Overview
Are you impotent?
Penile Tumescence Self-Test
What is an erection disorder?
Should it be treated?
Erection: How does it work?
What are the causes and risks of the condition?
What doctor should I go to?
What tests can be done?
medical history - physical examination - laboratory tests - Rigiscan - cavernosometry - penile tumescence self test
What are the treatments?
penile implant - psychotherapy or sex therapy - medication  - hormonal therapy - vacuum therapy  - pressure rings   - self injection therapy - prosthesis implantation  - vascular surgery
Treatment overview

Introduction

Until recently, there was only little choice in treatment in cases of diminished erections or impotence. Fortunately, times have changed. Due to the fact that much research has been successful over the years, many men may now be treated for this problem. Possible therapies differ from medication to injections to sexuologic counseling to surgery.

Most therapies are within the scope of the urologist, although many general practitioners feel confident enough to prescribe medication or engage in counseling.

Seventeen percent of males between the ages of 18 and 55 (occasionally) suffer from erection problems. Six percent of males in that age group have a problem with erections on a regular basis or even permanently. Of the males above age fifty-five, about one in three has an occasional erection problem or worse. Most of the men in that age group regularly consult their general practitioner for some reason or another. If both patient and doctor are not too shy to bring up the problem, then those contacts may prove to be a good opportunity to determine the cause of the erection problem and maybe start therapy.

Are you impotent?

Many men have erection problems but don't have the guts to confirm that. This denial, unfortunately, makes it impossible for them to enjoy sexual activities. It may help to realize that about one in four men have erection problems, so they are in the company of many. On the other hand, only five percent of those have touched on the problem with their doctor.

Only a short while ago, it was common just to ignore the problem, but nowadays the sexual wellbeing is considered to be an indicator of general health. Also, since males tend to live longer, they are even more entitled to treatment of erection disorders. Personal pride does no longer prohibit treatment. Today, a choice of many effective forms of treatment presents itself, either surgical or non-surgical. The first step towards successful treatment must however be taken by the patient, who must acknowledge that a problem exists.

What is an erection disorder?

The term erectile dysfunction is used to designate a problem with penile erections, when the penis does not harden enough or not at all, or when the erections does not last long enough during sexual encounters. Therefore, different types of erectile dysfunction exist. The impotence may be complete, i.e. 'nothing happens', or partial, when something does happen but the penis does not get hard enough to allow intercourse. A third possibility is that the penis does get erect rather normally, but falls limp again too quickly.

There is also a difference when we look at the duration of the erection disorder: some men have always had problems with erections, while others had good erections before, but these have become a problem later in life. Lastly, some erection disorders only come up in certain situations, while, in general, erections are okay.

These different types of erection problems are important when it comes to determining a cause, which in turn leads to a decision about the type of therapy.

Most erection disorders are caused by a combination of physical and psychological problems. It is important to keep this in mind when it comes to treating the problem.

Should it be treated?

An erection disorder is not life-threatening. The need for treatment depends on the amount of discomfort the problem is causing and the motivation of the patient. A long period of abstinence may induce a loss of interest in sexuality in one or both partners. Being curious when a new treatment is made public in the press may just not be enough. To enhance the chance of success, the patient and his partner should be really longing to be sexually active again.

Most therapies depend on the patient being able and willing to put some effort in it. It may take some motivation to learn medical procedures. If proper motivation is lacking, then the therapy will certainly fail.

A success will also depend on the partner, who must want to be sexually active again. In addition, the partner must also be willing to assist in certain therapies and will need to feel comfortable with the 'hassle' needed for a proper erection.

A certain commitment is necessary to solve the erection problems. If this is lacking in one of the partners, it will have a negative effect on the success of treatment.

Erection: how does it work?

Normal and satisfying erections depend on three things:

• there must be a longing for sexual activity
• the blood vessels to the penis must be in good condition
• the nervous system controlling the erection must function normally

A normal amount of hormones is less important, and is seldom lacking. On the other hand, the male hormones play a part in the sexual longing, the libido. If the longing is therefore lacking due to a shortage of hormones, often in old age, erections are often not desired.

