Erectile Dysfunction (ED, also called impotence) occurs in at least 10 % of all adult men, and although it becomes more common with age, some men have ED that began in their late teens or early 20's. In the past, this was thought to be primarily a mental problem, but research dating back to the mid 1980's, indicates that the problem is predominantly a physically based issue in the majority of men who go to a doctor for evaluation and treatment. The erection process, which seems so natural when it's working right, requires: a relaxed and receptive attitude to sexual stimulation; proper hormone levels; and, an intact biologic response sequence of nerves, blood vessels and the two internal penile cylinders (corpora cavernosa). Due to the complex nature of a successful erection, many seemingly unrelated nerve or blood vessel conditions, or even certain prescription medications, can be additive or causative factors of ED. The basic evaluation for ED includes hormone level testing, a good medical and sexual history, and a physical examination.
The most common type of physically based ED is a failure of the penile cylinders to "lock in" the incoming penile blood flow associated with sexual excitation so as to give a rigid "back bone" to the erection. This type of dysfunction is often called "venous leak" or "venous incompetence." A mental state of high anxiety or nervousness can aggravate venous leak. Even in men with a history of diabetes or heart disease in which many doctors presume the cause of ED is inadequate inflow of blood to the penile cylinders, the true cause is failure to lock the blood into the cylinders. This situation is often diagnosed by a history of progressive loss of function in which at first there is loss of a normal sized erection prior to achieving climax, which gradually becomes difficulty to even achieve a full erection with maximal self or partner induced stimulation.
Treatment is goal oriented and pragmatic, beginning with the simplest and least costly solutions which progress to the more involved. If a man is taking prescription medications that are known to impair erections, then the prescribing doctor can often substitute another medication to treat the primary medical condition which may be kinder to your erections. If hormone levels are abnormal, then high success rates are achieved from medications to reset these levels to normal. Thereafter, the pill medication, Sildenafil (trade name Viagra by the Pfizer Corporation) has been a successful early stage treatment for more than half of all men with mild to severe levels of ED. Interestingly, sildenafil is not physically addictive nor does it seem to decrease your natural erection ability. In fact, some men develop better natural erections when not taking the pill, if they use the pill on a regular basis.
For men who fail to respond to sildenafil, medication can be directly injected through the penile skin into the erection cylinders with a tiny and relatively painless needle with high success rates. I am assured by many of my diabetic patients who inject themselves with insulin once or twice daily, that when they have needed these penile injections to treat their ED, they find them to be no worse than their insulin injections. This type of therapy is called intra-cavernosal penile injection. There are several different injection agents used for this treatment, although prostaglandin E1 is the most common.
Alternately, several men will opt for the use of vacuum constriction devices (VCD). In this treatment, a clear vacuum tube is placed overtop a well-lubricated penis. The tube has at it's base a pre-loaded, rubber constriction ring. Once a proper vacuum has pulled enough blood into the penile cylinders to achieve erection, the rubber ring is relocated from the base of the vacuum tube onto the base of the penis just as the vacuum is released and the vacuum tube is removed from the base of the penis. The constriction ring which locks in the blood drawn in by the vacuum cannot be left on the penis for more than 30 minutes before it must be removed in order to restore normal penis blood flow.
For men who fail to achieve satisfactory erections with these treatments, the gold standard of treatment by which all others are measured is the surgically implanted penile prosthesis. Since the late 1960's research and clinical doctors have been using and refining surgical solutions for ED. The basic concept is to replace the malfunctioning inner part of the man's penile cylinders with new and functional penile cylinders within the "casing" of the natural cylinders. In this way, a reliable "back bone" to the erections is achieved without changing the sensation of the outer skin of the penis or pleasurable aspects of climax for either the man or his partner. The most commonly used penile implants have fully inflatable and deflatable cylinders that more closely simulate the natural rigid and soft states of the penis. Patient and partner satisfaction rates of about 90 % are reported by several different research groups that have evaluated penile implant therapy. Most men are treatable with the non-surgical options, but it is nice to know that something else is available when the simpler treatments fail.
All of these treatments have certain costs and success rates that vary. Also, each treatment has the potential for complications which must be discussed with a knowledgeable health care provider prior to beginning therapy.
Orgasm: The pleasurable sensation of achieving sexual climax, orgasm, is the most poorly understood and the least well studied areas of male sexual dysfunction. The most common treatable cause of orgasmic dysfunction is called premature ejaculation. In this case, the man is reaching orgasm and ejaculation either prior to sexual penetration of his partner, or too quickly after the initial penetration. Commonly used techniques to treat this condition have included: mental distancing during sex (thinking about other things); stop-start or penile head pinch maneuvers to decrease the penile stimulation level and restore control over timing of climax prior to hitting the orgasmic "point-of-no-return"; and, pelvic floor muscle strengthening exercises to enhance control over penile stimulation and the timing of climax. When these measures fail, doctors can prescribe a variety of different medications that have successfully lowered sexual stimulation levels to allow better orgasmic control without impairing the intensity of the orgasm once it is achieved.
Failure to achieve orgasm can be a more difficult problem to treat. There are several prescription medications known to impair orgasm. Often these medications can be replaced by equally effective medications that do not impair orgasm while treating the primary medical condition. Of course all changes in therapy must be at the discretion of the prescribing physician. However, in many cases the orgasmic failure is untreatable, either since there are either no clear causes, or the cause is loss of function due to an irreversible nerve disorder such as diabetes or multiple sclerosis. Clearly, there is a great need for ongoing medical research into the causes and potential treatments for orgasmic dysfunction.
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