, a few words of encouragement from their physician can be of great help.
Penile Implant
There is some evidence to suggest that an additional benefit may be gained by some men who have an implant but also take an oral PDE5 inhibitor. Penile prostheses can be divided into the following 2 broad categories: With the semirigid prosthesis, 2 matching cylinders are implanted into the corpora cavernosa (see the image below). These devices provide enough rigidity for penetration and rarely break. The major drawbacks are the cosmetic appearance of the penis (which remains semierect at all times), the need for surgery, and the destruction of the natural erectile mechanism when the prosthesis is implanted. The inflatable devices consist of 2 Silastic or Bioflex cylinders inserted into the corpora cavernosa, a pump placed in the scrotum to inflate the cylinders, and a reservoir that is contained either within the cylinders or in a separate reservoir placed beneath the fascia of the lower abdomen (see the images below).
Non-Specific Interventions
The inflatable prosthesis generally remains functional for 7-10 years before a replacement may be necessary. Improvements in these devices have resulted in a failure rate lower than 10%. Patient acceptance of these devices is very high, with nearly 100% of recipients expressing satisfaction. Part of this enthusiasm is related to the failure of other therapies and the highly motivated patient population. [115] This was a nonrandomized study in which all 138 subjects were initially offered sildenafil. The AUA observes that because diabetes, heart disease, and hypertension increase the risk of developing ED, optimal management of these diseases may prevent the development of ED.
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[1] Similarly, because attaining and maintaining a firm erection requires good vascular function, it is reasonable to assume that lifestyle modifications to improve vascular function (eg, smoking cessation, maintenance of ideal body weight, and regular exercise) may prevent or reverse ED. At present, however, only minimal data support these suppositions.
- Custom-compounded Tri-Mix or Quad-Mix injections for optimal efficacy.
- Hyperbaric oxygen therapy for radiation-induced tissue damage.
- Naltrexone low-dose for autoimmune/inflammatory contributions.
- Focus on magnesium-rich foods (nuts, seeds) for muscle relaxation.
- Avoiding constrictive clothing for prolonged periods.
- Second-generation antipsychotics with lower sexual side effect profiles.
In a clinical trial that included 106 men with newly diagnosed type 2 diabetes, Maiorino et al reported that men randomized to a Mediterranean diet demonstrated a significantly lesser decrease in erectile function, compared with men randomized to a low-fat diet (P=0.024).
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| L-Arginine | Increased nitric oxide | Gastrointestinal discomfort | Moderate |
| Yohimbine | Enhanced blood flow | High blood pressure, anxiety | Limited |
| Horny Goat Weed | Improve erectile function | Dizziness, rapid heartbeat | Anecdotal |
Total follow-up in the trial was 8.1 years. A systematic review and meta-analysis by Silva et al suggested that physical activity and exercise—particularly aerobic exercise of moderate-to-vigorous intensity—improve patient-reported ED. Although the risk of bias in the trials was deemed moderate to high, principally because of difficulties with blinding, pooled data showed a statistically significant improvement in erectile function scores.
- Tadalafil ODT (orally disintegrating tablet) for easier administration.
- Penile skin necrosis prevention with proper injection technique.
- Social support and group therapy for men with ED.
- Resveratrol supplements for potential endothelial benefits.
- Platelet-rich plasma combined with shockwave therapy.
- Avoiding grapefruit with certain PDE5 inhibitors due to interactions.
Benefit was detected with both short-term and long-term interventions as well as with physical activity and exercise alone or as an adjunct to usual care. One direction of research into treatment of ED focuses on restoration of the structure and function of dysfunctional erectile tissue, rather than simply relief of symptoms.
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Ideally, the patient’s partner should be involved in counseling, but even if this is not possible, the time spent may help resolve or at least clarify the problem and certainly helps determine which of the other options would be most beneficial and appropriate. Regardless of the etiology of ED, a psychological component is frequently associated with the disorder. The ability to achieve erection is intimately connected to a man’s self-esteem and sense of worth. Pure psychogenic ED is generally evident when a man reports that he has normal erections some of the time but is unable to achieve or to maintain a full erection at other times. Once the man has doubt regarding sexual performance, he loses confidence; thus, future attempts to have sexual relations provoke anxiety.
Oral ED Medications
In many instances, the couple must work together to resolve the problem, although in some cases, the relationship itself may be responsible for the problem. Referral to a sex therapist may be helpful. A study of 31 newly diagnosed men with ED (aged 20-55 years) who were treated with either tadalafil (n = 12) or tadalafil plus 8 weeks of stress management (n = 19) found that both groups showed significant improvement in perceived stress and erectile function scores but that the reduction in perceived stress was greater in the latter group. [116] This result suggests that stress reduction may be a useful component of ED treatment. Further research, involving randomized, controlled trials with larger samples and longer follow-up time, is needed. These techniques, termed regenerative therapy, include the following [119] : Intracavernous injection of platelet-rich plasma (PRP) Amniotic fluid matrices (wrapping of dehydrated human amnion/chorion membranes around the neurovascular bundle during radical prostatectomy) A consensus statement from the Sexual Medicine Society of North America recommends that these novel technologies are experimental and should be used only in the context of clinical trials.