Erotic stimulation, through one of the five senses or from memory, will start the 'erection procedure'. The nervous system will send chemical messages to the lower abdomen and back again. These messages will ensure that the muscle fibers within the so called cavernous bodies inside the penis will relax, causing the blood vessels to enlarge, thus allowing more blood flow towards these bodies. The two parallel cylindric erectile bodies are made up of spongy tissue and are filled with blood. The cylinders will then lengthen and stand out straight, thus causing an erection of the penis. The mounting pressure within the cavernous bodies will close the blood vessels, responsible for the backflow of blood from the penis, thus ensuring that the penis will remain rigid for some time.

An erect penis contains about eight times the amount of blood as a flaccid one. As long as the sexual arousal continues, the penis will remain rigid until orgasm and/or ejaculation.

What are the causes and risks of the condition?

Thirty years ago, a man who consulted his doctor for erection problems was told that no cure was available because the problem was caused by either old age or the psyche. Since then, much research has gone into the male erection. The accumulated knowledge has resulted in the 'official' classification of causes:

• Psychological
• Physical
• Mixed - psychological and physical
• Unknown

In the majority of cases, the causes are mixed in a combination of physical and psychological factors. When a man does not succeed in having a (sustained) erection, he will strain himself to perform better next time. A failure to do so will cause further psychological problems.

A psychological cause exists if no physical cause can be found. This type of erection problem usually takes root 'overnight', because of stress at the workplace, marital problems or financial trouble. Just about any situation that rambles around in one's mind all day long, may cause erection problems. A depression may too cause bad sexual performance ('stage fright').

Apart from this, every man will encounter a period in his life when erections are not as desired. This is part of a normal life cycle and needs no treatment.

Physical erection problems can have various causes. Most experts in the field agree on the following table:

Vascular disease (blood vessels and heart) is the predominant cause of erection problems. Narrowing (arteriosclerosis) of the blood vessels, high blood pressure, high cholesterol and other vascular diseases lower the blood flow to the penis. A low blood flow in and around the heart may cause a cardiac infarct, the same problem in the brain may cause a stroke; in the penis, it causes erection problems.

Another cause of erection trouble may be venous leakage, if the veins that drain blood from the cavernous bodies in the penis do not sufficiently close during erection, thus causing blood and pressure to 'leak' out of the penis. This in turn will make it impossible to build up enough blood pressure in the cavernous bodies for a sufficient erection.

Diabetes is a major cause of erection problems. The disease can damage blood vessels and nervous tissue. Both may have an effect on erections. In case of nervous tissue damage, especially the small nerve bundles leading towards the penis, the brain may be unable to conduct enough signals to the penis for a normal erection. In addition, the small blood vessels may also be affected in diabetes, further adding to a lessening potency. About half of the male diabetics will get erection problems later in life (55 and older).

Radical pelvic surgery can also lead to erection disorders. Surgery involving the prostate, bladder or large bowel may damage the nerves that play a role in erections. External radiation therapy to this area can have the same effect.

Neurological disorders signify another possible cause. Multiple Sclerosis, Parkinson's Disease and spinal cord injuries are among those that may lead to loss of potency.

Endocrine and hormonal disorders signify an indirect cause of erection disorders. A low concentration of the male sex hormone testosterone causes a diminished libido, i.e. a lesser amount of sexual desire. A too high production of prolactin by the hypophysis, a small gland near the brain, may add to a low testosterone production and, thus, cause a lower libido. Diabetes may also be considered an endocrine disorder.

Medication may also cause erection problems as an side effect. More than 200 different types of medication fall into this category. Patients should however never change the dose of the medication on their own without consulting their physician; the medication is always prescribed for a reason, so changing the dose may prove hazardous.

Drug and other abusive use, like drinking alcohol or smoking may damage the nerves and blood vessels needed for a normal erection.

What doctor should I go to?

A few different kinds of doctors and specialists are involved in the diagnosis and treatment of erection disorders:

• General practice
• Urology
• Internal medicine
• Endocrinology
• Sexology
• Psychology

The doctor you see most may be the best one to consult for your erection disorder. If you are already seeing a urologist because of another problem, or visiting the internal medicine department because of diabetes, it would be preferable to put the problem to that doctor, because he/she will have your medical history at hand. For many men, the general practitioner may be the first to consult. If the first-choice doctor prefers not to treat you, he/she may then advise you on the choice of another.

