Most
physicians suggest that treatments proceed from least
to most invasive. 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 regain sexual function.
Cutting
back on any drugs with harmful side effects is
considered next. For example, drugs for high blood pressure work in
different
ways. If you think a particular drug is causing problems with erection,
tell
your doctor and ask whether you can try a different class of blood
pressure
medicine.
Psychotherapy
and behavior modifications in selected
patients are considered next if indicated, followed by oral or locally
injected
drugs, vacuum devices, and surgically implanted devices. In rare cases,
surgery
involving veins or arteries may be considered.
Psychotherapy
Experts often treat psychologically based ED using techniques that
decrease the
anxiety associated with intercourse. The patient's partner can help
with the
techniques, which include gradual development of intimacy and
stimulation. Such
techniques also can help relieve 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
inserted into the urethra 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 for safety
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 of nitric oxide, a
chemical
that relaxes smooth muscles in the penis during sexual stimulation and
allows
increased blood flow.
While oral
medicines improve the response to sexual
stimulation, they do not trigger an automatic erection as injections
do. The
recommended dose for Viagra is 50 mg, and the physician may adjust this
dose to
100 mg or 25 mg, depending on the patient. The recommended dose for
either
Levitra or Cialis is 10 mg, and the physician may adjust this dose to
20 mg if
10 mg is insufficient. A lower dose of 5 mg is available for patients
who take
other medicines or have conditions that may decrease the body's ability
to use
the drug. Levitra is also available in a 2.5 mg dose.
None of
these PDE inhibitors should be used more than once a
day. Men who take nitrate-based drugs such as nitroglycerin for heart
problems
should not use either drug because the combination can cause a sudden
drop in
blood pressure. Also, tell your doctor if you take any drugs called
alpha-blockers, which are used to treat prostate enlargement or high
blood
pressure. Your doctor may need to adjust your ED prescription. Taking a
PDE inhibitor
and an alpha-blocker at the same time (within 4 hours) can cause a
sudden drop
in blood pressure.
Oral testosterone can
reduce ED in some men with low levels
of natural testosterone, but it is often ineffective and may cause
liver
damage. Patients also have claimed that other oral drugs—including
yohimbine
hydrochloride, dopamine and serotonin agonists, and trazodone—are
effective,
but the results of scientific studies to substantiate these claims have
been
inconsistent. Improvements observed following use of these drugs may be
examples of the placebo effect, that is, a change that results simply
from the
patient's believing that an improvement will occur.
Many men
achieve stronger erections by injecting drugs into
the penis, causing it to become engorged with blood. Drugs such as
papaverine
hydrochloride, phentolamine, and alprostadil (marketed as Caverject)
widen
blood vessels. These drugs may create unwanted side effects, however,
including
persistent erection (known as priapism) and scarring. Nitroglycerin, a
muscle
relaxant, can sometimes enhance erection when rubbed on the penis.
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. The most common side
effects are
aching in the penis, testicles, and area between the penis and rectum;
warmth
or burning sensation in the urethra; redness from increased blood flow
to the
penis; and minor urethral bleeding or spotting.
Research
on drugs for treating ED is expanding rapidly. Patients
should ask their doctor about the latest advances.
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 semirigid rubber sheath that
is
placed on the penis and remains there after erection is attained and
during
intercourse.
Surgery
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.
Implanted devices,
known as prostheses, can restore erection
in many men with ED. Possible problems with implants include mechanical
breakdown and infection, although mechanical problems have diminished
in recent
years because of technological advances.
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 consist of paired cylinders, which are
surgically inserted inside the penis and can be expanded using
pressurized
fluid (see figure 3). 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.
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