Posts Tagged ‘erectile smooth muscle’

Penile Injection Therapy: A Small Prick For A Bigger One

March 5, 2016

Andrew Siegel MD 3/5/2016

In 1983, at the American Urological Association meeting in Las Vegas, an event occurred that forevermore changed the field of male sexual dysfunction. Giles Brindley, a British physiologist, appeared from behind the podium and dropped his trousers, revealing to the audience his erection that had been induced by the injection of a medication directly into his penis. Commented one authority: “Farther down the Strip, Seigfried and Roy were making a white Bengal tiger disappear, and two circus aerialists—one sitting on the other’s shoulders—were traversing a tightrope without a net. But even in Vegas they’d never seen a show like this.” Few medical breakthroughs have had the dramatic effect that Brindley’s demonstration had, solidifying the principle that an erection is caused by smooth muscle relaxation in the erectile sinus tissues of the penis.

 

When first-line (healthy lifestyle) and second-line measures (ED meds, vibrational stimulation, penile pump)  are not sufficient in restoring erectile rigidity, penile injection therapy can be an effective and safe third-line option.

Penile injections of vasodilator drugs (medications that promote penile blood inflow) are beneficial for a wide range of medical conditions associated with ED. Vasodilator drugs injected directly into the penile erectile chambers bypass psychological, neurological, and hormonal factors and act locally on the erectile sinus tissues, causing blood to pour into the erectile chambers, inducing a rigid erection on demand. Injection therapy can be useful in ED due to psychological, neurological and hormonal causes as well as in men with some degree of blood vessel disease due to fatty plaque blocking arterial inflow. These injectable medications are the only such drugs that are capable of initiating an erection—in other words, achieving an erection without sexual stimulation.

A tiny needle is used to inject the medication into the side of the penis, directly into one of the paired penile erectile chambers. An erection usually occurs within 5-30 minutes and lasts for a variable amount of time, depending on the dosage of the medication. Injection-induced erections do not interfere with one’s ability to ejaculate or experience an orgasm.

Alprostadil (Caverject, Edex) is a commonly used vasodilator that increases penile blood flow and relaxes arterial and erectile sinus smooth muscle in the erectile chambers, resulting in a rigid erection. A combination of medications is often used to obtain optimal results. This combination is known as Trimix and consists of three drugs: Alprostadil, Papaverine and Phentolamine.

Who Knew? In 1982, French vascular surgeon Dr. Ronald Virag discovered the effect of Papaverine on erections when he mistakenly infused it into the penis, thinking he was administering saline. The patient immediately developed an erection and Dr. Virag realized that a new treatment for ED was possible.

Patients interested in using penile injection therapy are taught how to do the procedure during a urological office visit, at which time a test dose is administered. It is not a difficult technique to learn, although it requires some degree of dexterity. After learning the technique, the medication can be self-administered on demand. It often requires some trial and error to get the dosage just right so that the erection lasts an appropriate amount of time, in accordance with individual needs. With practice, one rapidly becomes skilled in the technique—not unlike learning to use contact lenses.

Side effects can be pain, bruising, scarring and prolonged erections. The most common side effect is a dull ache that is usually mild and tolerable. This typically happens with Alprostadil more commonly than with Trimix. A bruise may occur at the injection site and is best prevented by applying compression on the injection site for several minutes following the injection. Occasionally, a small lump can develop at the site of repeated injections and rarely penile scarring may be a consequence.

On occasion, a prolonged erection (priapism) may occur. It is undesirable to have an erection that lasts for more than four hours. If this occurs, it may require the injection of a medication to reverse the effects of the vasodilator drug and decrease penile blood flow in order to bring the erection down. This is safest done in an ER setting where cardiac monitoring can be performed.

Who Knew? Many male stars in the adult film industry use Trimix in order to achieve the erectile rigidity and durability necessary for their performances.

Sadly, there are some unscrupulous medical groups who prey on unsuspecting and vulnerable ED patients, often offering injection therapy without discussion of alternative treatments and charging patients exorbitant fees for medications such as Trimix.. See the following LA Times article concerning this:

http://articles.latimes.com/2011/apr/07/local/la-me-boston-medical-20110404

The reality is that medications such as Trimix can be obtained via prescription from your urologist at reputable compounding pharmacies for very reasonable fees. It should not cost an arm and a leg to obtain a rigid penis!

