Erectile dysfunction and treatment options

Porterbrook Clinic
Sheffield Care Trust
Andrology Service
(Urology)
Sexual Fitness
For Men
Erectile Dysfunction and
Treatment Options
Information for Users of our service
Dr Kevan Wylie
Clinical Lead
Lead Clinician (Andrology)
Porterbrook Clinic
75 Osborne Road
Nether Edge
Sheffield S11 9BF
Telephone: 0114 271 6671
Fax: 0114 271 8693
Email: [email protected]
www.porterbrookclinic.org.uk
Sheffield Teaching Hospitals
What is erectile dysfunction?
ED is only diagnosed when the problem
is persistent and recurrent.
When a man is at rest, the blood vessels
in his penis are constricted so that blood
ED can affect men of any age, although
flow in the penis is very low. When he
it is more common in older men, and is
becomes sexually aroused, chemical
likely to worsen over time without
messengers are sent via the brain and
effective treatment. Around 5% of men
central nervous system to tell the blood
under the age of 60 suffer from a
vessels in the penis to relax. This allows
complete inability to gain or maintain an
the spongy tissue in the penis to fill with
erection; this figure increases with age
blood, causing the lengthening and
to around one in four at the age of 70,
hardening of the penis – an erection.
and three in four at age 80. In addition,
Once the penis is stiff, a mechanism at
around 40% of men suffer from partial
its base compresses to maintain the
ED (also known as ‘erectile instability’).
blood volume, and consequently the
rigidity, until sexual stimulation ends.
What effect does it have?
A man with erectile dysfunction,
For
sometimes called ED or impotence, will
experiencing erectile problems strikes at
regularly be unable to achieve - or
the heart of their sense of self and can
maintain - a firm enough erection to
make them feel inadequate, useless and
enjoy sexual activity. This may be either
a failure. It is no surprise, therefore, that
because insufficient blood flows into the
erectile dysfunction causes many men
penis, or because the blood drains away
distress, anxiety, and a lowering of their
from the penis almost as soon as it gets
self-esteem, all of which can easily lead
there (known as ‘veno-occlusive disorder’).
to depression. This is compounded by
a
large
proportion
of
men,
the fact that men often find it difficult to
Who is affected?
admit they have problems with their
erections, which means that often they
Most men will find they are unable to
do not seek the treatment which is
get or maintain an erection occasionally,
readily available, and instead carry the
perhaps because of tiredness, stress or
problem around as a ‘shameful secret’.
too much alcohol; this is quite normal.
Sexual Fitness for Men
This in turn will have often have a severe
This is because, whatever causes ED, but
impact on a man’s relationships. If he
the biggest single factor in keeping it
has a partner, he may withdraw from any
going is often performance anxiety.
kind of physical contact with his partner,
Because, for many men, a properly
on the basis that he doesn’t want to
functioning penis is key to their sense of
‘start what he can’t finish’. This can be
‘manhood’, the stakes are extremely
hurtful and bewildering for his partner,
high, leading to fear and anxiety every
and even more so if she does not know
time intercourse is attempted; and
what is causing the distance between
anxiety is known to have a substantial
them; many men are ashamed or
effect on a man’s ability to become
embarrassed to discuss the difficulty with
sexually aroused.
their partner and she may imagine he
also means that it is very easy for what
has gone off her, or is having an affair.
might have been a “one-off” incident to
turn
into
a
(Unfortunately, this
persistent
problem).
If he does not have a partner, he is likely
to be very anxious about the possibility
A full assessment is required to establish
of experiencing ED with a new partner,
why a man is experiencing erectile
and
problems. Some indicators might be
may
avoid
dating
and
even
withdraw socially, leading to loneliness
and isolation.
those men:
whose erectile problems come on
gradually,
What causes ED?
who also notice a decline in nighttime and morning erections, and
It used to be thought that ED was “all in
who have difficulty getting or
the mind”, but it is now thought that
maintaining an erection even during
less than a third of cases are primarily
masturbation
psychological in nature. In approximately
are most likely to have ED with a
70% of men with ED, the main cause is
primarily physical origin; whereas those
organic – although psychological factors
whose problems occur suddenly,
can still play a big role in maintaining the
who continue to notice spontaneous
problem.
erections during the day or upon
wakening, and
Erectile Dysfunction and Treatment Options
who have little or no difficulty
„ Neurological disorders. These
getting full erections when they are
include multiple sclerosis, Parkinson’s
on their own
Disease and neuropathy caused by
are more likely to find their ED has a
psychological origin.
alcoholism.
