Erectile Dysfunction (ED) is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse. This condition affects one in two adult males to various degrees. Even though effective treatments for Erectile Dysfunction had been available for at least a decade before Viagra® was released in March 1998, it had been difficult for the afflicted individual to know where to seek help. Since the successful launch of Viagra®, talking about sexual dysfunction and seeking help became less taboo. Nonetheless, the topic remains sensitive for most men.
The advent of Viagra®, Levitra® and Cialis® has helped many men restore sexual performance. For many others, the high hope in such oral medications has quickly been deflated in light of certain side-effects or lack of efficacy. For these men, to re-confront these problems becomes more challenging than the first time.
The above referenced medications are not for everybody and are not without risks. It is estimated that between 30-70% of men do not respond to these drugs, depending on their age and underlying health problems, and at least 15% suffer from undesirable side-effects.
Erectile Dysfunction is very common. Although it tends to be more common in men over 40 years of age, it can affect all ages. In mid 1992, the results of the world’s largest Erectile Dysfunction study called ‘The Massachusetts Male Aging Study’ (MMAS) became available. These results showed that:
There are psychological and physical causes of Erectile Dysfunction.
Contrary to popular belief, only about 10% of cases of Erectile Dysfunction are psychological in nature, which are mostly the result of nervousness, lack of confidence or performance anxiety. In response to these situations, the sympathetic nervous system is activated, causing the blood vessels to constrict (vaso-constriction), temporarily reducing the blood flow to the penis, resulting in erectile difficulties. Psychological Erectile Dysfunction can be self-perpetuating: each failure increases the associated anxiety levels and frequently leads to a continual failure, and eventually physical Erectile Dysfunction. Other psychological causes include stress, guilt, sexual boredom, depression etc.
It is now known that 90% of cases of Erectile Dysfunction are caused or contributed by physical factors, most of which are related to impaired circulation, a condition generally referred to as “vascular insufficiency.”
The penis requires a healthy blood flow to be completely erect. A marginally reduced blood flow can cause significant difficulties. Therefore, the risk factors for Erectile Dysfunction are primarily vascular risk factors. They include:
Note: According to FDA’s alert May 2005, risk factors for developing sudden blindness in association with (though not conclusively proven) the use of Viagra®, Levitra® and Cialis® are: men above 50, diabetes, hypertension, high blood cholesterol, cardiac diseases and smoking. These are the same risk factors for developing Erectile Dysfunction in the first place!
Other physical causes are not common but can be readily diagnosed. They include:
Erectile Dysfunction can affect apparently healthy individuals as well.
Yes! Like any medical problem, Erectile Dysfunction should be treated promptly. The sooner it is diagnosed and treated, the better the outcome, for the following reasons:
Recent studies indicate that couples with a healthy sex life are affected less by problems such as depression, anxiety, hypertension, diabetes, ulcers, chronic fatigue, virus illness and other ailments. They also have a greater life expectancy.
There are several treatment options for Erectile Dysfunction including Intracavernous Pharmacotherapy (ICP), oral medications such as Viagra®, Levitra®, Cialis®, urethral suppository called MUSE®, penile prosthesis, vacuum suction device, vascular surgery, hormonal replacement therapy (HRT), and sex therapy. The following information is intended as general information. Your doctor’s recommendation as well as your individual preference is important in determining the best and most acceptable form of treatment for you.
ICP is by far the most effective treatment available. It is safe and suitable for most men with Erectile Dysfunction, regardless of age or medical condition. It’s a highly specialized form of ED treatment and yet simple to apply. ICP treatment has been widely used since the mid 80’s. Medical professionals who specialize in this form of treatment use various different combinations of medications.
ICP involves painless injection of a small amount of a pre-determined combination of vasodilators into the spongy tissue of the penis, using an auto-applicator. The combination causes dilatation of the penile arteries and penile tissues, resulting in an increase in blood flow to the penis, which is then stored in the erectile chambers. As pressure builds up against an unyielding envelope (called a tunica albugaenia), venous outflow is blocked, an erection develops within a few minutes. This induced erection feels perfectly natural and normal with the exception that it will not go down after ejaculation. The prescribed formula is individually tailored to allow the erection to last approximately 30-60 minutes regardless of the occurrence of ejaculation or the state of mind. Once ICP protocol is established, this treatment works predictably and reliably every time.
