We Have Questions: Erectile Dysfunction Treatments

Many men have occasional difficulty getting and maintaining an erection, whether it's due to stress, anxiety, fatigue or one too many drinks. While it might ruin the moment, it's usually not a reason for long-term worry.

If the issue becomes frequent or consistent, however, it may indicate erectile dysfunction (ED). The chronic condition affects more than 30 million men in the United States, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). One large self-reported study of ED prevalence worldwide indicated as many as 47.5 million men in the U.S. experience some degree of ED. While it's more common among seniors, younger guys can experience it, too.

Yet, despite its prevalence—and treatability—many men have trouble discussing it with their partners, let alone their doctor.

Erections may seem straightforward but are actually quite complex, involving an intricate dance between the brain and body. Because of this, various internal and external factors can contribute to ED, such as underlying health conditions, mood, relationship difficulties and physical impairments.

Likewise, ED treatment could involve a multifaceted approach, though most treatment plans include one or more of a handful of popular choices.

To shed light on ED and its treatment options, we talked to Chris Kyle, M.D., M.P.H., a urologist with PeaceHealth in Springfield, Oregon. Kyle discussed what causes ED, myths and misconceptions, and the different types of treatments available.

What do you think most men misunderstand or get wrong about the origins of their ED?

Kyle: What I think most men get wrong about erectile dysfunction in general is how common it is. I have a lot of men that come to me in the office that are very upset or concerned or embarrassed, and they feel like they're the only person who this has happened to. But these are men in their 40s or men in their 50s. It's interesting because, for me, it's very commonplace to talk to men about these issues, but they feel they're the only ones who are suffering. And this is just the percentage of people who will come and see me in the office. We know there's a much larger cohort of men who don't seek medical attention.

As for what they misunderstand, I think general health and cardiovascular fitness often play a role in that. So we'll see someone who's morbidly obese, [has] poorly controlled diabetes, poorly controlled hypertension, and yet they're confused as to why their erections aren't working.

What do you generally see as the top three or four contributors to ED these days?

I would say patient age, obesity and diabetes would be the top three contributors. And then again, I'd interject there that we see ED in people who don't have any of those factors. What I mean by that is we see people with ED who are young and who have no regular risk factors. And in terms of people who have long-term chronic erectile dysfunction, that's a bit more difficult to treat.

How do you get to the root cause of a patient's ED?

Some of it's just taking a brief history and physical and examining the medications and their medical problems. But ultimately, it doesn't always matter because the treatment is the same. So obviously if someone has poorly controlled diabetes, it's easy to work with them and their primary care physician to better control their diabetes. For hypertension, obviously, if they're on medications, that may be playing a role. We talk about that and whether that's something that needs to be addressed with whatever prescribing physician who gave them the particular medication.

But ultimately, if someone has de novo (new-onset) or some dysfunction where we don't know the etiology, it actually doesn't matter that much because we treat it very similarly.

If you could generalize, what are the main types/categories of ED treatments that physicians and therapists use?

Let me step back and say an erection is just the blood entering the penis where there's the corpora cavernosa, the tubes inside the penis, and more blood enters than leaves, so there's a mismatch of entry and exit. The tubes fill up and become firm, and the goal is to preserve that so you get an erection and preserve an erection—again to retain that mismatch to decrease the exiting of the blood from the penis.

That can be done with constriction devices, which is a more mechanical way of doing that, or a physical way of doing that. Sometimes, a constriction device is combined with a vacuum device. The vacuum device is something that uses negative pressure to pull the blood into the penis.

There are pills called phosphodiesterase type 5 [PDE5] inhibitors, and those work at a more pharmacological level or an enzymatic level, preventing the blood from leaving the penis. We have injections that are medications injected directly into the penis that do the same thing, that have the same pharmacological effect. There are medications that are placed inside the penis, inserted into the urethra, called urethral suppositories, so something that goes inside the urethra. That medication dissolves into the tubes around it and then can help with an erection. And then the last thing would be surgery.