„ Pelvic surgery. The chief culprit is
prostatectomy, but other major pelvic
Common physical causes of ED
and abdominal surgery can cause
problems to the blood and nerve
„ Cardiovascular disorders.
Atherosclerosis (a hardening and
narrowing of the arteries) can lead to
high blood pressure and reduce
blood supply to the heart and to
other parts of the body, including the
penis. Smoking, high cholesterol
supply.
„ Psychiatric illness. Includes
depression, anxiety, schizophrenia
and dementia.
„ Severe chronic disease such as kidney
or liver failure.
„ Trauma affecting blood and/or nerve
levels and obesity are common
supply to the penis, e.g. spinal injury
causes of atherosclerosis. The
or from cycling, and pelvic
deterioration to the blood supply
becomes increasingly apparent with
age.
„ Endocrine and metabolic disorders.
radiotherapy.
„ Local disease such as Peyronie’s or
phimosis.
„ Side effects of drugs. A surprising
Diabetes mellitus is the most
number of commonly prescribed
common cause of ED, accounting for
drugs can cause ED, including many
approximately a third of all cases.
prescribed for the disorders described
This is because, over time, it can
above, leading to a ‘double
damage both nerve and blood
whammy’. Chief amongst these are
supplies to the penis. Other
cardiovascular drugs and those that
endocrine disorders implicated in ED
treat depression, anxiety and
include hypogonadism (although,
psychosis. Recreational drugs such
contrary to popular opinion, low
as alcohol, marijuana, cocaine,
testosterone only accounts for a
amphetamines and especially
small minority of ED cases); under or
smoking can all be implicated in ED.
over-active thyroid; and elevated
prolactin levels in the blood.
Sexual Fitness for Men
The power of the mind
„ Fear of losing control or of
contracting a sexually transmitted
Sometimes men believe they should be
able
to
produce
an
erection
to
command, any time they want – as if
getting an erection were like switching
on the TV. This is nonsense!
disease
„ Cultural or religious worries such as
guilt over extra-marital sex
„ Sexual boredom or reduced
attraction to partner
„ A significant loss such as the onset of
In addition to adequate arterial
blood and nerve supply to the penis,
men
need
adequate
sexual
stimulation and to be in the right
frame of mind before they can
engage fully and successfully in
sexual activity.
a major chronic illness, being
bereaved or being made redundant
„ Guilt over an affair – or pain over a
partner’s affair
„ Unresolved questions about sexual
orientation
„ Worrying about his penis size or
ability to satisfy his partner
Factors that can influence erection
„ Anxiety over his partner’s sexual
include:
issues, for example if his partner is
„ Psychiatric illness such as depression,
suffering from loss of interest or pain
anxiety, schizophrenia and dementia
„ Stress and anxiety at work or home,
during sexual activity.
It would also be fair to say that some
or tiredness from working long hours
men have unreasonable expectations.
„ Attempting to have sex too soon in a
For example, a thirty year old man might
new relationship, before he is
worry that he cannot make love for the
sufficiently comfortable and relaxed
third time that day when he has been
in his partner’s presence
working hard all week and is exhausted;
„ Anger, conflict or other problems in a
or a sixty year old widower in a new
long- standing relationship
relationship may worry that his erections
„ Fear of being overheard or
are ‘not right’ because they are not as
interrupted e.g. by children or
firm as they were when he first met his
in-laws
wife forty years before.