The medicine used in ICP is a combination of vasodilators, each of which is FDA-approved, known as papaverine, phentolamine, atropine and prostaglandine E1. Since ICP is a localized form of treatment, the side-effects are minimal and local. Its overwhelming success rate, minimal side-effects and ease of use have made ICP a preferred choice for most patients who have access to this type of treatment. For patients who do not respond to, or suffer from the side-effects of the oral medications, ICP is a welcome relief since it works well in most cases.
Even though ICP is effective in most men, it may not be as effective in advanced Erectile Dysfunction when most of the normal elastic tissue has been replaced by fibrosis, a common end-result of delayed treatment. The only remaining solution is the insertion of a penile prosthesis.
ICP has a favorable side-effect profile. Given the benefits, the side-effects are minimal. They include:
You can start and stop ICP any time you wish. ICP enables you to immediately achieve and maintain an erection, the very reason most men seek help at the first place. In that context, ICP can be used on as needed basis. However, long term improvement is unlikely. Such occasional use does not address the issue of poor circulation, poor erectile reflex and the progressive loss of normal healthy tissue and elasticity.
Physicians often recommend ICP as part of a Treatment Program that aims not only to provide a reliable erectile response short- term, but also to improve the long-term prognosis. Each patient is different, hence the treatment program has to be personalized to suit the individual needs and expectations. A course of treatment typically requires 2 to 3 ICP applications a week for a period of twelve (12) months. In more advanced cases, patients may use ICP 3 to 4 times a week. Generally speaking, the more erections you experience, the easier it is for the next one to occur on its own, stronger and more reliable.
You may experience return of natural erections and spontaneous erections during the course of treatment, but it is important to complete the full course of treatment. A follow-up evaluation is necessary.
ICP sustains the erection regardless of the occurrence of ejaculation. With longer-lasting erections and sexual contact, a premature ejaculator becomes less sensitive to sexual stimulation. The assurance that the erection will not go down after ejaculation helps eliminate the performance anxiety, thus reducing the urge to ejaculate. A new habit can be formed and ejaculatory control can improve.
Note: If Premature Ejaculation is of recent onset, it is often a symptom of Erectile Dysfunction. Treating ED will improve the ejaculatory control.
As a rule, medical professionals cannot make claims or promise cure but would focus on optimizing the treatment outcome as a balanced decision between benefits and potential side-effects. Such notion is well maintained and respected in order to avoid abuse and false representation.
ICP on its own is not intended to cure Erectile Dysfunction, nor does it promise cure. With proper dosing, it provides a predictable and dependable erectile response. The observation that many ED patients no longer need ICP after a period of time has provoked many debates. Such improvement could be a direct result of a renewed confidence, a psychological gain, or a representation of actual physical improvement, or a combination of both. A few references regarding the claims of “cure” are included at the end of this information package.
Failure to treat Erectile Dysfunction leads to progressive loss of the remaining healthy tissue and eventually irreversible loss of erectile function if the window of opportunity has been passed. So it is important to treat Erectile Dysfunction with urgency, regardless of the final outcome. Long term improvement might be complete or partial; either is worth the effort.
Men with recent-onset psychological Erectile Dysfunction still have a reasonably intact physiological function. Restoring the confidence level with repeatedly successful erections helps resolve the psychological conflicts; the erectile function tends to improve. Untreated, psychological Erectile Dysfunction can deteriorate to physical Erectile Dysfunction, a process called “disuse atrophy”, which is then more difficult to reverse.
The penile tissue is a vascular organ that requires a healthy supply of oxygenated blood to stay supple and responsive to sexual stimulation. Such provision comes with the occurrence of regular erections, either sexually-induced or physiologically-induced (REM sleep). When the ability to achieve and maintain an erection is compromised for one reason or another, the supply of the much needed oxygenated blood is reduced. The penile tissue starts to atrophy, loses its normal elasticity and responsiveness to sexual stimulation; erectile function worsens. When fibrosis has predominantly replaced the normal healthy penile tissue, the condition becomes unresponsive to medical therapy. A penile prosthesis is then the only solution.
