Erectile Dysfunction

Erectile Dysfunction

• Persistent inability to attain or maintain penile erection adequate for sexual intercourse

  • “Persistent” means it happens repeatedly, not just once in a while

  • The penis does not become or stay firm enough for sexual activity

  • Doctors now use the term “erectile dysfunction” instead of the older word “impotence”

Prevalence of ED

• Affects about 20–30 million men in the United States

• It is underreported, meaning many men don’t tell their doctor because they feel embarrassed or think it’s just part of aging

• The chance of having ED increases as men get older, it’s more common in older adults

Causes of ED

• Psychogenic (mental/emotional)

• Organic (physical)

• Mixed (psychogenic + organic)

  • Many people have both mental and physical causes at the same time

Psychogenic Causes of ED

• The person can still have morning erections or get an erection when alone

  • This means the body is working fine, but the mind may be blocking it during sex

• Past trauma, such as sexual assault or molestation, can affect confidence or comfort with intimacy

• Mental health conditions like depression or schizophrenia can reduce sexual interest or function

• Anxiety, stress, or feeling guilty about sex can interfere with arousal

• Relationship problems or conflict with a partner can make it harder to relax or stay aroused

Medical Conditions that can cause ED

• Neurogenic

• Hormonal

  • Hypogonadism: low testosterone levels

  • Hyperprolactinemia: too much of the hormone prolactin, which can lower testosterone and reduce sexual desire

• Vascular (40% of ED cases)

  • Atherosclerosis

  • Hypertension

  • Diabetes

  • Peyronie’s disease

• Anemia

• Kidney failure

• Thyroid disease

Evaluation of ED

• History and Physical Exam

• Medication Review

• Lab Tests: 

  • Testosterone, prolactin

  • Fasting lipid panel

  • Fasting blood sugar

  • Complete blood count (CBC)

  • Creatinine and urinalysis

  • TSH

Lifestyle causes of ED

• Alcohol

• Illegal Drugs

• Tobacco Products

Diabetes and ED

• Diabetes is one of the most common causes of ED because it damages nerves and blood vessels that control erections

• 20% to 85% of men with diabetes experience ED (it’s very common)

• The worse the blood sugar control (higher HbA1c), the more severe the ED tends to be

• 46% of diabetic men with ED also have severe depression, showing how both physical and emotional health are connected

• 63% of men with diabetes say their doctor never asked about sexual function, so the problem is often overlooked in care

• Why this happens:

  • High blood sugar damages nerves (neuropathy) and blood vessels, both essential for an erection

  • Hormone changes and poor circulation make the condition worse over time

Smoking and ED

• Smoking greatly increases the risk and severity of ED because it damages blood vessels and reduces the body’s ability to get proper blood flow for an erection

• How Smoking Affects the Body:

  • Decreases Nitric Oxide (NO)

  • Causes Atherosclerosis

  • Reduces Penile Blood Flow

• Good News:

  • Quitting smoking early or avoiding it altogether can lower the risk of developing ED

Medications and ED

• Some medications can cause ED or make other causes (like diabetes or vascular disease) worse

• Medications may directly cause ED or add to existing problems by affecting blood flow, hormones, or nerve signals

• Stopping the medication doesn’t always fix ED unless there’s a clear timing link , meaning ED started right after the medication was started

• Doctors must balance the benefits of the medication (what it’s treating) against the risk of ED before making any changes

Medications that cause ED

• Antihypertensives

• Antidepressants

• Antipsychotics

• Cimetidine

• Digoxin

• Phenobarbital

• Phenytoin

• Gemfibrozil

• Tobacco

• Alcohol

• Cocaine

• Amphetamines

Medications that decrease libido (sexual desire)

• Beta-blockers

• TCAs

• SSRIs

• BZDs

• Spironolactone

Antihypertensives (bp meds) and ED

Highest to lowest risk to cause ED

1. Central agents (highest)

2. Thiazide diuretics (highest)

3. Beta blockers

4. Calcium channel blockers

5. ACEI (lowest)

6. ARBs (lowest)

Process of Care Model

1. Evaluation and Diagnosis

2. Modify Reversible Causes

3. 1st-Line Therapy

4. 2nd-Line Therapy

5. 3rd-Line Therapy

Modify Reversible Causes 

• Fix or treat things that can be reversed or improved, such as:

  • Substance abuse

  • Medications that cause ED

  • Hormone problems

  • Psychological issues (stress, anxiety, depression)

1st-Line Therapy

• Oral medications

• Sex therapy for relationship or mental causes

• Vacuum erection device (VED)

2nd-Line Therapy

• Alprostadil (injection), a drug that increases blood flow, can be given:

