Practical Approach To Erectile Dysfunction

Andrew Siegel MD  9/16/17

ED is a highly prevalent condition and a common reason for a urology consultation.  A pragmatic approach to its diagnosis and treatment–the topic of today’s entry–has always worked well for my patients.  A practical approach starts with simple and sensible measures, and only in the event that these are not successful, proceeding with more complex and involved strategies, dividing management options into four tiers of complexity. 

 Principles to managing male sexual issues are the following:

• If it ‘ain’t broke,’ don’t fix it: “First do no harm.”
• Educate to enable informed decisions: “The best prescription is knowledge.”
• Try simple, conservative options before complex and aggressive ones: “Simple is good.”
• Healthy lifestyle is vital: “Genes load the gun, but lifestyle pulls the trigger.”

Questions that need to be asked in order to evaluate ED include the following:

• How long has your problem been present?
• Was the onset sudden or gradual?
• How is your sexual desire?
• How is your erection quality on a scale of 0-5 (0 = flaccid; 5 = rigid)?
• Can you achieve an erection capable of penetration?
• Is your problem obtaining an erection, maintaining an erection, or both?
• Is your problem situational? Consistent? Variable?
• Are nocturnal, early morning and spontaneous erections present?
• Do you have a bend or deformity to the erect penis?
• How confident are you about your ability to complete the sexual act?
• Are there ejaculation issues (rapid, delayed, painful, inability)?
• Do you have symptoms of low testosterone?
• What treatments have been tried?

Of equal relevance are medical, nutritional, exercise and surgical history, medications, and use of tobacco, alcohol and recreational drugs.  A tailored physical includes blood pressure, pulses and an exam of the penis, testes and prostate.  Basic lab tests including urinalysis, serum glucose, HbA1c, lipid profile and testosterone.

Information derived from the evaluation as described above will provide a working diagnosis and the ability to formulate a treatment approach.  Although a nuanced and individualized approach is always best, four lines of treatment for ED are defined—from simple to complex—in a similar way that four lines of treatment can be considered for arthritis.  For arthritis of the knee, for example, first-line therapy is weight loss to lessen the mechanical stress on the joint, in conjunction with physical therapy and muscle strengthening exercises. Second-line therapy is anti-inflammatory and other oral medications that can help alleviate the pain and inflammation. Third-line therapy is injections of steroids and other formulations.  Fourth-line therapy is surgery.

If the initial evaluation indicates a high likelihood that the ED is largely psychological/emotional in origin, referral to a qualified psychologist/counselor is often in order.  If the lab evaluation is indicative of low testosterone, additional hormone blood tests to determine the precise cause of the low testosterone are done prior to consideration for treatment aimed at getting the testosterone in normal range.  If the lab evaluation demonstrates unrecognized or poorly controlled diabetes or a risky lipid and cholesterol profile, appropriate medical referral is important.

Practical treatment of ED

 Credit for photo above goes to one of my patients; note the 7 prodigious appendages!

First-line: Lifestyle makeover

 A healthy lifestyle can “reverse” ED naturally, as opposed to “managing” it. ED can be considered a “chronic disease,” and as such, changes in diet and lifestyle can reverse it, prevent its progression and even prevent its onset.

My initial approach is to think “big picture” (and not just one particular aspect of the body working poorly).  Since sexual functioning is based upon many body components working harmoniously (central and peripheral nerve system, hormone system, blood vessel system, smooth and skeletal muscles), the first-line approach is to do what nurtures every cell, tissue and organ in the body. This translates to getting down to “fighting” weight, adopting a heart-healthy and penis-healthy diet (whole foods, nutrient-dense, calorie-light, avoiding processed and refined junk foods), exercising moderately, losing the tobacco habit, consuming alcohol in moderation, managing stress (yoga, meditation, massage, hot baths, whatever it takes, etc.), and getting adequate quantity and quality of sleep. Aside from general exercises (cardio, core, strength and flexibility training), specific pelvic floor muscle exercises (“man-Kegels”) are beneficial to improve the strength, power and endurance of the penile “rigidity” muscles.

If a healthy lifestyle can be adopted, sexual function will often improve dramatically, in parallel to overall health improvements. Many medications have side effects that negatively impact sexual function. A bonus of improved lifestyle is potentially allowing lower dosages or elimination of medications (blood pressure, cholesterol, diabetic meds, etc.), which can further improve sexual function.

“The food you eat is so profoundly instrumental to your health that breakfast, lunch and dinner are in fact exercises in medical decision making.”  Thomas Campbell MD

 

Above: A nice, healthy meal consisting of salmon, salad, veggies and quinoa

 

Above: Not the kind of belly you want–visceral obesity is a virtual guarantee of pre-diabetes–if not diabetes–and greatly increases one’s risk of cardiovascular disease, including ED

Bottom line: Drop pounds, eat better, move more, stress less, sleep soundly = love better!

