Sex Therapy
Erectile dysfunction may cause a significant number of men to develop impotence from
psychological causes that can be overcome. When a
physiological cause is treated, subsequent self-esteem
problems may continue to impair normal function and
performance. Qualified therapists (e.g., sex counselors,
psychotherapists) work with couples to reduce tension, improve
sexual communication, and create realistic expectations for
sex, all of which can improve erectile function.
Psychological therapy may be effective in conjunction with
medical or surgical treatment. Sex therapists emphasize the
need for men and their partners to be motivated and willing to
adapt to psychological and behavioral modifications, including
those that result from medical or surgical treatment.
Oral Medication
Oral medications used to treat erectile dysfunction include
selective enzyme inhibitors (e.g., sildenafil [Viagra®],
vardenafil HCl [Levitra®], tadalafil [Cialis®]) and yohimbine
(Yohimbine®, Yocon®).
Selective enzyme inhibitors are available by prescription and
may be taken up to once a day to treat ED. They improve
partial erections by inhibiting the enzyme that facilitates
their reduction and increase levels of cyclic guanosine
monophosphate (cGMP, a chemical factor in metabolism), which
causes the smooth muscles of the penis to relax, enabling
blood to flow into the corpora cavernosa.
Patients taking nitrate drugs (used to treat chest pain) and
those taking alpha-blockers (used to treat high blood pressure
and benign prostatic hyperplasia) should not take selective
enzyme inhibitors.
Men who have had a heart attack or stroke within the past 6
months and those with certain medical conditions (e.g.,
uncontrolled high blood pressure, severe low blood pressure or
liver disease, unstable angina) that make sexual activity
inadvisable should not take Cialis®. Dosages of the drug
should be limited in patients with kidney or liver disorders.
Viagra® is absorbed and processed rapidly by the body and is
usually taken 30 minutes to 1 hour before intercourse. Results
vary depending on the cause of erectile dysfunction, but
studies have shown that Viagra is effective in 75% of cases.
It helps men with erectile dysfunction associated with
diabetes mellitus (57%), spinal cord injuries (83%), and
radical prostatectomy (43%).
In clinical studies, Levitra® has been shown to work quickly,
provide consistent results, and improve sexual function in
most men the first time they take the drug. It also has shown
to be effective in men of all ages, in patients with diabetes
mellitus, and in men who have undergone radical prostatectomy.
Cialis® has been shown in clinical trials to stay in the body
longer than the other selective enzyme inhibitors. It promotes
erection within 30 minutes and enhances the ability to achieve
erection for up to 36 hours.
Common side effects of selective enzyme inhibitors include
headache, reddening of the face and neck (flushing),
indigestion, and nasal congestion. Cialis® may cause muscle
aches and back pain, which usually resolve on their own within
48 hours.
Yohimbine improves erections for a small percentage of men. It
stimulates the parasympathetic nervous system, which is linked
to erection, and may increase libido. It is necessary to take
the medication for 6 to 8 weeks before determining whether it
will work or not.
Yohimbine has a stimulatory effect and side effects include
elevated heart rate and blood pressure, mild dizziness,
nervousness, and irritability. Yohimbine's effects have not
been studied thoroughly, but some studies suggest that 10% to
20% of men respond to treatment with the drug.
Ease of administration makes oral medication advantageous.
Some drugs, however, are suitable for only a relatively small
group of men, and in many cases, oral medications may by less
effective than other treatments.
Self-Injection
Self-injection involves using a short needle to inject
medication through the side of the penis directly into the
corpus cavernosum, which produces an erection that lasts from
30 minutes to several hours. Prostaglandin (alprostadil,
Caverject®, Edex®), and phentolamine (Regitine®) produce
results similar to Viagra but are localized in the penis after
injection. They cause vascular dilation and a relaxation of
smooth muscle. Prostaglandin is the only substance currently
approved for erectile dysfunction treatment. Phentolamine is a
heart medication with similar effects used by some physicians
to treat impotence.
These drugs have been shown to produce erections in 80% of men
who inject them. Some men claim that they produce erections
that feel natural and improve sex. The injections are
relatively painless and create an erection that begins about 5
to 15 minutes after the injection. It is recommended that
self-injection be performed no more than once every 4 to 7
days. Side effects include infection, bleeding, and bruising
at the injection site, dizziness, heart palpitations, and
flushing. There is a small risk for priapism (an erection that
lasts for more than 6 hours and requires medical relief).
