YOU & WEE UROLOGIC SURGERY & WELLNESS
DR. JARED J. WALLEN, MD
A message from Dr. Wallen regarding your Erectile Dysfunction:
A diagnosis of erectile dysfunction (ED) can be difficult to deal with. Together we can navigate treatment options and restore your function so that you may be able to participate in sexual activity again should you so choose. The process of an erection and ultimate sexual intercourse, orgasm, and de-tumescence (becoming flaccid again) require a highly coordinated response from the neurologic, vascular, psychologic, and sensory systems. The penis should be thought of as an inflatable rod and the cardiovascular system (the heart and blood vessels) is the pump and tubing that inflates the rod. You need good blood flow in to fill up the rod and you need the little valves in the veins to close and trap it there. This process normally happens for on average 3-6 mins of penetrative intercourse before normal ejaculation and orgasm occur and shut the system down. If the blood vessels in your heart are not functioning well, it is likely that blood vessels in your penis are not functioning well. In fact, ED is proven to be a 3 to 5 year indicator of potential heart problems for the simple reason that the blood vessels in the Penis are 1/2 the size of the blood vessels in the Heart and become clogged or blocked sooner, even with less severe disease. Among many causes of erectile dysfunction are things like coronary artery disease, neural compromise from spinal problems or trauma, diabetes, smoking, pelvic surgery, drug use including alcohol and marijuana, etc.
If you are safe for sexual activity, this means that you can walk up 2 flights of stairs without getting winded, short of breath or chest pain then the 1st treatment option is lifestyle modifications. This includes things like following a Plant-Based Diet and avoiding all animal proteins, eating plenty of antioxidant rich foods like fruits and vegetables, ensuring 40-45 mins of cardiovascular activity (walking, swimming, biking, running, etc) 5 days or more a week, avoiding Drugs, Alcohol or smoking usage, following a low salt diet, Pelvic Floor Muscle Exercises, and managing medical conditions such as low testosterone, diabetes, high blood pressure, obesity, and many others.
The 2nd treatment option is Oral Medications. These common medications are: Viagra, Levitra, Cialis, Stendra, etc. You must be careful taking these
medications with other medications for blood pressure or specifically alpha blockers for BPH or lower urinary tract symptoms. If you take these medications discuss with Dr. Wallen as you can other-wise experience an unsafe drop in blood pressure. These medications can be taken daily or on demand prior to sexual activity. However, it should be noted that manual or visual stimulation is required for an erection. These pills are safe when used in coordination with your doctor however sometimes specific side effects should be noted: Blurry vision, change in color vision, diplopia, hypotension, myalgias, headache, nasal congestion, etc. These pills should never be taken in combination with nitrates for chest pain without specific consultation with a doctor.
The 3rd treatment option is a Vacuum Erection Device (VED). This is a plastic tube that is fit over the penis and pressed against the base of the penis and pubis. It then uses suction via a hand pump or battery- operated suction to pull blood into the phallus and cause engorgement. This is often used in conjunction with a restriction band that fits around the base of the penis to trap the blood in. This cannot be used with the band for more than 30 minutes at a time. Patients have reported in the past that this causes a floppy penile base where the band is and can limit the effectiveness of activity. Further patient feedback is such that the manual hand pump VED device may be gentler on you to use as you can pump as slow or fast as is comfortable. Discuss with your doctor if you take anticoagulation medications (Coumadin, aspirin, Plavix, warfarin, Lovenox, etc).
How to USE the VED:
- Place the penile ring Around the Cylinder of the VED (no ring required for Penile Rehab)
- Use Vaseline or Lubrication on the skin at the base of the penis to ensure a good seal
- Slide the Cylinder of the VED over the shaft and glans penis
- Press Firmly into the skin to ensure a good seal
- Press the button to create suction in the VED (Or squeeze the pump if your device is manual)
- Continue suctioning until the penis is fully engorged
- Slide the Restriction Band off the VED to the base of the penis
- Participate in activity, but Remember to Remove the band within 30 minutes after placement.
Another use for a Vacuum Erection Device is for what is called “Penile Rehab.” This is done to maintain penile length in the face of increasingly severe erectile dysfunction. This is certainly used for patients who have had prior prostate procedures or other radical pelvic surgery, but also any patient who has erectile dysfunction and especially if you are no longer having nighttime erections. In this setting, the vacuum erection device is used 3-5 times per week for approximately 30 minutes at a time with NO restriction band. This is to cause engorgement in and stretching of the phallus. This is thought to be helpful because typically men with increasingly severe erectile dysfunction lose their nocturnal erections which would otherwise stretch out the penis and bring in new blood flow to the tissues daily. So, using the VED will bring engorgement and nutrient rich blood to the tissues. Caution again should be advised for patients taking anticoagulant medications.
