Erectile dysfunction Treatment methods

There are many currently applied methods of ED treatment. They include conservative treatment, surgeries, and psychotherapy. The choice of the most appropriate course of management depends on the aetiology of the dysfunction, its clinical picture, and a joint decision of the specialist and the patient. In some cases, it is possible to combine pharmacology with surgery.

Psychotherapy

If the sexual dysfunction has a psychological background, psychotherapy may bring about the desired results. If there is no organic cause of the dysfunction, the problems may result from stress, depression, different anxiety disorders, as well as personal problems. After detailed history taking (special forms and psychotests) and exclusion of other aetiological factors, the patient starts therapeutic sessions with the psychologist, trying to find the cause and proper solution to the problem. Very often, the therapeutic process involves also the participation of patient’s partner, which provides the man with mental comfort and deepens mutual relations. Psychotherapy may be combined with other forms of treatment.

Conservative treatment

Pharmacological treatment:

PDE5 inhibitors 

One of the most successful and commonly used methods of treatment includes pharmacotherapy with a popular group of medicines for erectile dysfunction, so called phosphodiesterase inhibitors (Sildenafil, Vardenafil, Tadalafil) – with the most popular one being Viagra. These medicines function by blocking the enzyme (phosphodiesterase 5 – PDE-5) metabolising cyclic GMP, which leads to an increased and stable concentration of this compound (cGMP) in smooth muscles of the vessels. This enables vasodilation of arterioles and cavernous bodies, and an increased blood inflow, leading to a successful erection. 

These medicines were invented in the course of a search for an effective agent against coronary disease. They may be used in patients with ED of vascular origin, and mixed ED. Due to their dilatory effect on all vessels, and drug interactions, PDE5 inhibitors are contraindicated in patients taking nitrates (e.g. nitroglycerin) and in patients whose sexual intercourse could be connected with a risk of cardiovascular incident.

Adverse events include mainly headaches, vertigo, hot flushes, and visual disturbances.

Testosterone

In patients with erectile dysfunction and decreased level of androgens (i.a. testosterone), oral, intramuscular, or transdermal (patches) supplements of testosterone may be administered. Testosterone supplementation has a positive effect on well-being, and increases patient’s libido. Although this kind of therapy is not advised as the only treatment method, it improves the effectiveness and treatment outcomes when combined with other methods.

Other medicines used in the therapy of erectile dysfunction include: pentoxifylline improving blood flow, yohimbine (natural, herbal substance influencing the contractility of the vessels), as well as apomorphine, with a central action on hypothalamus responsible for erection

Injections to cavernous bodies

This therapy was presented in the 90s, when it was discovered that the administration of papaverine (a vasodilator and smooth muscle relaxant) to the penis results in an effective erection which can be maintained for some time. Since that time, a few different preparations (and their combinations) have been introduced. This is a very effective method of treatment which in most cases leads to an erection lasting up to a few dozens of minutes (depending on the dose) and allowing for a satisfactory intercourse. After a proper training given by the physician, the man can do the injections himself (if correctly performed, they are completely painless). The most common medicine used for injections to cavernous bodies is alprostadil, a synthetic prostaglandin, relaxing the walls of arteries supplying blood to the penis. Alprostadil is also produced in the form of special suppositories, inserted into the urethra (so called MUSE system). There are also medicines combining alprostadil and papaverine, or containing even three different active substances. Adverse effects include priapism (a long and painful erection), as well as scarring of injection sites and pain of the penis. Unfortunately, due to the discomfort connected with the method of administration, patients are reluctant to use it.

Mechanical methods

Vacuum penis pump – the mechanism of action

Mechanical methods supporting erection have been known for a long time. One of them is the vacuum pump. It is composed of a special cylinder placed around the penis, connected to a hand- or battery-operated pump, and an erection ring. The device pumps out air from the cylinder, creating a vacuum and thus drawing blood to the cavernous bodies. After obtaining a proper erection, the cylinder is taken off the penis, and the erection ring is pushed to the base of the penis. It is supposed to maintain erection and to prevent blood backflow. Simplicity and safety makes it a good and effective method. However, it should be remembered that it does not cure the cause and is only a symptomatic and supportive measure. Over half of men using penile pumps achieve excellent results. However, due to the limitations of this device (it is cumbersome to use, the intercourse cannot be spontaneous, and there is much discomfort connected with its use), patients frequently resign from this method of therapy.

Surgery

Penile prostheses

The procedures implanting penile prostheses, which used to be very popular and much more frequently performed, are now considered a last resort, used only in case of failure of other methods. This is mainly due to the introduced oral agents from the group of phosphodiesterase inhibitors (sildenafil).

Hydraulic penile prostheses

Penile prostheses may be divided into semi-rigid rods, semi-rigid hydraulic prostheses, and hydraulic prostheses composed of a few parts. Implants of the first type have one, unchanged shape, which cannot be modified after implantation. This means that the penis is rigid all the time and its volume does not change. A much better solution is in this respect the hydraulic prosthesis, which has the shape of the penis at rest and can be pumped up before the intercourse, to a volume appropriate for erection. This method ensures erectile function, irrespective of the physiological mechanisms or patient’s pathologies. However, it should be remembered that the implantation of the prosthesis is always invasive and connected with complications, pain and discomfort in the postoperative period. Sometimes the prosthesis cannot remain fully hidden, and the aesthetic effect may be unsatisfactory (unnatural shape of the penis, its shortening). It is also important that most of the implanted prostheses make it irreversibly impossible or much more difficult to get a natural erection.

Reconstructive surgeries

In case of injured sex organs or their vessels and nerves, it is possible to carry out reconstructive procedures. They are performed in patients after traumas and traffic accidents, or with defects leading to a significant loss of function. These are mostly very complicated and technically difficult to conduct procedures, and their effect may be unsatisfactory. However, for many patients, they may be the only therapeutic option restoring a normal erectile function.

Intravascular procedures

Organic changes in the vessels are responsible for over 50% of cases of erectile dysfunction (ED) in men from the general population. This rate is even higher in the group of patients with ischaemic heart disease, diabetes, and other diseases connected with atherosclerosis of peripheral vessels. Most of the cases of erectile dysfunction of vascular origin are connected with changes within the arterial system (iliac and pudental arteries mainly).

Vessels supplying blood to the penis

One of the recently presented therapeutic methods in the treatment of ED of vascular origin is the endovascular procedure consisting of balloon angioplasty of the iliac and pudental arteries, restoration of their patency and implantation of vascular drug-eluting stents (DES). 

This is currently a field of great interest of urologists and radiologists performing vascular interventional procedures, mostly due to the potential effectiveness of this method in restoring the sexual function in men in whom the conservative treatment was not successful.

The procedure of percutaneous arterial angioplasty in patients with erectile dysfunction is very similar to other intravascular procedures on peripheral arteries if it comes to the course of the intervention, indications, and adverse effects.

Owing to the cooperation between the leading research centres and thanks to advanced studies on the role of endovascular procedures in restoring patency of vessels supplying blood to the penis, an innovative method of intravascular intervention in the treatment of erectile dysfunction has been introduced in the recent years. The VEDI procedure allows for restoration of a normal blood flow and sexual function.