What are the choices for treating
Treatment of erectile dysfunction depends first on whether the causes are mainly psychological or physical. As an example if a young patient has normal erections during sleep, if his physical examination and lab tests do not indicate a problem and if he is generally in good health--the cause is likely to be psychological. In such a case, the most effective treatment may be sexual counseling with a psychologist who specializes in sex therapy. The therapist may recommend that the patient's sexual partner be included in counseling sessions.
For erectile dysfunction with mainly physical causes, the treatment may depend on the particular problem. For example, in some men with erectile dysfunction due to pelvic injuries, surgery may be recommended. For some men with very low testosterone levels, testosterone replacement therapy may be recommended.
For the majority of men whose erectile dysfunction has mainly physical causes, there are three generally accepted treatment options: vacuum constriction devices, penile injection therapy, and penile prostheses. These treatments cannot correct the causes of erectile dysfunction, but they can help achieve a rigid penis sufficient for sexual intercourse. They work in different ways.
Vacuum constriction devices (VCDs) consist of a plastic cylinder, a vacuum pump and an elastic constriction band. There are five steps (1) Lubricant is applied to the penis. (2) The cylinder is placed over the penis. (3) Air is pumped out of the cylinder to create a vacuum, which causes an erection. (4) The constriction band, mounted on the open end of the cylinder, is transferred to the base of the erect penis to maintain the erection. (5) The cylinder is removed. The constriction band can safely be left on the penis for a half hour.
It is important for safety to use only a prescription VCD in which all parts, including the pump and the elastic constriction band, are made by a reputable manufacturer.
In penile injection therapy, vasoactive drugs are injected into the erection chambers, the corpora cavernosa. These drugs work by expanding arteries and relaxing penile tissue. Blood flow then increases into these two erection chambers, helping to cause an erection.
One frequently used vasoactive drug is alprostadil, also known as prostaglandin-E1 (PGE1). Vasoactive drugs are often used in combination. Some frequently used combinations are papavarine/phentolamine, papaverine/phentolomine/PGE1 and PGE/phentolamine.
The doctor may inject a vasoactive drug or combination of drugs as a diagnostic procedure to test how well the penis responds. If penile injection therapy is chosen as a treatment, the patient will be taught how to do the injections himself.
A penile prosthesis is a plastic device surgically implanted inside the penis so the penis can be made rigid. A prosthesis does not change the ability to urinate, ejaculate or have an orgasm.
There are two basic types of prostheses. The simpler type is a semirigid but malleable rod. The other type is inflated with fluid to make the penis stiff. An inflatable prosthesis comes in three basic designs: one-piece, two-piece and three piece. Your doctor will demonstrate these devices during your visit to the center.
What are the main advantages and disadvantages of each treatment?
Vacuum constriction devices, penile injection therapy and penile prostheses are all effective treatment options, each in its own way. Reported patient satisfaction averages over 70 percent for each treatment.
Yet, a satisfactory treatment for some patients may be unsatisfactory for others. Each has its own set of advantages and disadvantages. In addition, each patient has his own preferences. On the basis of individual preferences, patients may weigh treatment advantages and disadvantages quite differently in making a choice.
Following are some of the major advantages and disadvantages to consider for each treatment choice.
Vacuum Constriction Devices
Vacuum constriction devices (VCDs) are reliable and safe, with no serious side effects when reputable prescription devices are used properly (after patient instruction by trained professionals). If a man wants to discontinue use of a VCD and try another treatment, he has that option. About three out of four men who begin using a VCD continue to use it. Most dropouts occur in the first three months. Interruption of lovemaking is the most common complaint by VCD users and their partners. Some men also report numbness or coldness of the penis and/or discomfort when ejaculating.
Penile Injection Therapy
Injection therapy tends to produce a firm erection, which may last an hour or more. A man can inject himself before sexual activity begins. Erections occurs five to 15 minutes after the injection.
With practice, the injection procedure is easy to do. It is usually painless, though some men report discomfort following injection. This discomfort is generally mild. As with VCD therapy, the patient has the option to discontinue treatment. Most dropouts take place in the first month or two.
Injection therapy may have complications or side effects. The most serious is a prolonged erection. This is an erection lasting more than four hours. If a prolonged erection lasts too long, the penis can be injured. The doctor will provide information beforehand on how to seek treatment in case of a prolonged erection.
The chances of a prolonged erection with injection therapy range from one to eight percent, but it rarely occurs once a patient has had proper instruction and dosage adjustment. Other potential side effects with injection therapy include the possibility of scar tissue eventually forming in the penis.
For men surgically implanted with penile prostheses, patient satisfaction rates are high. They average over 83 percent for both semirigid malleable prostheses and inflatable prostheses. With a prosthesis in place, a man can create an erection whenever he wishes. The erection may be slightly shorter in length than a natural erection would be, but rigid enough for sexual intercourse. There is no change in skin sensation and no change in ability to have an orgasm.
Once a prosthesis is implanted, however, it is difficult for a patient to change his mind and choose a different treatment option. Removal of the prosthesis requires another operation.
Failure of the device is possible. Even though prostheses are constantly being improved and made more reliable, any mechanical device can fail. For an inflatable prosthesis, the chances of mechanical failure are about one out of ten. For the simpler semirigid malleable prosthesis, chances of mechanical failure are about one out of 20. Mechanical failures or other device problems usually require another operation to correct the problem.
Possible complications from surgery, such as infection, may also require removal of the prosthesis. Again, this means another operation.
Cost and time considerations in choosing a treatment.
In addition to the advantages and disadvantages discussed above, cost and loss of time from work or other activities may be considerations in choosing a treatment. If cost is a consideration, vacuum constriction devices have a clear advantage. They are far less expensive than the operation necessary to implant a prosthesis, and less expensive over time than the drugs necessary for injection therapy.
As to patient time required, usually one training session is enough to learn to use a vacuum constriction device, in addition to follow-up as scheduled with the doctor.
For injection therapy, several visits to the doctor may be necessary in the first two months to learn self-injection, adjust the dosage and check for any complications.
Implanting a prosthesis usually means one to two days in the hospital, 10 to 21 days before resuming usual activities after surgery and one or two follow-up office visits.
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Questions to ask a doctor before chooing a treatment