A course of ICP treatment results in regular erections that last 30-60 minutes each time. Each ICP-induced erection helps rebuild the sexual confidence, a psychological benefit, as well as the natural erectile reflex, a physical benefit. Similar to an exercise program intended to rehabilitate a weakened muscle, a course of successive erectile responses can improve the blood flow, the penile elasticity, hence the erectile function. The extent of improvement can vary depending on age, the severity and duration of dysfunction, the presence of concurrent illnesses and other health risk factors. Generally speaking, if a weak dose of ICP, as seen during the diagnostic assessment, results in positive increase in blood flow and an erectile response, full or partial, the condition is said to be reversible and the prognosis is promising.
To optimize your chance of long term improvement, complete the full course of treatment as recommended, look after your general health, maintain a healthy diet and an active life-style, reduce stress and control your vascular risk factors, if any.
The advent of these drugs has helped many men restore erectile function. These drugs belong to a group of drugs called c-GMP Phosphodiesterase Inhibitors.
Viagra® was originally intended to treat angina or chest pain. During early clinical trials, some of these patients noticed an improvement in their erectile function. Its therapeutic indication was then changed to Erectile Dysfunction. When Viagra® was submitted to the FDA after six months of trials, its approval was “fast-tracked” and the drug was released in March 1998 for the treatment of Erectile Dysfunction. Viagra® alone will not give you an erection; sexual stimulation is necessary for the drug to have an effect.
These drugs are not for everybody and are not without risks. It is estimated that between 30-70 % of men do not respond to these drugs depending on their age and underlying health problems. Many cannot take these drugs due to contraindications, and at least 15% suffer from undesirable side-effects. With the exception of specific differences, these drugs have more or less the same clinical effects.
An alleged link between these pills and development of permanent blindness was made public in May 2005. Despite the drug makers’ position that there was no evidence to support the causality, the FDA has enforced a new label to warn men of the possible side-effect. The condition, called “non-arteritic anterior ischemic optic neuropathy” or NAION, is caused by a blockage of blood flow to the optic nerve.
Risk factors for NAION include diabetes and heart disease, two of the leading causes of Erectile Dysfunction. The agency also identified other risk factors for NAION: being older than 50, smoking, high blood pressure, and high cholesterol. These are notably also the risk factors for Erectile Dysfunction at the first place!
This product was released in 1997. It contains a vasodilator called Alprostadil (or Prostaglandine E1) prepared in the form of a pellet, which is inserted in to the urethra via an applicator. The medicine is expected to absorb through the urethral wall into the erectile chambers called the corpus cavernosa. It is now known that its effect is limited because it contains only one vasodilator and the drug is poorly absorbed; only a sub-therapeutic level can reach the corpus cavernosa. For these reasons, MUSE® rarely induces a complete erection. Common side- effects include urethral discomfort, bleeding, scarring and stricture. Its usefulness has been limited.
The use of penile prosthesis was popular until the mid 80’s when more effective and less invasive treatment option became available. The advent of ICP and oral medications has made this option the last resort.
The best penile prosthesis comprises of two inflatable tubes, a pump and a reservoir. The tubes are inserted into the corpus cavernosa, irreversibly destroying their structures in the process. The pump is placed in the scrotum; and the reservoir in the abdomen. When the pump is activated, fluid flows from the reservoir into the tubes, which harden and become erect. Pressing a valve on the pump mechanism deactivates it, and the fluid returns to the reservoir; the penis becomes flaccid.
Penile implant surgery is a fairly invasive and expensive procedure. It takes about 2-4 hours on the operating table and about 4-8 weeks to recover.
The following complications are possible:
The VSD is essentially a cylindrical pump (battery or manually operated), which encloses the penis. When activated, air is sucked out of the sealed chamber, creating a vacuum. Blood is then drawn to the penis thanks to the vacuuming effect. A firm rubber ring is then placed at the base of the penis to trap the blood in the erectile chambers, keeping the penis firm.
The VSD has the following disadvantages:
In patients with advanced Erectile Dysfunction unresponsive to ICP and surgical implant of a penile prothesis is not an option, the use of VSD may remain the only option. In our experience, it is otherwise best to use VSD as an adjunctive therapy to ICP to help maintain the blood flow.
Approximately 2% of patients are candidates for vascular surgery. These include arterial bypass and venous ligation. The risks of vascular surgery are those related to major surgery. Your doctor will let you know if you are suitable for this form of treatment.