If we're in a situation where those tubes just don't work or they don't respond to all these different treatment options, we surgically go in and clear out all of the erectile tissue from the tubes and then put artificial cylinders inside the tubes. We place a fluid reservoir in the abdomen and a pump in the scrotum so that we can inflate and deflate these new tubes for erections. That's called an inflatable penile prosthesis. They also make a different type of penile prosthesis, which is kind of malleable. It's something that doesn't require filling and emptying, but it's something that can be sort of bent one way or the other.

So again, to summarize, we've got constriction devices, we've got a vacuum. We've got pills. We've got injections and pills that are pushed inside the urethra, and then we've got penile prosthesis.

Is there a progression that's usually followed, or does the root cause determine where to begin?

The root cause usually doesn't play a huge role. What I would say about the root cause is, number one, it's not always clear. Number two, there can be multiple causes for it. And sometimes the root cause, caused by one thing, can lead to more of a psychological problem with the other. So not usually, except in very specific circumstances, there's no standard progression or standard algorithm that's used with treating erectile dysfunction. A lot of it is patient interest and patient desire, because there are some who prefer to start with pharmacotherapy and there are some people who prefer to start with a nonmedication, nonprescription treatment.

What are some of the potential side effects, if any, of medications, injections, etc.?

So side effects of medications—there's headaches, flushing, congestion, sometimes people have some vision changes. Some people have such a bad headache when they take a PDE5 inhibitor that, even though they can get an erection, they're not interested, and it can kind of kill the mood. The side note of that is they can see a doctor and get a prescription.

And then for the injections, the side effect we worry about the most is something called priapism, which is a painful erection, nonsexually related, that can last more than four hours. That can actually cause damage to the penis. In fact, when we give people the injections, I usually give the first injection to them in our clinic in the morning so if they have an erection that doesn't go away, they can come back to our clinic so we can reverse it rather than having to go to the emergency department.

There's some concern with repeated injections to the penis that they can develop some scar tissue or even some curvature of the penis, so we have them switch which side they use and alter the exact location that they inject. For patients who are taking blood thinners, that can increase the risk of bruising in their penis. A lot of medications that are injected have to be kept in the refrigerator, so that can decrease some of the spontaneity.

What are the newest treatment options you've seen? How do they work?

In terms of what's new, there's the FDA-registered Class II medical device, Eddie by Giddy™. It's basically an improved kind of wearable device and it's one of the newest things we've seen on the market. It is an advancement in traditional wearable devices.

The original wearable constriction devices were either a ring in shape—just a circle—or they were a band that encircled the entire penis.

The original device was problematic for several reasons. If you look at the anatomy of the penis, there are three chambers. There's the two corpora cavernosa—those are the tubes I mentioned earlier—that fill up with blood and then help with an erection and keep an erection upright. You keep the blood inside those tubes, and that's what generates an erection. But there's also the corpus spongiosum. That is the tube that surrounds the urethra and also provides the blood supply to the head of the penis.

So with something that is more of a traditional constriction device—either a metal ring or just a band that goes around everything—you end up constricting that corpus spongiosum, which can impair the blood supply to the head of the penis. Sometimes men will complain about having numbness or a cold feeling at the head of their penis. But also because it's constricting the urethra, when there's ejaculation, that can also be quite uncomfortable for patients.

Eddie® is more of a horseshoe or omega-shape wearable device. It has a band that joins the bottom pieces together. What that's in place, it constricts the corpora cavernosa, the tubes that fill with blood to give an erection, but it does not constrict the corpus spongiosum. So it's a much more comfortable experience for the patient. It's designed with the actual anatomy of the penis in mind rather than just a ring.

So when we talk about first-line therapy, we talk about these wearable devices, we talk about pills, but we also talk about how you can use both of those together. There's very little risk in using those together, so patients and their partners can figure out what combination works best for them. Maybe they have a time when they prefer to use the pill. Maybe they have a time they prefer to use Eddie, or a time they decide to use both.