„ Fear of intimacy or commitment,
perhaps when the spectre of getting
There is no
reason why most men should not be able
to continue to have a satisfying sex life
married or having children is raised
Erectile Dysfunction and Treatment Options
into their seventies, eighties or beyond;
routinely
but that doesn’t mean that their
testosterone,
erections will be quite as quick to come
prolactin levels by arranging a blood test,
or as firm as they were when he was a
and if any of these are abnormal, further
young man.
screening may be arranged. In addition,
check
lipid,
glucose,
free
thyroxine
and
a physical examination may be arranged
It is also very important to remember
if an underlying medical problem is
that you are a man, not a robot. In his
suspected.
book ‘The New Male Sexuality’, sex
therapist Bernie Zilbergeld points out
In addition, where appropriate we offer
that, “In their attempt to run like well-
further
oiled machines, men overlook what they
RigiScan, DIR and NEVA, we can monitor
already know: that machines themselves
erectile tumescence and rigidity, both
have conditions, including being well-
during laboratory tests and at home
oiled. When we’re made aware of these
during the night; this can help to
needs we don’t get upset, we just fulfil
establish
them”. He goes on to explain how to
functioning normally, suggestive of a
identify your pre-conditions for good sex,
psychological basis for the erectile
and to work out how to get these
problems.
conditions met.
Doppler ultrasound system can evaluate
diagnostic
tests:
whether
the
with
penis
the
is
Additionally, the MIDUS
the blood vessels in the penis and
Assessing ED
measure arterial blood velocity where
‘venous leak’ is suspected. The GSA can
Because experience has shown that the
measure nerve conduction in the genital
causes of ED are usually complex, here at
area.
the Porterbrook Clinic we undertake a
rigorous assessment to build up a full
Managing and Treating ED
picture of the possible factors involved.
Men are invited to attend an assessment
Men, in particular, have a tendency to
interview with their partner, where a
think that “fixing the penis” is all that’s
thorough psychosexual, psychological,
needed to solve sexual problems caused
relationship and medical history is taken.
by ED; but this isn’t always the case. We
Following
take
the
Sexual Fitness for Men
history
taking,
we
an
integrated
approach
to
treatment at the Porterbrook and offer a
floor exercises for men’ produced by the
full range of physical and psychosexual
NHS in Sheffield).
treatments.
Third, information
We often find the best
may be given on lifestyle changes that
results are achieved when a short course
could have an impact on erectile
of sex therapy is undertaken alongside
functioning, including a referral to one of
other treatments; this is not surprising
the medical staff at the Clinic if it
when you consider that, for many
appears that medication changes might
couples, there will have been a long
be warranted. Fourth, it can help you to
period without sexual activity before
look at any underlying difficulties in the
treatment begins, and the couple may
relationship that might be exacerbating
need to learn how to be intimate with
the sexual difficulty. Finally, it can help to
each other all over again.
re-establish the sexual relationship and
iron out any of the problems that can
A brief overview of the different
sometimes arise when sexual functioning
treatments for ED is given below. We
is restored. Another leaflet in this series,
will work with you to tailor-make a
“What is psychosexual therapy?” gives
programme of treatment that is most
more
appropriate for you.
involved.
Psychosexual Therapy
Vacuum pump
Psychosexual therapy, either on your
Here a tube is placed over the penis and
own, or ideally with your partner (if you
suction is applied via an electric or hand
have one), can work on many levels.
pump (Figures 1-4). This draws blood
First, it can provide information and
into the penis where it can be trapped
support
using a special restricting ring placed at
regarding
the
different
information
about
what
is
treatment options. Second, you may be
the base of the penis.
taught how to practice pelvic floor
highly effective way of producing an
exercises (also called Kegels) regularly, as
erection and is suitable for long-term use
this will tone your muscles, increase
by most men, particularly those for
blood flow to the area and increase
whom
pleasurable sensations.
(Ask your
advisable. Sometimes partners complain
therapist for a copy of the leaflet ‘Pelvic
that the erection feels cold and there is,
drug
This can be a
treatments
are
not
Erectile Dysfunction and Treatment Options
Figure 1
Figure 2
Sexual Fitness for Men
Figure 3
of course, a lack of spontaneity.
Figure 4
Erectile Dysfunction and Treatment Options
Oral Treatments
It is very important to be clear that
none of these four drugs is an
There are currently four oral drugs
aphrodisiac: rather, they only work
licensed in the UK for the treatment of
in response to sexual stimulation.
ED. Three of these, sildenafil (Viagra),
This means that you need to be ‘in
tadalafil (Cialis) and vardenafil (Levitra)
the mood’ and to engage in sexual
belong to the group of medicines called
activity before you can expect to get
phosphodiesterase 5 (or PDE-5) inhibitors.
an erection!
