Andrew Siegel, MD 10/3/15
(My patient Ben Blank, a talented artist and cartoonist, gave me the cartoon shown above in 1998 when Viagra first became available. It is hanging in one of my exam rooms)
Erectile dysfunction is usually caused by a combination of many factors, including lifestyle, medical issues, medications, impaired blood flow, nerve damage, pelvic muscle weakness, stress and psychological conditions.
Managing any medical problem should employ a sensible strategy trying the simplest, safest, and least expensive alternatives first. If unsuccessful, more aggressive, complicated and invasive options can be entertained.
For example, when a patient presents with arthritis, he or she is not offered a total knee replacement from the get-go (at least I hope not!). In accordance with the aforementioned strategy, managing knee arthritis should start with rest and anti-inflammatory medications and proceed, if necessary, down the pathway of exercise/physical therapy, arthroscopy, endoscopic knee surgery, and ultimately if all else fails, under the proper circumstances, to prosthetic joint replacement.
A Sensible and Practical Approach To Erectile Dysfunction
A similar approach should be applied to managing erectile dysfunction. Unfortunately, however, many patients and physicians alike seek the “quick fix” and ignore many treatments that can help prevent or reverse the condition.
I like to adhere to the following principles to manage sexual dysfunction:
- Provide education (verbal and in writing) so informed decisions can be made.
- Try simple and conservative solutions before complex and aggressive ones.
- If it isn’t broken, don’t fix it: “First do no harm.”
- Healthy lifestyle is crucial: “Genes load the gun, but lifestyle pulls the trigger.” Lifestyle improvement measures are of paramount importance.
“Doping” is common among athletes, who use illicit drugs to enhance their athletic performance. In my urology practice, many of my patients “dope”—with legal drugs—in an effort to improve their sexual performance. Is there not a better and more natural way than starting with performance-enhancing drugs from the get-go?
Don’t get me wrong, the oral meds for ED (Viagra, Levitra, Cialis and Stendra) are “revolutionary” additions to the limited resources we once had to treat ED. Although far from perfect—expensive, contraindicated with certain cardiac conditions and for those on nitrate medications, associated with some annoying side effects, and not effective in everyone—nonetheless, for many men they are highly effective in creating a “penetrable” erection.
These drugs are commonly used as the first-line approach to ED. As useful as they are, I contend that “doping” should not be first-line treatment, but should be reserved for situations in which the simple and natural first-line interventions fail to work.
Since erections are nerve/blood vessel/erectile smooth muscle/pelvic skeletal muscle events, optimizing erection capability involves doing what you can to have healthy nerves, blood vessels and muscles. How does one keep their tissues and organs healthy? The first-line approach is commonsense—getting in the best physical (and emotional) shape possible. This might mean a lifestyle makeover to get down to “fighting” weight, adopting a heart-healthy (and penis-healthy diet), exercising regularly, drinking alcohol moderately, avoiding tobacco, minimizing stress, getting enough sleep, etc.—measures that will improve all aspects of health in general and blood vessel health in particular.
Focused pelvic floor muscle exercises improve the strength and endurance of the male “rigidity” muscles that surround the deep roots of the penis.
Since intact and functioning nerves are fundamental to the erectile process, activation of the nerves via penile vibratory stimulation can be an effective means of resurrecting erectile function.
The vacuum suction device—a.k.a., the penis pump—is a means of drawing blood into the penis to obtain an erection and enable penetration.
Second-line treatments are the well-established oral medications for ED. Although Viagra, Levitra, Cialis and Stendra all have the same mechanism of action, there are nuanced differences in potency, time to onset, duration of action, side effects, etc., so it may take some trial and error to find out which works best for you. Cialis uniquely is approved for both ED and prostate issues, so can be an excellent choice if you have both sexual and urinary issues.
Third-line alternatives include urethral suppositories and penile injection therapy. Suppositories are absorbable pellets that are placed in the urethra that act to increase penile blood flow. Injections do the same, but are injected directly into the penile erectile chambers.
Fourth-line treatment is the prosthetic penile implant. One variety is a semi-rigid non-inflatable device and another is a hydraulic inflatable device. They are implanted surgically within the erectile chambers and can be deployed on demand to enable sexual intercourse. For the right man, under the right circumstances, the penile implant is a life changer—as magical as a total knee replacement can be—converting a penile “cripple” into a functional male. However, it is vital to understand that the implant is a fourth-line approach, and less invasive options should be exhausted before its consideration.
Bottom Line: Sadly, our medical culture and patient population often prefer the quick fix of medications or surgery rather than the slow fix of lifestyle measures. A sensible approach to most medical issues—including ED—should be the following:
- Get educated about all treatment options.
- Explore the simplest, safest, and least expensive alternatives first.
- Before considering medications to improve performance, think about committing to a healthy lifestyle and getting into optimal physical shape, including exercising the rigidity muscles of the penis and using vibratory nerve stimulation.
Wishing you the best of health,
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Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.
Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.
Tags: Andrew Siegel MD, Cialis, do no harm, doping, ED, erectile dysfunction, erection, healthy lifestyle, Levitra, male sexual function, pelvic floor muscle exercises, penile injection therapy, penile vibratory nerve stimulation, penis, prosthetic penile implants, Stendra, urethral suppositories for erections, vacuum suction device, Viagra