NON-ORAL THERAPY FOR
Jonathan P. Jarow, M.D.,
associate professor of urology at
The Johns Hopkins Hospital
My first-line ED treatment is Viagra. If Viagra doesn't work, I suggest using a vacuum erection device (VED or trying drug injection therapy. A third, highly effective treatment is the surgical implantation of a penile prosthesis. In order to get an idea about how the VED works, I have a patient watch an instructional video in my office. To experience the injectable medication, the man will undergo a test injection in the office that same day.
VED Therapy Backgrounder - Vacuum erection therapy was created in 1961 by a long-time sufferer of ED. This plastic device (actually an external vacuum) can induce an erection. The better-made VEDs cost between $200 and $500 and are available with a physician's prescription.
Q. How does a VED device work?
A. To achieve an erection, the user places the clear plastic cylinder over his penis and uses either a manual or special electrical pump to create negative air pressure in the cylinder. Regardless of the source of the erection problem, this vacuum causes the vessels in the penis to fill with blood, just as they would during a normal erection. Once an erection is achieved (it takes about two minutes or so), the user slips off a flexible tension ring from the bottom of the cylinder and places it around the base of his penis to keep the blood from flowing out. This sustains the erection once the cylinder has been removed. The resulting erection can be sustained for at least 30 minutes.
Q. Does the VED have any advantages?
A. From a practical point of view, a VED is one of the best ED treatments available. It's very effective, works for almost everybody, and is very inexpensive over the long haul. There are no serious side effects when used properly, and it can be utilized whenever an erection is desired. About half of the men who purchase the device like it and keep using it. I've found that the VED works for about 90 percent of my patients but working and liking to use it are two different things altogether.
Q. What are the VED disadvantages?
A. Many men and their partners don't like the device because the erection it produces is not "normal." Some pump users complain that their penis feels numb, or that it becomes discolored, misshapen, and cold to the touch. Many couples complain about the interruption of intimacy it brings to lovemaking. Also, some men complain that the constriction ring at the base of the penis causes mild discomfort upon ejaculation or varying degrees of ejaculation impairment.
Penile Injection Therapy Backgrounder - Penile injection therapy was discovered fortuitously. In 1980, the French physician Ronald Virag reported that during penile surgery, he inadvertently injected an anesthetized patient in the wrong part of the penis with papaverine - a substance derived from the opium poppy. The resulting relaxation of the smooth muscle of the penile arterial walls created an unexpected two-hour erection. This mistake prompted serious research into the use of injectable medications to relieve ED. Around the same time, Giles Brindley, a British physiologist and research scientist, discovered that injecting the drug phenoxybenzamine into the corpora cavernosa of the penis could produce an erection within minutes. At a meeting in Paris in 1984, New York urologist Dr. Adrian Zorgniotti presented his first case studies of self-injection utilizing a combination of papaverine and phentolamine. The latter drug blocks the action of neurotransmitters that cause vasoconstriction, causing the smooth muscles of the penis to relax. Two years later, Japanese researchers presented evidence that injecting the drug prostaglandin E-1 produced powerful erections. Slowly, news of the favorable results with the injectable medication began to spread within the small international community of urologists who were treating ED. Most began utilizing all three (papaverine, phentolamine, and prostaglandin E-1) in what was referred to as "trimix."
Q. Is it difficult to persuade a man to inject his penis?
A. Most men shudder at the thought. I tell them it won't hurt, but they don't believe me until they experience it for themselves. After being coaxed into receiving a test injection in the office, most men are pleasantly surprised to learn that it really doesn't hurt.
Q. Will injection therapy work for everybody?
A. It works for 70 to 80 percent of all men suffering from ED, with highest success rates in men with non-vascular causes of ED (psychogenic, hormonal, neurogenic). After undergoing a radical prostatectomy, some men experience pain and burning when injecting the medicine, (alprostadil). Only 1 to 5 percent of men have this reaction, but it's enough to prevent them from using the drug again.
Q. Will someone who has undergone a nerve-sparing radical prostatectomy benefit from injection therapy?
A. Some men who undergo a radical prostatectomy with one or both neurovascular bundles spared still can't achieve an erection after being injected. The nerves could play a role here but for some it has more to do with the fact that they might have anatomic variations in blood supply to the penis. Somehow blood supply has been compromised during a normal prostatectomy and this contributes to their ED. Complicate this with other risk factors, such as partial nerve injury or diabetes, and an erection can become very difficult to achieve.
Q. Do you recommend MUSE?
A. MUSE (available since 1997) employs a small, specially-designed plastic plunger that is placed on the tip of the penis. Once the plunger is pressed, a rice-size pellet of medication (alprostadil) is pushed into the urethra. Moisture left by urine causes the pellet to dissolve, triggering an erection minutes later. Certainly less invasive than a hypodermic injection of medication, MUSE, an acronym for "medicated urethral system for erection," turns out to be a poor solution. Many men complain of a burning pain in the penis after the drug has been inserted, and there is a small risk of urethral injury. Since the efficacy of MUSE is extremely low - 10 percent or less, according to on 1998 study and the side effects are worse than injection therapy, I don't recommend it as a first-line treatment after a radical prostatectomy.