  • Transurethrally (inserted into the urethra)

  • Intracavernosally (injected directly into the penis)

3rd-Line Therapy

• Penile prosthesis (implant)

  • A surgical option if other treatments fail

Treatment of ED

• Counseling

• Non-Pharmacologic

• Pharmacologic

• Surgical

• Alternative Therapies

Counseling

• Counseling can be combined with other treatments, such as medication or devices, to improve success

• It can be very effective, studies show it helps up to 82% of patients

• It is especially helpful when ED is related to stress, anxiety, guilt, relationship problems, or past trauma

• A patient should be referred to a mental health professional or sex therapist if he has:

  • A history of sexual assault or molestation

A patient should be referred to a mental health professional or sex therapist if he has:

• A history of sexual assault or molestation

Non-Pharmacologic Therapy

• Vacuum Devices

  • Vacuum Erection Devices (VEDs)

  • Do not use if the patient is taking blood thinners like warfarin, heparin, or LMWH, because it increases the risk of bleeding or bruising

• Constriction Devices

• Success depends on proper instruction and consistent use, patients need to be taught how to use the device safely and correctly

When should patient not use VEDs?

• If the patient is taking blood thinners like:

  • Warfarin

  • Heparin

  • LMWH

• Because it increases the risk of bleeding or bruising

Vacuum Erection Device (VED)

• Is a non-pharmacological option that helps a man achieve an erection using suction and a constriction band

• How It Works:

  1. A vacuum cylinder is placed around the penis

  2. Air is pumped out (using a manual or electric pump), creating negative pressure

  3. This pulls blood into the penis, filling the corpora cavernosa

  4. A constriction band is then placed at the base of the penis to keep the blood from flowing out

• The band is kept on until orgasm or for no more than 30 minutes to prevent injury

• The method is safe and effective for many men, including those who can’t take oral medications

• Avoid use in patients taking blood thinners (warfarin, heparin, LMWH) because of the risk of bruising or bleeding!

VED Components

• Vacuum Cylinder

• Vacuum Pump

• Constriction Band

Vacuum Erection Devices (VED) vs. Sildenafil (Viagra)

• This study compared VED and sildenafil (a PDE-5 inhibitor) to see which treatment men preferred

• 52 patients were successfully treated with a VED

• They were then switched (converted) to sildenafil to see how they responded

• 36 patients responded well to sildenafil

• 66% chose to continue sildenafil, they preferred the convenience of oral medication

• 33% chose to return to using VED, likely due to side effects or personal comfort

• Key Takeaway:

  • Most patients preferred oral therapy (sildenafil) because it’s easier and more natural-feeling

  • However, VED remains a good non-pharmacological option for those who can’t tolerate or respond to medication

VED Advantages

• Affordable ($300–$500)

• Effective and safe

• High satisfaction rate

• May help restore natural erections in some patients after regular use!

VED Disadvantages

• Lack of spontaneity

  • Requires preparation time before intercourse

• “Cold” erections (less warmth) and sometimes trapped ejaculation due to the constriction band

• Pivoting

  • The penis may feel less rigid at the base, causing movement (“hinge effect”)

• Risk of bruising

• Requires manual dexterity 

  • Difficult for patients with neuropathy, arthritis, or obesity

Physiology of Erection

1. Brain triggers arousal

2. Nerves release neurotransmitters (chemical messengers) that tell blood vessels in the penis to relax

3. Blood flow increases into the penis while the veins that drain blood tighten

   1. This traps the blood and maintains the erection

The vascular system (blood flow) must be intact for this to work properly

Key Neurotransmitters in an Erection

• Nitric oxide

• Prostaglandin E

• Acetylcholine

• Vasoactive intestinal peptide (VIP)

• Primary neurotransmitters mediating erection

Detumescence

• Loss of erection

How does the sympathetic system affect erection and relaxation of penile muscles?

• Neurotransmitter: Norepinephrine (NE)

• Pathway: α-adrenergic

• Effect: Causes contraction of smooth muscle in penile blood vessels

• Result: Blood leaves the penis → Detumescence (loss of erection)

How does the parasympathetic system affect erection and relaxation of penile muscles?