- Sildenafil (Viagra) is the original and most widely known PDE5 inhibitor.
- Intracavernosal injection of papaverine (less common now).
- Proper storage of injection medications (refrigeration often required).
- Mindfulness during sexual activity to stay present and reduce anxiety.
- Regular prostate cancer screening for early detection and treatment.
- Penile prosthesis: three-piece inflatable is the most popular type.
[120] Nevertheless, men’s health clinics are increasingly offering such treatments, often at exorbitant cost.
- Oral PDE5 inhibitors like sildenafil and tadalafil.
- Injectable medications such as alprostadil for direct penile injection.
- Vacuum erection devices that increase blood flow mechanically.
- Penile implants for a permanent surgical solution.
Although not approved for this indication in the United States, LiESWT has proved effective in European patients with severe ED that is unresponsive to treatment with PDE5 inhibitors.
How do health care professionals treat ED?
Less improvement was seen in elderly patients and those with hypertension. Patients with ED from veno-occlusive dysfunction may be candidates for endovascular embolization of venous leaks. Technical success rates for this approach have ranged from 86% to 97%, and the overall clinical success rate is 59.5%. Major complications (eg, symptomatic pulmonary embolism) have been reported in less than 1% of cases. Selected patients with ED are candidates for surgical treatment.
Endovascular treatment
A small number of healthy young men have developed ED as a result of trauma to the pelvic arteries. Revascularization procedures such as rotating the epigastric artery (or even smaller vessels) into the corpora have been attempted. AUA guidelines recommend arterial reconstructive surgery as a treatment option only in healthy patients who have recently acquired ED as the result of a focal arterial occlusion and who have no evidence of generalized vascular disease. On occasion, men who have difficulty maintaining erections as a result of venous leaks may benefit from undergoing a surgical procedure designed to eliminate much of the venous outflow. Although there was considerable initial enthusiasm for this and other surgical approaches was significant, this type of surgery has become rare because of a lack of long-term efficacy. [121] In a prospective nonrandomized study from China that compared a 9 week LiESWT treatment with 100 mg on-demand sildenafil in a group of 78 men, the two treatments had similar efficacy and safety at baseline and 3-month follow-up.
What is erectile dysfunction (ED)?
AUA guidelines recommend against the use of such procedures. [1] Endovascular embolization of venous leaks can provide a significantly less invasive and more effective approach for these cases. In the past, the placement of prosthetic devices within the corpora was the only effective therapy for men with organic ED. At present, however, it is the last option considered, even though more than 90% of men with an implant would recommend the procedure to their friends and relatives. Before selecting this form of management, the patient and his sexual partner should be counseled regarding the benefits and risks of this procedure (see Table 2 below).
How to use ED pills properly
Advantages and Disadvantages of Different Types of Penile Implants for Erectile Dysfunction (Open Table in a new window) Implants are usually used for men who have not experienced success with other therapies or who require penile reconstructions. Men who have undergone a radical prostatectomy for prostate cancer and in whom a nerve-sparing procedure was not performed or was not successful often do not respond to oral PDE5 inhibitors, and these men are good candidates for a penile implant. The same is true for men treated with radiation therapy, though more of these men tend to respond to oral agents. Daily use of a vacuum erection device for a month before implantation of a penile prosthesis may prove beneficial. A randomized controlled trial by Canguven et al found that this strategy was associated with a significantly greater mean stretched penile length on the day of surgery; in addition, surgeons reported easier corporal dilatation intraoperatively. [122] However, evaluation of LiESWT trials is complicated by their heterogeneity; they have used a variety of devices and a wide range of applied energies, number of shocks per session, and frequency and total number of sessions.
Treatment for erectile dysfunction
The mean follow-up was 19.54 months, and questionnaires were used to obtain the data. Complications include infections (occurring in 2% of patients), erosion of the device blue pillmen through the urethra or skin (2%), and painful erections (1%). The development of an antibiotic-coated device has further reduced the infection rate. Patients should also be counseled that the penis does not lengthen as much as with normal erections. Sexual counseling is the most important part of treatment for patients with sexual problems.
Preparing medication
Many professional sexual counselors are skilled in working with patients, but the primary care physician, the urologist, and the gynecologist also serve in this capacity to some degree. These are usually the first professionals to learn about the problem, and they often have to extract the information about the sexual problem from the patient. Men are frequently reluctant to discuss their sexual problems and must be specifically asked. Opening a dialogue allows the clinician to begin the investigation or to refer the patient to a consultant. Regardless of any subsequent therapy, the emotional aspects of the disorder must be addressed.