Clinical review

Warning: This article contains sexually explicit material

Erectile dysfunction

Wallace Dinsmore,  Christine Evans. 

Treatment of erectile dysfunction is initiated after taking a patient's history and examination (see previous articles), and possibly investigation.

	Medical management

Top Medical management Vacuum devices Surgical management

In highly selected patients with a clear psychological problem psychotherapy or sex and couple therapy can be used, but these are time consuming and are available to only a small number of patients. Erectile dysfunction is of a largely psychological nature in a third of patients, in a third it is largely physical, and the remaining third have both physical and psychological factors.

The first line treatment for erectile dysfunction with most practitioners is now with alprostadil by an intracavernosal injection or an intraurethral pellet, even in patients with minor psychological problems. In this group the treatment may break the "failure cycle," especially if given in combination with limited psychotherapy and sensate focus techniques.

Injected treatment
Papaverine was introduced in the early 1980s as the first effective intracavernosal injection treatment for erectile dysfunction. Given in doses of 7.5-90 mg, initially alone and later with phentolamine as a synergist in the ratio of 30:1, these treatments did not have a product licence but they were effective, cheap, and easy to use, although they had a high incidence (up to 25%) of prolonged erection.

View larger version (40K): [in this window] [in a new window]   Intracavernosal injection of alprostadil

Intraurethral treatment
The medicated urethral system for erection (MUSE) is a pellet of prostaglandin (in doses of 125, 250, 500, or 1000 µg). This pellet is placed in the urethra through the meatus and produces an erection after about 15 minutes. This treatment is a popular choice for both patients and physicians because of its ease of use, but, in common with other prostaglandin treatments, it has a relatively high incidence of penile pain, which may make patients less willing to continue the treatment.

Oral treatment
Yohimbine has been used for many decades and may be taken as a 5 mg tablet three times daily or as 5-15 mg about an hour before intercourse. It is more effective in patients with psychological erectile dysfunction. Although it has been claimed to work for about half of patients, many specialists believe its effects to be largely placebo related. Its side effects are minor (sometimes slight anxiety), and it is contraindicated in severe hypertension. It is not licensed, and no long term toxicological data are available,

Hormonal treatment
Testosterone is usually ineffective in treating erectile dysfunction in patients with normal serum testosterone concentrations and may exacerbate the problem by increasing a patient's sexual drive without improving his ability to perform. It may be given orally but is usually given as an intramuscular depot injection at intervals of 3-4 weeks, by daily patches, or by implants every six months. Great care should be exercised in patients with possible carcinoma of the prostate, and levels of prostate specific antigen (PSA) should be checked initially and every six months.

Ethical considerations
Some clinics insist on seeing both members of a couple before starting treatment, but many clinics see only the male partner and are therefore totally reliant on his history. However, many patients are not in a relationship and are afraid to embark on one because of fear of erectile failure. The confidence gained by the certainty of obtaining an erection enables a proportion of this group (whether their problem is psychological or physical) to initiate a relationship, and many patients will have a resumption of normal erectile function.

There are reports of intracavernosal injections and, increasingly, oral sildenafil being misused in live sex shows and prostitution

View larger version (76K): [in this window] [in a new window]   Vacuum pump and constriction rings

	Vacuum devices

Top Medical management Vacuum devices Surgical management

There are many vacuum devices, either manual or battery operated, currently available for treating erectile dysfunction. The penis placed in a plastic tube, and venous blood is drawn into it by suction. Once it is erect, a rubber constriction ring is placed at its base to prevent detumescence. These devices are generally safe, but the erection should not be maintained for more than 30 minutes as the penis may become cold and painful because of the constriction. Vacuum devices are the preferred option for patients who are afraid of injections or in whom injections have not been successful. They cost from £100 to £300 and are usually supported by manufacturers' helplines and money back guarantees.

	Surgical management

Top Medical management Vacuum devices Surgical management

Surgery for venous leakage and microvascular techniques for revascularisation of the corpora are rarely done, and the results are not good. The only surgical treatment of any value is inserting a penile prosthesis. Since their advent in the mid-1970s, prostheses have developed considerably from poorly concealed, low cost, trimmable silastic rods to ones made of silicone outside a metal core and self contained, inflatable cylinders. Inflatable devices are either two part prostheses with a combined reservoir and pump that sits in the scrotum or three piece models in which the pump alone sits in the scrotum and the reservoir lies in the lower abdominal wall.

Indications for use of prostheses have changed with the development of intracorporeal injections, vacuum devices, and oral preparations. Patients commonly needing surgery are those who have had pelvic surgery or who have diabetes or atherosclerosis. Prostheses are also useful in patients impotent with Peyronie's disease (which seems to be getting commoner) as they correct the deformity as well as the impotence.

View larger version (50K): [in this window] [in a new window]   Three piece penile prosthesis in which the pump alone sits in the scrotum and the reservoir lies in the lower abdominal wall

Cost apart, the choice of prosthesis is up to the patient. The semi-rigid cylinders do stick out and are therefore not suitable for younger men with children in the house, those participating in swimming and sporting events, and naturists. The cost of an inflatable prosthesis is not countenanced by some NHS trusts, but persuasion may be possible in a particularly deserving case such as a young diabetic patient impotent through no fault of his own and whose marriage is at risk.

Operative procedure
The operation is done under regional or general anaesthesia. Circumcision is often necessary with many semi-rigid prostheses, so this should be done initially.

Postoperative management
Pain relief must be provided as the operation is painful.

Postoperative problems
Infection occurs in 1-10% of cases, depending on the difficulty of the procedure. Repeat operations are more prone to infection. It is usually necessary to remove the infected part or complete prosthesis, and, although difficult, it is possible to replace it six months later.

View larger version (82K): [in this window] [in a new window]   Appearance of a penis after insertion of an inflatable prosthesis, with the device deflated (top) and inflated (left)

Prognosis
Penile prostheses give acceptable results. In many large series over 80% of patients and their partners were satisfied with the results. In those with Peyronie's disorder, a prosthesis straightened the penises of 70%. There is no real age limit for the operation, but a prosthesis should not be inserted unless it is going to be used.

	Acknowledgments

The picture of a live sex show is by Axel Kirchhof and reproduced with permission of Action Press and Rex Features.

Wallace Dinsmore is consultant physician at Royal Victoria Hospital, Belfast, and Christine Evans is consultant urologist at Clwyd Hospital, Rhyl.

The ABC of sexual health is edited by John Tomlinson, physician at the Men's Health Clinic, Winchester, and London Bridge Hospital, and formerly general practitioner in Alton and honorary senior lecturer in primary care at University of Southampton.