• Neurotransmitter: Nitric Oxide (NO)

• Pathway: NANC = Non-Adrenergic, Non-Cholinergic

• Effect: Causes relaxation of smooth muscle in penile arteries → more blood flow

• Result: Blood fills the penis → Erection

Physiology of PDE-5 Inhibitors

• Parasympathetic nerves release Nitric Oxide (NO) → this is the “go” signal for an erection

• Nitric Oxide (NO) increases cGMP from GTP

  • Think of cGMP as a relaxing messenger that tells penile smooth muscles to relax

• Muscle relaxation allows more blood to enter the penis → erection happens

• What normally happens (without the drug):

  • The enzyme PDE-5 breaks down cGMP into inactive cGMP, which ends the erection (causing detumescence)

• What PDE-5 Inhibitors Do:

  • Block PDE-5, so cGMP stays active longer

  • This means muscles stay relaxed and blood stays in the penis 

    • Erection is maintained!

What does PDE-5 normally target to decrease an erection?

• cGMP

  • Decrease of cGMP cause increase of PDE-5 that ends the erection, that’s why medications like PDE-5 inhibitors causes more cGMP which allows more relaxation which allows more blood to flow into penis to be erected

Pharmacologic Therapies

• Oral Therapy

  • PDE-5 Inhibitors

  • Yohimbine 

• Topical Therapy

  • Nitroglycerin or ISDN creams

  • Minoxidil

  • Aminophylline cream

• Urethral Alprostadil Suppositories

• Intracavernosal Injections

  • Alprostadil

  • Papaverine

  • Phentolamine

• Testosterone Therapy

Testosterone Contraindications

• Hematocrit > 50%

• Sleep apnea

• Severe lower urinary tract symptoms (AUA index >19)

• Uncontrolled/ poorly controlled heart failure

• Men desiring fertility

American Urological Association (AUA) 2014 Position Statement

• The FDA is reviewing possible cardiovascular (heart) risks linked to testosterone use

• Research on whether testosterone helps or harms heart health is conflicting, there isn’t enough strong evidence yet

• Inappropriate Use:

  • DO NOT use testosterone unless the patient has confirmed hypogonadism (low testosterone)

  • Giving testosterone when levels are normal is not appropriate

• Therapy should only be started and monitored by an experienced physician

• Patients must be taught about the risks and benefits before starting treatment

Normal Testosterone Levels

• 280–300 ng/dL

  • Testosterone levels must be measured in the morning because levels are highest at that time and drop throughout the day

  • Two separate low readings are needed to confirm testosterone deficiency

    • This helps make sure it’s not just a temporary drop caused by stress, illness, or lack of sleep

Testosterone Replacement Therapy

• Intramuscular Testosterone Injection

• Testosterone Patches 

• Topical Testosterone Gel

• Buccal Testosterone Tablet

• Subcutaneous Testosterone Implants

Topical Testosterone Gel → Drugs

• AndroGel

• Testim

Topical Testosterone Gel

• 1% testosterone gel comes in 5–10 g tubes or packets, each containing 50–100 mg of testosterone

• Only about 10% of the applied dose is absorbed through the skin into the bloodstream

• Apply once daily to clean, dry, intact skin on the upper arms, shoulders, or abdomen

• This allows steady absorption of testosterone throughout the day

• Wash hands after applying the gel

• Cover the site with clothing to prevent accidental transfer to women or children (which can cause unwanted hair growth or early puberty)

• Bypasses first-pass metabolism, which helps maintain steady hormone levels and reduces liver toxicity risk!

Testosterone Patches → Drugs 

• Androderm

Testosterone Patches

• Apply to back, thigh, upper arm, or abdomen (rotate sites daily)

• Local skin irritation is very common (redness, itching, rash)

  • Up to 60% of users discontinue due to irritation

• Other possible side effects:

  • Headache, depression, rash, and GI bleeding (rare)

• Avoids first pass metabolism 

Buccal Testosterone Tablet → Drugs

• Striant

Buccal Testosterone Tablet

• Stick the tablet to the inner cheek or gum surface near the upper incisor (front tooth)

• Frequency: Twice daily (every ~12 hours)

• Provides pulsatile release 

  • Steady absorption through the oral mucosa into the bloodstream

• Adverse Effects:

  • Local irritation (most common)

  • Bitter taste or dry mouth

  • Stomatitis (gum inflammation)

  • Anxiety (rare systemic effect)

• Bypasses first-pass liver metabolism

Intramuscular Testosterone Injection → Drugs

• Testosterone enanthate

• Testosterone cypionate

Intramuscular Testosterone Injection

• These forms are lipophilic (fat-loving), so they dissolve slowly in fat tissue

  • This allows gradual release of testosterone into the bloodstream over days to weeks

• Pros: 

  • Provides steady testosterone levels after injection

  • Avoids first-pass metabolism (bypasses the liver)

• Cons: 

  • Fluctuations in energy, mood, and libido, levels go up after injection and drop before the next dose

  • Gynecomastia (breast enlargement) can occur in about ½ of patients, especially early in therapy

