There is a range of ED treatments and interventions available, including:
- Oral medication (such as Viagra®)
- Transurethral delivery of alprostadil (MUSE®)
- Vacuum Erection Devices (such as the VED®)
- Compounded drugs inserted into the penis
Dr. Alarcon typically suggests that treatment proceed along a path moving from least invasive (like oral medications) to the most invasive (like penile implants). It’s important that you talk to Dr. Alarcon about which ED treatment or combination of treatments is right for you.
Oral medications for erectile dysfunction include, sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). All of these medications work to relax the muscles in the penis, allowing blood to rapidly flow in. On average, the drugs take about an hour to begin working. Sildenafil and vardenafil tend to last for about 8 hours while tadalafil can last up to 36 hours. While oral medications work for some people they are not effective for everyone. Examples include men who you have cardiovascular disease or take nitrates for chest pain, men who are diabetic or take high blood pressure medication, men who have had a radical prostatectomy or other pelvic surgery. Additionally, oral medications take time to work and can have side effects such as headaches, flushing, upset stomach and blurred vision. Finally they are expensive and must be continually replaced.
Injection Therapy and MUSE
Local medication delivered directly into the penis may be a good choice for men with ED due to neurogenic (nerve) damage, low hormone levels, or psychogenic causes. It is also a good option for men who can’t take oral medication. There are two delivery systems: injections and urethral suppositories, also called MUSE (Medicated Urethral System for Erection)… Both deliver the a drug or combination of drugs that relax smooth muscle tissue to allow sufficient blood flow for erection. The most common approved drug is alprostadil (a form of prostaglandin). Other effective drug combinations may include various formulations of papaverine, phentolamine, and protastaglandin.
Injections for ED are given directly into the penis with a very fine-gauge needle. The idea may pose a psychological hurdle, but the method is virtually painless and is easily learned under supervision of a clinical professional. Erection begins in 5-20 minutes and lasts 30-90 minutes. They may be prescribed for penile rehabilitation after prostate cancer surgery as well as for chronic ED from other causes. However, in cases where the blood supply is compromised, or there is venous leakage whereby an erection can’t be sustained, injections are unlikely to help.
Injection Therapy Disadvantages
- Psychological barrier for some men
- More invasive than MUSE
- Need for refrigeration
- Learning proper use and disposal of needles
- Expensive (these drugs are typically not covered by insurance)
- Unlikely to be effective for patients with venous leak
- Possible inner scarring/curvature if improperly administered
Injection Therapy Advantages
- High rates of effectiveness and consistency
- Can be used daily, but not more than once in a 24-hour period
- May also be used with a VED
Injection therapy includes possible temporary bruise at injection site; risk of scarring within the penis leading to curvature
MUSE (Medicated Urethral System for Erection)
The MUSE treatment involves using an applicator to insert a very small, medicated suppository into the urethra at the tip of the penis. Effectiveness ranges from 30-58% for all types of ED, and may not be equally effective each time a man uses it. Erection begins in 5-10 minutes and usually lasts for 30 to 60 minutes. It can be used daily, and may be prescribed for penile rehabilitation.
- Applicator makes insertion easy
- May be more acceptable for some men than injections
- May be used with a VED for penile rehabilitation
- Can be used daily, but never more than twice in a 24-hour period
- Less effective than injections and results may be inconsistent
- At higher doses, men may experience pain or burning
- Expensive (MUSE is not typically covered by insurance)
Side effects are relatively rare for both MUSE and injections. However, never use either except as instructed, and never increase the dose or frequency without Dr. Alarcon’s supervision. There is a risk of an erection lasting too long (priapism). IMPORTANT: Any erection that lasts beyond 4 hours requires emergency treatment.
Among the wide range of treatments for ED (e.g. Oral Drugs, Injections and Penile Implants), Vacuum Erection Device (VED) Therapy remains the safest, most effective and non-invasive treatment available.
VED therapy is the only natural, drug free treatment for erectile dysfunction proven over 90% effective. VED therapy even works for diabetic and high blood pressure patients. Additionally, VED therapy is not associated with side effects common to oral medications. Best of all studies have shown that both patients and their partners report a high level of satisfaction with VED therapy. Benefits of VED include:
- No surgery
- No serious side effects
- Long term satisfaction
- Easy to learn and easy to use
- For men who have had prostate cancer surgery, some clinical studies, and many leading Urologists, encourage daily use of Vacuum Therapy to help maintain penile health and restore adequate blood flow to the penis.
