Erectile Dysfunction / Impotence

What is Erectile Dysfunction?
What causes sexual impotence or erectile dysfunction?
Are all cases of impotence the same?
What treatment options are available for me?

What is Erectile Dysfunction?
Erectile Dysfunction is the science of dysfunctions of the Male Reproductive System, also commonly referred to as “impotence”.

What causes sexual impotence or erectile dysfunction?
Impotence or erectile dysfunction has been and continues to remain an extremely common disorder that is said to afflict as many as 10% of the male population. Andrological research in the past years has advanced tremendously and has established conclusively that in 80% to 90% of the cases of chronic impotence, the cause is not in the mind but in the body.
Some causes of impotence include:

• Diabetes Mellitus
• Hypertension (also know as High Blood Pressure)
• Atherosclerosis
• Renal (Kidney) Failure
• Heart Disease
• Neurological Disorders such as Multiple Sclerosis, Parkinson’s Disease, Stroke, Paraplegia, or Spinal Cord Lesions
• Sudden Pelvic or Perineal Injuries
• Gradual Injuries, as in bicycle-riders
• Surgery on areas such as Bowel, Rectum, Bladder, Spine, Prostate, Urethra
• Local Problem such as Peyronie’s Disease
• Some Prescribed Medications

Are all cases of impotence the same?
No. There are several types of impotence:

• Arteriogenic – In this case, the arteries supplying blood to the penis do not bring in enough blood to cause an erection. This can occur because of the narrowing of arteries in the elderly, in diabetics, in those with high blood pressure, or injury to the pelvic region which causes a block in the artery to the penis (which is most common in younger patients). This is also found to be common in bicycle and other riders because of the sustained friction to the region.
• Venogenic -- In this case, the veins of the penis leak blood and prevent the development of a rigid erection. This type of impotence is extremely common and can occur either from birth or suddenly after years of normal sexual function.
• Neurogenic – In this case the nerve supply to the penis is interrupted. In order for an erection to be initiated and maintained a proper conduction of impulses along the delicate nerve supply to the penis is required. These nerves activate the veins and alter the dynamics of blood flow between them. This type of impotence occurs mostly in men who have had back or spinal injuries, injury to other nerves supplying the penis, a wide variety of surgical procedures that can cause incidental injury, disorders of the nervous system, and most commonly diabetes. Impotence is extremely common in diabetics and as many as 50% of all diabetics are impotent.
• Endocrinological (or Hormonal) – This case occurs when there is an imbalance or insufficiency of sex hormones in the blood stream. Generally, hormonal changes can affect the libido (or sex drive) rather than the quality of the erection.
• Mixed – Sometimes, more than one factor can be operative in the same patient. Such patients generally have systemic disease (for example, diabetes, kidney failure, and liver failure).
• Psychogenic – Before labeling a case in such a manner, a thorough investigation is necessary to prove that no organic or bodily cause exists. Only the can treatments proceed.

What treatment options are available for me?
There are several treatment options available for impotence, among them:

• Sexual Counseling – This can be extremely effective in helping patients deal with sexual problems, such as impotence caused by psychogenic reasons.
• Oral Medication –
• Hormone Replacement Therapy--
• External Vacuum Devices –
• Penile Injections –
• Microsurgery –
• Etc.

Choices For Men With Erectile Dysfunction: Which Pill Is Right For Me?
Bruce R Kava, MD FACS
Assistant Professor of Urology
University of Miami School of Medicine
Chief, Urology Service
Department of Veterans Affairs Medical Center
Miami, Florida

Erectile dysfunction affects 30 million men in the United States, who spend $1.7 billion dollars a year on products to improve their sexual function. It is hard to remember a time in which a major sporting event did not have an endorsement for one of these products. While the pharmaceutical companies would like us to think that taking a pill can invigorate us to hit a home run like Rafael Palmeiri, or throw a football through a tire with the pinpoint accuracy of a NFL quarterback, they do not mention that these medications are not for everyone. They are drugs that have potentially life threatening side effects, and should not be purchased without a prescription from a doctor that is knowledgeable not only about the drugs, but also the person that is taking them.

ED: A Common Condition in Men
Erectile dysfunction or “ED” is defined as the inability to obtain or maintain an erection sufficient for satisfactory sexual activity. It is the most widely studied disorder of male sexual function. Other less publicized disorders include: disorders of sexual desire, ejaculatory and orgasm disturbances, as well as disorders involving penile pain or curvature. ED is highly prevalent in the adult male population, and may effect as many as 50% of men between the ages of 40-70 years old.

In order to develop an erection, blood must be able to rapidly enter the male penis through two small arteries that course through the lower pelvis, just under the scrotum. The trigger for this blood flow event lies within the muscles that line the inside of the penis which relax involuntarily when there is sexual stimulation. Over the last 15 years a large amount of research has gone into defining the physiology of male erections. What has become clear is that for a man to develop a satisfactory erection there must be adequate blood flow, a well functioning nervous system, and a reasonable level of circulating male hormones such as testosterone. Diseases that affect any of these body systems can cause ED. In fact, population studies have confirmed that age, high blood pressure, diabetes, heart disease, cigarette smoking, excessive alcohol consumption, and low male hormone levels are significant risk factors for the development of ED. In addition, there are a large number of medications that are used to treat these disorders which may also cause ED.

