Impotence, more precisely termed “erectile dysfunction,” has received increasing attention because of the
availability of new treatments approved by the U.S. Food and Drug Administration (FDA). The National
Institutes of Health (NIH) Consensus Development Conference on Impotence (December 7-9, 1992) defined it
as “male erectile dysfunction, that is, the inability to achieve or maintain an erection sufficient for satisfactory
sexual performance.” Especially given the fact that sexual desire and the ability to have an orgasm and
ejaculate may well be intact despite the inability to achieve or maintain an erection.
The typical initial evaluation of a man complaining of ED is conducted in person and includes sexual, medical, and psychosocial histories as well as laboratory tests thorough enough to identify comorbid conditions that may predispose the patient to ED and that may contraindicate certain therapies. History may reveal causes or comorbidities such as cardiovascular disease (including hypertension, atherosclerosis, or hyperlipidemia), diabetes mellitus, depression, and alcoholism. Related dysfunctions such as premature ejaculation, increased latency time associated with age, and psychosexual relationship problems may also be uncovered. Most importantly, a history can reveal specific contraindications for drug therapy. Additional risk factors include smoking, pelvic, perineal, or penile trauma or surgery, neurologic disease, endocrinopathy, obesity, pelvic radiation therapy, Peyronie’s disease, and prescription or recreational drug use. Other critical elements are alterations of sexual desire, ejaculation, and orgasm, presence of genital pain, and lifestyle factors, such as sexual orientation, presence of spouse or partner, and quality of the relationship with the partner. Finally, a history of the partner’s sexual function may be helpful. Attention is given to defining the problem, clearly distinguishing ED from complaints about ejaculation and/or orgasm, and establishing the chronology and severity of symptoms. An assessment of patient/partner needs and expectations of therapy is equally important.
The management of erectile dysfunction begins with the identification of organic comorbidities and
psychosexual dysfunctions; both should be appropriately treated or their care triaged. The currently available therapies that should be considered for the treatment of erectile dysfunction include the following: oral phosphodiesterase type 5 [PDE5] inhibitors, intra-urethral alprostadil, intracavernous vasoactive drug injection,
vacuum constriction devices, and penile prosthesis implantation. Oral phosphodiesterase type 5 inhibitors,
unless contraindicated, should be offered as a first-line of therapy for erectile dysfunction.
A penile implant is a device that is placed into a man’s body and is designed to help him get an erection.
Following the routine outpatient procedure, a four to eight week recovery period is necessary before the implant
is used. A penile implant (also called a penile prosthesis) is concealed entirely within the body, and requires
some degree of manipulation before and after intercourse to make the penis erect or flaccid. There are different
types of implants based on the manner of operation, naturalness of the erection and the number of components
implanted. In choosing a penile implant, considerations include medical condition, lifestyle, personal preference
and cost. The primary difference between the two implant types is that flexible rod implants, or malleable
implants, produce a permanently firm penis. The inflatable implants produce a controlled, more natural
erection. Both the malleable and inflatable implant enable men with erectile dysfunction to have a satisfactory
erection for sexual intercourse and to experience the joys of sex again.
Peyronies disease is an inflammation of the erectile bodies in the penis, otherwise known as the
corpora cavernosa. Peyronies Disease is more common than people think, occurring most often in
men between the ages of 40-60, but can occur at any age. The cause of Peyronies Disease is
unknown. In fact, since the description by the French surgeon, Francois Peyronie, in 1743, not a
great deal of progress has been made in understanding the reasons and progression of Peyronies
disease. Peyronies Disease probably represents a phlebitis or inflammation of the veins that are in
the corpora cavernosa or ‘erectile bodies’ or channels in the penis. Occasionally, infection or trauma
can cause Peyronie’s, but for the most part, its reason for starting is unknown. Peyronies Disease is
most common in men in their forties to sixties, but can be seen as early as the twenties and thirties.
The disease usually presents with one of three problems. Most common is pain on erection; secondly
is curvature of the penis with erection; and lastly, difficult having erections, or impotence. All of these
may lead to inability to have satisfactory intercourse.
The usual findings of a patient with Peyronies Disease, is a lump in the penis that is usually felt when
the penis is soft. This is usually the area where the discomfort occurs in those patients that do have
discomfort with erections. In many cases, Peyronies Disease will present with mild aching or
uneasiness in a specific area of the penis well before any lump or “plaque” can be felt. As time
progresses, the plaquing may spread causing more irregularity, bending or discomfort. In most
patients, however, only a single lesion is felt.
Because we are not certain of the reason for Peyronies Disease, it is difficult to plan any treatment
that is universally effective. There is no definite cure for Peyronies Disease. Spontaneous regression
and disappearance of Peyronies Disease and all of the symptoms does occur in some patients, and
therefore, therapy which is not particularly risky or aggressive is justified.
Two medical therapies include vitamin E and POTABA. Occasionally these drugs will soften the
plaque and relieve the symptoms. Vitamin E is safer and cheaper and has no side effects. It is far and
away the most common initial treatment plan. We usually use 400-500 units two times a day. Failure
to resolve the symptoms in twelve months usually means that this treatment will not be effective.
Treatments that have been recommended or tried in the past include the steroid injections into the
plaque, ultrasound and radiation therapy. None of these treatments have been uniformly effective.
In patients where discomfort is a significant problem, some form of anti-inflammatory drug such as
ibuprofen (Advil) can be used or some other similar drug.
Other treatments depend on the extent of the disease and the amount of symptoms. In certain cases,
injections of steroids into the plaque might soften it. In most cases, however, a period of observation
between four to twelve months is given before any aggressive therapy should be undertaken.