Treatment of erectile dysfunction

Improving your general health could help improve your symptoms. Your doctor will advise you to stop smoking, drink less alcohol, and exercise regularly.

Depending on your individual situation, your doctor may recommend that you adapt your diet. It is important to discuss this with the doctor first. As a general rule, try to have a varied diet that is low on sugar, salt, and fatty foods.

Sildenafil is the oldest available PDE5I and is available as a pill. It comes in doses of 25, 50, and 100 mg. The dosage can be adjusted according to your needs. You can feel the effects of the drug 30-60 minutes after taking it. They may last for up to 12 hours. If you eat a fatty meal right before taking sildenafil, the drug is less effective.

Topical therapies mean medications are applied to the skin. Two specific formulations of alprostadil have been approved for topical therapy. The first one is the urethral pellet medication inserted into the tip of the penis (intraurethral). The second one is a cream formulation applied to the external opening of the urethra at the tip of the penis.

Alprostadil is a well-known drug for the treatment of ED. Commonly they are considered as the second-line therapy but they can be a first-line treatment option also. The major advantage of alprostadil cream is that adverse events are very rare and there are no interactions with other drugs (e.g. blood pressure medications, blood thinners such as heparin or warfarin).

Alprostadil is absorbed from the urethra and relax smooth muscle in the vessels of the penis to increase blood flow. Alprostadil cream includes a permeation enhancer in order to facilitate absorption of alprostadil. The mechanism of action is similar to intraurethral alprostadil.

You should not use alprostadil if you are allergic to it, or if you have:

• sickle cell anaemia or the sickle cell anaemia trait
• leukaemia
• a tumour of the bone marrow (multiple myeloma)
• a curved or deformed penis
• penile fibrosis or Peyronie’s disease
• if you have a penile implant

The most common adverse events of topical therapies are local pain and dizziness with possible hypotension. In some cases, urethral bleeding and urinary tract infections occur while penile fibrosis and priapism are very rare.
Topical alprostadil has the advantage of only topical side effects that include penile erythema, penile burning and pain. Systemic side-effects are very rare.

To make sure alprostadil is safe for you, tell your doctor if you have:

• a history of blood clots
• heart disease, high blood pressure (hypertension)
• a bleeding or blood-clotting disorder; or
• a disease that could be passed in blood (such as hepatitis or HIV).

Use a condom to prevent transfer of this medicine to your sexual partner.

Extracorporeal Shockwave Therapy (ESWT) is a therapy in pulses of focussed shock waves with very low intensity is directed at the penis to improve erectile function. It consists of several sessions, and it can be repeated if necessary.

ESWT is being researched as a new treatment option for ED. It is not a standard treatment option. Specific ESWT devices are necessary to treat ED. Discuss with your doctor if ESWT is the proper treatment for you and is available in your hospital.

If you have mild ED and you cannot or do not want to take PDE5Is, your doctor may recommend ESWT. Keep in mind that ESWT is currently no standard option for the treatment of ED.

ESWT causes minor damage to the penile tissue. During the healing process, new blood vessels are formed, which increase the blood flow to the penis. This may result in an improved ability to get and maintain an erection.

Intracavernous injections are a treatment option for ED where you inject drugs into the spongy tissue in the penis to open the blood vessels.

Intracavernous injections would be a treatment option if previous treatments such as lifestyle changes or PDE5Is were unsuccessful. Although many men will be scared by the idea of placing a needle into their penis, most men who choose injection therapy quickly realize that the benefits of the injection far outweigh a tiny pinprick.

The drugs in intracavernous injections relax smooth muscle in the vessels in the penis to increase blood flow. This results in an erection 10-15 minutes after the injection, even without sexual stimulation.

The most common drug used for intracavernous injections is alprostadil. In some cases, your doctor may recommend a combination of drugs to improve the effectiveness or reduce the side effects. Common medications include papaverine, phentolamine, vaso-active intestinal peptide, atropine, and forskolin. Dosages may vary and can be adjusted as needed. Keep in mind that not all drugs are available in all countries.

You might receive in-office training from your urologist to learn how to inject yourself. In some cases, your partner may receive training as well. During the training, the urologist will also discuss the correct dosage with you.

The location of the injection is essential. Ensure to inject at the base of the penis, and between 2 and 4 ‘o clock, or 8 to 10 ‘o clock positions to not damage the urethra or the nerves and blood vessels in the penis. Then, gently apply pressure for 2-5 minutes at the injection site to prevent bruises. If the correct dosage is injected, you will have an erection within 10-15 minutes.

The vacuum erection device (VED), is a cylinder-shaped device that comes with a rubber or silicon constrictive ring that tightens around the penis. A VED makes it possible to get and maintain an erection.

You should consider a VED if PDE5Is are not effective. A VED is also an alternative treatment option if you cannot use PDE5Is or if you do not want to take medication for ED.

By placing the cylinder over your penis, you create a vacuum with a manual or an electronic pump that removes the air from the cylinder. This process draws blood into the penis so that it gets swollen and then erect.

After removing the pump you need to place the rubber or silicone ring around the base of the penis, to keep an erection. Never leave the ring on for more than 30 minutes.

It is important to be aware that the blood drawn into the penis is dark in color. As a result, your penis feels colder to the touch and looks slightly blue once the band is in place. Some people do not mind, but if this makes you or your partner uncomfortable, make sure to discuss your concern with each other, and your doctor.

It is very important to know that the ring should be removed after 30 minutes. The blood drawn into the penis is low in oxygen, and the lack of oxygen can damage the skin in the penis.

If you choose to use a constrictive ring without a VED, make sure that it is made of flexible material like silicone or rubber. Never use rigid materials such as steel or hard plastic because they may be difficult to remove.

A penile implant, also called a penile prosthesis, is a medical device that is surgically implanted into the erection chambers of the penis in case of severe ED.

There are two types of penile implants: semi-rigid, noninflatable implants and inflatable implants.

Semi-rigid implants consist of two bendable rods that are implanted in the erection chambers of the penis. They can be bent into position during sexual activity. With this type of implant, the penis is always semi-rigid, which may be difficult to conceal.

Inflatable penile implants are devices filled with fluid consisting of two inflatable cylinders placed in the erection chambers of the penis, a hand-controlled pump placed in the scrotum, and a reservoir that stores fluid when the penis is not erect. The device is inflated by squeezing the pump several times to move the fluid from the reservoir to the cylinders. Afterward, the pump is also used to move the fluid back to the reservoir (Fig. 1).

You need surgery for both types of implants. Both types of implants are placed entirely inside the body. Inflatable implants are used more often because they result in a more natural situation. In complicated cases, semi-rigid implants may be more suitable. Discuss the choice between the two implants with your urologist.