  • Requires needle use and sometimes clinic visits

Intramuscular Testosterone Injection Needle Size

• 20 gauge, 1.5-inch

Subcutaneous Testosterone Implants → Drugs

• Testopel

Subcutaneous Testosterone Implants

• Small implantable pellets that contain testosterone

• Placed under the skin (subdermally) by a healthcare provider

• Slowly dissolve and release testosterone into the bloodstream over time

• Once implanted, the pellets gradually release testosterone for up to 246 days

  • This provides a steady, long-term testosterone level, avoiding the ups and downs seen with injections

• Done in a doctor’s office

• Common sites:

  • Lower abdomen

  • Deltoid (upper arm)

  • Proximal thigh

  • Buttocks

• Adverse effects:

  • Pellet extrusion 

    • It can pop out if not placed deep enough

  • Infection at the insertion site

  • Fibrosis 

    • Scar tissue buildup under the skin

• Bypasses first-pass metabolism

Monitoring for Testosterone Therapy

• Recheck 3–6 months after starting treatment

  • If stable →  monitor annually afterward

• What to monitor for:

  • Efficacy

  • Adverse effects

• Target range: 280–800 ng/dL

  • Aim for the mid-normal range (around 400–600 ng/dL).

  • Avoid supraphysiologic levels (>800 ng/dL), which can cause harm

• Monitor:

  • PSA

    • Repeat at 3–6 months, then annually

  • Digital Rectal Exam (DRE)

    • Repeat at 3–6 months, then annually

  • CBC (Complete Blood Count)

    • Check at baseline, 3, 6, and 12 months after starting therapy

    • If hematocrit > 54% → stop therapy

• Sleep apnea

  • Testosterone can worsen or unmask sleep apnea, so monitor for loud snoring, fatigue, or breathing pauses during sleep

• Skin effects

  • May cause acne or oily skin

Cardiac Risk Stratification

• Essential before a patient is started on a PDE5 inhibitor

• Sexual activity and PDE5 inhibitors both increase cardiovascular demand (↑ heart rate, ↑ blood flow)

• So, before starting therapy, patients must be screened to ensure their heart can safely handle both the medication and sexual activity

• Follow guideline-based risk categories:

  • Low risk

  • Intermediate (medium) risk

  • High risk

Princeton III Consensus Criteria

• Purpose is to determine if a man with erectile dysfunction can safely have sexual activity or take PDE-5 inhibitors, based on cardiac risk

• Step-by-step Process: 

  • Sexual Inquiry

    • Ask all men about sexual activity and possible ED symptoms

  • Confirm ED

    • If yes → evaluate exercise ability (since sex = mild/moderate cardiac stress)

  • Assess Exercise Tolerance:

    • If the patient can:

    • Walk 1 mile in 20 minutes OR

    • Climb 2 flights of stairs in 10 seconds OR

    • 4 minutes on the Bruce treadmill

    • Indicates adequate cardiovascular capacity for sexual activity

• Low Risk:

  • Can safely engage in sexual activity and start PDE-5 inhibitors

• Intermediate Risk:

  • Uncertain cardiovascular stability

  • Do a stress test:

  • If Pass → Low risk (okay to treat)

  • If Fail → High risk (refer to cardiologist)

• High Risk:

  • No sexual activity or PDE-5 inhibitors until cleared by a cardiologist

Efficacy of PDE5 Inhibitors

• Based on a meta-analysis of 27 randomized trials, the success rate for sexual intercourse was:

  • 57% in men taking sildenafil (Viagra)

  • 21% in men taking placebo

  • So, PDE5 inhibitors significantly improve erectile function in most men with ED

• All PDE5 inhibitors have similar efficacy

Lower Response Rates of PDE5 Inhibitors

• Age >65 years

• Diabetes

• Radical prostatectomy 

  • Nerve injury or removal near prostate reduces erection ability

Drug interactions with PDE5 Inhibitors

• Nitrates

• Alpha-blockers

• Vardenafil

  • May cause prolong QT interval

  • Use caution in patients with QT prolongation or taking Class IA or III antiarrhythmics

CYP3A4 Inhibitors DDI with PDE5 Inhibitors

• Protease inhibitors (particularly ritonavir)

• Ketoconazole

• Itraconazole

• Erythromycin

• Cimetidine

CYP3A4 Inducers DDI with PDE5 Inhibitors

• Phenytoin

• Rifampin

• Phenobarbital

• Carbamazepine 

PDE5 Inhibitors → Drugs

• Sildenafil

• Vardenafil

• Tadalafil

• Avanafil

Sildenafil

• t_1/2 = 4 hrs

• Decreases 30% w food

Vardenafil

• t_1/2 = 4-5 hrs

• Decreases 18% w food

Tadalafil

• t_1/2 = 17.5 hrs (long)