Prior to the late 1990s, the only treatment available to men with ED were medications that could be injected directly into the penis, a vacuum canister that was applied to the outside of the penis and created an erection through suction, and surgical placement of a prosthetic device into the penis and scrotum. While these treatment options are still available, and provide very satisfactory results in many men with ED, they are not the first choice for the majority of men with ED. What was clearly needed was a pill that could be taken to improve erections.

The Little Blue Pill:
In 1998, Pfizer received approval for a new pharmaceutical agent that dramatically enhanced erections in men when compared with a placebo group. Sildenafil, whose trade name was Viagra was an immediate success. It proved to be highly effective in men suffering from ED as a result of a wide range of causes including: diabetes, high blood pressure, heart disease, depression, atherosclerosis, medication induced ED and following prostate cancer surgery. Over the last several years, Viagra has proven to be extremely safe, even in men with heart disease. It is easily tolerated and has a few side effects which can each occur in up to 15% of patients. These side effects include headaches, upset stomach, nasal stuffiness, dizziness, blue visual changes, and flushing. These side effects are not particularly dangerous, and are dependent upon the dose taken: the higher the dose, the greater the chance of one of the side effects occurring. As a result, most men will start at 25mg or 50mg and may increase the dose to 100mg if needed. Viagra is taken at least an hour prior to engaging in sexual activity, and is preferably taken well after consuming a meal due to the fact that fatty foods can interfere with its absorption into the blood stream. The use of Viagra is absolutely contraindicated in men taking any type of nitrate (including, but not limited to nitroglycerine, isosorbide, and imdur) and it should be taken with caution in men taking certain prostate medications such as terazosin (Hytrin) or doxazosin (Cardura). When taken at higher doses, these drugs can interact with Viagra and cause a drop in the blood pressure and make someone feel dizzy.

Newer ED Products
Vardenafil (Levitra) and tadalafil (Cialis) are both members of the same class of drugs as sildenafil (Viagra). They all interfere with the breakdown of an enzyme called PDE5. By impairing the breakdown of this enzyme in the penis, there is more smooth muscle relaxation, and as described above, more penile blood flow. Both vardenafil and tadalafil are highly effective in men with ED compared with placebo controlled men.

While all three of these medications are effective in up to 70% of men with ED, and all three drugs work by a similar mechanism of action there are significant differences between them. These differences are primarily in the duration of action, the time of onset of action, and side effect profiles. It is important to note that there have been no head to head trial comparing all three of these agents, nor is there expected to be a study in the near future.

Vardenafil (Levitra) received FDA approval in August, 2003. It can be taken in 2.5, 5, 10, and 20 mg doses. While higher doses may improve its efficay, the risk of side effects also increases with dose as well. Vardenafil has a rapid onset of action, between 30 and 45 minutes. This is slightly faster than the other two agents. While laboratory testing has shown that it is has a greater ability to bind to the PDE5 enzyme than the other two drugs, a variety of factors related to its absorption into the blood stream counteract this. As a result, it is no more effective than the other two medications. Vardenafil has a similar side effect profile to sildenafil, and can cause headaches, visual disturbances, dizziness, and headaches. It should never be taken in anyone taking nitrates, and also should never be taken by someone taking any prostate medications such as terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), or alfuzosin (Uroxatral).
Tadalafil (Cialis) is the newest medication approved for male ED. While it has a slower onset of action, which can occur at 45 minutes to 2 hours after taking the medication, it has the distinction of being effective for up to 36 hours. This may improve the spontaneity of sexual activity for some couples. It also however may increase the amount of time during which a side effect may be present. Its interaction with a different type of PDE enzyme in the body may cause back and muscle pain in some people, which may last for the 36 hours in which the medication is present in the blood stream.

Tadalafil should never be taken by patients who take nitroglycerine and any of the prostate medications other than 0.4mg of Flomax (tamsulosin). It has a slightly lower incidence of upset stomach, flushing, and visual changes than the other two medications.

Choices for Men with ED
With three oral medications available for male ED, men have a variety of choices related to drug effectiveness, the amount of time that it needs to take affect, the duration of the affect, as well as medication side effects. We at the Department of Urology at University of Miami School of Medicine are working closely with the pharmaceutical companies to better define which medication is better for certain individuals. We also are striving to develop ways to counteract some of the side effects of the drugs as well as improving their success. Our goal is to tailor an ED regimen that is best for the individual, whether involving oral medications. injections,or surgery.

Sexual health is a right of all individuals. The three medications available to treat men with ED work very well and are extremely safe when used by appropriate individuals. For men who are embarrassed about talking about issues related to sex with their doctors, these drugs have become a useful starting point to begin a discussion.

Sexual health has been found to significantly improve the quality of life and provide a sense of well being for individuals. When there is a problem in the bedroom, it may in fact unmask a medical problem like diabetes or heart disease that you may not know about. In fact, recent studies have confirmed that erectile dysfunction may in fact antedate a cardiac event by several years in many individuals. One of our goals is to help you find out whether you have an undiagnosed medical condition that can lead to ED. At the Department of Urology in the University of Miami Medical Center, we provide you with a compassionate and totally confidential evaluation. If you have a problem with ED or another sexual problem, please call us at 305-243-6630.