In many societies and cultures, sexual function and problems with sexual function are rarely discussed openly. As a result, research into the pathophysiology and treatment of erectile dysfunction has progressed more slowly than many other fields of medicine. The advent of oral therapy and the media coverage of Viagra as the first effective oral treatment available for erectile dysfunction make us think that there is a heightened awareness and a willingness to discuss erectile dysfunction more openly. This does not appear to be entirely the case because before the advent of oral therapy, only about 10% of men with erectile therapy sought help, and with the advent of oral therapy, about 20% are seeking help.
Because erectile dysfunction is not a disease in and of itself, rather, it is a manifestation of an underlying disease process, it is important to search for these disease processes during the history and physical examination because many of these diseases (e.g., diabetes mellitus, high cholesterol level, and cardiovascular disease) are associated with significant morbidity (i.e., illness or disease) and possibly mortality (death). Furthermore, erectile dysfunction has been shown to have a significant impact on quality of life (an evaluation of healthy status relative to the patient’s age, expectations, and physical and mental capabilities), self-esteem, incidence of depression, and partner relationships. Thus, the treatment of erectile dysfunction and the underlying causative disease processes may have a significant impact on the overall well-being of the man and also affect his partner.
The selection of the appropriate therapy for each individual depends on several factors: medical, personal, cultural, ethnic, religious, and financial. Each form of therapy has its own advantages and disadvantages that make it more or less suitable for individual patients, potentially modifiable risk factors include:
- Lifestyle changes: weight loss, smoking cessation, decrease in alcohol consumption, dietary changes to decrease cholesterol level, avoidance of recreational drugs, and changing bicycle seat, if appropriate.
- Improving psychosocial factors: attempting to resolve conflicts with partner if present, stress reduction, treatment for anxiety or depression if present.
- Improving one’s understanding of sexual function: understanding the sexual response cycle, age-related changes in sexual function, and the impact of erectile dysfunction on sexual function.
- Identification of iatrogenic causes (i.e., those resulting from treatment, such as surgery, medication, or procedures) of erectile dysfunction. Erectile dysfunction may be the result of certain medications, and in select cases, different medications may be employed.
Most men with erectile dysfunction will not be able to permanently restore their erectile function. Some men with identifiable vascular causes and no other underlying medical conditions and who are willing to undergo surgery may be candidates for penile bypass surgery or venous ligation surgery; however, this is a small number of men. Most men require a pill, injection therapy, the vacuum device, or a penile prosthesis to allow them to achieve an erection when they wish to have an erection. It is important for your physician to discuss each of these therapies with you and to review the pros and cons of each so that you may decide which form of therapy is most appropriate for you and your partner. If the cause of your erectile dysfunction is believed to be psychogenic (originating from the mind or psyche), then sexual counseling would be a first-line therapy. It is important to realize that psychosocial factors are important in all forms of erectile dysfunction, and psychosexual therapy may be of benefit to couples with organic erectile dysfunction as well as those with psychogenic erectile dysfunction.
Current therapies available for the treatment of erectile dysfunction include:
- Oral therapy: Viagra is the only FDA-approved oral therapy at this time, but other oral therapies are being developed.
- Injection therapy: Caverject and Edex (both prostaglandin E2) are the two FDA-approved therapies; triple P (phentolamine, prostaglandin, and papaverine), papaverine, and bimix (papaverine and phentolamine) are available at select institutions.
- Mechanical therapy: the vacuum device is the most commonly available mechanical therapy.
- Surgical therapy: penile prosthesis, arterial revascularization, and venous leak surgery have all been employed.
Other therapies, such as trazodone and yohimbine, are available, but these are not recommended as first-line therapies for erectile dysfunction. Apomorphine SL is currently available overseas, but not in the United States. A variety of oral, topical, and injection therapies are currently awaiting FDA approval or are under investigation.
Medical, Pharmacologic, and Physiological Treatments
In this chapter, we explore the medical treatments that are available for ED. We discuss several approaches to reverse ED caused by necessary medications like antihypertensive drugs. We offer you balanced information about Cialis, Levitra, and Viagra, and we discuss how to use them in describe treatments such as the penile vacuum device and surgical implants, as well as experimental surgery for penile vascular disease. We offer recommendations for what not to do. We discuss the pros and cons of each option in terms of personal pleasure and relationship satisfaction as well as effectiveness in treating ED.
The Fix-and-Foster Principle
There is a two-part guiding principle for treating physical ED: fix and foster. After the physical cause is “fixed,” the couple will need to heal from the distress ED caused and use relationship and psychosexual skills to recover cooperation and foster sexual intimacy and satisfaction. Your physician is trained to alleviate biological problems when possible but does not have the power to ensure relationship satisfaction. That is your job! “Fixing” the medical cause of your ED does not itself foster sexual and relationship satisfaction. Don’t settle for less.
How does one treat anorgasmia?
Congenital anorgasmia is rare and is believed to be related to an overstrict upbringing. Nocturnal emissions (“wet dreams”) may occur, but repression of the normal sexual responses prevents the individual from achieving climax and ejaculation. In this situation, psychotherapy may help, as may the use of a vibrator. Acquired orgasmic dysfunction may be caused by medical therapy. Fluoxetine (Prozac) has been associated with a delay in ejaculation and an absence of orgasm in up to 40% of patients who take it. Changing to a different antidepressant may lead to an improvement in ejaculatory and orgasmic function. In some individuals with orgasmic dysfunction, changes in their techniques of tactile stimulation may help with the orgasmic dysfunction.
How does one treat priapism?
The treatment of high-flow priapism is aimed at stopping the inflow of blood through the abnormal artery. This can be achieved sometimes with the injection of a chemical into the penis that tells the arteries to close down, or the abnormal artery can be occluded. Specialized radiologists are able to identify the abnormal artery and inject a substance or device into the artery to block it off. Because more than one artery supplies blood to the penis, this embolization does not usually cause any damage to the penis or to subsequent erections.
If treated early, low-flow priapism can be treated with the injection of a medication into the side of the penis. If one waits too long and the rigidity has lasted longer than 6 hours, then the physician must first wash out the stagnant blood from the penis before injecting the chemical that stops the erectile process. In certain cases, surgical treatment is required to bring the erection down. Unlike high-flow priapism, low-flow priapism causes damage to the penis, which makes it more difficult and sometimes impossible to achieve an erection in the future, another reason to seek treatment early.