ERECTILE DYSFUNCTION
Treatment of Erectile dysfunction is a very personal journey, it is important that we establish your individual goals. Whether you aim to achieve erections suitable for sexual activity, to maintain the health and length of your penis, for self-satisfaction or to promote a positive sense of self we will work with you to guide you through your penile rehabilitation and sexual renavigation journey. If you have a partner, they are an important part of your journey and we do encourage you to bring them to your appointments
Erectile dysfunction (ED) is a common issue for men over the age of 40 with a significant number of Australian men suffering from it. ED can understandably have an impact on sense of self and quality of life. There are many causes of erectile dysfunction and often the cause is multifactorial. Psychological factors such as life stressors, performance anxiety and depression are common causes of ED. More serious medical conditions related to ED are vascular and metabolic disorders, such as narrowing of the arteries, high blood pressure and diabetes. Hormonal issues such as low testosterone and the use of prescription, recreational drugs, cigarette smoking and alcohol can cause ED. Lastly, neurogenic ED is caused by interference with the nerve function, such as with surgery for prostate cancer and some surgeries on the bowel.
Achieving an erection is a complex process involving vascular, hormonal, neurological and psychological components. There are two tubes of spongy tissue called the Corpora Cavernosa that run the length of the penis. During arousal the brain sends messages to the erectile nerves which release chemical messengers called neurotransmitters, these neurotransmitters signal the arteries supplying blood to the spongy tubes in the penis to fill with blood. The spongy tubes expand and pressurise to stop the blood from draining out of the spongy tubes until stimulation is complete. Men with healthy erectile function can achieve erections with arousal/ stimulation, and experience erections during the night when they are sleeping.
Dependent on your prostate cancer you may or may not have a nerve sparing prostatectomy. Even with a nerve sparing prostatectomy the nerves will need time to recover. This recovery time can vary from a few months up to two years. Recovery of erections post prostatectomy is variable between patients but age, baseline sexual function, comorbidities and technical considerations with surgery will have an impact on your individual recovery. There are many interventions available to treat ED post prostatectomy. We will work with you to establish your individual goals and then implement an individualised treatment plan. For many men the goal of treatment is to achieve erections suitable for sexual activity, whereas some men who are not sexually active aim to maintain the length of their penis and to optimise the health of their penis. Pharmacologically (tablets and injections) or mechanically induced erections are important to avoid the adverse structural damage that can occur while you are not having natural erections. If penile rehabilitation is started early after surgery, adverse changes such as penile fibrosis (scarring) and loss of length and girth can be prevented.
Men who have undergone surgery on the lower portion of the bowel may also experience erectile dysfunction due to damage to the nerves responsible for erections. Penile rehabilitation should be commenced to maintain penile health and prevent loss of length and girth and effective treatment offered to achieve erections. Sense of self and adapting to intimacy with a stoma is an important topic and you may find it beneficial to invite your partner to your consultation.
Many men and their partners wonder how things will be with altered erections. We refer to recovery as sexual renavigation as it is likely that the sexual experience is altered in some ways when you have erectile dysfunction. By learning about sexuality and pleasure many men and their partners find they can heighten the sexual experience by shifting their mindset to ‘pleasure focused’ activities. Simple sex education is not to be underestimated!
Despite ED, in most cases libido, arousal and pleasure pathways remain and men are still able to orgasm with or without an erection. Maintaining intimacy is important and many men and their partners find that intimacy and outercourse is pleasurable and they can maintain a good sex life. With the use of tablet, injectable medications and / or vacuum pumps and other aids many men achieve full erections which are satisfying and report good quality of life with these treatments. Post-prostatectomy as the prostate secretes the seminal fluid, orgasm and the ‘sense of completion’ remain but there is dry ejaculate. Sometimes climacturia (leakage or urine with orgasm) occurs, there are conservative interventions to help with this which can be discussed with you.
Pharmacologically (tablets/injections) and mechanically induced erections prevent the structural damage associated with infrequent or no erections. Evidence shows that a penile rehabilitation program will prevent structural damage and may offer men a better chance at recovering normal erectile function. We will discuss your individual goals with you and discuss maintaining intimacy in the event of loss of erections. Managing anxiety related to lack of erections and performance issues is important as high anxiety levels will further impair the ability to achieve and maintain erections. The treatment options available for ED range from simple non-pharmacological interventions such as a vacuum device and other aids, to the use of tablet medications and in suitable patients the use of injectable medications or a penile prosthesis.
