Erectile Dysfunction and Treatment Options

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1 Porterbrook Clinic Sheffield Care Trust Sexual Fitness For Men Erectile Dysfunction and Treatment Options Andrology Service (Urology) Sheffield Teaching Hospitals Information for Users of our service Dr Kevan Wylie Clinical Lead Lead Clinician (Andrology) Porterbrook Clinic 75 Osborne Road Nether Edge Sheffield S11 9BF Telephone: Fax:

2 What is erectile dysfunction? When a man is at rest, the blood vessels in his penis are constricted so that blood flow in the penis is very low. When he becomes sexually aroused, chemical messengers are sent via the brain and central nervous system to tell the blood vessels in the penis to relax. This allows the spongy tissue in the penis to fill with blood, causing the lengthening and hardening of the penis an erection. Once the penis is stiff, a mechanism at its base compresses to maintain the blood volume, and consequently the rigidity, until sexual stimulation ends. ED is only diagnosed when the problem is persistent and recurrent. ED can affect men of any age, although it is more common in older men, and is likely to worsen over time without effective treatment. Around 5% of men under the age of 60 suffer from a complete inability to gain or maintain an erection; this figure increases with age to around one in four at the age of 70, and three in four at age 80. In addition, around 40% of men suffer from partial ED (also known as erectile instability ). What effect does it have? A man with erectile dysfunction, sometimes called ED or impotence, will regularly be unable to achieve - or maintain - a firm enough erection to enjoy sexual activity. This may be either because insufficient blood flows into the penis, or because the blood drains away from the penis almost as soon as it gets there (known as veno-occlusive disorder ). Who is affected? Most men will find they are unable to get or maintain an erection occasionally, perhaps because of tiredness, stress or too much alcohol; this is quite normal. For a large proportion of men, experiencing erectile problems strikes at the heart of their sense of self and can make them feel inadequate, useless and a failure. It is no surprise, therefore, that erectile dysfunction causes many men distress, anxiety, and a lowering of their self-esteem, all of which can easily lead to depression. This is compounded by the fact that men often find it difficult to admit they have problems with their erections, which means that often they do not seek the treatment which is readily available, and instead carry the problem around as a shameful secret. Sexual Fitness for Men

3 This in turn will have often have a severe impact on a man s relationships. If he has a partner, he may withdraw from any kind of physical contact with his partner, on the basis that he doesn t want to start what he can t finish. This can be hurtful and bewildering for his partner, and even more so if she does not know what is causing the distance between them; many men are ashamed or embarrassed to discuss the difficulty with their partner and she may imagine he has gone off her, or is having an affair. If he does not have a partner, he is likely to be very anxious about the possibility of experiencing ED with a new partner, and may avoid dating and even withdraw socially, leading to loneliness and isolation. What causes ED? It used to be thought that ED was all in the mind, but it is now thought that less than a third of cases are primarily psychological in nature. In approximately 70% of men with ED, the main cause is organic although psychological factors can still play a big role in maintaining the problem. This is because, whatever causes ED, but the biggest single factor in keeping it going is often performance anxiety. Because, for many men, a properly functioning penis is key to their sense of manhood, the stakes are extremely high, leading to fear and anxiety every time intercourse is attempted; and anxiety is known to have a substantial effect on a man s ability to become sexually aroused. (Unfortunately, this also means that it is very easy for what might have been a one-off incident to turn into a persistent problem). A full assessment is required to establish why a man is experiencing erectile problems. Some indicators might be those men: whose erectile problems come on gradually, who also notice a decline in nighttime and morning erections, and who have difficulty getting or maintaining an erection even during masturbation are most likely to have ED with a primarily physical origin; whereas those whose problems occur suddenly, who continue to notice spontaneous erections during the day or upon wakening, and Erectile Dysfunction and Treatment Options

4 who have little or no difficulty getting full erections when they are on their own are more likely to find their ED has a psychological origin. Common physical causes of ED Cardiovascular disorders. Atherosclerosis (a hardening and narrowing of the arteries) can lead to high blood pressure and reduce blood supply to the heart and to other parts of the body, including the penis. Smoking, high cholesterol levels and obesity are common causes of atherosclerosis. The deterioration to the blood supply becomes increasingly apparent with age. Endocrine and metabolic disorders. Diabetes mellitus is the most common cause of ED, accounting for approximately a third of all cases. This is because, over time, it can damage both nerve and blood supplies to the penis. Other endocrine disorders implicated in ED include hypogonadism (although, contrary to popular opinion, low testosterone only accounts for a small minority of ED cases); under or over-active thyroid; and elevated prolactin levels in the blood. Neurological disorders. These include multiple sclerosis, Parkinson s Disease and neuropathy caused by alcoholism. Pelvic surgery. The chief culprit is prostatectomy, but other major pelvic and abdominal surgery can cause problems to the blood and nerve supply. Psychiatric illness. Includes depression, anxiety, schizophrenia and dementia. Severe chronic disease such as kidney or liver failure. Trauma affecting blood and/or nerve supply to the penis, e.g. spinal injury or from cycling, and pelvic radiotherapy. Local disease such as Peyronie s or phimosis. Side effects of drugs. A surprising number of commonly prescribed drugs can cause ED, including many prescribed for the disorders described above, leading to a double whammy. Chief amongst these are cardiovascular drugs and those that treat depression, anxiety and psychosis. Recreational drugs such as alcohol, marijuana, cocaine, amphetamines and especially smoking can all be implicated in ED. Sexual Fitness for Men

