Erectile Dysfunction

Erectile dysfunction, sometimes called “impotence,” is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word “impotence” may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved.

MALE GENITOURINARY ANATOMY

The penis contains two chambers called the corpora cavernosa, which run the length of the organ. A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

WHAT IS ERECTILE DYSFUNCTION?

Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult.

In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED.

ED is treatable at any age, and awareness of this fact has been growing. More men have been seeking help and returning to normal sexual activity because of improved, successful treatments for ED.

WHAT CAUSES ERECTILE DYSFUNCTION (ED)?

Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Causes of ED include the following:

Diseases:

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease account for about 70 percent of ED cases.

Lifestyle Choices:

Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of erectile dysfunction. Smoking, being overweight and avoiding exercise are possible causes of ED.

Surgery:

Surgery (especially radical prostate and bladder surgery for cancer) can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

Medications:

In addition, many common medicines such as blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug) can produce ED as a side effect.

Psychological Factors:

Psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause ED. Men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, and depression).

Smoking:

Other possible causes of ED are smoking, which affects blood flow in veins and arteries.

Hormones:

Hormonal abnormalities, such as not enough testosterone, may also be a factor in ED.

HOW IS ED DIAGNOSED?

Patient History:

Medical and sexual histories help define the degree and nature of ED. A medical history can disclose diseases that lead to ED, while a simple recounting of sexual activity might distinguish among problems with sexual desire, erection, ejaculation, or orgasm.

Using certain prescription or illegal drugs can suggest a chemical cause, since drug effects account for 25 percent of ED cases. Cutting back on or substituting certain medications can often alleviate the problem.

Physical Examination:

A physical examination can give clue to systemic problems. For example, if the penis is not sensitive to touching, a problem in the nervous system may be the cause.

Abnormal secondary sex characteristics, such as hair pattern or breast enlargement, can point to hormonal problems, which would mean that the endocrine system is involved.

The examiner might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem for example; a penis that bends or curves when erect could be the result of Peyronie’s disease.

Laboratory Tests:

Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes.

Measuring the amount of free testosterone in the blood can yield information about problems with the endocrine system and is indicated especially in patients with decreased sexual desire.

Other Tests:

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of ED.

Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than psychological cause.

Psychosocial Examination:

A psychosocial examination, using an interview and a questionnaire, reveals psychological factors. A man’s sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

CONSERVATIVE TREATMENT

How is ED Treated?

Conservative treatment measures to treat erectile dysfunction are always considered first before invasive measures such as surgery. Some conservative treatment measures include the following:

Lifestyle Changes

For some men, making a few healthy lifestyle changes may solve the problem. Quitting smoking, losing excess weight, and increasing physical activity may help some men regainsexual function.

Medication Changes

Cutting back on any drugs with harmful side effects is considered next. For example, drugsfor high blood pressure work in different ways. If you think a particular drug is causingproblems with erection, tell your doctor and ask whether you can try a different class of bloodpressure medicine.

Psychotherapy

Experts often treat psychologically based ED using techniques that decrease the anxietyassociated with intercourse. The patient’s partner can help with the techniques, whichinclude gradual development of intimacy and stimulation. Such techniques also can helprelieve anxiety when ED from physical causes is being treated.

Drug Therapy

Drugs for treating ED can be taken orally, injected directly into the penis, or insertedinto theurethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA)approved Viagra, the first pill to treat ED. Since that time, vardenafil hydrochloride (Levitra)and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested forsafety and effectiveness.

Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE)inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects ofnitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulationand allows increased blood flow.

Many men achieve stronger erections by injecting drugs into the penis, causing it to becomeengorged with blood. These drugs may create unwanted side effects, however, includingpersistent erection (known as priapism) and scarring.

A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances and what would be the most appropriate choice for their particular situation.

Vacuum Devices

Mechanical vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it.

The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body.

One variation of the vacuum device involves a semi rigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse.

SURGICAL TREATMENT INTRODUCTION

SURGICAL TREATMENT FOR ED:

Surgery usually has one of three goals:

  • To implant a device that can cause the penis to become erect
  • To reconstruct arteries to increase flow of blood to the penis
  • To block off veins that allow blood to leak from the penile tissues

The most common surgery performed for ED is Penile Implant surgery. Implanted devices, known as prostheses, can restore erection in many men with ED. There are two main types of implants:

Malleable implants:

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods.

Adjustment does not affect the width or length of the penis.

Inflatable implants:

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid.

Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted.

The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis somewhat.They also leave the penis in a more natural state when not inflated.

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the crotch or fracture of the pelvis. The procedure is almost never successful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

SURGICAL TREATMENT

Penile Implant surgery is performed under sterile conditions in the operating room with the patient under general or spinal anaesthesia. The operation usually takes between 1 and 2 hours and is performed as outpatient day surgery with no overnight stay required in the hospital.

Your surgeon will perform the following:

An incision is made across the top of the scrotum at the base of the penis.

Special instruments are inserted through the incision to stretch the spongy tissues inside the hollow chambers of the penis (corpora cavernosa).

Your surgeon then flushes the chambers with antibiotic fluid to reduce the risk of infection post operatively.

The implant rods or cylinders are then inserted into position inside the penis. If an inflatable prosthesis is used, a pump and valve is inserted into the scrotum and a fluid reservoir is implanted under the abdominal wall through an incision your surgeon will make internally.

When the prosthesis is in place and functioning, your surgeon will suture the incisions closed.

POSTOPERATIVE GUIDELINES

  • You will be sent home with pain medications to keep you comfortable.
  • You will have a urinary catheter in place that will be removed the next day at your surgeon’s office.
  • If an inflatable implant is inserted it will be left inflated until your appointment with your surgeonthe next day.
  • You should apply an ice pack to the groin area to minimize pain and swelling. Apply ice over atowel, never directly on the skin, for 20 minutes every hour.
  • You will be given oral antibiotics to decrease the risk of postoperative infection.
  • Your surgeon will instruct you on how to use your new implant once the pain and swelling hassubsided.
  • Most patients can resume sexual activity in 6-8 weeks.

RISKS & COMPLICATIONS

As with any surgery there are potential risks involved. It is important that you are informed of these risks before the surgery takes place.

Most patients do not have complications after Penile Implant surgery; however complications can occur and depend on which type of surgery your doctor performs as well as the patient’s health status. (obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to Penile Implant surgery.

Medical complications include those of the anaesthesia and your general well-being. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reaction to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attack, strokes, kidney failure, pneumonia, bladder infections
  • Complications from nerve blocks such as infection or nerve damage
  • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization,or rarely death.

Specific complications for Penile Implant surgery include:

Infection:

Infection can occur with any operation. Infection rates vary but are generally low for healthy men. Infection can occur weeks or longer after penile implant surgery and may present as pain, swelling of the scrotum, fever, or drainage.

If infection occurs it can usually be treated with antibiotics but may require further surgery to remove the implant until the infection can be resolved. In rare cases, the prosthesis has eroded through the skin requiring surgical intervention.

Mechanical Breakdown:

Although rare, mechanical breakdown can occur and requires surgery to repair or replace the broken prosthesis. Mechanical problems with implants have diminished in recent years due to technological advances.

Injury to the Urethra:

Damage to the urethra is rare but can occur during surgery requiring repair.

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