Medications such as Viagra, Cialis, Spedra and Levitra are PDE5 inhibitors (PDE5i) and through various complex processes cause vasodilation (increased blood flow) to enhance erectile responsiveness. Taking these medications as instructed is crucial as the medications will not spontaneously provoke an erection, stimulation is necessary. Mindset is crucial to success.
As with any medication there are potential side effects, and these medications are unsuitable for some men with specific cardiac (heart) conditions.
The different tablets have different onset and duration times and can be taken daily or ‘on demand’. When using an ‘on demand dose’ (taken when an erection is wanted) men should try these on multiple separate occasions before deeming them ineffective as the response to PDE5i increases with successive doses. To produce an erection these medications require functioning nerves, in the early days post prostatectomy or bowel resection when your nerves are yet to recover, the medication is unlikely to produce an erection. As the nerves recover over time and you start to notice some erectile function, PDE5i can be re-trialled if they have not previously worked.
Vacuum erection devices (VED) offer a safe, low cost and drug free option for both penile rehabilitation and achieving an erection for sexual activity. Using the VED to maintain the health of your penis should be thought of ‘a gym for the penis’ as there is some evidence that with regular use you are maintaining elasticity through stretch, maintaining length, and reducing the risk of scarring over time. The flaccid penis is placed in a cylindrical tube sealed at the base of the penis to enable suction. Through pumping the device up and down the pressure in the cylinder is reduced and venous blood is drawn into the corpora cavernosa (spongy tubes) leading to engorgement. A constriction band can be used to maintain the erection. The constriction ring should not be in place for more than 30 minutes else there is a risk of ischemic damage (reduced blood can damage the penile tissue).
Pumping should not be vigorous as bruising can occur. The motion should be slow and steady, and it is essential to use sufficient lubricant. Perseverance is the key to VED success. VED are highly effective when used correctly and with the use of easy to manoeuvre devices can be incorporated into sexual activity. There are various devices available, please see our blog page for more information on pumps!
For more information on pumps, read our PUMP IT UP blogs
Intracavernosal injections (ICI) involve injecting a medication into the spongy tissue of the penis. The medication produces a rigid erection within a few minutes and is NOT reliant on functioning nerves, so has a very low failure rate. Penile injections are great for men who have side effects with tablet medications. The quick action of the medication is excellent for spontaneity and can often be a cycle breaker of performance anxiety.
Once the apprehension of self-injecting is overcome and adequate dosage is established, ICI is a very effective treatment choice. Needle phobia can be combatted with ‘needleless’ injecting devices or by a willing partner injecting for you! Penile injections are a treatment option regardless of whether or not you are sexually active, many of our patients opt for penile injections just to maintain sense of self, for self-satisfaction or simply restoring a bodily function.
For men who have undergone prostatectomy or a bowel resection resulting in erectile dysfunction this treatment option is often chosen as the medication is not reliant on functional nerves as with the tablet medications. Subsequently, they offer a great treatment option in the early weeks – months post-surgery whilst the nerves are recovering, and in the event of a non-nerve sparing surgery.
Men are carefully educated about preparation of the medication and safe self- injection. It is important to be guided by a specialised, experienced health care professional. You will be well supported through the journey of incorporating penile injections into your life and have a point of call for troubleshooting.
A penile prosthesis is a surgically implanted prosthetic device. An implant is placed into the corpora cavernosa which is connected to an implanted fluid reservoir and an activation button which is implanted in the scrotum. The penile prosthesis presents a great option for men who have failed less invasive treatment measures. The penile prosthesis is a last line treatment option as once the prosthesis is implanted, other treatment options would be ineffective.
Men who are overweight, have high blood pressure, high cholesterol or diabetes are at much higher risk for erectile dysfunction. Implementing an exercise regime, being mindful of your diet and ensuring you are of healthy weight is crucial for optimising erectile function, and erectile function recovery. We work in collaboration with exercise physiologists and physiotherapists to help you implement sustainable and enjoyable lifestyle changes.
Salonia, A., Bettocchi, C., Boeri, L., Capogrosso, P., Carvalho, J., Cilesiz, N. C., Cocci, A., Corona, G., Dimitropoulos, K., Gül, M., Hatzichristodoulou, G., Jones, T. H., Kadioglu, A., Martínez Salamanca, J. I., Milenkovic, U., Modgil, V., Russo, G. I., Serefoglu, E. C., Tharakan, T., Verze, P., & Minhas, S. (2021, Sep). European Association of Urology Guidelines on Sexual and Reproductive Health-2021 Update: Male Sexual Dysfunction. Eur Urol, 80(3), 333-357. https://doi.org/10.1016/j.eururo.2021.06.007