Repeated injection may cause scarring of erectile tissue,
which can further impair erection.
Urethral suppositories containing prostaglandin (aprostadil),
like Muse® (Medicated Urethral System for Erections), may be
an alternative to injection. Using a hand-held delivery
device, a man inserts a prostaglandin pellet through the
meatus (penis opening) into the urethra. Prostaglandin is
absorbed through the urethral mucosa and into the surrounding
erectile tissue. It is available with a prescription, is well
tolerated, and may improve erections in 60% of men who use it.
In addition to the side effects associated with injecting
aprostadil, pain in the penis and perineum (area between
scrotum and rectum) may occur with suppository use.
Vacuum Devices
Vacuum devices work by manually creating an erection. The
penis is inserted into a plastic tube, which is pressed
against the body to form a seal. A hand pump attached to the
tube is used to create a vacuum that draws blood into the
penis, causing the penis to become engorged. After 1 to 3
minutes in the vacuum, an adequate erection is created. The
penis is removed from the tube and a soft rubber O-ring is
placed around the base of the penis to trap blood and maintain
the erection until removed. The ring can be left in place for
25 to 30 minutes.
Vacuum devices work best in men who are able to achieve
partial erections on their own. They are easy to use at home,
require no other procedure, and typically improve erections
regardless of the cause of impotence. Some men experience a
numbing feeling after placing the O-ring. Since the penis is
flaccid between the ring and the body, the erection may be
somewhat floppy.
Penile implants involve surgical insertion of malleable
or inflatable rods or tubes into the penis. A semi-rigid
prosthesis is a silicon-covered flexible metal rod. Once
inserted, it provides the rigidity necessary for intercourse
and can be curved slightly for concealment. It requires the
simplest surgical procedure of all the prostheses. Its main
disadvantage is that concealment can be difficult with certain
types of clothing.
An inflatable penile prosthesis consists of two soft silicone
or bioflex (plastic) tubes inserted in the penis, a small
reservoir implanted in the abdomen, and a small pump implanted
in the scrotum. To produce an erection, a man pumps sterile
liquid from the reservoir into the tubes by squeezing the pump
in the scrotum. The tubes act as erectile tissue and expand to
form an erection. When the erection is no longer desired, a
valve allows the fluid to return to the reservoir. Inflatable
prostheses are the most natural feeling of the penile implants
and they allow for control of rigidity and size.
The surgical procedure to implant the inflatable prosthesis is
slightly more complicated than for a semi-rigid implant. Also,
because there are more mechanical parts, there is a higher
risk for mechanical failure requiring repair or adjustment.
A self-contained inflatable prosthesis is similar but has
fewer parts. It consists of a pair of inflatable tubes in the
penis with a pump attached directly to the end of the implant.
The reservoir is also located in the shaft of the penis. Its
compact design allows for simpler implantation, but because it
takes up more space in the penis, there is less room for
expansion.
Types of Penile Implants
for Erectile Dysfunction Vascular Reconstructive Surgery
A small percentage of men undergo vascular reconstructive
surgery to improve blood flow to the penis. Revascularization
involves bypassing blocked veins or arteries by transferring a
vein from the leg and attaching it so that it creates a path
to the penis that bypasses the area of blockage. Young men
with only local arterial blockage are the best candidates for
this procedure. It may restore function in 50% to 75% of men.
Venous ligation is performed to prevent venous leak.
Problematic veins are bound (ligated) or removed, which allows
an adequate amount of blood to remain in the penis. It may
improve function in 40% to 50% of men, but some men may
experience problems over the long term.
Vascular surgery for erectile dysfunction is rarely
performed and is generally considered experimental. Risks
include nerve damage and the creation of scar tissue, both of
which are causes of impotence. Surgeons experienced with these
procedures may be difficult to find.
For more information about The Austin Diagnostic Clinic's
urology department or this topic,
please call 512/901-4021.
The Austin Diagnostic Clinic, A
Multi-Specialty Medical Clinic
12221 MoPac Expressway North |
Austin, TX 78758 | 512.901.1111
Serving the communities of Austin, Round Rock, Pflugerville, San
Marcos and
Central Texas since 1952
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