The 4th treatment option would be the delivery of a combination of medications locally to the penis. This can be done via an intraurethral suppository (MUSE) or gel, or via an injection into the penis with a tiny needle.
These treatments can be a combination of anywhere from 1- 4 medications. Some of these medications can result in scar tissue formation (corporal fibrosis) from prolonged use. This can cause or worsen deformity or curvature of the penis. To help prevent this it is recommended to alternate sides of the shaft and to travel up and down the length of the shaft for each new injection. In short, do not always inject in the same spot repeatedly. You should also never inject at the 12 or 6 o’clock positions on the top or bottom of the shaft of the penis as the nerves and blood vessels are on top and the urethra is on the bottom. It should be noted that patient to take MAO inhibitors (a type of Anxiety and Depression medications) should not use this treatment, if you are taking these medications please discuss this with your doctor prior to use. This is also the one main treatment form that can cause a Priapism (an erection lasting longer than 4-6 hours). There is only about a 10% chance however this is an emergency and you should call your doctor immediately or seek care at the nearest Emergency Room.
How to perform an Injection:
- Draw up medication
- Wipe down the skin surface with an alcohol wipe
- Insert the tiny needle approximately 1-2cm into the side of the shaft of the penis at the 3 or 9 o’clock position and inject instructed dosage
- Remove Needle
- Apply pressure with alcohol wipe to the site of injection for 2-3 mins to stop any minor bleeding
- Wait 15-20 minutes as this will give the penis all the signals necessary for an erection to occu
The 5th option includes doing an outpatient surgery to place either an inflatable or semi-rigid penile implant.These devices are a permanent prosthetic implant to provide an erectile function to the penis and unless malfunction or infection occurs typically last up to 10-15 years. In fact, satisfaction is very high as greater than 90% of patients and their partners are satisfied after this procedure is performed. These devices are non-visible after surgical placement. These surgeries do require that you stop any anticoagulation medications and have appropriate medical optimization or clearance.
This procedure typically lasts 45 mins and is done in an outpatient fashion. The patient typically goes home with a surgical drain and a jockstrap with a dressing. Follow up in the office typically occurs 3 days after your procedure. There are 3 typical incisions that can be used to place a penile implant. The Infrapubic (just above the base of the penis), Penoscrotal (in the junction of the bottom of the penis and scrotum), or Subcoronal (behind the head of the penis similar to a circumcision incision). I can perform all of these and choose based on many individual factors with each patient. If all things are equal, I believe the Infrapubic approach to be the best as it offers the quickest and easiest recovery for patients. Typical recovery periods range from 3-6 weeks prior to being able to participate in activities.
As with any surgery, there are risks involved including bleeding, infection, erosion of the implant, device malfunction, need for revision surgery, pain, cosmetic dissatisfaction, perforation of the urethra, injury to any surrounding structure, as well as the risks of anesthesia including but not limited to heart attack, stroke, and death. However upwards of 60-80% of devices are still functional 15-20 years after surgery. It should be noted that these devices provide erectile function, but this function is somewhat different than normal erection given that there is a prosthetic in place. The inflatable devices tend to be more common as they offer both the erect and flaccid state of a normal erection. Furthermore, the transition between the flaccid and erect state is operator dependent by a manual pump in the scrotum. Look forward to future innovation that will allow this transition from flaccid to erect to be operated by your blue tooth device or a fab style switch. It also should be noted that in the flaccid state you may be able to see a fold or outline of the device through the outside of the skin but should not see the actual device. The semi-rigid device tends to be a better option for a man that is desiring erectile function but has poor manual dexterity. However, many patients report this to be more difficult to conceal as it is basically semi-solid rods that are implanted into the corpora cavernosa which are the chambers that typically fill with blood causing an erection. These rods are then bent UP and Down for activity as compared to the inflatable device where the cylinders are inflated and delated by sterile saline that is sealed in the device once it is placed surgically. This intervention should correct your erectile dysfunction without changing your ability to ejaculate, achieve orgasm, or change or sensation in the penis.
The 6th option that exists is experimental studies. They are currently 2 new interventions that we know about to treat erectile dysfunction but are currently undergoing experimental study. The 1st is an injection into the penis of stem cells or platelet rich plasma (PRP). The 2nd is low intensity extra corporal shockwave lithotripsy to the penis. These studies are ongoing, however, would likely require you to travel to a different location for therapy. If you are interested in these options please discuss with Dr. Wallen.