Second-line: ED pills and mechanical devices

In my opinion, the oral ED medications should be reserved for when lifestyle optimization fails to improve the sexual issues. This may be at odds with other physicians who find it convenient to simply prescribe meds, and with patients who want the quick and easy fix.  However, as good as Viagra, Levitra, Cialis and Stendra may be, they are expensive, have side effects, are not effective for every patient and cannot be used in everyone, as there are medical situations and medications that you might be on that preclude their use. In the second-line category, I also include the mechanical, non-pharmacological, non-surgical devices, including the Viberect and the vacuum suction devices.

Viagra (Sildenefil). Available in three doses—25, 50, and 100 mg—it is taken on demand and once swallowed, it will increase penile blood flow and produce an erection in most men within 30-60 minutes if they are sexually stimulated, and will remain active for up to 8 hours.

 Levitra (Vardenefil). Similar to Viagra, it is available in 5, 10, and 20 mg doses. Its effectiveness and side effect profile is similar to Viagra.

Cialis (Tadalafil).  Available in 2.5, 5 mg, 10mg, and 20 mg doses, its effectiveness and side effect profile is similar to Viagra. Its duration of action is approximately 36 hours, which has earned it the nickname of “the weekender.” Daily lower doses of Cialis are also FDA-approved for the management of urinary symptoms due to benign prostate enlargement.

Stendra (Avanafil). Similar to Viagra, it is available in 50, 100 and 200 mg doses. Its advantage is rapid onset.

Vacuum suction device                                                                                                                          This is a mechanical means of producing an erection in which the penis is placed within a plastic cylinder connected to a manual or battery-powered vacuum. The negative pressure engorges the penis with blood and a constriction band is temporarily placed around the base of the penis to maintain the erection.

Viberect device                                                                                                                               Initially employed as a means of triggering ejaculation in men with spinal cord injuries using vibrational energy, it has achieved wider use in provoking erections in men with ED. The device has dual arms that are placed in direct contact with the penile shaft. The vibratory stimulation will cause an erection and ultimately induce ejaculation.

Third-line: Vasodilating (increase blood flow) urethral suppositories and penile injections

These drugs are not pills, but other formulations (suppositories and injections) that increase penile blood flow and induce an erection.

M.U.S.E. (Medical urethral system for erection).  This is a vasodilator pellet—available in 125, 250, 500, and 1000 microgram dosages—that is placed into the urinary channel after urinating.  Absorption occurs through the urethra into the adjacent erectile chambers, inducing increased penile blood flow and potentially an erection.

Caverject and Edex (Prostaglandin E1) are vasodilators that when injected directly into the erectile chambers result in increased blood flow and erectile rigidity. After one is taught the technique of self-injection, the medication can be used on demand, resulting in rigid and durable erections.  A combination of medications can be used for optimal results– this combination is known as Trimix and consists of Papaverine, Phentolamine, and Alprostadil.

Fourth-line: Penile implants

There are two types of these devices that are surgically implanted into the erectile chambers under anesthesia, most often on an outpatient basis. Penile implants are totally internal, with no visible external parts, and aim to provide sufficient penile rigidity to permit vaginal penetration.

The semi-rigid device is a simple one-piece flexible unit consisting of paired rods that are implanted into the erectile chambers. The penis with implanted flexible rods is bent up for sexual intercourse and bent down for concealment. The inflatable device is a three-piece unit that is capable of inflation and deflation. Inflatable inner tubes are implanted within the erectile chambers, a fluid reservoir is implanted behind the pubic bone and a control pump in the scrotum, adjacent to the testes. When the patient desires an erection, he pumps the control pump several times, which transfers fluid from the reservoir to the inflatable inner tubes, creating a hydraulic erection which can be used for as long as desired. When the sexual act is completed, he deflates the mechanism via the control pump, transferring fluid back to the reservoir.

Penile implants can be a life changer for a man who cannot achieve a sustainable erection. They provide the necessary penile rigidity to have intercourse whenever and for however long that is desirable.

 

Wishing you the best of health,

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Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

• Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
• Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
• Amazon page
• Co-creator of the PelvicRx male pelvic floor muscle training DVD

Tags: Andrew Siegel MD, ED, ED evaluation and treatement, ED medications, erectile dysfunction, healthy lifestyle, Kegel exercises for men, pelvic floor muscle exercises, penile implants, penile injection therapy, vacuum suction device, Viberect device