- Works with all other ED treatment options
- Works as a stand alone treatment or in combination with other treatments
- Medicare coverage
About half of men with erectile dysfunction choose VED therapy. Many choose to VED therapy because they take blood pressure medications or nitrates, which can be contraindicated with the leading PDE5 inhibitors (Viagra, Cialis, etc.). Others chose VED therapy because oral medications are ineffective after prostate surgery, because the nerves ending to the prostate are in a state of shock or injury. Some people use vacuum erection devices in conjunction with oral medications (Viagra, Cialis, etc.) to help enhance the effectiveness of such medications. Vacuum therapy can be used as an exercise to prevent atrophy (muscle shrinkage) in the penis. Men typically have 3-5 nocturnal (night-time) erections during sleep. If a person has ED, these natural erections do not occur. This can result in the penis shrinking in both length and circumference. Vacuum therapy allows for men to stretch the penis providing arterial blood flow to the penis to help maintain length and size.
There are some risks to vacuum therapy. Some of these risks include: potential pain, bruising, numbness, or a cold sensation in the penis. Some men find the tension band irritating and may prevent ejaculation.
A penile implant is a device that is surgically placed within the penis. There are two types: a semi-rigid or malleable rod, or an inflatable (with fluid) cylinder with additional components to create the inflation.
In the first instance, a pair of semi-rigid or malleable rods is placed side by side in the penis chambers (soft expandable chambers – see section on Anatomy). In the second type, the hollow cylinders will be placed in the penis, while the other components (a fluid reservoir, a pump to transfer the fluid from the reservoir into the cylinders) will be placed in the abdomen and/or scrotum. Candidates for penile implants include men for whom all other treatment options have been unsatisfactory. In the case of post-prostatectomy patients, most patients (especially nerve-sparing patients) will be expected to wait 12-18 months after treatment to give sufficient time for erectile function to either return, or respond to less invasive therapies.
Candidates may be expected to use other therapies, especially a VED, prior to implant in order to stretch the penis to allow the largest possible implant. It’s important to note that the penis can never be stretched beyond the capacity a man is born with, but treatment for prostate cancer or chronic ED can result in size reduction over time, hence the recommendation for pre-implant size enhancement. Patients and their partners who ultimately decide on implants report high degrees of satisfaction, since the erections obtained with an implant take only seconds to employ and are quite natural in appearance and feel, especially with the inflatable device.
- Reliable erection that can be created on demand
- One-time insertion
- 85% of patients have the same implant after 10 years
- Risk of infection
Possibility of mechanical breakdown; possibility of the device eroding through tissue, or migrating out of location; such side effects require surgery to correct.
A possible cause of ED is low hormone levels, or hypogonadism. This basically means low testosterone, the primary male hormone, and ED can be a symptom of this condition. Hypgonadism may be related to aging, but does not always result in ED. There may be other symptoms including loss of libido (sex drive), depression, fat gain, and reduced muscle and bone mass. Hypogonadism is the least common single source of ED, but when other causes have been ruled out, a simple blood test can determine if this is an underlying problem. There are complex reasons why androgen levels might drop, so other tests may be ordered. It may take weeks or months to determine the problem, since hormone levels tend to fluctuate. There is conflicting clinical evidence that simply raising hormone levels will reverse ED. Not all low-testosterone patients report improvement when given supplementation. If testosterone supplementation is indicated, Dr. Alarcon will suggest the best preparation for you: oral, patches, pellets, creams, gels, or shots. Long term testosterone supplementation creates other health problems. Supplements may be prescribed for a trial period with careful tracking of results. If ED does not improve, supplements will be stopped.
- If ED is caused by low androgen, supplements may resolve the problem
- All forms of supplements are easy to use
- Possible lengthy diagnostic process
- May not resolve ED
- Long term use may create other health problems
Risk of side effects varies with the type and duration of supplementation; may include acne, hair loss, gum tenderness or mouth irritation; and fatigue. Long term use may reduce testicle size and affect the liver, kidney and prostate.
Erectile Dysfunction – Further Reading
- Questions & Answers about Erectile Dysfunction
- Medications & Devices in ED Treatments
- Treating Erectile Dysfunction with Penile Implant (Penile Prosthesis)
- Causes and Treatment for Male Impotence
- Coloplast Titan Penile Implant Surgery
- A Four-Minute Video Can Save Your (Sex) Life
- Erectile Dysfunction Overview
- Profile: A Man Who Chose A Penile Implant
- Overcoming Erectile Dysfunction Surgically
- Exercise and Men Sexual Health
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