Treating Erection Problems With Drugs

How to Treat Impotence With Drugs

Stop erection problems now!

The frequency of erection problems is high: even among normal men it is estimated that about 1 man in 12 has an erection problem. Among diabetic men, the frequency is much higher - up to 50 % of men with diabetes have some kind of erection problem.

Erection problems are often called erectile dysfunction, abbreviated to ED for short.

But what is ED or erectile dysfunction, and how is it treated with drugs?

Impotence is a word that carries lots of judgments, and it certainly sounds very pejorative. It is more commonly called erectile dysfunction, and it is defined very simply: a man has erectile dysfunction when he can't get an erection hard enough to sustain sexual intercourse. There are other related conditions: diminished libido (low sex drive or lack of desire), and delayed ejaculation or premature ejaculation are the most common conditions associated with erection problems.

ED or erectile dysfunction increases in frequency in the older age groups. The cause can be ascribed to circulation problems, nerve problems, hormonal problems, psychological issues, or it may be drug induced. But most often it is down to a combination of one or more of these factors. (AKA: vasculogenic, neurogenic, endocrine, psychogenic, and prescription drug induced.)

There's no hard and fast classification of erection problems. It ranges from an erection that is not firm enough for intercourse to an erection which allows penetration but then fades away, or does not last long enough for intercourse to be completed. Surgery is not such a good option; the implantation of a prosthetic inflatable device is major surgery, with attendant risks, and has a high failure rate. By contrast, one of the main avenues of treatment over the past ten years has been by drugs. The rapid response and effective action of these drugs is important - they represent an instant treatment for a man who is unable to have sex, and thereby provide a rapid boost to self-esteem and sexual self-confidence. This will reduce the feelings of anger, depression and low self-esteem so common among men with ED.

How does drug treatment for Erectile Dysfunction (ED) work?

The erectile chambers of the penis consist of two longitudinal structures (each called a corpus cavernosum) which run along the length of the penis from its base to the coronal ridge. These corpora cavernosa are made up of spongy tissues surrounded by smooth muscle. Normally, a degree of muscle tone keeps the muscles fibres slightly tense, thereby preventing blood flowing into the expandable tissues. When the muscles relax, blood may enter, and the tissues swell, which has the effect of squeezing the veins leading blood away from the penis. (The veins are squeezed between the rather inelastic tunica albuginea which surrounds the whole of the erectile tissue and the corpora cavernosa.) With blood unable to drain away, the penis becomes erect. This process is far from simple, and involves many chemicals, nerve impulses and interacting somatic and chemical factors. Disruption to any part of the process may cause a man to develop erectile dysfunction.

The various factors involved in impotence or erectile dysfunction

The most common factor is vascular - a problem with either the veins or the arteries of the penis. Clearly either impaired arterial function (arterial insufficiency) or a leaking vein (veno-occlusive disease) may contribute to erection problems. Such problems originate in conditions such as hypertension, hyperlipidemia, diabetes adn smoking.

But neurological problems are also a common cause of impotence. Nerve impulses resulting from sexual stimulation cause the release of nitric oxide and prostaglandins in the base of the penis - these substances then cause the smooth muscles of the penis to relax and allow blood to flow in, thereby causing an erection to develop. Injury to any part of the nerve network that promotes these chemical actions can render a man impotent. Such damage can result from groin injury, prostate surgery, MS, and neuropathy associated with diabetes.

Hormonal factors sometimes play a part in the onset of erectile dysfunction. Testosterone declines with age - as most men over 50 years of age will know - and this reduction in blood testosterone may result in fewer night-time erections and a lower level of libido. There are also a number of medications which may produce high prolactin levels, which antagonizes the action of testosterone. These include SSRIs (prescribed for mood disorders) and ranitidine (prescribed for stomach acid problems). In addition, some antihistamines, antidepressants, antihypertensives, sedatives and anxiolytics (anti-anxiety drugs) have been all been blamed for causing erection problems.

We must not forget the influence of stress and anxiety on a man's sexual system. Stress can produce impotence by raising blood catecholamine levels - these stress hormones oppose smooth muscle relaxation. Purely psychological factors may include fear of sex, fear of women, fear of pregnancy, fear of failure and so forth. The inability to get erect causes much anxiety, which in itself is likely to cause erectile failure at the next sexual situation, thereby perpetuating and compounding the erectile dysfunction.

Treatment options for Erectile Dysfunction (Impotence)

Treatment involves a lot of information being provided to the patient and his partner: ED is not a problem that occurs in isolation.

