Clearing Up ED

Erectile dysfunction expert explains treatments and misconceptions

/ Author:  / Reviewed by: Robert Carlson, M.D

Erectile dysfunction (ED) or impotence cramps the sex lives of millions of men around the world. ED is a sensitive issue for many men. As such, some patients may feel timid to talk about their erection problems, which may lead to some serious misconceptions about the condition.

dailyRx News had the recent privilege of speaking with Parviz Kavoussi, MD, a dailyRx Contributing Expert and urologist in Austin, Texas who specializes in male infertility and sexual medicine.

Dr. Kavoussi laid out the basic facts about ED and addressed some common misconceptions about the condition.

dailyRx: What is ED?

Dr. Kavoussi: ED is the inability to achieve or maintain an erection that is satisfactory for intercourse. This can include losing an erection before or during intercourse, getting a partially rigid erection, or getting no erection at all.

dailyRx: How common is ED?

Dr. Kavoussi: It is estimated that over 30 million men in the United States alone and over 100 million worldwide suffer from erectile dysfunction. This number is projected to increase.

dailyRx: What conditions are associated with ED?

Dr. Kavoussi: ED is associated with diabetes, high blood pressure, smoking, high cholesterol, vascular disease, neurologic disease, prostate diseases, and some treatments of prostate diseases. ED is more common as men age, but age alone does not cause ED. It is the more common occurrence of certain health issues in men that come with age that are associated with ED.

dailyRx: What are the available treatment options for ED?

Dr. Kavoussi: Oral medications such as Viagra, Levitra, and Cialis are typically the first line of therapy for most men with ED. Not all men are candidates to use these medications and they can be unsafe in certain circumstances. This will be discussed during the consultation with the doctor. These medications will be effective in approximately 70 percent of men who use them properly.

Vacuum erection devices have been used to treat ED for nearly 100 years and have been FDA approved. A vacuum erection device consists of a clear plastic cylinder with an opening over one end that is placed over the penis. A hand or battery operated pump is connected to the cylinder which creates a vacuum by pulling air out of the cylinder to increase blood flow into the penis. Once an erection is achieved, an elastic ring is placed around the base of the penis to keep the rigidity of the erection. The elastic ring should not be kept on the penis for longer than 30 minutes to minimize the risk of injury.

Urethral suppositories are small medicated pellets that are inserted into the urinary channel, the urethra, using an applicator. The only FDA approved urethral suppository is MUSE®. The medication absorbs into the tissue of the penis to increase blood flow and result in an erection. MUSE will typically work within 5-10 minutes of administration and sexual activity may be attempted once a rigid erection is achieved, typically within the first 30 minutes after use of the medication. The erection may last after ejaculation, but loss of the erection is expected within an hour of using MUSE. Patients are trained to administer MUSE in the office, before being allowed to do it at home.

Self-injection therapy has been used for ED since the early 1980s. This consists of injection of medication through a very small needle directly into the penile body (corpus cavernosum) to increase blood flow and cause an erection. Most men describe the sensation of the injection like pulling a hair out of the skin. The injection is performed approximately 5-10 minutes prior to sexual activity. This may seem like an unpleasant or scary treatment, but it is a quick and easy technique that most men tolerate quite well. Patients are trained to do injections in the office before they are allowed to do it at home.

Penile prostheses or implants are a good option for treating men with ED who have failed other more conservative treatments such as oral medications. Penile prostheses are surgically inserted into the body of the penis and are completely concealed within the body. The procedure replaces the tissue in the body of the penis with cylinders to allow for rigid erections.

There are two main types of penile prostheses. There are semi-rigid malleable rods, e.g., positionable implants and inflatable penile prostheses.

The semi-rigid malleable device is placed by inserting a pair of flexible rods within the erection bodies of the penis under general anesthesia. Men can then bend the penis in either an erect or flaccid position.

