Male Sexual Dysfunction
Erectile dysfunction, ED, or impotence, is very common. Some degree of inability to get or maintain an erection suitable for sexual function, is so common over the age of 50 to almost be normal or physiological. Many causes are at play here. Often smoking and vascular disease, together with high cholesterol , high blood pressure, and diabetes, all have significant impact. Psychological causes (stress, anxiety, depression) are possible but less prevalent. Medications to treat things such as blood pressure or central nervous system disorders can be causative.
Modern therapy for ED include first line measures of vasoactive oral drugs such as Viagra, Cialis and Levitra. These all work within 30 minutes of administration but their efficacy can be affected by food and alcohol. They are not suitable for those men with a severe cardiac condition, and the co-existent use of heart nitrate medications is an absolute contra-indication the their use. Side effects generally include facial flushing, frontal headache, slight nausea, and with Viagra,transient alteration of colour perception.
If the above is unsuccessful , or not safe, then second line treatment is by penile injections of Caverject Impulse (alprostadil) which is dose titrated and given by the patient or their partner. This is up to 80 % successful in achieving a usable erection. Side effects can include bruising, and occasionally development of a penile bend (Peyronie's disease).
Caution : some "men's clinics" promote a nasal spray with exaggerated claims of success. This product may be such as apomorphine, which has a mild central effect on erections, but is an unregulated medicine. Major pharmaceutical companies have decided not to bring this product to the market as there is no clinical advantage over Viagra. Beware of these clinics which usually make claims "too good to believe", they are usually being chased by Fair Trading and will often change names but not methods. Caveat emptor!
Other more established methods can involve vacuum devices and penile constriction rings, or finally an inflatable penile implant surgically placed. The latter, while more invasive, has a very durable track record with a low mechanical failure rates. The relliable prostheses are those of AMS (AMS 700) or Coloplast Titan.
Retrograde ejaculation is where the ejaculate fluid, at time of orgasm, goes back up into the bladder rather than out the urethra. This quite commonly occurs after TUR prostate. After radical prostatectomy surgery for cancer, there may be a sense of orgasm, but there is no ejaculate at all, as there is no longer a prostate to produce such fluid.
Peyronie's disease is an acquired bending of the penis. The cause is not usually known. It is a benign and self-limiting disorder of an excess deposition of scar tissue in the lining of the penile erectile shaft. In its acute phase there may be penile pain with erection and variable bending usually in the upward direction. Downward and / or lateral bending can also happen. The bend does not fully stabilise until 12 months or more. During this time, intrapenile injections of verapamil or Collagenase could be considered for moderate improvement in angulation (I refer patients to Dr Chris McMahon for these). If the degree of bend is so much as to interfere with intercourse, then penile plication surgery can be considered. The side effects of surgery include penile shortening, possible rebending and possible penile numbness. If co-existent erectile failure is present, then the treatment of choice is an AMS 700 or Coloplast Titan penile implant prosthesis.