Erectile Dysfunction / Urinary Incontinence
Email Raji.Kooner@svha.org.au or call 02 8382 6980 for a confidential appointment.
Erectile dysfunction is a very common condition in our society.
Erectile dysfunction is the inability to have an erection sufficient for penetration.
40% of 40 year olds and up to 70% of 70 year olds will have suffered some degree of erectile dysfunction at some stage.1, 5
Despite being a relatively common condition in our community, there’s a lot of people that have erectile dysfunction that don’t seek treatment.
This is indeed unfortunate as there are a lot of good treatments available and patients need to be educated regarding these.
Importantly erectile dysfunction is also a marker for possible other health conditions2 and we should look at erectile dysfunction as a sentinel event for patients.
It can be a marker for vascular disease, maybe the patient that has erectile dysfunction may have some heart disease and other issues and so hence it’s important for us to investigate these other possible co-existing problems and we can really benefit a patient’s overall health.
So the usual test that we do for erectile dysfunction is a hormone evaluation.3 We would do baseline blood tests, initially a full blood count, electrolytes, liver function tests. We check the thyroid, we check for diabetes by doing a blood sugar level. We check for the cholesterol and triglyceride levels. We check the blood pressure on a patient. We then do the hormone test which is testosterone, serum hormone binding globulin, prolactin, FSH and LH to make sure there’s no problem with the hormonal axis in that patient.
We do a cardiovascular examination, an examination to check for pulses, make sure the patient has good pulses present. We examine the testes, we check the prostate to make sure there’s no evidence of prostate cancer. Once we’ve done all those tests we then look at managing a patient.
Sometimes patients can have a psychological component for erectile dysfunction. So it’s important to discuss the family dynamics, the family situation, the marital status etc and occasionally patients may just need counselling and or medical therapy for improvement.4
The first step in treating erectile dysfunction after assessment and review of psychological factors is to trial the use of oral agents.
These are known as phosphodiesterases inhibitors. These have really revolutionised the management of erectile dysfunction5, prescription medication agents are commonly used. They’re given usually on demand, so they’re taken half an hour to an hour before sexual activity.
It is important to remember that patients to have be in the mood for these to work, they won’t just work miraculously.
They actually have quite a low side effect profile rate, some dyspepsia or tummy upset, nasal stuffiness and rarely some nausea or some headaches.6
Studies have shown that there’s no increased risk of any heart problems with these medications6 but if you’re on any nitrates, special heart medications. It’s important to tell your doctor because they interact with these.
One particular prescription medication is somewhat unique in that it be given on a lower dose on a daily basis.
In this way if patients don’t wish to take it on a demand basis or they’re embarrassed about taking it and don’t like the idea of planning for sexual activity, they can take a lower dose on a daily basis and this can be efficacious7 for example for single people who don’t have a partner.
Sometimes taking these medications is all that’s needed to improve erectile dysfunction and patients can then stop taking them because their cause might be psychological. So that’s usually my first step with erectile dysfunction.
The second method worth investigating is the use of a vacuum pump device.
This is a device that is inserted over the penis, the patient purchases this, there’s a one off cost.
The patient pumps the vacuum pump, it creates a negative pressure, the penis becomes erect the patient slips a band, a firm band over the base of the penis. This allows the patient to have sexual intercourse without the cost of oral therapy.
The disadvantage is that there’s a bit of a “hinge effect” because the erectile tissue goes inside the patient and the vacuum pump only works on the outside part. The vacuum pump is, however, relatively easy to use, inexpensive once you’ve purchased it and you can reproduce the erection consistently every time.8
The third option is penile injection therapy which is prostaglandin or triple-mix injections.
These are injections that are given into the penis.
The patient draws a little amount of the medication up into a tiny insulin syringe and injects it into the side of the penis.
Initially this can be quite daunting or concerning for patients but once they try it it’s very simple, it’s like patients giving themselves an insulin injection when they have a diagnosis of diabetes.
It’s very efficacious9, it takes five or 10 minutes to have an effect and it can last up to half an hour to an hour depending on the dosage that’s used.
The success rate for injection therapy is very good9 but it’s important if it’s not right initially to see your doctor again to get the dose rechecked and ensure that you’re using it properly.
The main side effects are some scarring that can occur from where the needle is put into the shaft of the penis but if you rotate this site (change the injection site regularly) that risk is very low.
The other side effect is priapism which is a prolonged erection. That usually occurs if the dose has not been given appropriately and it’s quite rare if the dose is given at a low dose initially.10 But if patients get an erection that will not settle, it’s important to go to the accident and emergency department and get treated straight away so that you don’t have any permanent side effects.
So prostaglandin injection therapy is an excellent treatment that is available for patients.
In summary, my first line of treatment is oral agents, followed by a vacuum pump or prostaglandin injection therapy and most patients will be able to have erections satisfactory for intercourse with one or more of these options. The other option which is greatly underutilised in our community and is very efficacious is the penile prostheses. See sexual rehabilitation post prostatectomy
References
1. Ian A R Smith, Nicholas McLeod, Prem Rashid - Erectile dysfunction – when tablets don’t work - Australian Family Physician - Volume 39, Issue 5, May 2010 - https://www.racgp.org.au/afp/2010/may/erectile-dysfunction-when-tablets-don-t-work2. Stephen W. Leslie, Thushanth Sooriyamoorthy - Erectile Dysfunction - NLM - https://www.ncbi.nlm.nih.gov/books/NBK56225
3. KARL T. REW AND JOEL J. HEIDELBAUGH - Erectile Dysfunction - Am Fam Physician. 2016;94(10):820-827
4. Geoffrey Whittaker, 7 Psychological Causes of ED & Treatment Options (02/22/2024) - HIMS - https://www.hims.com/blog/psychological-causes-of-ed
5. Sharon A. Huang and Janette D. Lie - Phosphodiesterase-5 (PDE5) Inhibitors In the Management of Erectile Dysfunction - 6. Armaan Dhaliwal and Mohit Gupta - PDE5 Inhibitors - NLM - https://www.ncbi.nlm.nih.gov/books/NBK549843/
7. Should you take a daily erectile dysfunction pill? - Harvard Health Publishing - https://www.health.harvard.edu/mens-health/should-you-take-a-daily-erectile-dysfunction-pill
8. What are penis pumps and how do they work? - Healthy Male (funded by the Australian Government Department of Health and Aged Care) - https://healthymale.org.au/health-article/what-are-penis-pumps-and-how-do-they-work
9. Priyanka Bearelly, Elizabeth A Phillips, Shu Pan - Long-term intracavernosal injection therapy: treatment efficacy and patient satisfaction
10. Michael Silberman, Gavin Stormont, Stephen W. Leslie - Priapism - NLM - https://www.ncbi.nlm.nih.gov/books/NBK459178/