The inflatable penile prostheses consist of hollow cylinders that are placed within the erectile bodies of the penis under general anesthesia. A pump is used to transfer saline (salt) from a reservoir to the cylinders through tubing to create an erection. A button (release valve) is then pressed on the pump, which is placed inside the scrotum in a position which is easily accessed and felt, to transfer saline out of the cylinders and back to the reservoir to return to a natural appearing flaccid state.

For either type of prosthesis, one small incision is made to place all of the components. This is almost always performed as an outpatient procedure with the patient going home on the same day and almost always without a catheter. The surgery typically takes an hour or less.

Ninety to 95 percent of penile prostheses result in erections satisfactory for intercourse. They offer the advantages of very natural appearing erections and flaccid states and spontaneity without having to wait for any type of medicine to work. There is a greater than 90 percent satisfaction rate with men who have undergone penile prosthesis placement; 92 percent of men would recommend it to other men; and 90 percent of these men’s partners would recommend it to others.

dailyRx: What are the costs of these treatments?

Dr. Kavoussi: Oral medications are typically around $100-$120/month for either a low daily dose or six to eight on-demand higher doses to be used just when needed.

Vacuum erection devices can range between $300 and $700 depending on the model.

Urethral suppositories are around $350 for six suppositories, which is the typical monthly number provided. That is if insurance does not cover it, which is often the case.

Self-injection therapy for the FDA approved non-compounded product is between $450 and $700 for six injections, which is the typical monthly number provided. That is if insurance does not cover it, which is, again, often the case.

Penile prosthesis implants are typically covered by private insurance, almost always covered by Medicare, and typically just require a copay. If they are not covered, they are expensive, in the range of a new car.

dailyRx: What are some common misconceptions about ED?

Dr. Kavoussi: It used to be believed that ED was 90 percent primarily psychogenic (psychological) and only 10 percent physical. We now understand that it is the other way around.

We believe that the source of ED is physical 90 percent of the time and solely psychological 10 percent of the time. That being said, the majority of men with physical sources for ED compound the problem as it impacts them psychologically.

A common misconception is that ED is only an indicator of sexual health. The truth is that we now know that ED is a marker for a man's overall health status.

It was previously believed that ED was related to aging. The incidence of ED certainly increases with age, but it is not directly a result of aging as much as it is a result of the comorbid health conditions that can go along with aging. The prevalence of ED mounts with comorbid conditions including type 2 diabetes mellitus, obesity, cardiovascular disease, cigarette smoking, hypertension, and abnormal cholesterol parameters.

It has been established that ED is a predictor of cardiovascular disease in men. In fact, the future risk of cardiovascular events associated with ED is comparable to the future risk of cardiovascular events in men who are cigarette smokers or have a family history of cardiovascular disease. Multiple studies are correlating ED with a significantly higher risk of cardiac events, such as heart attacks. Men with ED are 45% more likely than men without ED to experience a cardiac event after 5 years of follow-up and have an 80% higher risk of subsequent coronary artery disease at 10 years.

In essence, ED has become a marker for a man's overall health and should be used as a screening tool.

Other misconceptions about ED include:

  • A man is less of a man somehow if he has ED. As our understanding of different problems on men's nerves, blood vessels, and hormones has advanced, it is clear that ED is no reflection of an individual's manliness.
  • ED can't be fixed. Almost all cases of ED are treatable, it just depends what the appropriate treatment for each individual man is and if they are willing to use that treatment.
  • Tobacco, alcohol and drugs don't effect erections. It is clear that they do.
  • If a man has ED, he must not be attracted to his partner. The biological causes of ED typically outweigh this misconception.
  • It is expected that my erections are going to worsen with age. Although this appears true when looking at population statistics, it is not age that causes ED, but the more common occurrence of certain health issues in men that come with age that are associated with ED.

We would like to thank Dr. Kavoussi for taking time to share his expertise on erectile dysfunction.

Review Date: 
October 24, 2012