Erectile dysfunction (ED) is defined as the inability to have or maintain an erection hard enough or long enough for sexual intercourse. Another less common form of make sexual dysfunction is premature ejaculation. This is when ejaculation happens before the erection is complete.
ED is a common condition that affects at least 12 millions of American males between ages of 40-79. It can happen at any age, including 20’s, but the most common age range is 40-79. Some expert believe that the numbers are much larger than reported. This is because most men do not like to talk about their sexual disabilities or see a doctor for it. Yet erectile dysfunction can be a treatable condition. As is the case for all medical conditions, the sooner you start the treatment, the better the outcome.
How does erection happen:
In order to understand how to treat the ED we have to understand what went wrong and where.
Let’s examine normal physiology of erection. It is controlled by 4 factors:
- Hormones (Particularly Testosterone)
- Nerves
- Arteries
- Veins
Assuming that the hormone levels are normal, first there is a sexual stimulation. This stimulation causes certain brain circuits to stimulate the Autonomic Nervous system. This in turn causes the arteries of the penis to dilate and the veins of the penis to constrict. This way blood rushes into the penile body through the Arteries and ends up staying there because the veins are constricted and do not drain the blood. As there is more stimulation, there is more arterial blood coming in and more venous constriction. Thereby the erection becomes stronger. Once ejaculation happens, the Autonomic nervous system is inhibited. The arteries constrict not letting any more blood in. The Veins dilate draining the blood that is pooled in the penile body. Thus, the penis goes back to the relaxed state.
Erectile dysfunction can happen if any of these steps are altered:
- If there is hormonal imbalance, then the normal stimulations do not happen. Low testosterone is the most common. However, the ratio of different hormones matters as well. For example, one can have a normal Testosterone but high Estrogen and that can cause issues as well.
- Nerves lose their sensitivity over time. The nerves throughout our body become less sensitive to stimulations with aging. Therefore, the same sexual stimulus that worked when we were a teenager or in 20’s, may not work as well. This particularly happens to the nerves in the glans of the penis.
- Arterial pressure may not be enough to get blood into the penile body on time. This problem happens with cholesterol plaques and other arterial problems. It is very similar to what happens to the arteries of the heart or brain leading to heart attack or stroke. Smoking, high blood pressure, Diabetes, poor eating habits are some of the risk factors.
- Penile veins cannot constrict enough to let the blood pool and cause the erection. This phenomenon is called leaky vein and it is more common cause of ED. This is usually due to weakening of small muscles around the veins, poor nerve communication between the autonomic nerves and the veins of the penis. This goes back to nerves losing their sensitivity over time.
Treatments:
The available treatments so far have been limited and help some patients and not others. Overall there are several treatment options. These include Medications, Pumps, implants, and Biologic treatment which is the latest and has changed the way we approach and treat erectile dysfunction.
a. Medication: These are a family of medication called PDE-5 (Phosphodiesterase-5) inhibitors. The most famous member of this family is Viagra (Sildenafil). Others are Levitra (Vardenafil); Cialis (Tadalafil), and Stendra (Avanafil).
These medications increase the arterial blood flow and pressure into the penis. Therefore, it works better for arterial problems but not as well for Neurogenic or Venous problems.
Another issue is that it takes any pill takes about 45 minutes to get absorbed and start working. Therefore, the patient has to take the pill and wait 45 minutes before they can have an erection and sexual intercourse.
Another medication is an injectable form which works in a similar way as the pills. This is Edex (Alprostadil). It is a Prostaglandin E1 molecule. It increases arterial blood flow into the penis. It is injected by the patient into his penis when ready for intercourse. This method works much faster than pill. However, many people do not feel comfortable self-injecting into their penis.
b. Penis Pump: There are many different makes and models of pumps. All of them are basically a vacuum, battery operated, which increases the blood flow to the penis by simply applying vacuum.
Using this device needs extreme care and caution. Applying too much pressure can cause penile fracture and/or Penile trauma leading to scarring of the corpus cavernosum of the penis. This causes a curved erection which is known as Peyroni’s disease, which we will talk about in more detail in other sections.
c. Penile Implants: Two parallel silicon tubes are surgically implanted into the corpus cavernosum of the penis. One on each side. These tubes are connected to the saline reservoir implanted in the pelvic area and a manual balloon pump implanted in the scrotum. When erection is desired the balloon inside the scrotum is pumped and the saline is directed into the silicon tubes, creating an erection. There is a release valve just above the scrotal pump which is pressed in order to reverse the erection.
The draw back to this method is that it is a rather big surgery. At times pumping and releasing the saline can be painful and inconvenient. Also, it does not address nerve insensitivity and it may even cause more nerve insensitivity because some nerves are cut during the surgery. All that being said if everything else fails, implant may be the treatment of choice. However, all other options have to be explored before surgical intervention.
d. Biological (regenerative) treatment: This is latest development in sexual dysfunction care. With this method, in most instances, we use patient’s own body to heal itself. In doing so we are treating the underlying cause and restoring the natural and normal erection function.
Depending on what is the cause of the ED, patient is given the choice of what biologics and what methods to use. Most patients need one treatment regimen. However, it is recommended to repeat the treatment once a year or so to prevent recurrence.
First: proper diagnosis is done through ultrasound and measuring different aspects of the penile blood flow. This way we know more exactly what we are treating.
Second: Shock wave therapy is applied to the penis in order to break any plaque or scars that have formed over the years and prevent proper blood flow. Shock wave therapy is a nonpainful method where high frequency ultrasound wave is applied to the region of the body being treated.
Third: Local anesthesia is applied to the base of the penis. Then the biologic treatment of choice is injected into the penile shaft into Corpus Cavernosum and the glans.
Patient is instructed to use a penile pump daily for a few weeks in order to increase the blood flow. This way the injected biologic stimulates new arterial growth known as angiogenesis.
Needless to say, that comprehensive hormonal workup should be done. Also, patient should stop smoking, eat healthier, exercise more frequently, and control their blood pressure or diabetes better in order to remove the offending agents and decrease the risk factors.
The advantages of Biologic treatment:
- It virtually has no side effects
- It is completely natural
- It addresses all 3 aspects of the erection pathway.
It forms new arteries (Angiogenesis) so that the blood flow is increased. It strengthens the venous muscles and walls so that there is no “leaky vein”. It helps regenerate new nerve endings, thus increasing the sensitivity.
On top of it all, patient is always ready for intercourse as it presents. They don’t have to wait for a pill to start working, inject their penis, or pump saline into the penile implant.