Urologists are often consulted in case of erection disorders, especially when a physical cause is suspected. Many have 'subspecialties' on erection disorders.

If a psychological cause is suspected, then a sexologist or psychologist may be the first option when considering treatment. In many cases of erection disorders, a psychological problem is present, either from the beginning or due to 'stage fright' when it was discovered that the erection was not as granted as it was before because of a physical problem.

A visit to your doctor must be based on two questions:

• Why do I have erection problems?
• What can be done about them?

What tests can be done?

The first visit will start with an extensive medical history, including psychological and sexual aspects of your life. The doctor will ask questions about stress and fatigue, and about the relationship between you and your partner. This will probably include questions of a personal nature, but these are necessary to get an overview on the whole of your sex life, in turn necessary to determine the best possible treatment.

In order to determine the cause the doctor must make sure if there are any factors contributing to the erection problems, like diabetes, alcohol abuse, medication. Stress at work or home needs also to be evaluated.

When the medical history is complete, a physical examination will follow. This will include a rectal examination to check the prostate and an examination of the genitals, i.e. penis and testicles. In some men there might also be a curvature of the penis in erection, usually known as Peyronie's disease, which is caused by scar tissue in one or both cavernous bodies. If the curvature is serious, then this problem will need to be addressed first. Blood pressure measurements may also be necessary during the examination.

Laboratory tests will usually be done to make sure that the hormone levels are normal.

If a general practitioner, which will often be the first doctor to present the erection problems to, is unable to come to the right diagnosis, or feels to inexperienced with the subject, he will most probably refer the patient to a urologist. A urologist may decide to do additional examinations, which will make a more defined diagnosis possible. These may include a so called Rigiscan and a cavernosography/metry.

A Rigiscan is a device that measures the force of the erection and looks a bit like a small version of the devices used for blood pressure measurements. In order to be able to measure the erection, the patient is often subjected to watching erotic movies in a special, private, room. A simpler version of the Rigiscan is the 'postal stamp' method, in which a couple of postal stamps are glued together around the penis before going to sleep. A lot of men with erection problems have normal erections during sleep; every normal man has an erection a couple of times during the night. With the postal stamp method, a normal erection reveals itself because the stamps will have been torn in the morning. Since a lot of men find it a bit ridiculous to put postal stamps around their penis, a few companies are now manufacturing special strips of paper, which has the additional advantage of measuring the maximum diameter of the erect penis.

A cavernosometry is always combined with a cavernosography. This test is usually done only to exclude certain blood vessel problems, when previous therapy has failed, so it is not a 'standard test'. With a fine needle one of the cavernous bodies is punctured, so these can be filled with a special solution. This makes it possible to visualize the blood vessels leaving the cavernous bodies in order to check for leakages. Also, the amount of flow to the penis through the needle, which is needed for a sufficient erection will give information about the functioning of the blood vessels.

Treatment options

Known treatment options are (from least invasive to most invasive):

• psychotherapy or sex therapy
• medication
• hormonal therapy
• vacuum therapy
• pressure rings
• self-injection therapy
• prosthesis implantation
• vascular surgery

The choice of therapy will be governed by the cause of the erection problems. Sextherapy will be the first choice if a psychological/sexual problem is considered the main cause of the erection disorder. However, often a mix of physical and psychological causes exists, so non-invasive methods to regain erections may be used either alone or in combination with sex therapy.

The vacuum therapy and self-injection therapies are currently most widely used, because side effects are minimal and together they seem to work for most men with erection problems. Both may also be used in combination with sex therapy.

In some men, a low hormone level may cause loss of sufficient erections, but these cases are rare. If so, the hormones may be added using oral medication or injections.

Psychotherapy consists of sessions in which a psychotherapist will try to help the patient and his partner to understand what the problem is, identify stress factors and deal with them.

Sex therapy is more to the point as far as sex is concerned. Patient and partner are taught to explore each other in a sexual way and practical exercises are prescribed to lessen the tension between both partners, so as to improve their sexual relationship. These exercises may consist of sexual acts.