5 The power of the mind Sometimes men believe they should be able to produce an erection to command, any time they want as if getting an erection were like switching on the TV. This is nonsense! In addition to adequate arterial blood and nerve supply to the penis, men need adequate sexual stimulation and to be in the right frame of mind before they can engage fully and successfully in sexual activity. Factors that can influence erection include: Psychiatric illness such as depression, anxiety, schizophrenia and dementia Stress and anxiety at work or home, or tiredness from working long hours Attempting to have sex too soon in a new relationship, before he is sufficiently comfortable and relaxed in his partner s presence Anger, conflict or other problems in a long- standing relationship Fear of being overheard or interrupted e.g. by children or in-laws Fear of intimacy or commitment, perhaps when the spectre of getting married or having children is raised Fear of losing control or of contracting a sexually transmitted disease Cultural or religious worries such as guilt over extra-marital sex Sexual boredom or reduced attraction to partner A significant loss such as the onset of a major chronic illness, being bereaved or being made redundant Guilt over an affair or pain over a partner s affair Unresolved questions about sexual orientation Worrying about his penis size or ability to satisfy his partner Anxiety over his partner s sexual issues, for example if his partner is suffering from loss of interest or pain during sexual activity. It would also be fair to say that some men have unreasonable expectations. For example, a thirty year old man might worry that he cannot make love for the third time that day when he has been working hard all week and is exhausted; or a sixty year old widower in a new relationship may worry that his erections are not right because they are not as firm as they were when he first met his wife forty years before. There is no reason why most men should not be able to continue to have a satisfying sex life Erectile Dysfunction and Treatment Options

6 into their seventies, eighties or beyond; but that doesn t mean that their erections will be quite as quick to come or as firm as they were when he was a young man. It is also very important to remember that you are a man, not a robot. In his book The New Male Sexuality, sex therapist Bernie Zilbergeld points out that, In their attempt to run like welloiled machines, men overlook what they already know: that machines themselves have conditions, including being welloiled. When we re made aware of these needs we don t get upset, we just fulfil them. He goes on to explain how to identify your pre-conditions for good sex, and to work out how to get these conditions met. Assessing ED Because experience has shown that the causes of ED are usually complex, here at the Porterbrook Clinic we undertake a rigorous assessment to build up a full picture of the possible factors involved. Men are invited to attend an assessment interview with their partner, where a thorough psychosexual, psychological, relationship and medical history is taken. Following the history taking, we routinely check glucose, free testosterone, lipid, thyroxine and prolactin levels by arranging a blood test, and if any of these are abnormal, further screening may be arranged. In addition, a physical examination may be arranged if an underlying medical problem is suspected. In addition, where appropriate we offer further diagnostic tests: with the RigiScan, DIR and NEVA, we can monitor erectile tumescence and rigidity, both during laboratory tests and at home during the night; this can help to establish whether the penis is functioning normally, suggestive of a psychological basis for the erectile problems. Additionally, the MIDUS Doppler ultrasound system can evaluate the blood vessels in the penis and measure arterial blood velocity where venous leak is suspected. The GSA can measure nerve conduction in the genital area. Managing and Treating ED Men, in particular, have a tendency to think that fixing the penis is all that s needed to solve sexual problems caused by ED; but this isn t always the case. We take an integrated approach to Sexual Fitness for Men

7 treatment at the Porterbrook and offer a full range of physical and psychosexual treatments. We often find the best results are achieved when a short course of sex therapy is undertaken alongside other treatments; this is not surprising when you consider that, for many couples, there will have been a long period without sexual activity before treatment begins, and the couple may need to learn how to be intimate with each other all over again. A brief overview of the different treatments for ED is given below. We will work with you to tailor-make a programme of treatment that is most appropriate for you. floor exercises for men produced by the NHS in Sheffield). Third, information may be given on lifestyle changes that could have an impact on erectile functioning, including a referral to one of the medical staff at the Clinic if it appears that medication changes might be warranted. Fourth, it can help you to look at any underlying difficulties in the relationship that might be exacerbating the sexual difficulty. Finally, it can help to re-establish the sexual relationship and iron out any of the problems that can sometimes arise when sexual functioning is restored. Another leaflet in this series, What is psychosexual therapy? gives more information about what is involved. Psychosexual Therapy Vacuum pump Psychosexual therapy, either on your own, or ideally with your partner (if you have one), can work on many levels. First, it can provide information and support regarding the different treatment options. Second, you may be taught how to practice pelvic floor exercises (also called Kegels) regularly, as this will tone your muscles, increase blood flow to the area and increase pleasurable sensations. (Ask your therapist for a copy of the leaflet Pelvic Here a tube is placed over the penis and suction is applied via an electric or hand pump (Figures 1-4). This draws blood into the penis where it can be trapped using a special restricting ring placed at the base of the penis. This can be a highly effective way of producing an erection and is suitable for long-term use by most men, particularly those for whom drug treatments are not advisable. Sometimes partners complain that the erection feels cold and there is, Erectile Dysfunction and Treatment Options

