Treatment for erectile dysfunction depends on whether the problem is caused by psychological or physical factors, or a combination of these.
Even if erectile dysfunction has a physical cause, it often has adverse psychological effects that make the problem worse and treatment more complicated.
The following treatments have a reasonable chance of success:
• Improving lifestyle, giving up unhealthy habits/behaviour
• Treatment to modify reversible causes
• Change in current medication, e.g. blood pressure medication
• Hormone replacement with male hormone testosterone
• Corrective surgery in case of penile curvature (Peyronie’s disease) and trauma
• Oral treatment
• Vacuum constriction devices
• Psychosexual therapy
• Intra-cavernosal injection therapy
• Surgery (prosthesis)
The least invasive treatment should be considered first. Non-surgical treatments work for 60 to 70% of men and may make surgery unnecessary.
Although treatments like injections are effective more than 80% of the time, up to 60% of men may eventually drop out of treatment. Sometimes, once men can get an erection again, they realise they have overestimated its importance in their relationships. They may decide that the nuisance or cost of the treatment is not worth the effort.
Erectile dysfunction, whether caused by blood vessels (vascular), hormonal, nervous system, or psychological problems, can be treated with a range of prescription drug therapies.
• Increase of blood flow into the penis (erection-producing medications)
• Reduction of performance anxiety by ensuring successful erections
• Adjustment or replacement of medication taken for other conditions. If such drugs affect your erections, your doctor may review them in an attempt to reduce side effects. Never adjust your dosage without consulting your doctor.
• Correction of abnormal hormone levels through testosterone replacement therapy. Abnormal hormone levels, however, are a rare cause of erection problems.
Vacuum erection apparatus
This is a vacuum pump that sucks blood into the penis and then a constriction band is placed around the base to prevent outflow of blood. Intercourse can then take place. This is often a difficult process to get used to, but some men are extremely happy with it. It is safe, provided the constriction band is not left on for longer than 60 minutes.
Combination injection therapy is available at clinics and some pharmacies. Penile injections can be dangerous if incorrectly administered. The technique and dosing must be supervised by a properly trained professional. Complications include bleeding, bruising, infection and a prolonged painful erection (priapism), which can permanently damage the penis.
Surgery for erection problems is chosen when non-surgical treatments and psychotherapy have not been effective. Surgical approaches include penile implants, which can be very successful and produce satisfactory results in 80 to 90% of men, and repairs to the vascular system in the penis – as well as surgery to correct penile curvature (Peyronie’s disease, which is a painful condition of the penis which results in deformity or curvature of the penile shaft, making penetration impossible). Peyronie’s may also have a direct impact on erectile function.
• A bendable rod can be implanted into the penis. This makes the penis rigid enough to have sex, yet leaves it flexible enough to be tucked away in your pants unobtrusively.
• A cylinder may be implanted that extends when fluid from a reservoir tucked under the abdominal muscle is pumped into it.
This is done by manually squeezing a small pump that is connected to the reservoir and implanted into the scrotum. While implants mean that you can avoid using drugs, they do require surgery and involve all the risks normally related to surgery: adverse reaction to anaesthesia, possible blood loss and infection. About 4% of implants have had to be removed as a result of infection.
In five to 10% of cases there may be mechanical failure of the device, in which case a second operation is necessary for repair or removal. Urologists perform most penile implants and costs can range from about R20 000 to more than R60 000, depending on the type of implant. The results of repeat surgery are unfortunately often inferior to the primary procedure.
An intracavernosal injection (into the body of the penis) sounds painful, but is actually not. It will produce an erection for 20-30 minutes or longer. Different drugs can be used, namely Prostaglandin, Paraverine or Fentolamine. Prostaglandin is the most widely used and marketed as Caverject.
Surgery to repair or remove blood vessels of the penis may be appropriate in the case of a young man who suffers erectile dysfunction as a result of injury, such as a car accident. In older men, it tends to be more difficult to repair damaged blood vessels, as damage may be extensive. These specialised blood vessel repair (revascularisation) operations should only be done by specially trained urologic surgeons.
Reduction of venous outflow can sometimes improve erections. This condition is very rare and the operation will only be performed after proper workup using blood flow evaluations.
Reviewed by Dr Dave Bowden MBBCh (Wits), FCS (SA) Urol. Specialist Urologist in private practice, Christiaan Barnard Memorial Hospital, Cape Town. (February 2015)