Technique of Penile Injection

Preliminary tips:

  • Shave the base of the penis to make the process easier.
  • If possible, immediately before injecting, manipulate the penis to obtain some penile blood flow and filling.  The procedure will be easier with a plumper penis.
  • Avoid injecting into superficial veins.
  • The injection only needs to be done on one side even though there are two injection chambers, since they communicate.
  • Vary the injection site to avoid scarring.
  • Do not inject more than three times weekly.

 

Triple-P_Injection

(Author: Post Prostate, Source: Own work; 16 March 2013)

  1. If you are right-handed, use your left thumb to protect the 12 o’clock position (penile nerves) and your left index finger to protect the 6 o’clock position (urethral channel). If you are left-handed, use your right thumb to protect the 12 o’clock position (penile nerves) and your right index finger to protect the 6 o’clock position (urethral channel).
  2. Use an alcohol swab to cleanse the base of the penis in order to prevent infections and then set aside the swab and save.
  3. Holding the prefilled syringe like a pen, in dart-like fashion penetrate the skin of the penis at a right angle, passing the needle as far as it will go. The site should be between the 1 o’clock and 3 o’clock position for a righty and 9 o’clock and 11 o’clock position for a lefty. The base of the shaft is the easiest location for the injection; however, because the erectile chambers run all the way to the head of the penis, any shaft location is acceptable for the injection site.
  4. Inject the full contents of the syringe by applying pressure to the plunger.
  5. Remove the syringe and use the alcohol swab to apply pressure to the injection site for several minutes.
  6. Observe your penis becoming increasingly rigid and the rest is up to you!

Bottom Line:  Penile injection therapy can be an effective and safe option for restoring erectile function when first and second-line measures are not sufficient.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

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 and PelvicRx: comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training programs. Built upon the foundational work of Dr. Arnold Kegel, these programs empower men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.  

Pelvic Rx can be obtained at http://www.UrologyHealthStore.com, an online store that is home to quality urology products for men and women.  Use code UROLOGY10 at check out for 10% discount. 

 

 

 

 

 

 

 

 

 

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An Erection Is A Symphony, With An Orchestra And Conductor

October 10, 2015

Andrew Siegel MD    October 10, 2015

Gaga_Symphony_Orchestra

(Gaga Symphony Orchestra live at Palazzo Zuckermann, Padua, Italy; photo taken by Carlo Alberto Cazzuffi, September 2012; Permission to copy and distribute under the terms of the GNU Free Documentation License)

Achieving a rigid erection is a “symphony” that results from the interplay of four “orchestral sections,” nerves, blood vessels, erectile smooth muscle, and erectile skeletal muscle (pelvic floor muscles). The orchestral sections are led by the “conductor,” the brain (the main sex organ). Although each individual “musician” within the orchestral sections has a unique role, all work together in harmony to create a beautiful “symphony.” If any musician or orchestral section is off key, the disharmony can cause the “symphony” to be flawed resulting in a sub-par performance.

Sections of the Orchestra

Nerves: You can think of the nerves as the string instruments—the violin, viola, cello and double bass—vibrating in sync. This is arguably one of the most important sections, providing more than half of the musicians.

The penis has a rich supply of nerves that connect with the spinal cord and brain. Without these nerves and connections, the penis would be numb, cut off from the rest of the body and incapable of being stimulated with either touch or erotic stimulation.

Here is how things work when nerves are functioning well:

  • When the penis is stimulated by touch, nerves relay this information to spinal cord centers, which then relay the message to the penile arteries to increase blood flow, resulting in the penis becoming engorged.
  • Touch to the penis is also conveyed directly to the brain, enhancing this reflex spinal cord response.
  • Erotic stimulation (visual cues, sounds, smells, touch, thoughts, memories, etc.) further stimulates the penis from excitatory nerve pathways that descend from the brain.
  • With touch stimulation of the head of the penis, a reflex contraction of the pelvic floor muscles causes even more blood to be pushed into the penis, leading to a rigid erection.

Blood vessels: You can think of the blood vessels as the percussion instruments—the piano, xylophone, cymbals, drums, etc.—pulsing rhythmically. Kettledrums or timpani bring a level of excitement to the music. 

Inflation of the penis is all about blood inflow and trapping. When there are issues with blood flow or blood trapping, it becomes very difficult to obtain and/or maintain an erection.

Here is how things work when the blood vessels are functioning well:

  • With touch or erotic stimulation, nerves (as discussed above) cause the muscle within the walls of the penile arteries to relax, which increases penile blood flow.
  • Muscle relaxation within the small arteries of the sinuses of the penile erectile chambers increases blood flow, resulting in penile engorgement.

