Erectile Dysfunction

There are currently approximately 30 million men in the US suffering from ED, and it is expected that the worldwide prevalence of ED will surpass 300 million men by 2025. ED often has a profound effect on quality of life and is often associated with other medical conditions, including diabetes, hypertension, hyperlipidemia, obesity, smoking, and coronary artery disease. In fact, ED can serve as an early indicator underlying cardiac disease in an otherwise asymptomatic man. ED is a progressive disorder that increases with age. Likewise, additional risk factors may increase the severity of ED, for example, the presence of diabetes approximately doubles the risk of ED. Risk factors for ED include depression, hypertension, hyperlipidemia, and smoking, and the presence of more than one risk factor greatly increases the likelihood of ED. Fortunately, multiple treatment options are available, and almost all men can be successfully treated to restore sexual function.

In reality, most cases of ED are multifactorial. Evaluation of the man with ED involves a complete history, including medical conditions, medications, and a complete physical examination. Basic lab tests may include serum testosterone, creatinine, CBC, Hemoglobin A1C, and lipid profile. Validated questionnaires, such as the International Index of Erectile Function (IIEF), can be utilized for objective measurement of patient-reported erectile function. For complex patients, further tests can be utilized to evaluate penile blood flow. These include intracavernosal injection of medications in order to produce an erection, which can be combined with penile Doppler ultrasound to measure arterial flow and venous leak within the penis during erection.

If the patient is considered high risk for a cardiac event, then formal cardiac evaluation is warranted prior to beginning therapy. Lifestyle modifications are first-line treatment options. These include weight loss, tobacco cessation, and medical management of any associated conditions (HTN, DM, dyslipidemia). Additionally, any medications that may contribute to ED should be altered, if possible (beta blockers, diuretics).

Medical treatment of ED began with intracavernosal injection agents in the 1980’s. Medications include prostaglandin E1, papaverine, and phentolamine. Later in the 1980’s, intraurethral suppositories of alprostadil were approved (MUSE). In 1998, sildenafil was approved as the first phosphodiesterase type 5 inhibitor and revolutionized ED therapy. Since then, tadalafil and vardenafil have been approved in the US. These medications increase the erectile response to normal sexual stimulation. Common side effects include a headache, flushing, nasal congestion, and vision changes (blue tint). These are all mild and temporary.

Surgical treatment of ED is for men who have failed conservative measures. Placement of an inflatable penile prosthesis (IPP) is a very important consideration for patients who have failed oral therapy or who don’t want to continue injection therapy. An IPP is the most common procedure performed for ED with very high success and satisfaction rates. Developed in 1973, penile implants have now been on the market for over 40 years. IPP is the best long-term solution for severe ED, as the erection feels natural to the patient and his partner, it functions anytime one chooses and is maintained as long as desired. Covered by Medicare and most private insurance carriers, an IPP is an outpatient operative done with general or spinal anesthesia. Performed through a small hidden scrotal incision, a penile implant is invisible in your body while producing a completely natural erection and sexual experience. Sensation, orgasm, ejaculation, and urination are unaffected. The IPP has the highest success rate of all the treatments for Peyronie’s disease and erectile dysfunction, and over 90% of men and their partners are satisfied after the procedure.