Medication for erection problems has been available for centuries. Erectile Dysfunction has been a problem of all times, our own not excluded.

Until recently, Yohimbin^®, extracted from the yohimbine tree, was the only one available showing to have some effect in some men, although, scientifically speaking, the effect was never considered proven. It is still used, especially if a psychological problem is suspected, to enhance libido, i.e. the sexual desire. It can be prescribed in two ways. Either the patient uses Yohimbin 5 mg 3 times daily for 4-6 weeks, or one tablet of Yohimbin is used 45 minutes before the 'scheduled' intercourse. The results seem to be about the same: Yohimbin helps in about 30% of cases. The erection disorder may return after the medication is stopped. side effects include headaches, sweating, dizziness and nausea. Men suffering from stomach ulcers or high blood pressure better avoid Yohimbin.

Recently, Viagra^® was introduced by a company called Pfizer. Viagra is an inhibitor of the enzyme phosphodiesterase and acts by narrowing the exit of the blood from the cavernous bodies, thus enhancing erection. The tablets have been released on the market a short time ago, so extensive, longstanding trials are not available yet, but it was shown to work in 70-80 percent of men with erection problems. The problem is that we don't know yet in which cases it works and when it doesn't. The tablets are to be taken if an erection is desired and Viagra will then enhance erections if an appropriate sexual desire is present. The effect of Viagra will commence after about 45 minutes and will last for 3-4 hours. Possible side effects include headaches, dizziness and a blue discoloration of vision, but maybe more will be discovered when Viagra has been used by more men for a longer period. Viagra counteracts the effects of nitrate medication, used by many patients with heart trouble; the combination of Viagra and nitrates may prove hazardous to the heart.

Another, somewhat less non-invasive form of medication is Muse^®, which consists of a very small tablet to be introduced into the urethra using a special tube-like device. Muse consists of prostaglandin, a hormone with a limited and largely unknown function, which is capable of narrowing the blood vessels exiting the cavernous bodies, the same way as Viagra does. It works in over fifty percent of cases, but is rather expensive. Adverse affects include penile pain and irritation of the urethra.

Hormonal treatment is only indicated in cases of a serious shortage of the male sex hormone testosterone. This may cause a loss of sexual appetite and therefore erection problems. In those cases, testosterone should be administered, either by injection, tablets or skin pads. Less than 4 percent of men have a shortage of hormones and may benefit from this therapy. Side effects can be prostate enlargement, liver damage and fluid retention in the body; patients with liver problems, heart disease, kidney problems or prostate cancer should refrain from using additional male sex hormones.

The vacuum therapy is a non-invasive and safe method to regain a certain amount of erection capability. The device used consists of a clear tube made of plastic, which can be placed over the penis. The tube is put into place before or during love making. When properly placed, it completely surrounds the penis, shutting it off from outside air. A small pump is then used to create a vacuum around the penis, thus drawing blood to the cavernous bodies and inducing an erection. When erection is complete, an elastic ring is then pushed off the cylinder around the penis, ensuring that the blood will not flow out again once the vacuum is released.

This method will work in about 90 percent of men, even in cases where vascular problems exist and in some cases after removal of a prosthesis implant. On the other hand, many men cease to use the device, because it is a rather 'artificial' method of obtaining an erection. The erection only takes place in the outside portion of the penis, while the remainder of the cavernous bodies remain flaccid; this may cause the penis to be unstable and difficult to steer. The penis may feel a bit colder than expected due to a restrained blood flow. The elastic ring may remain in place for about 30 minutes without harming the penis. In some men a slight bleeding of the superficial blood vessels may result either from creating a vacuum too quickly or leaving the ring on too long. These side effects are not damaging to the penis and no treatment is necessary. Some technical insight is handy, while men with sickelcell anemia, leukemia or clotting diseases should not use the device. Many men are quite happy with its use.

The pressure rings may also be used on their own, in cases where sustaining an erection is the problem, not getting one. In those cases, the ring is placed at the base of the penis when the erection is complete, making sure that the blood won't be able to flow out and keeping the penis rigid. Like the vacuum therapy, the ring may remain in place for 30 minutes.