Once absorbed, these help the blood
vessels in the penis to relax, which
Intracavernous injection
usually helps to produce an erection.
The fourth oral treatment, apomorphine
You or your partner are taught to inject a
(Uprima),
stimulate
drug (usually alprostadil or papaverine)
receptors in the brain to send the right
is
thought
to
into the penis shaft using a very fine
messages to the penis to produce an
needle (Figure 5).
erection.
automatic erection within around 15
minutes.
Figure 5
Sexual Fitness for Men
This produces an
The erection may continue
Figure 6
after ejaculation, but should subside
applicator, following urination (Figure 6).
within about an hour. This is a highly
The penis is then massaged for a few
effective treatment that can be used up
seconds until the drug is dissolved,
to three times a week, but some men
producing an erection within 5-10
find it uncomfortable or inconvenient.
minutes. Some men experience mild pain
related to the drug as well as the procedure.
Intraurethral therapy
Surgical treatments
This works in a similar way to the
An artificial penile implant (or prosthesis)
injection, although it is not as reliably
may be inserted surgically; one type
effective.
A small pellet containing a
maintains the penis in a state of semi-
much higher dose of alprostadil is
rigidity but allows it to be bent
introduced into the opening at the end
downwards out of the way when not in
of the penis via a special disposable
use;
another
type
uses
a
pump
Erectile Dysfunction and Treatment Options
implanted in the scrotum to produce an
Do I have to pay for treatment?
erection when required. Both of these
options carry some risk of complication,
Psychosexual therapy is available free at
such as infection, mechanical failure or
the Porterbrook. Other treatments are
erosion of the prosthesis (where the
only free if:
implant erodes through to the outside of
„ You had already been diagnosed as
the body). They should only therefore be
suffering from erectile dysfunction on
considered
14th September 1998 and were
when
other
forms
of
treatment have been unsuccessful.
receiving treatment for it on the NHS
In addition, a small number of ED cases
at that time;
caused by abnormalities in blood-flow
„ You have been diagnosed as
into and out of the penis can be treated
suffering from erectile dysfunction
by surgery.
and also suffer from diabetes
mellitus, multiple sclerosis, spinal
If you would like further information
cord or severe pelvic injury, single
about any of the treatment options
gene neurological disease,
described above, please ask for the
poliomyelitis, spina bifida, Parkinson’s
individual Clinic treatment leaflets.
disease, kidney failure, prostate
cancer or have had your prostate
removed.
In addition, if your GP and a Porterbrook
specialist consider that you are suffering
from severe distress as a result of your
ED, meaning significant disruption to
your home and work life, and a marked
effect on your mood, behaviour and
relationships, they may in exceptional
circumstances arrange for you to receive
free treatment through the Porterbrook,
or Andrology service whilst you receive
counselling and support for your distress.
Sexual Fitness for Men
For all other men, treatment is available
on private prescription.
Helpful books include:
Neither the
Porterbrook nor your GP will charge for
A New Male Sexuality by Bernie
the prescription, but you will have to pay
Zilbergeld (Bantam Doubleday Dell
for the treatment itself.
Publishing, 1999)
In addition,
most chemists will also charge a private
dispensing fee; this fee can vary, so it’s
Impotence: A Guide for Men of All Ages
worth shopping around. Some people
by Wallace Dinsmore and Philip Kell
find it cheaper and more convenient to
(RSM Press Ltd)
get their prescription by post via an NHS
service such as Pharmacy2U - Tel 0870
Coping with Erectile Dysfunction: How to
787 6210 www.pharmacy2u.co.uk or
Regain Confidence and Enjoy Great Sex
Boots Direct.
by Michael Metz and Barry McCarthy
(New Harbinger, 2004)
Further information
The Sexual Dysfunction Association
(formerly the Impotence Association) is a
UK charity providing help and advice on
all kinds of sexual problems to men and
women.
The website includes free,
downloadable leaflets, articles and
reviews
of
sex
help
books:
www.sda.uk.net
Written by ROSE WHITELEY for the Porterbrook Clinic, Sheffield
© Porterbrook Clinic 2006
Erectile Dysfunction and Treatment Options
NOTES
Sexual Fitness for Men
NOTES
Erectile Dysfunction and Treatment Options
C3
© Porterbrook Clinic 2006