ED: Surgical Management (Erectile Dysfunction)
Scientists once believed erectile dysfunction (ED)—was a problem only of the mind and not of the body. But recent data suggest a physical (or organic) cause in more than half of all cases, especially those involving older men. It is estimated between 15 to 30 million American men suffer from ED, although not all men are equally distressed by the problem. But what is involved in impotence and what is available to correct it? The following information should help you talk to your urologist about this frustrating issue, and some of the options that may help solve it.
What happens under normal conditions?
The internal structure of the penis includes two cylinder-shaped chambers, the corpora cavernosa. Filled with spongy tissue containing smooth muscles, fibrous tissue, veins and arteries, these chambers run the length of the organ and are surrounded by a membrane cover, called the tunica albuginea. The urethra, the channel through which urine and semen exit the body, is located on the underside of the corpora cavernosa and is surrounded by spongy tissue. The longest part of the penis is the shaft, which ends in the glans. The meatus is the opening at the end of the urethra.
Erection is the culmination of a complex set of physical, sensory and mental events, involving both the nervous and vascular systems. It begins when physical or psychological stimulation (arousal) causes neurotransmitters or impulses in the brain (chemicals such as dopamine, acetylcholine and nitric oxide) to tell the muscles of the corpora cavernosa to relax, allowing blood to fill the organ's tiny open spaces. As the tunica's fibrous or elastic tissues trap the blood, the penis engorges, or increases, in an erection. When stimulation finally ends pressure inside the organ decreases as the muscles contract, usually after ejaculation. Blood then flows from the penis and the penis returns to its normal shape and size.
What is erectile dysfunction (ED)?
Erectile dysfunction refers to the inability of a man to attain and maintain an erection sufficient for intercourse. It occurs when there is reduced blood flow to the penis or nerve damage, both of which can be triggered by a variety of factors. Scientists once believed that ED was an emotional issue alone. But today they know that physical factors are just as important as psychological triggers—stress, marital/family discord, job instability, depression and performance anxiety—in provoking this problem. It is important to note that hundreds of medications can also contribute to impotence while they fight allergic reactions, high blood pressure, ulcers, fungal infections, anxiety, depression and psychoses.
Who is at risk for erectile dysfunction (ED)?
These risk factors in men are known contributing factors:
Vascular diseases: Hardening or narrowing of arteries, often associated with high cholesterol, can also restrict blood flow to the penis, particularly if you are over 60. Because smoking can lead to any of the factors responsible for vascular problems—such as high blood pressure—it is probably an important factor in both arterial disease (atherosclerosis) and ED.
Neurologic disorders: Spinal cord diseases or injuries, brain injuries, multiple sclerosis, Parkinson's disease and other progressive diseases can interrupt nerve impulses to and from the brain. Another cause of ED is peripheral neuropathy in which the nerves leading to the penis fail to send coordinated signals to the penis. Peripheral neuropathy can be caused by diabetes, HIV infection, certain medications and other less common conditions.
Diabetes poses both neurological and vascular problems because it damages small blood vessels and nerves throughout the body, impairing the impulses and blood flow necessary for an erection.
Other conditions/illnesses: In addition, other chronic illnesses such as prostate and bladder cancer and well as hormonal imbalances and penile disorders can disrupt the nerve impulses and blood flow necessary for normal erections.
What are the symptoms of erectile dysfunction (ED)?
Failing to achieve and/or sustain an erection is the primary sign of ED. But diagnosing the specific cause and prescribing appropriate treatment usually require a variety of tests, beginning with a complete history and physical examination.
Your doctor may order additional laboratory tests to assess any conditions that may be interfering with normal erectile function, particularly arterial flow to the penis. A blood test, for instance, is normally used to reveal blood lipids and triglycerides, both of which indicate atherosclerosis if elevated. A urinalysis identifies protein and glucose levels that can suggest diabetes.
While these analyses focus on your chemical status, erectile function tests are the principal tools your doctor will use to tell how the blood vessels, nerves, muscles and other tissues of your penis and pelvic region are working. Normal nocturnal penile tumescence (NPT), or healthy involuntary erections during sleep, suggests that nerve function and blood supply are intact.
An imaging technique called duplex ultrasound may also be used. It monitors blood flow, vein leaks, scarring of erectile tissue and some signs of atherosclerosis. During the test, an erection may be produced by injecting the stimulator prostaglandin into the penis and then measuring vessel expansion and penile blood pressures and flow, both of which are compared to the limp penis. In either case, duplex ultrasound can illustrate a specific blood vessel disease that may rule out a need for vascular surgery.
How erectile dysfunction (ED) is surgically treated?
The past several decades have ushered in a new treatment era for ED. Because of the advent of many advances, today urologists are helping millions of impotent men perform better and longer.
Penile prostheses: Surgically implanted devices to ensure rigid erection have become highly reliable therapeutic solutions.
Vacuum erection devices: Vacuum erection devices have proven to be safe alternatives in producing rigidity of the penis by drawing blood into the organ with a pump and holding it with an "occluding band."
Penile injection therapy: Penile injection therapy is a relatively quick and effective way to send vasoactive drugs directly into the corpora cavernosa where they expand the vessels, relax the tissue and increase blood flow for an erection.
Oral Therapy: Furthermore, the pills: sildenafil, tadalafil and vardenafil have become the treatments of choice for millions of men who have experienced the drugs' ability to boost levels of cyclic guanosine monophosphate (cGMP), a chemical factor in metabolism responsible for relaxing blood vessels.
Penile arterial revascularization: This procedure is designed to keep blood flowing by rerouting it around a blocked or injured vessel. Indicated only for young men (under 45) with no known risk factors for atherosclerosis, this procedure is aimed at correcting any vessel injury at the base of the penis caused by adverse events such as blunt trauma or pelvic facture. When such an event leaves a penile vessel too injured or blocked to transfer blood, the surgeon may microscopically connect a nearby artery to get around the site, clearing the pathway so enough blood can be supplied to the penis to enable an erection.
Venous ligation surgery: This procedure focuses on binding leaky penile vessels that are causing penile rigidity to diminish during erection. Because venous occlusion, necessary for sufficient firmness, depends on arterial blood flow and relaxation of the spongy tissue in the penis, this approach is designed to intentionally block off problematic veins so that there is enough blood trapped in the penis to create an appropriate erection. Since long-term success rates are less than 50 percent, this technique is rarely a choice for correcting ED.
In fact, you are not a candidate for either penile vascular surgery if you have insulin-dependent diabetes or widespread atherosclerosis. You are also not suited if you still use tobacco or experience consistently high blood serum cholesterol levels. Neither of these surgeries will work if you have injured nerves or diseased and/or generalized damaged blood vessels. Also, if you are a candidate, be aware that vascular surgeries are still considered experimental by some urologists and may also not be covered by your insurance.
What can be expected after surgical treatment for erectile dysfunction (ED)?
Most of the best known treatments for ED have excellent track records for being both effective and safe. But in making your choice, make sure to discuss the potential complications of each option with your doctor.
For instance, the good news about a penile prosthesis is that it does not usually affect urination, sex drive, orgasm or ejaculation. But on rare occasions, these semi-rigid, silicone-covered rods or hydraulic devices can cause pain or reduced sensation. While injections can initiate erections within 15 minutes to several hours, be aware that they also can produce prolonged or painful ones, not to mention a scarring of penile connective tissue (fibrosis).
At the same time, a vacuum erection device should take only one to three minutes to give an erection, usually with no serious side effects if used properly. However, the use of the erection device to maintain the erection is limited to 30 minutes.
Sildenafil, tadalafil and vardenafil have nearly 80 percent success rates, primarily because they are a solution that works within one hour. But on occasion they can cause headaches, flushing, indigestion or muscle aches. Also, if you have heart disease or low blood pressure, the Food and Drug Administration (FDA) cautions a thorough examination before getting a prescription. You cannot take these drugs if you are taking nitroglycerine or any similar drug.
Frequently asked questions:
Is age a factor in impotence?
Yes. Data suggest that while not an inevitable part of aging, the risk of impotence increases as we grow older. Some experts suggest the numbers may be underreported since men are still embarrassed by this physical and psychological issue. However, the reassuring news is that it is treatable in all age groups.
What should I remember about erectile dysfunction?
Also called impotence, ED is the consistent inability to sustain and maintain an erection, is a widespread problem. It affects over 50 percent of men between ages 40 and 70. Luckily, oral drugs, vacuum devices, injectable medications, psychotherapy and even surgery have made impotence very treatable. The promising news is that new drugs are sure to join existing non-invasive treatments while other experimental options, such as gene therapy, are on the horizon. In addition, ongoing modifications of today's standard treatments may eventually improve the picture for impotent men.
Where can I get more information?
Urology Care Foundation Patient Brochures:
Erectile Dysfunction: Causes, Risks & Talking To Your Doctor
Erectile Dysfunction: Primary Treatment Options
Erectile Dysfunction: Secondary Treatment Options
Urology Care Foundation Fact Sheets:
Diagnosing Erectile Dysfunction
Treating Erectile Dysfunction: Medical Options
Treating Erectile Dysfunction: Surgical Treatment Options
Preventing Erectile Dysfunction: What You Should Know
Reviewed: January 2011
Last updated: April 2013