Erectile Dysfunction Causes & Treatments
What are the main causes of ED?
There are multiple causes of ED, the ones that have been proven are listed below. When the conditions listed in bold are addressed they may improve ED.
- Hormonal/Low Testosterone
- Obesity (being overweight)
- Heart disease
- Blood vessel disease
- Peyronie’s Disease (add link)
- Smoking tobacco
- Prostate cancer treatment eg prostatectomy, radiation
- Metabolic Syndrome
- Blood pressure/cholesterol
- Spinal Cord Injury, Neurologic Disease
- Kidney failure
- BPH/LUTS (add link)
How is ED diagnosed?
An assessment of a man’s health, medical conditions, medications and lifestyle will be performed. The impact of ED on the individual and couple will also be assessed via questionnaire. A focused physical examination is mandatory and prostate cancer screening will be discussed when appropriate. Blood tests may be performed if a hormonal issue is suspected. Imaging tests may be used to check for structural abnormalities and blood flow in select cases. The results of these tests will help your doctor determine the best treatment options.
Dr. Shridharani recommends that individuals bring their partner to the consultation if one exists and the man with ED is comfortable doing so. He believes this will appropriately address all issues affecting the man and partner as well as involving them both in the care plan.
Treatment options include conservative, medical and surgical options. Conservative measures such as lifestyle changes should accompany any medical and surgical treatment.
What lifestyle changes can one adopt to improve ED?
Lifestyle changes are the cornerstone of ED management. Since ED is a early warning sign of more sinister diseases, changing your lifestyle often benefits overall health and lessens health risks. A man should stop smoking if he does. This is not easy and help will be offered. Adoption of a Mediterranean or Asian diet is a good start. The key is to develop a healthy eating pattern with portion control that you can stick to. Routine exercise that elevates your heart rate for 30-60 minutes, 3 times a week is a good start as well.
If lifestyle changes do not work to treat ED, what’s the next step?
First line medical therapy comes in the form of pills that most men are familiar with. Sildenafil, tadalafil, avanafil and vardenafil are equally effective for ED but differ in how long they last and their side effects. General side effects associated with these pills include flushing, headache, upset stomach, stuffy nose, muscle aches with tadalafil, and blurry/blue vision only with sildenafil. To maximize benefits they need to be taken at the appropriate time prior to planned intercourse. Foreplay is of equal importance and your “head needs to be in the game.” The medications should not be taken with alcohol and sometimes taking the medications with a fat heavy meal can decrease their benefits. If one doesn’t work you may try another prior to moving on to more invasive treatments.
Caution: You should not take PDE5 inhibitors or over-the-counter medications for ED if you are taking nitrates for your heart. They can cause an unsafe drop in blood pressure that is extremely difficult to mange medically and can threaten your life.
There is a also a risk of prolonged erections lasting greater than 4 hours. If this occurs you should seek immediate medical attention at a emergency medical center. However, this is rare.
Can testosterone replacement fix my ED?
Possibly, but most often no. If a hormonal issue is identified by your symptoms, a testosterone level may be obtained. Treatment with testosterone replacement to an appropriate level may help your ED in select situations. However, many things can cause ED in the same individual. Testosterone replacement is more likely to increase you desire for intercourse. However, there is a possibility younger men are more likely to have ED responsive to testosterone replacement. They may be more likely to have an isolated hormonal, non-vascular cause of their ED. Another situation where testosterone may help is in men with diabetes. Testosterone replacement and erection pills in diabetics may actually lead to improved health overall.
What’s the deal with the vacuum pump?
Vacuum devices are a great treatment for mild ED, and can be used with pills. The device creates a negative pressure environment or suction to draw blood into the penis. If being used for intercourse a constriction band may be placed at the base of the penis. You can get a pump online, or obtain a medical grade device. One necessary feature you should look for in a pump is a pop-off valve to prevent over pressurization. Teaching sessions for device use are available and may lessen frustration with initial usage.
For moderate to severe ED vacuum pumps may not be a great options but it can always be trialed since there are minimal side effects. Men usually complain about using the constriction ring and about the unnatural cold feeling of the penis when the penis is fully erect. Bruising can occur and this device is not recommended for men on blood thinners or men with bleeding conditions. Men with penile curvature from Peyronie’s disease may also find it difficult or uncomfortable to get a full erection.
The pills do not work, are there any other medical options?
One of the most effective medical therapies for moderate to severe ED is penile injection therapy. When they are offered as a treatment the usual response is “you want me to do what?” However, after men get the injection in the clinic they are usually amazed with the results and are satisfied with continued usage.
Penile injection involved obtaining a medication such as trimix, which is a compounded formulation containing three different medications that promote erections by different pathways. Usually a very small needle, like one that injects insulin, is placed directly in the side of the penis away from the vital structures located on the top and bottom of the penis. Erection usually occurs within 5-20 minutes, and with the correct dose it should last as long as you want. A small percentage of men may experience penile pain with the medication, but not necessarily with the injection. For men who experience this discomfort the medication can be adjusted to prevent this. 5% of men can develop a prolonged painful erection lasting greater than 4 hours called priapism. To prevent this from occurring the most appropriate dose for you will be determined during a clinic teaching session. There is also a small risk of developing penile curvature; however, that risk is no greater than the risk of developing it in the general.
MUSE is a urethral suppository or pellet that is placed within the urethra by an applicator to obtain an erection. Some men experience pain, burning, or irritation after placing the pellet. There is a small chance of vaginal irritation in the partner after MUSE use. Erections usually occur 5-20 minutes after pellet placement. This is a good option for men who are needle averse or cannot undergo a procedure to correct their ED. It is not recommended this option be used in patients whose partners are pregnant.
Can I combine pills with the injections or urethral pellets?
Although there are studies showing some benefit combining pills and pellets in some populations, this practice is not advisable unless recommended by an ED specialist.
What if the pills, and injections do not treat my ED, what are my options now?
After medical therapy fails, or the medical therapy does not offer the reliability that you demand you may be a candidate for penile implantation. Link to penile implants
What is the next step?
Millions of men suffer with erectile dysfunction. Many of these men will not discuss these issues with their care providers out of embarrassment, fear of unknown treatments or the idea that this is a normal part of aging. Erectile dysfunction is not necessarily a normal part of aging and if ED impacts your life you should seek help from a healthcare provider you trust. Dr. Shridharani has advanced urological training in the management of sexual dysfunction, and his clinic is devoted to Men’s Health. We provide a comfortable setting where your quality of life issues will be managed at your pace. Our mission is to help you regain full sexual function and intimacy with your loved one.