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Erectile Dysfunction: Diagnosis &Treatment

Erectile Dysfunction Overview

Dr. Shabsigh makes specific treatment recommendations for sexual dysfunction only after a comprehensive medical history review, physical examination, blood workup and other tests as indicated. He regards each patient encounter as an opportunity to help preserve or improve overall health, and firmly believes that every man should have a thorough annual check-up.

Erectile Dysfunction Affects Quality of Life

If a serious medical condition (such as depression, diabetes, high blood pressure, obesity, or a metabolic disorder) is affecting sexual function, it may be affecting other areas of life as well, reducing the quality of life, and consequently should be treated. There are treatments that can be performed at home and during the day that will allow a surprising amount of control over erectile dysfunction. Many natural substances are reported to provide benefits in this area as well. These include Korean gingseng, L-arginine, vitamin E, Chinese herbal remedies, and ginko biloba. 
Some of these have been tested by clinical studies, however it’s important to remember that many over-the-counter medications are not regulated. These medications could be dangerous, or cause harmful interactions with other medications. It’s a good idea to consult the National Institute of Health’s (NIH) online database ( www.pubmed.gov ) to research possible supplements. Also, be sure to tell the doctor about any drug or supplement that is being taken.

When lifestyle approaches or disease management fails to address a patient’s sexual dysfunction, Dr. Shabsigh discusses a broad range of medical and surgical options with men and couples. During this process, he considers patient preferences related to invasiveness, convenience, effectiveness, possible side effects, partner satisfaction, and cost. Once the doctor and patient agree on an approach, treatment is administered.

Medical Treatments of Erectile Dysfunction

In addition lifestyle or psychosocial changes, the doctor may discuss medical treatment options. A blood test may discover a testosterone deficiency, and therefore testosterone replacement therapy may be a good choice. Testosterone deficiency is infrequently the only cause of ED, but it may contribute to ED in as many as 34% of affected individuals. If the doctor finds low testosterone along with other factors such as low sexual desire, erectile dysfunction, ejaculatory dysfunction, fatigue, muscle weakness, obesity, or an unstable mood, the doctor may prescribe testosterone replacement therapy. Testosterone therapy is not recommended for men with female partners trying to conceive, as sperm counts may be affected.

Erectile Dysfunction - Drug Treatments

Another first-line treatment for ED is PDE-5 inhibitors. This family of drugs includes Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). They typically begin working within 20 to 30 minutes. The effects of Viagra and Levitra generally last for about 6 to 8 hours, and the effects of Cialis last for up to 36 hours. The choice of medication depends on the patient history, as well as the desired effect. Cialis is more flexible in terms of timing for sexual activity. These drugs have minor side effects such as headache, facial flushing, upset stomach, nasal congestion, and back pain. This type of medications is contraindicated in men taking nitrates medications and may not be generally used in men for whom sexual activity is inadvisable due to their underlying cardiovascular status.

Drugs like CialisTM Viagra® and Levitra® do not work for about a third of the patients who try them, and even when they do work, they do not address the underlying health conditions that cause sexual dysfunction. Moreover, such conditions usually worsen over time, to a point where such medications provide little if any relief. Dr. Shabsigh cautions against what he calls the “hallway prescription”—when a man who visits his doctor for another condition asks for an erection-producing drug on his way out the door. 

Vacuum Therapy for Erectile Dysfunction

Sometimes oral medications for ED are not effective for a patient, or may be incompatible with their medical history. Second-line therapy includes vacuum constriction devices, penile self-injection, and transurethral therapy. Vacuum constriction devices (VCDs) have actually been around for quite some time, and the ErecAid is the most popular option. A cylinder is placed over the penis, and then a pumping action pulls blood into the penis, causing an erection. The man may then slide a band or ring on to the base of their penis in order to retain the erection, and the ring may be left in place for up to 30 minutes. Vacuum therapy is generally safe, but can be associated with bruising, pain, and a decrease in the force of ejaculation. The vacuum does not interfere with medication, and can be combined with other therapies.

"Our data support the potential benefits of a combination therapy with one of the oral medications such as Viagra, Levitra or Cialis plus testosterone for men with erectile dysfunction and low testosterone who find the oral medications by themselves ineffective," said Dr. Shabsigh. "When assessing erectile dysfunction, doctors and patients should consider using a simple blood test to determine if low testosterone is a contributing factor.

Erectile Dysfunction Treatment - Self-injection Therapy

Self-injection therapy offers the patient quick results, and a high success rate (80%) with minimal side effects. The injected solution is a prescription medication (often Caverject Impulse or Edex) or a mixture combined by a physician or pharmacy often contains, papaverine, phentolamine and/or alprostadil. Unwanted results such as priapism can be a result of an overdose. Rare side effects such as bruising, bleeding, or a build up of scar tissue (fibrosis) may also occur in some patients. Transurethral therapy involves a medicated urethral system (MUSE) to deposit medication in to the urethra in order to obtain erections. The patient will place the suppository inside the urethra with a specially designed applicator. MUSE is quite safe, but some patients do find side effects such as burning, bleeding, pain, or low blood pressure. 

Implants and Revascularization - Treatments of Erectile Dysfunction

Third-line therapies, which are a more serious treatment approach, include penile implants, and in rare cases, revascularization. Implants are a permanent solution to ED, and are excellent permanent choices for men whose underlying cause cannot be treated, or are unresponsive to other treatments. There are generally two different kinds: bendable or semi-rigid rods, and multi-piece inflatable implants. Both of these are implanted into the penile tissue itself. The bendable rods, also known as a malleable device, create erections when the patient straightens their penis by hand into an erect position. Inflatable implants are significantly more natural looking, and tend to be concealed better than malleable implants. They consist of two inflatable cylinders, a pump, and a reservoir that holds fluid. Insertion of penile implants generally requires local, spinal, or general anesthesia, and the patient may need to stay overnight. The patient can resume sexual activity approximately one month after the surgery, depending on the healing process. The procedure is relatively simple, and is not particularly invasive, but because it is permanent, it should be considered as a last resort for treating ED.

Revascularization is performed on patients with considerable damage to the primary artery in the penis that leaves the patient with an inability to obtain erections. It is rarely used as a treatment option for ED, but rather for patients with serious injuries to the penile artery.

Everyone Can Have Better Sex

Dr. Shabsigh says his patients are his best teachers, and he often refers to an 94-year-old patient who came to him some time ago. The man stated with a level voice that he worked part-time, paid taxes, swam, and played tennis, and that if he did all of that, he deserved to have sex. Dr. Shabsigh could not have agreed more.“Everyone can have better sex—even those with cancer, advanced heart disease, or debilitating injury.” There is something for everyone in Dr. Shabsigh’s approach to promoting healthy sexual function at every age.