Self-injection therapy consists of injecting a solution into the penis to achieve an erection. In the 80's it was found that certain medication could induce a sustained erection for some time when injected directly into the cavernous bodies. Since the medication starts working within 15-20 minutes, it should be injected by the patients themselves or their partners. Fortunately, this is easily learned.

Different kinds of medication can be used to achieve this. Papaverin was the first to be used; nowadays it is used in a combination with phentolamine (Androskat^®), leading to a more stable erection. Prostaglandin (Caverject^®) is also used in this regard. In all cases, the injection therapy works by narrowing the blood vessels that drain the blood from the cavernous bodies, in much the same way Viagra, mentioned above, does.

The injection method is taught by a urologist, who must first figure out the right dose to inject. The target is to cause an hour's worth of erection, which may then differ somewhat, since erotic stimulation usually lengthens the effect. As with the vacuum device, the erection won't stop after ejaculation or orgasm. The method works in about 70 percent of men, provided that the blood vessels to the penis are functioning properly and there is no venous leakage. The method may be used frequently, albeit with intervals of at least three days.

Side effects include pain in the penis, especially when prostaglandin is used, and a chance on priapism, a prolonged and painful erection, which is rare and usually only happens in the beginning. The erection should not last longer than 4 hours, because the penis may be permanently damaged with a longstanding erection. With this method, some handiness with needles and syringes is necessary, while some men are just outright scared to use the needles on themselves. For this reason, injection devices have been developed, which take over much of the work.

A penile implant of a penile prosthesis is one of several options available for the treatment of impotence. The penis consists of three hollow tubes running along the length of the shaft. One of these, the urethra, runs along the bottom of the penis and brings urine from the bladder out through the end of the penis. The other two matched tubes running side-by-side on the top of the penis are constructed much like an automobile tire with an outer tube and an inner tube. The erection is created by the two inner tubes filling and pushing against the outer tubes, much like a tire that is inflated with air.

One of the treatment options for erectile dysfunction is the placement of prosthetic inner tubes within the penis to mimic the inflation process and create an erection. Penile implants were first used in the 1950s, and since then further advances have occurred. Different types of prostheses have been developed, and hundreds of thousands of men throughout the world have been successfully treated with penile implants.

Today there are three types of penile prostheses: the semi-rigid implant, the inflatable implant and a self-contained inflatable implant. 

Semi-rigid implants are paired, silicone-covered, malleable (bendable) metal rods. The semi-rigid prosthesis allows the penis to be rigid enough for penetration, but the malleable rods allow it to be flexible enough to allow concealment in a curved position. It is the simplest of all prostheses and has the least chance of mechanical failure. It is also the simplest to place. 

One major limitation is that the penis is always semi-erect. Even thought it can bend, concealment is a potential problem when wearing some types of clothing. Another disadvantage is that the prosthesis does not inflate, so the erection achieved is only from the size and rigidity of the prosthesis.

Inflatable prostheses are the most natural of the implants. These are soft, paired inner tubes made of silicone or bioflex, which are inert plastics. The inner tubes are filled with a solution that comes from a small reservoir placed under the muscles of the abdomen. A pump is used to transfer the fluid from the reservoir to the penile cylinders (inner tubes). The more fluid that is pumped into the inner tubes, the firmer and larger the erection. When the erection is no longer desired, the fluid returns to the reservoir, leaving the penis soft and pliable. 

A major advantage of an inflatable penile implant is a more natural erection with total patient control, both in the amount of fluid that is put into the penis and the time the erection is desired. The erection will last indefinitely until the patient transfers the fluid back into the reservoir. One major disadvantage is that the surgical implantation is a little more complicated than a simple semi-rigid implant. Also, with the multiple parts there is a higher chance of mechanical failure which might require revision or repair. Many of the companies do have insurance policies to cover part or all of the costs of the prosthesis replacement but not the surgical or hospital fees. 

Self-contained inflatable implants are paired silicone cylinders which have a pump at the very tip of the prosthesis, along with a reservoir within the shaft that transfers fluid in such a way that the cylinder becomes firm. 

The advantage of this type of prosthesis is that the surgery is somewhat simpler than the multicomponent prosthesis.

The major disadvantage is that the inflatable portion of it does not significantly increase the girth of the penis. It is also not as soft or as easily concealed as the multicomponent implant when deflated.

Implants are effective in treating almost every cause of impotence. There is over a 90 percent success rate when both partners are informed of the nature and limitations of the prosthesis. Prostheses require no further treatment after implantation, and there is no external equipment which might have negative connotations to the partner. No medicines or injections are needed, and once the prosthesis is placed and functioning there are no further costs. The newer prostheses are very reliable and the chance of mechanical failure is very low, in the range of 2 to 4 percent per year.

Once an implant has been placed, natural erections usually no longer occur. If the prostheses were later removed, the normal erections would be unlikely to return. There is a small chance of infection, which would require removal of the prosthesis. Some patients can develop surgical complications or anesthetic complications. Occasionally, a patient will notice numbness at the head of his penis, and intercourse can be uncomfortable. Because the erection is not caused by increased blood flow to the penis, the head of the penis is not part of the erection, and this softness may be bothersome to some patients.

Recently, the safety of silicone and silicone products such as silastic have been questioned. Breast prostheses using liquid or gel forms of silicone were removed from the market by the FDA. Concerns raised were the inflammatory responses to this type of silicone, which included pain, scarring and disfigurement. In addition, possible associations were raised between silicone and the development of immune disorders, such as rheumatoid arthritis, and a possible association to an increased development of cancer. It is noteworthy that the solid silicone breast implants that are filled with water were not removed from usage. In May 1994 a class action suit was filed against the major manufacturer of penile prostheses, claiming many of these same issues. The penile prostheses are all of the solid variety and use water as a filling. Most observers feel the suit is without basis, but of course, only time will tell, and there needs to be more research and follow-up. Solid silicone products are used extensively in medicine and include cardiac pacemakers and brain shunts. Thousands and thousands of implants of all types have been used for years with very few and predictable risks and side effects.

Some insurance policies will cover the cost of prostheses; this can be established through our business office. Patients who are considering a prosthesis should be aware that other types of therapy might be available, including vacuum devices and self-injection therapy.

Vascular surgery may consist of constructing a bypass, as in heart surgery, to improve the blood flow towards the penis. Nowadays, this kind of surgery is still rarely done, because less than 1 percent of men may benefit, the failure rate is very high and other treatment options, like implantable prostheses, offer better prospects.

In some men, venous leakage is a major contributing factor in the erection disorder. The leak causes the blood to drain from the penis too quickly, thus making it impossible to keep up the blood pressure inside the cavernous bodies, leading to a loss of erections. It may then be an option to try to locate the vein that is causing the leak and closing it using a suture. In many cases, however, there is not just one vein responsible, but many, causing the surgery to fail after some time, when the other leaking blood vessels start leaking as much as the sutured one did before.

Which treatment?

In order to make a right decision about the type of treatment, several factors need to be taken into account:

The opinion of the partner about the erection disorder and possible treatment options may be just as important as that of the patient himself. A lot of the therapies mentioned also involve the partner, since some 'artificial' effort is needed to achieve an erection. Apart from that, some patients think that a normal erection may be paramount in the partner's view for a normal marital life, while the partner may think that erections are not that important at all.

The frequency of the sexual activities. The choice of therapy may be different if erections need to be achieved once a month or many times a week.

Some therapies will change your life. A semi rigid prosthesis will probably make it less desirable to reveal a bend but erect penis in swimming trousers, so swimming will be impossible after surgery. In case of vacuum therapy or injection therapy, you will need to take everything with you when you go on holiday.

Some therapies, like the implants, cause permanent damage to the penis, which cannot be reversed. As a first choice therapy, these options are therefore less desirable. Apart from that, if the future should bring forth a new therapy, for which intact cavernous bodies are necessary, previous implant surgery would unfortunately render it useless.

Financial cost. Some therapies are covered by insurance, others are not, or will only be partly reimbursed. Some therapies involve costs on a regular basis, like medication, while others, like the vacuum device or surgery, are more or less one-time events - not including follow-up visits to the hospital an malfunction of the devices.

The effectiveness and safety of the treatment. Some devices and medication have been 'on the market' for only a short period and long-term effects and safety is yet unknown.

Treatment overview