In 1998, the release of ViagraTM, heralded the era in America of treating erectile dysfunction using pills. With the release of this drug, the discussion of erectile dysfunction (ED) was brought out of the bedroom, and into the physician's office. Numerous TV commercials and print ads can be seen that address this issue. Today there are 3 orals agents as well as other pharmacological treatments, and surgical and non-surgical therapies to correct erectile dysfunction.
Fortunately, the treatments are very effective and do not require carrying a bathtub with you at all times as you may be led to believe by Lily, nor do you have to talk to your self in a mirror prior to walking into your doctor's office to receive the Pfizer product. Due to the excellent understanding of the disease and the treatment options that are available, patients no longer need to suffer in silence.
It has been estimated that up to 50% of men over age 60 are effected by this condition. ED has been estimated to have an incidence between 15 and 30 million people. Advancing age has been associated with an increasing incidence of the disease, however advancing age does not preclude being able to maintain a healthy sex life, and many patients well into their 70's and even 80's are able to have sexual relations. Physical causes such as other underlying diseases, injury or very commonly side effects from numerous drugs have been associated with erectile dysfunction. Some of the disease processes that are commonly associated with erectile dysfunction include heart disease, elevated cholesterol, hypertension, diabetes and prostatic disease.
Stress, depression, and smoking may also be related to erectile dysfunction. Neurologic conditions such as stroke, spinal cord injuries, Parkinson's disease, and multiple sclerosis have also been associated with erectile dysfunction. Lifestyle factors such as obesity and a sedentary lifestyle may also be causative.
The oral agents sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) have very similar mechanisms of action by inhibiting phosphodisterase 5. When this occurs with sexual stimulation, the relaxation of the smooth muscle of the penis is maximized, resulting in an erection. These agents should not be used by patients who are using nitrate containing drugs due to the risk of developing profound hypotension. The length of effectiveness of these medications vary, and lifestyle can help Urologists prescribe the appropriate drug.
Despite what the commercials claim oral agents are not going to work for all patients. Some patients are not able to use these drugs due to other medications that could result in a serious adverse event. However, the good news is that other alternatives exist for these patients.
Medications that are injected directly into the penis preceded the use of oral agents by more than 25 years. At the 1983 meeting of the American Urological Association, the British physiologist Gile Brindley shocked the audience when he revealed an erection that was created by a self- injection of phenoxybenzamine.
In the era that followed, many urologists prepared various cocktails of drugs that were injected into the penis. These mixtures usually consist of varying doses of papaverine, phentolamine, and prostaglandin E1. These drugs caused vasodilatation and induced an erection. Prior to the introduction of the oral agents that are now commonly used these substances were in widespread , until a patent-infringement lawsuit was introduced that questioned the ability to use these combinations without paying a royalty to do so. As a result their use fell out of favor, however in 1995; Lilly introduced Caverject which supplanted the use of these agents and is still available today.
Caverject (alprostadil- prostaglandin E1) is a potent vasodilator that also has an indication for usage in patients with congenital heart disease. The drug is now supplied in a pre-mixed syringe. The patient dials up the correct dosage of the medication and self injects the drug in the lateral aspect of the penis with a very small needle.
After a brief training session, patients can easily inject themselves up to 3 times weekly. The injections are fairly well tolerated and can be associated with minor side effects such as pain or irritation at the injection site. Priapism, an erection that lasts longer than 4 hours has been reported with the use of these substances. The formation of fibrous tissue within the penis has also been reported with the long-term use of these substances.
Despite all the advances that have been made with regards to pharmacological advances some patients may not be well suited for these treatments. Cardiology patients using nitroglycerine should not use any of the oral agents. The side effects of facial flushing or blue vision may preclude the use of oral drugs for others. The oral agents certainly do not work in all patients. Patients may lack the manual dexterity to perform self-injection with Caverject.
A viable alternative for patients such as these is the vacuum erection device (VED). VEDs have been in use for many years, and prior to the introduction of the oral pharmacotherapies, were a very popular treatment alternative. This is a very safe form of treatment and can be used in most patients; however patients with sickle cell disease or other maladies associated with bleeding disorders should not use VEDs.
VEDs consist of a cylinder which is placed on the penis. Suction that is either battery operated or a manual pump device is then attached. By applying negative suction, blood is drawn into the penis, and then a rubber constriction band is placed around the base of the penis to trap the blood. The cylinder is then removed and an erection is maintained.
This treatment is fairly inexpensive, easy to use and reliable. Drawbacks to its usage do exist. Satisfaction rates of up to 80% have been reported with VEDs, although patients and their partners complain of a cold glans penis despite the erection being present. Patient complaints include difficulty with ejaculation (the penile constriction band also compresses the urethra preventing the ejaculation from occurring), penile bruising and pain.
Patients often ask, "Why should I undergo surgery to remain sexually active? ". Patients who undergo this surgery commonly are those who do not respond to oral agents, however many times patients who opt for this form of therapy do so as it may suit their lifestyle or desire to do so.
Prosthetic surgery does offer a permanent long-term solution to erectile dysfunction without the need to rely on oral drugs. Patients who undergo implantation are able to resume a healthy, spontaneous sex life. When the prosthesis is flexed into position, or inflated, sexual activity may for as long as you wish to. Ejaculation and orgasm do occur in patients who have been implanted. Reliance upon costly drugs with potential side effects is also eliminated.
As appealing as a prosthetic device may be to some, certain drawbacks do exist. As with all surgical procedures, a period of healing and inactivity must occur. Because the inflatable or malleable erectile bodies are inserted into the corpora cavernosum, the patient loses all possibility of obtaining a natural erection and must rely on the device. ‘
As with any foreign body that is implanted, the concern about infection remains etched in the surgeons mind. Implants are frequently placed in patients who are diabetics; patients who are notoriously prone to infections elsewhere in the body. Other patients who have undergone radiation therapy which may predispose to infection. Surgeons take great care in preparing the patient preoperatively, administering intravenous antibiotics during the course of the procedure and by giving antibiotics post-operatively. Meticulous surgical technique and sterility also helps to decrease the rate of infection in this group of patients.
Some of the newer prosthetic devices have a specialized surface antibiotic coating with rifampin and minocycline which has been shown to decrease the infection rate. Another innovative approach that has made prosthetic surgery safer has been the introduction of Parylene, which is a wear-reducing micro coating that the prostheses are made of. This coating has resulted in lower rates of mechanical failure of the inflatable devices.
In the properly selected, motivated patient, the insertion of an inflatable prosthesis is an excellent alternative that is easy to use, and results in both patient and partner satisfaction.
So, if Erectile Dysfunction occurs, do not despair. Seek help from a Urologist as there are numerous excellent treatments that are available and one of them will most likely be appealing to you.
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Published On: February 15, 2010