Treatments for Impotence

Impotence (erectile dysfunction) is a common problem in men, and can be caused by many factors. Medical problems such as diabetes, high blood pressure, cardiac disease and peripheral vascular disease can all make erectile dysfunction more likely, and smoking is a major risk factor. The number of men with impotence increases with age.

Impotence is a common problem after treatments for prostate cancer. The impact of treatments depends on a number of factors including:

• Type of treatment (surgery, brachytherapy, external radiation, hormones)
• Time since treatment
• Your erectile function before treatment
• Other medical conditions that you may have

Many men are not aware that treatments are available. Another problem with getting treatment is that impotence can be a difficult topic for men to discuss, but urologists are aware of the problem and are used to talking about it. Sometimes the problem may be related to stress or anxiety and this can be helped as well. Impotence should not be something that you suffer with alone, and your urologist will be able to discuss the issues with you in detail.

Tablet treatments for erectile dysfunction

For men who need treatment, it is usual to start with oral medications (trade names for available drugs are Cialis, Levitra and Viagra). These treatments require the presence of functioning nerves to work, and so are unlikely to be effective if you have had prostate surgery that has affected the nerves. However, some recovery is possible even if nerves have been damaged, so tablets are a sensible place to start.

There are side effects associated with these tablets, and they cannot be taken if you also take nitrates or GTN spray. Talk to your doctor if this is the case. These side effects include back pain, indigestion and headache.

If the tablets do not help (you are encouraged to try them on a number of occasions) then the next steps to consider are injection therapy or a vacuum device.

Injection treatment for erectile dysfunction

This form of treatment involves self-injection with a very small needle near the base of the penis a short time before you wish to have intercourse. Once you have been taught how to do it, it is easy and results can be very good.

Vacuum device for erectile dysfunction

The vacuum erection device is another method of obtaining erections. It looks cumbersome, but once you get the hang of how to use it, it can be a good method. The device creates a vacuum which draws blood into the penis, and a temporary rubber constriction ring is then placed around the base of the penis. When you wish the erection to subside, you simply remove the ring.

Inflatable penile prosthesis for erectile dysfunction

Insertion of a penile prosthesis is an operation for erectile dysfunction that has not responded to other forms of treatment. Although recovery from the operation is generally quite quick, it should be considered very carefully as if the device is removed, you would not be able to get an erection again with another form of treatment.

The device is reasonably complex, and highly engineered. It consists of three parts, as shown in the diagram below. Essentially, the device uses fluid to fill two rods, and these give an artificial erection.

The two rods are inserted into the penis, and these are connected to a fluid reservoir (inserted into the lower abdomen), and to a pump (inserted into the scrotum).

By squeezing the pump, fluid is moved from the reservoir to the rods, which lengthen (and some devices also expand). When you no longer wish to have an erection, pressing the small button on the pump causes fluid to move from the rods back to the reservoir, and the erection goes away.

The link below takes you to a video animation of how the device works.

What is the erection like with an inflatable prosthesis?

It is important to have realistic expectations of the results of surgery, and a urologist will discuss this with you in detail. Although this operation can allow you to regain an active sex life, the erections are not spontaneous, and need to be initiated by you pressing the pump. Also, although most sensation during intercourse comes from the glans (head) of the penis, which is relatively unaffected by the operation, both partners report different sensations than they used to feel when erections were spontaneous. For men, sensation may be reduced, and for women, it is common to report that the penis feels ‘cold’ during intercourse. The implant will not make your penis larger. An approximate guide to erect penile length after the operation can be given by putting the flaccid penile on full stretch.

Potential side effects and complications of an inflatable prosthesis

All procedures have the potential for side effects. Although these complications are well recognised, the majority of patients do not have problems after the operation. Listed below are some of the complications that can occur. This is not an exhaustive list, and should not be considered as advice; you need to discuss these issues in a consultation with a urologist.

Common complications of a penile prosthesis include:

• Pain after the procedure, in the penis, scrotum and wounds. This is usually well controlled.
• Some bruising around the scrotum. This should be minimal.

Rare complications of a penile prosthesis include:

• Intra-operative complications, which require halting the procedure, and re-booking for a later date. These will be discussed with you, but include injury to the urethra, and perforation of the corporal bodies (where the cylinders are put in).
• Early or late infection of any part of the device. Because the device is a foreign body, if it gets infected the whole device will need to be removed and a new one reinserted at a later date.
• Erosion of part of the device through the skin. This normally requires removal of the entire device, as infection is usually present.
• Early or late failure of the device (see figures below for a rough guide)

To give an idea of complication rates, a study of 955 penile prostheses implanted in an Australian Centre showed the following results:

• An intraoperative complication rate up to 3%
• Infection on the prosthesis requiring removal =1%
• 90% of the implanted prostheses still work at 5 years
• 85% of the implanted prostheses still work at 10 years
• 90% of men are satisfied with the outcome, to the point that they would make the same decision again.

Reference: Chung E, Van CT, Wilson I, Cartmill RA. Penile prosthesis implantation for the treatment for male erectile dysfunction: clinical outcomes and lessons learnt after 955 procedures. World J Urol. 2013 Jun;31(3):591-5.

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Disclaimer

The author of this article does not endorse the use of any particular device or treatment for erectile dysfunction. This information is intended as an educational guide only, and is here to help you as an additional source of information, along with a consultation from your urologist. The information does not apply to all patients. Not all potential complications are listed, and you must talk to your urologist about the complications specific to your situation.