Similar to menopause, men can experience a condition called “andropause” caused by low testosterone. Symptoms may include feeling of sluggishness, fatigue, poor sleeping habits, poor attention and concentration, poor mental clarity and cognitive function, weight gain, poor appetite, low sex drive and Erectile Dysfunction. Hormonal replacement may improve these symptoms but not necessarily the erectile function.
If appropriate, your doctor may recommend a course of hormonal replacement as an intramuscular testosterone injection. A standard regimen consists of three injections with a 2 week interval between each injection; this regimen can be repeated if it shows positive benefits.
Sex therapy is traditionally considered the treatment of choice for patients with psychological Erectile Dysfunction. It requires the cooperation of the sexual partner and involves multiple sessions with an experienced sex therapist. Patients often find psychological treatment either impractical due to lack of participation from the partner, or to be a long, tedious and expensive process often with inconsistent results.
On the contrary, treatment that results in a tangible erection such as that from ICP can often provide immediate relief and rapid restoration of confidence, often enough to resolve the psychological conflict. When dealing with a more complex and deep rooted psychological case, the physical effect of ICP may only provide a short term relief. Expert help from an experienced psychologist or sex therapist is necessary for long term improvement.
The application of ICP results in a reliable, full and lasting erection regardless of the state of mind (i.e. the fear of failure, anxiety or nervousness). With the security of having a full erection every time you make love, you will be able to focus more on the pleasures of lovemaking (i.e. giving and receiving pleasure), instead of worrying about losing your erection. As soon as you are more relaxed and your confidence has been restored, you may be able to perform sexually without using ICP.
To optimize the effect of the treatment, you should start using ICP each and every time you have sexual intercourse. In order to avoid relapses, you should complete the Treatment Program recommended by your physician. This treatment is not designed to be permanent but rather a remedial measure to help “snap” you out of that cycle of repeated failure and jump start you on the path of success.
Disclaimer: The information contained in this package is for general reading and is not intended to provide medical advice which can only be obtained by direct consultation with the doctors.
Textbook of Erectile Dysfunction
Culley C. Carson, Roger S. Kirby and Irwin Goldstein
First published 1999
Quote from page 347 and 351:
“Currently, there are over 500 publications on Intracavernous Pharmacotherapy (ICP) and reports have been made on approximately 250,000 injections administered to more than 20,000 patients. Intracavernous administration of erection inducing agents is the most efficacious and has not yet been surpassed by any other form of therapy.” “Intracavernous Pharmacotherapy is currently the most effective treatment for erectile failure. This does not mean that it is limited to severe organic impotence; psychogenically impotent patients may benefit from this type of treatment to initiate later spontaneous erections”
Intracavernous injections: still the gold standard for treatment of erectile dysfunction in elderly men
International Journal of Impotence Research (2001) 13, 172-175
“The use of oral sildenafil citrate in elderly men resulted in a significantly low incidence of functional erection (31.8%) as compared to ICI. The sildenafil response was considered inferior to ICI response by 43.6% of men who previously responded to ICI” “In conclusion, the use if ICI of vaso-active drugs may still be considered as the treatment of choice in elderly men suffering from organic impotence because it is safe, hardly invasive and highly effective.”
Progressive treatment of erectile dysfunction with intracorporeal injections of different combinations of vasoactive agents
Int J Impot Res. 1999 Feb;11(1):15-9
“Overall, sustained rigidity was achieved in 441 of the 452 patients (97.5%)"
Five and Six Vasoactive drugs combination for diagnosis and treatment of impotence
Int J. Impotence Research (1994)6, Suppl. 1
A four year experience with vasoactive multilevel acting drugs combination in 104 patients with mean follow up of 12 months shows:
Three-year outcome of a progressive treatment program for erectile dysfunction with Intracavernous injections of vasoactive drugs Urology 2000 Oct 1;56(4):647-52
ICI is effective in 97.6% of patients with progressive dosification. At the three-year follow up visit (of 610 patients):
Intracavernous Injections for erectile dysfunction in patients with cardiovascular diseases and failure or contraindications for sildenafil citrate
Int J. Impotence Research (2002) 14,38-43
The aim of this study was to evaluate the effectiveness of a progressive program for the treatment of ED in patients with cardiovascular disease in whom sildenafil citrate (Viagra) was not an option.
The total success rate was 94.3%
A one-year follow up of 100 patients showed:
7% drop out for health or marital reasons
3% drop out because of treatment failure
90% have successful coitus, of which 87.8% use ICP and 12.2% no longer need ICP
Intracavernosal therapy: when oral agents fail
Curr Urol Rep.2001 Dec;2(6):468-72
“Intraurethral and oral agents for the treatment of erectile dysfunction have been introduced over the last few years, but early reports of patient satisfaction and reproducibility of erectile rigidity have not matched those of intracavernosal therapy. Thus, injection therapy remains on the forefront of treatment options”.
Short term use of intracavernous vaso active drugs in the treatment of persistent psychogenic erectile dysfunction
Int J Impot Res. 1998 Dec;10(4):211-4
“64% needed the injection for less than three months, only 12% needed the injections up to one year. We concluded that intracavernous self injection of vasoactive drugs is an effective alternative in the treatment of men with persistent psychogenic impotence when sex therapy is unsuccessful”
Patient’s characteristics of those who claim “cure” from penile injection therapy
Int. J. Impot Res. (1994) 6, Suppl.1
Robert J Krane, Irwin Goldstein et al.
The figures quoted are statistically significant (p0.05)
Long term results in auto-injection treatment with 3 schemes of vasoactive agents in psychogenic and organic erectile dysfunction
Int J. Impot Res. (1994) 6, Suppl.1
If “cure” is defined as when patients gained their natural erections and “good” is defined as when patients had natural erection but they still continued injection, then:
In the psychogenic group cure 50%, good 20%
Organic group (mixed) cure 20%. good 40%
Organic group (arterial/hypertensive) cure 10%, good 10%
Diabetic young patients: cure 20%, good 40%
Diabetic old patients: cure 0%, good 30%
Cure and return of spontaneous natural erections are reported worldwide. The figures may vary depending on the subject population, the severity of ED and presence of other medical conditions. These figures vary from study to study of course. Nonetheless, curative effect and improvement in long term use of ICP are reported.
ICP Therapy effective as cure for impotence
“Long experience with intracavernosal therapy (ICI) using PGE1 has shown that it is not only effective and safe to use, but it has been quite successful in curing impotence. Reviewing 12 years’ experience with the compound, he said that as many as one patient in three regained their potency while on therapy.”
“The quality of erection was consistently good, and there were no contra-indications or systemic reactions. It had also been demonstrated that there were no undesirable effects over the long term.”
“On the other hand, for premature ejaculation Dr Virag indicated use of papaverine with an alpha-blocking compound.”
Return of spontaneous erection during long term intracavernosal alprostadil treatment
Urology Volume 57, Issue 3 March 2001 Page 536-541
“Long term treatment improved the penile circulation, and most men reported an increase in return of spontaneous erections”
Current perspective on intracavernosal Pharmacotherapy for erectile dysfunction
Int J Impot Res 2000 Oct;12 Suppl 4:S91-S100
“Thirty percent of males afflicted with erectile dysfunction (ED) do not respond to oral drugs, another 15% reveal contraindications to currently available therapy, and a subset of patients actually prefer injection therapy due to its predictable short time-to onset of erection and reliable rigidity compared to oral drug”
Sex can be better and safer with injection therapy
Senior World Online
Salient points from the article:
30-40% of men suffering from impotence prefer to use injections rather than the well-known pill Viagra® to achieve the desired results. The number would be higher if patients were given full information about all the options.
ICP provides more rigid and more predictable erections. It is also easy and safe to use, even for patients who have a health problem.
There are a number of contraindications to using Viagra, but none to injection therapy.
Lack of information from doctors about the availability of injection therapy was an issue.
80-90 % of doctors are only prescribing Viagra® and patients are left in the dark about the possibilities of self-injection therapy.
Nowadays, patients are sent home with a Viagra® pill, which is useless in terms of diagnostic value, and there is no discussion. Less than 10% of patients get proper guidance and assistance.
From a world survey covering 300 medical centers and about 100,000 patients, Dr Virag said “Injection therapy should remain the first-line treatment.”
ICP has been a well established treatment for ED for over 20 years. The convenience and the efficacy of the c-GMP Phosphodiesterase Inhibitors may not provide an answer to men in whom the pills do not work or cause side-effects. For these men, ICP is the first option.