Erectile smooth muscle: You can think of the erectile smooth muscle as the woodwind instruments—the piccolos, flutes, oboes, clarinets and bassoons—ranging from the highest tones in the orchestra to the lowest, analogous to the great range of smooth muscle contractility within the erectile chambers.

The erectile smooth muscle within the sinuses of the erectile chambers governs the inflation/deflation status of the penis. When the smooth muscle is contracted (squeezed), the penis cannot inflate with blood, but when the muscle relaxes, blood gushes into the sinuses and inflates the penis. Issues with the erectile smooth muscle make it difficult to obtain or maintain an erection.

As we age, smooth muscle in all arteries of the body stiffens, causing high blood pressure; paralleling this, there is an age-related stiffness of the erectile smooth muscle, which causes erectile dysfunction.

Here is how things work when the erectile smooth muscle is functioning well:

  • With touch or erotic stimulation, the smooth muscle within the sinuses of the erectile chambers relaxes, under control of the nerves, which allows blood to flow into and fill the sinuses.
  • As the sinuses approach complete filling, veins that drain them are pinched, trapping blood within the sinuses.
  • This smooth muscle relaxation results in penile blood pressure becoming equal with the overall systolic blood pressure (normally 120 millimeters) and an engorged penis, plump but not rigid.

Erectile skeletal muscles (pelvic floor muscles): You can think of the erectile skeletal muscles as the brass instruments—the trumpets, French horns, trombones, and tubas, made of brass and capable of the loudest sounds in the orchestra. These instruments are particularly important in the loudest, most exciting portions of the music, corresponding to the role of the pelvic floor muscles as one approaches climax, maintaining rigidity and driving ejaculation.

The pelvic floor muscles are the rigidity muscles, necessary for transforming the plump penis to a rock-hard penis. These “rigidity” muscles surround the deep roots of the penis. When these muscles are not functioning optimally, one loses the potential for full rigidity.

Half of the penis is hidden and internal and is known as the penile roots. Like the roots of a tree responsible for  foundational support, the roots of the penis stabilize and support the erect penis so that it stays rigid and skyward-angling with excellent “posture.” When erect, it is these muscles that are responsible for the ability to lift one’s penis up and down as the muscles are contracted and relaxed. These rigidity muscles compress the roots of the penis, causing backflow of pressurized blood into the penis; additionally they are responsible for ejaculation—compressing the urethra (urinary channel that runs through the penis) rhythmically at the time of climax to cause the expulsion of semen.

An erection–defined in mechanical (hydraulic) terms– is when the penile blood inflow is maximized while outflow is minimized, resulting in an inflated and rigid penis. The pressure in the penis at the time of an erection is sky-high (greater than 200 millimeters), the only organ in the male body where high blood pressure is both acceptable and necessary for healthy function. If the systemic blood pressure were this high, it would be considered a “hypertensive crisis.” This explains why blood pressure pills are the most common medications associated with erectile dysfunction.

Unlike humans, many mammals have a bone called the os penis to permit penile rigidity. In the absence of this handy set up, nature has cleverly engineered a better alternative…after all, who wants an erection 24-7-365? A convenient and readily available fluid—blood—is used as a liquid medium and pressurized tremendously to achieve an erection. Brilliant!

Here is how things work when the pelvic floor muscles are functioning well:

  • With touch stimulation of the head of the penis, there is a reflex contraction of the pelvic floor muscles; every time the head of the penis is stimulated, the pelvic floor muscles contract.
  • The pelvic floor muscles surround the roots of the penis and as they compress and squeeze the roots with each contraction, blood within the roots is forced back into the external penis, thereby pushing more blood into the penis and causing more clamping of venous outflow—a tourniquet-like effect—that results in penile high blood pressure and full-fledged rigidity—a brass-hard penis.

Brain: You can think of the brain as the conductor of the orchestra—the maestro—who has the vital role of unifying and coordinating the individual performers, setting the tempo, executing meter, “listening” critically and shaping the sound of the ensemble accordingly. The conductor is the key player and if he is having an off day and does not bring his “A” game, there will be disharmony in the orchestra and the symphony will be flat and unimpressive.