Q. Which injectable medication do you recommend?
A. I start most of my patients with Caverject (alprostadil), also called prostaglandin. This 1995 FDA-approved prescription drug comes in two strengths in a disposable, single-dose syringe that's pre-filled with the erection-enhancing medication. Injected directly into the base of the penis five minutes before a sexual encounter, the drug increases blood flow and produces an erection. Caverject is much more readily available than trimix (you need a pharmacy with a compounding license for this preparation). Many men like the convenience of Caverject. It doesn't need to refrigerated and it's easier to transport.
Q. What if Caverject doesn't work?
A. I then recommend trimix. I also recommend trimix when a patient experiences pain from Caverject. However, if a patient has a painful reaction with Caverject, he will frequently have a similar reaction with trimix. In that situation, a combination of papaverine and phentolamine (bimix) can be tried.
Q. Why does injection therapy fail for some men?
A. While the injections have a high success rate (over 70 percent), the drugs may not be able to override poor blood flow to the penis. In some cases, the trimix may produce an initial erection, but venous drainage (inability of penile tissues to trap blood) in the penis allows blood to escape rapidly, resulting in an unsustainable erection.
Q. What about the problem of prolonged erection?
A. Patients typically achieve an erection within 20 minutes. The erection can last between 30 and 90 minutes, becoming more rigid with sexual stimulation. However, the erection does not always disappear immediately after ejaculation. If too much of the drug has been administered, priapism - an unwanted, prolonged erection that lasts for longer than three or four hours - can develop. This painful and dangerous medical condition is named for Priapus, the Greek god of procreation. It can lead to the destruction of erectile tissue if left untreated. Thankfully, this serious condition can be reversed by injecting an adrenaline-like drug into the penis.
Penile Implant Backgrounder - Before the advent of injectable and oral medications, penile implant surgery was the only effective treatment for ED. The penile implant was used by men with irreversible ED from physical causes, such as diabetes, pelvic surgery, or physical trauma to the penis. The prosthetic implant and surgery, which costs between $12,000 and $20,000, was their only option.
Q. What types of implants are available?
A. There are two basic types: inflatable (of which several types are available), and the malleable, semi-rigid implant. It is impossible to distinguish between the two during sexual intercourse. but outside sex, the user can easily tell the difference.
Q. What are the major differences between the two devices?
A. Functionally, they both work well. However, the inflatable implant leaves the penis looking and feeling like a normal penis. When flaccid, it's floppy and natural looking; when erect, it's full of fluid (not blood, but saline). Your partner won't know the difference.
Q. How does the inflatable device work?
A. Two extremely compact hollow cylinders, which come in a variety of widths and lengths, are implanted within the penis. A small container that holds fluid for the cylinders is inserted in the lower part of the abdomen and a pump is implanted in the scrotum. The patient squeezes the pump several times, which transfers the fluid from the container to the inflatable cylinders, which then expand, widening and lengthening the penis. To get rid of the erection, the valve at the top of the pump is squeezed and the fluid returns to the abdominal reservoir, causing penile flaccidity.
Q. What are the pros and cons of this device?
A. The inflatable implant has the significant advantage of allowing an instant erection. The disadvantage is the inherent complexity of a mechanical device. When a problem occurs, surgery is needed to fix it.
Q. How does the malleable semi-rigid implant work?
A. This device consists of two silicone rods that can easily be bent or straightened. Once surgically implanted in the corpora cavernosa, a man will have a permanent erection. Bending the rods so that the penis is close to the body conceals it, while straightening the organ with one or two fingers immediately readies it for intercourse.
Q. Which device do most patients opt for?
A. 90 percent pick the inflatable prothesis. Even though it's more expensive and the complications and risk of breakage greater, they choose it simply because it provides a more natural result. Because they have to live with it every day, they want something that looks and feels more natural. Obese men often choose the malleable device and feel less self-conscious about it. Because of their girth, they can have their penis pointing out all day long and no one will know.
Q. Is implant surgery difficult?
A. The surgery is actually quite simple and straightforward for both types of devices: It is a one-hour, outpatient procedure. Even the most complex hydraulic devices are inserted through a two-inch incision in the scrotum. For the malleable implants, a pair of silicone rods are implanted in the corpora cavernosa. While it's a less serious operation than a radical prostatectomy, there is much more postsurgical discomfort associated with penile implant surgery. This pain, bruising and soreness can last for weeks and patients typically must take 10 days to two weeks off work until the area has healed.
Q. If implants work so well, why aren't they recommended first?
A. Penile implant surgery is usually a last resort. Although there is nothing wrong with this approach, for many men it's a disservice. In medicine, the option of last resort is usually something that rarely works or has terrible side effects. Implants present a medical conundrum because they are one of the best treatments we have for ED. Implants have the highest patient and partner satisfaction rating, running higher than 90 percent. The only reason they're offered last is because of the surgery involved. In addition, if removal of the device is necessary, the other erectile dysfunction treatments will not be effective because corporal tissue is destroyed with implantation. Also, its risks, although very infrequent, can be significant.
Q. What are the risks with implants?
A. While the devices are simple to install and use, infection occurs in about two percent of cases. In this case, the implants have to be removed. Depending on the degree of infection, another implant may be reinserted immediately or after sufficient healing. But in rare cases, scarring may be so severe that subsequent reimplant is impossible and leaves the patient without any hope of intercourse.