• No change w food (okay perioddd)

What is a big counselling point w Sildenafil and Vardenafil

• Sildenafil: Decreases 30% w food

• Vardenafil: Decreases 18% w food 

• Must avoid fatty meals before taking the medication

  • Especially high fat meals

Avanafil

• Is a PDE-5 Inhibitor

• Fastest onset of all PDE5 inhibitors

  • Works in about 15 minutes

• No generic available yet ( very expensive)

• Can be taken with or without food

• Take 15–30 minutes before sexual activity

Which PDE-5 Inhibitor has the fastest onset?

• Avanafil

• Works in about 15 minutes

Nitrates and PDE5 Inhibitors

• ABSOLUTELY CONTRAINDICATED

• If absolutely needed: must be separated 24 hrs between

PDE5 Inhibitors Precautions

• Limited Safety Data for (so don’t use for):

  • MI

  • Stroke (CVA)

  • Life-threatening arrhythmia within past 6 months

  • BP < 90/50 or > 170/110

  • Retinitis pigmentosa

  • Congestive heart failure (CHF)

  • End-stage renal disease (ESRD)

  • Severe hepatic impairment

• Use Lower Starting Dose In:

  • Older adults (≥65 years)

  • Hepatic impairment

  • Severe renal impairment (CrCl < 30 mL/min)

Start low and go slow! Use lowest effective dose to prevent hypotension and accumulation

PDE5 Inhibitors Adverse Effects

• Headache

• Flushing

• Dyspepsia

• Nasal congestion

• Abnormal vision

  • Blue or green is hard to see

• Back pain

PDE5 Inhibitors – Reasons for Treatment Failures

• Unrealistic Expectations

• Poor Patient Education

• Inadequate Doses

• Inadequate Number of Attempts

• Food or Drug Interactions

Patient Counselling w PDE5 Inhibitors

• Inform all patients of Nitrate interaction

• Food Interactions w Sildenafil & Vardenafil

• Sexual Stimulation Required

  • PDE5 inhibitors enhance natural erections, but do not cause them automatically

    • Patient must be sexually aroused for nitric oxide (NO) to be released

• Take only one tablet per 24 hours

• Drug Interactions

• Tablet Splitting 

  • Make sure patient has splitting machine

Choosing an Agent

• Concurrent Alpha-Blocker Use

  • If patient has BPH use an uro-selective BPH med

• History of QT Prolongation

  • Avoid vardenafil

• Ability to take with a meal

• Onset vs Duration

If patient has ED and BPH, what’s a good option?

•  PDE5 Inhibitors and Uro-selective BPH med

Intracavernosal (IC) Injections → Drugs

• IC Alprostadil

Intracavernosal (IC) Injections

• The medication is injected directly into the corpora cavernosa

• The injection contains vasoactive substances

  • They dilate (open) blood vessels, increasing blood flow and causing an erection

• Success rates: 70%- 90%

• Works regardless of cause (etiology)

  • Helpful even if ED is due to nerve injury, diabetes, or vascular disease (so nice if oral meds cannot help)

IC Alprostadil

• Is a synthetic form of Prostaglandin E₁

  • A natural chemical that helps dilate blood vessels

• It relaxes smooth muscle in the penis, specifically:

  • The trabecular smooth muscle

  • The helicine and cavernosal arteries

• This allows increased blood flow into the corpora cavernosa, leading to an erection

• Unlike PDE5 inhibitors, alprostadil works even without sexual stimulation 

  • Because it acts directly on the smooth muscle

• The lowest effective dose is always found in the doctor’s office first

• The average maintenance dose is about 20 mcg

• Works quickly, within 5 to 20 minutes after injection

• Erection lasts long enough for intercourse, but should not exceed 1 hour

• The goal is to titrate (adjust) the dose so that the erection lasts less than 1 hour

Big differnce between Intracavernosal (IC) Injections and PDE5 inhibitors?

• Intracavernosal (IC) Injections works even without sexual stimulation 

• While PDE5 inhibitor required the “arousal” for the person to have an erection

Main reasons to use Intracavernosal (IC) Injections

• Neurogenic

• Vasculogenic

• Psychogenic

• Mixed (combination of causes)

Intracavernosal (IC) Injections Contraindications

• Sickle cell disease

• Multiple myeloma

• Leukemia

• Penile fibrosis

• Penile curvature 

Intracavernosal (IC) Injection Advantages 

• Highly effective

• High satisfaction once fear is gone

  • