Erectile Dysfunction (ED)

Erectile Dysfunction is inability to achieve or maintain an erection satisfactory for intercourse. This encompasses a spectrum of problems, including partial erections, erections that disappear before satisfying yourself or your partner (early detumescence), or the complete inability to obtain any erection at all.

Erectile Dysfunction is very common. According to the Massachusetts Male Aging Study, Erectile Dysfunction affects approximately 30 to 40 million American Males. Interestingly, 80% of the time, ED has a medical etiology, with only 20% of patients having a psychological problem as the main cause of their problem.

Erectile Dysfunction can be fixed in almost every case.

ED has many etiologies:

  • Vascular (40%)
  • Diabetes (30%)
  • Medications (15%)
  • Pelvic surgery, radiation or trauma (6%)
  • Low Testosterone (3%)

Importantly, Low Testosterone (T) is the cause of ED in a very small percentage of the cases. Therefore, testosterone replacement therapy does not cure ED in most cases. Low T is mainly related to libido or sexual drive and overall energy levels.

Erectile Dysfunction and the Cardiovascular Connection:

According to the Massachusetts Male Aging Study, ED was associated most strongly with heart disease and cardiovascular risk factors such as hypertension, diabetes, smoking, obesity, and a lack of physical activity. More recently, a number of high-profile reports have concluded that ED may be a predictor of serious cardiovascular events (heart attack or stroke). According to one study by Thompson and colleagues, 15% of men presenting with the new onset of ED will develop a cardiovascular event in the next 7 years. Another study by Blumentals concluded that men with ED have a 2-fold increased risk for a heart attack, and the risk increases with age.

These studies suggest that men with ED (who have no prior history of cardiovascular disease) should be evaluated by a primary care physician or cardiologist for cardiovascular risk factors. Identifying and treating these risk factors may reduce deaths from heart attacks and strokes. Conversely, if a patient presents with known heart disease or risk factors for cardiovascular disease, he should be questioned regarding his sexual health and ED. Many of these patients can benefit by receiving therapy for ED.

Diagnostic Evaluations

After 14 years of private practice, we can safely conclude that men want know why they have ED. This also allows us to properly direct your treatment. As a result, we have adopted a “cause-oriented” approach with our patients. We routinely obtain a panel of lab tests and offer a penile ultrasound of the penile blood vessels. This enables us to diagnose blood flow problems in the penis, ruling out psychological problems as the cause of your ED. Based on the diagnostic workup, we advocate the best treatment option for each individual patient. If a patient has a normal workup, we have a sexual therapist on site that can counsel our patients effectively.

Erectile Dysfunction Treatments

Based on our diagnostic evaluations, we always advocate a specific treatment option that will work with a patient’s unique value system and goals.  There are multiple treatments for ED, however, it is very common to offer oral pills (Viagra, Levitra, Cialis) as a first line of therapy. Unfortunately, oral pills fail in 30-40% of the patients.  When the pills fail, we offer several other treatment options: Injection Therapy, Urethral Suppositories, Vacuum Erectile Devices (VEDs), and the implantation of an Inflatable Penile Prosthesis (IPP).  Due to the lack of reliability, spontaneity, and cost, the first 3 options fail in 70% of the patients at the end of one year of follow-up.  As a result, the single best treatment option available beyond an oral pill is the Inflatable Penile Prosthesis.  The IPP is a water-filled device that is placed through a small incision in a 30-45-minute outpatient procedure. Despite the fact that the IPP demonstrates the highest levels of patient and partner satisfaction rates (92-98%), it still remains a relative secret to the community at at large due to a lack of patient and physician education and marketing.  Interestingly, only 5% of of all urologists perform all of the IPP’s, emphasizing the importance of referring the patient to a qualified ED specialist.

Penile Implants

Penile Implants come in 2 varieties:

  1. Semi-rigid
  2. Inflatable–a) 2 piece & b) 3 piece

Semi-rigid implant is a solid malleable implant that is placed into the shaft of the penis for people with no manual dexterity. It is analogous to a hanger, implying that you can bend it up when your are ready for sex, and bend it downwards when you are finished. The main issue with the malleable implants are that they are always rigid, decreasing the over patient satisfaction with the product.

The inflatable implants are the most desirable products because they are more easily concealed and soft when they are deflated. The 2 and 3 piece implants are similar, but the 3 piece has the best results and is the most commonly used by prosthetic urologists. The inflatable prostheses have 3 components: 2 cylinders that are placed within the shaft of the penis, a pump in the scrotum (adjacent to the testicles), and a reservoir to hold the water (saline). The 2 piece implant combines the pump and the reservoir together, making it slightly more bulky and less flaccid when completely deflated (less fluid is moving from the pump to the cylinders). The 3 piece requires the pump to be placed behind the pubic bone in the pelvis, making the 2 piece an excellent solution for patient’s that are unable to accommodate a pelvic reservoir for a variety of medical reasons.

The 3 Piece Inflatable Penile Implant is a minimally invasive procedure that is performed through a 3cm incision where the pubic hair is located. All of the components listed above can be placed through this small opening. The procedure is outpatient (home the same day), and the recovery time is quick and manageable. The implant is very easy to use–by squeezing the pump (which is entirely contained in the scrotum), fluid is transferred to the penis, resulting in an erection. In order to return the penis to its non-erect state, a button on the pump is simply depressed. After the device is placed, patients do not need medications to perform sex, and the device is free of maintenance. Patients can engage in sexual relations spontaneously and with confidence. They continue to experience normal sensations, including orgasms and ejaculations. With enhancements to these devices, infection rates are less than 1%, and mechanical failures are rare. Medicare and many commercial plans cover the procedure, making this the most affordable option for many people. Basically, an IPP is a life-changing, transformational procedure that restores the “manhood” to the men that receive them.

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