Psychological and emotional status has a significant impact on erectile function. Mood, stress levels, interpersonal and relationship issues, etc.—acting via the mind-body connection and mediated via the release of neurochemicals—can influence erectile function for better or worse. Stress, for example, induces the adrenal glands to release a surge of adrenaline. Adrenaline constricts blood vessels, which has a negative effect on erections, the basis for the common occurrence of adrenaline-fueled performance anxiety.

The Fix

Now that we have looked at the sections of the orchestra and have deconstructed the erectile process, let us use this schema as a means of treating the specific part of the process that may have gone awry.

Nerves: Since intact and functioning nerves are fundamental to the erectile process, stimulation of the nerves can be an effective means of resurrecting erectile function. Penile vibratory stimulation induces the reflex between the penis and the spinal cord that results in gradual filling of the penis with arterial blood. It contributes to erectile rigidity via inducing reflex contractions of the pelvic floor muscles when the vibrations are applied to the head of the penis. By enhancing this reflex and triggering nerve activity in the brain, spinal cord and peripheral nerves, vibratory stimulation is capable of inducing an erection and ejaculation.

Blood Vessels: Clogged arteries caused by fatty plaques, often a consequence of an unhealthy lifestyle, can compromise the blood supply to the penis. Lifestyle “remake” consists of common-sense measures to improve all aspects of health in general and blood vessel health in particular. This means getting 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. The oral ED medicationsViagra, Levitra, Cialis and Stendra—can be helpful when there is compromised blood flow to the penis. They work by inhibiting the chemical that causes erections to dissipate.

Erectile Smooth Muscle: Age-related dysfunction of erectile smooth muscle is a difficult issue to manage. However, lifestyle measures can be helpful as well as adopting a “use it or lose it” attitude towards sexual function—exercising the penis via regular sexual activity will actually help the health of the smooth muscle of the penile arteries and sinuses.

Erectile Skeletal Muscle: Pelvic floor muscle training will improve the strength, tone and endurance of the pelvic floor muscles and will optimize the rigidity function.

Brain: Finding a solution for the psychological and emotional issues that adversely affect sexual function would merit winning the Nobel Prize! Lifestyle measures are vital for optimal brain function. Getting sufficient sleep is particularly important. Stress management is essential as stress is one of the main erection killers. Finding balance in life is key. When in a sexual situation, being “in the moment” as opposed to “spectatoring”—observing your performance as if you are a third party—is fundamental for optimal functioning.

Bottom Line: An erection is a highly complex symphony, orchestrated by the main sex organ—the brain—and executed at the level of the penis via the individual performances of the orchestral members who comprise the orchestral sections—the nerves, blood vessels, erectile smooth muscle and the pelvic floor muscles. All orchestral members play a vital role in the creation of a magical synergy, resulting in a spirited, powerful, passionate performance that climaxes in a tension-releasing symphonic finale.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

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.

Erectile Rigidity: “A Perfect Storm”

December 13, 2014

shutterstock_v162886

Andrew Siegel MD   12/13/14

**Note: Although the following blog is written primarily for men, it is equally relevant to females. Since the penis and clitoris are homologous organs, whenever you see “penis” you can substitute “clitoris.”

Last week’s blog reviewed how the penis is one of the most “magical” of organs—how it is uniquely capable of transforming its shape, size and constitution in a matter of nanoseconds. The take home message was that the remarkable upsurge is possible because inflow of blood to the penis is maximized while outflow is minimized, resulting in penile blood pressures that far exceed arterial blood pressure.

Rigid erections can only occur when there is a “perfect storm” of events. First, the arterial blood flow to the penis needs to increase substantially (pre-penile event). Second, smooth muscle within the arteries and the spongy sinuses of the erectile chambers of the penis must relax to allow engorgement with blood (penile event). Third, the pelvic floor muscles must engage to turn the swollen penis into a rigid penis (post-penile event). The blood pressure in the penis resulting from the inflow of blood alone–in the absence of the contribution from the pelvic floor muscles–cannot exceed systolic blood pressure, so the pelvic floor muscles play a vital role with respect to penile rigidity and durability of erections.

So, when erections go south, it comes down to failure in one or more of the three events,  pre-penile, penile, or post-penile.

 

Pre-penile ED

The problem lies within the arterial blood supply to the pelvis, which is not capable of delivering enough blood flow to fill the penis. Typically, the pelvic arteries are clogged with fatty plaque (atherosclerosis), which is often due to an unhealthy lifestyle: poor diet, physical inactivity, being overweight and use of tobacco. Diabetes is a very common cause of impaired blood flow (although it also affects the nerve supply in an adverse way). Insufficient blood flow may also occur because of the blood pressure lowering effect of blood pressure medications.

Solution to Pre-penile ED: Lifestyle “angioplasty”— getting 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.—all common sense measures to improve all aspects of health in general and blood vessel health in particular.

 

Penile ED

The problem lies within the penis itself. Because of poorly functioning smooth muscle within the arteries and spongy sinuses of the erectile chambers, the penis cannot properly swell up with blood. This smooth muscle cannot relax enough to allow blood flow to inflate the penis and pinch off the venous drainage. This failure of relaxation of the smooth muscle in the penile arteries and spongy sinuses parallels the failure of relaxation of smooth muscle in our arteries that causes high blood pressure (“essential” hypertension). Loss of this smooth muscle and scarring can also happen with aging, following prostate cancer surgery, from Peyronie’s disease or because of disuse atrophy.

Solution to Penile ED: Age-related malfunctioning smooth muscle and scarring is a difficult issue to manage. However, lifestyle measures can be helpful as well as adopting a “use it or lose it” attitude towards erectile function—exercising the penis via regular sexual activity will actually help its continued functioning and health of the smooth muscle of the penile arteries and spongy sinuses.

 

Post-Penile ED

 The problem is weakened pelvic floor muscles. These feeble muscles are incapable of compressing the roots of the penis sufficiently to increase the blood pressure in the penis to the levels needed for full erectile rigidity.

Solution to Post-Penile ED: Pelvic floor muscle training to improve the strength, tone and endurance of the pelvic floor muscles will optimize erectile rigidity and durability.

 

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

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A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: http://www.MalePelvicFitness.com

Co-creator of Private Gym pelvic floor muscle training program for menhttp://www.PrivateGym.com  

Sleep Erections: What’s Up with Them?

November 27, 2014

11/29/14

Andrew Siegel, MD

** This is equally relevant for the ladies as well as the gentlemen! Women get sleep erections just as men do, although obviously not as dramatic. Don’t forget that the clitoris is the female counterpart to the penis and it is qualitatively the same, although smaller in stature.

3 screw icon square

There are 3 reasons humans experience erections: psychogenic, reflex, and nocturnal (sleep). Psychogenic erections are caused by erotic thoughts or sensual stimulation through vision, hearing or smell. Reflex erections occur in response to touch—sensory nerve impulses travel from the genitals to the spinal cord centers and then from the spinal cord centers back to the genitals. Nocturnal erections have a unique mechanism controlled by the brainstem.

Erections of the male penis and female clitoris can and do happen in non-sexual circumstances, particularly during sleep. Sleep erections often occur during a phase of sleep known as rapid eye movement (REM) sleep. During a typical night of sleep, 4-5 episodes of REM sleep will occur, each lasting about 10-15 minutes, at which time both dreams and erections are prominent. Interestingly, the content of dreams at the time of sleep-related erections is rarely erotic in nature. Of note, female REM sleep related clitoral erections occur along with other signs of arousal including vaginal lubrication.

Sleep erections are most prominent during puberty and gradually lessen with aging. As we get older, episodes of sleep erections become come fewer, shorter, less intense and begin later in the sleep cycle.

There seems to be a relationship between quality of sleeping and dreaming and the presence of sleep erections. Those who have the best quality sleep and dreams seem to have the best quality sleep erections, followed by poor sleepers/good dreamers, followed by good sleepers/poor dreamers and followed by poor sleepers/poor dreamers.

 Q. Why do we get sleep erections?

 A. The purpose behind sleep related erections is theorized to be to improve the oxygenation of the smooth muscle of the erectile tissue of the penis and clitoris to help maintain normal erections.

In the non-erect state, the blood oxygenation in the erectile tissue is 20–40 mm, while in the erect state it is 90–100 mm. It is thought that the flaccid state with its low oxygenation favors collagen and connective tissue formation in the smooth muscle of the erectile chambers, resulting in scarring and the potential for problems in achieving erections.

The hormone testosterone and the ED medications Viagra, Levitra, Cialis and Stendra have been found to improve the frequency, magnitude, duration and rigidity of sleep erections.

Bottom line: Sleep erections, present in both sexes, are a mechanism for protecting the anatomy and function of the erectile tissues, another clever trick that nature has devised to help ensure reproduction.

 

 

Reference: van Driel MF: Sleep-Related Erections Throughout the Ages. J Sex Med 2014;11:1867-1875