Vacuum devices as a treatment for the impotent man and his non-erect penis

Rather like a so-called penis pump, the vacuum device is designed to draw blood into the penis through the creation of a partial vacuum in a plastic cylinder placed over the penis. The arteries passively dilate and blood is drawn into the corpora cavernosa, though a constricting band placed around the penis may be needed to keep the blood in place if the man suffers from venous leakage. This band should not be left on for more than 30 minutes at a time, though this will be long enough for intercourse even if the penis is only semi-rigid. Petechiae (pinpoint bleeding of capillaries into the skin) may develop on the penis, but the machines are safe enough and do allow intercourse, though the man's sensation may not be particularly rewarding.

Penile prostheses and Erectile Dysfunction

These are inflatable or semi-rigid devices which are implanted into a man's penis in place of his own erectile tissue. There has historically been a fairly high failure and infection rate. A more modern form of surgery for impotence is surgery to improve the flow of blood to the penis. This can be successful when the surgeon is experienced and the patient is properly selected.

A penile support sleeve to improve erectile firmness

A support sleeve may allow penetration of a soft penis into the vagina but it hardly seems likely to produce much sexual pleasure for the man.

Pharmacologic agents and the treatment of ED

Vasoactive agents will relax the blood vessels of the penis and permit the accumulation of more blood in the corpora cavernosa. The early drugs were delivered directly into the corpora cavernosa by injection, and produced a response within ten minutes. Men with arterial insufficiency, or nerve-related, or psychologically induced forms of impotence need lower doses of vasoactive agents than those with veno-occlusive disease.

The pre-Viagra generation of drugs included papaverine, phentolamine and alprostadil.

Papaverine is a smooth muscle relaxant which causes vasodilation. Alprostadil is a man-made prostaglandin which has the effect of relaxing the smooth muscle in the corpora cavernosa, which in turn causes the blood to flow into the corpora and enlarge them, as it would in a natural erection.

Phentolamine is an alpha-blocker which opposes arterial constriction and thereby increases arterial inflow to the penis.

These drugs were a great success for many men, but they were not without problems: the man had to inject himself in the penis, which was sometimes painful and could produce scarring; other side-effects reported included priapism (long lasting erection which may lead to tissue necrosis), fibrosis (which may lead to Peyronie's disease), penile pain and hematoma at the injection site.

Papaverine caused priapism more often than alprostadil but alprostadil was reported to cause more penile pain. Fibrosis of the corpora cavernosa occurred more frequently with papaverine than alprostadil. When injected together, smaller doses of each compound were needed.

Alprostadil, available as Caverject, was the first FDA approved agent to treat erectile dysfunction before Viagra came on the market. It was often prescribed in combination with phentolamine or combined with phentolamine and papaverine. The first formulation was better for men with erectile dysfunction of vascular origin; the second for men with psychologically induced impotence. The injections were given on the side of the shaft of the penis, with the needle site being chosen located closer to the body than the head of the penis, taking care to avoid visible blood vessels and alternating sides with each injection. Patients were advised not to inject if the penis was partially erect since this increased penis outflow and medication was flushed away in the blood stream. Medications were then less effective in promoting a viable erection that would last for the duration of intercourse.

Other drugs used from time to time to treat ED have included Yohimbine, which is an alpha-2-adrenergic blocking agent. The effectiveness of Yohimbine as a treatment for erectile dysfunction has not been proven, and as it tends to promote anxiety and high pulse rates in susceptible men it must be regarded as a treatment of limited benefit, especially now that Viagra has been proven safe and successful.

Hormone replacement as a treatment for erection problems is described in detail elsewhere on this website.

Psychological or "organic" Erectile Dysfunction?

Psychological issues surround all cases of ED and impotence - if not before it develops, certainly after it has done so! But for erectile problems that have a purely psychological origin (e.g. anxiety, nervousness, anger), the onset of erectile dysfunction is sudden and unexpected. In the case of organic ED, in other words that caused by an underlying physiological problem, the onset is more gradual. One can test for nerve damage by stimulating the glans - does the man feel it? - and scratching the perineum (which should make the anus contract). Assessment of the condition of the prostate is also important, as is the presence or absence of Peyronie's disease. Tests for high lipid levels, which may occlude the arteries of the penis, and high blood pressure, are also helpful in assessing whether or not a physiological condition lies behind the onset of erectile dysfunction.

Phosphodiasterase inhibitors - aka Sildenafil Citrate, aka Viagra - and Erectile Dysfunction

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Young men and erection problems