8 Figure 1 Figure 2 Sexual Fitness for Men

9 Figure 3 of course, a lack of spontaneity. Figure 4 Erectile Dysfunction and Treatment Options

10 Oral Treatments There are currently four oral drugs licensed in the UK for the treatment of ED. Three of these, sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) belong to the group of medicines called phosphodiesterase 5 (or PDE-5) inhibitors. Once absorbed, these help the blood vessels in the penis to relax, which usually helps to produce an erection. The fourth oral treatment, apomorphine (Uprima), is thought to stimulate receptors in the brain to send the right messages to the penis to produce an erection. It is very important to be clear that none of these four drugs is an aphrodisiac: rather, they only work in response to sexual stimulation. This means that you need to be in the mood and to engage in sexual activity before you can expect to get an erection! Intracavernous injection You or your partner are taught to inject a drug (usually alprostadil or papaverine) into the penis shaft using a very fine needle (Figure 5). This produces an automatic erection within around 15 minutes. The erection may continue Figure 5 Sexual Fitness for Men

11 Figure 6 after ejaculation, but should subside within about an hour. This is a highly effective treatment that can be used up to three times a week, but some men find it uncomfortable or inconvenient. Intraurethral therapy applicator, following urination (Figure 6). The penis is then massaged for a few seconds until the drug is dissolved, producing an erection within 5-10 minutes. Some men experience mild pain related to the drug as well as the procedure. Surgical treatments This works in a similar way to the injection, although it is not as reliably effective. A small pellet containing a much higher dose of alprostadil is introduced into the opening at the end of the penis via a special disposable An artificial penile implant (or prosthesis) may be inserted surgically; one type maintains the penis in a state of semirigidity but allows it to be bent downwards out of the way when not in use; another type uses a pump Erectile Dysfunction and Treatment Options

12 implanted in the scrotum to produce an erection when required. Both of these options carry some risk of complication, such as infection, mechanical failure or erosion of the prosthesis (where the implant erodes through to the outside of the body). They should only therefore be considered when other forms of treatment have been unsuccessful. In addition, a small number of ED cases caused by abnormalities in blood-flow into and out of the penis can be treated by surgery. If you would like further information about any of the treatment options described above, please ask for the individual Clinic treatment leaflets. Do I have to pay for treatment? Psychosexual therapy is available free at the Porterbrook. Other treatments are only free if: You had already been diagnosed as suffering from erectile dysfunction on 14th September 1998 and were receiving treatment for it on the NHS at that time; You have been diagnosed as suffering from erectile dysfunction and also suffer from diabetes mellitus, multiple sclerosis, spinal cord or severe pelvic injury, single gene neurological disease, poliomyelitis, spina bifida, Parkinson s disease, kidney failure, prostate cancer or have had your prostate removed. In addition, if your GP and a Porterbrook specialist consider that you are suffering from severe distress as a result of your ED, meaning significant disruption to your home and work life, and a marked effect on your mood, behaviour and relationships, they may in exceptional circumstances arrange for you to receive free treatment through the Porterbrook, or Andrology service whilst you receive counselling and support for your distress. Sexual Fitness for Men

13 For all other men, treatment is available on private prescription. Neither the Porterbrook nor your GP will charge for the prescription, but you will have to pay for the treatment itself. In addition, most chemists will also charge a private dispensing fee; this fee can vary, so it s worth shopping around. Some people find it cheaper and more convenient to get their prescription by post via an NHS service such as Pharmacy2U - Tel or Boots Direct. Further information Helpful books include: A New Male Sexuality by Bernie Zilbergeld (Bantam Doubleday Dell Publishing, 1999) Impotence: A Guide for Men of All Ages by Wallace Dinsmore and Philip Kell (RSM Press Ltd) Coping with Erectile Dysfunction: How to Regain Confidence and Enjoy Great Sex by Michael Metz and Barry McCarthy (New Harbinger, 2004) The Sexual Dysfunction Association (formerly the Impotence Association) is a UK charity providing help and advice on all kinds of sexual problems to men and women. The website includes free, downloadable leaflets, articles and reviews of sex help books: Written by ROSE WHITELEY for the Porterbrook Clinic, Sheffield Porterbrook Clinic 2006 Erectile Dysfunction and Treatment Options

14 Sexual Fitness for Men NOTES

15 NOTES Erectile Dysfunction and Treatment Options

16 C3 Porterbrook Clinic 2006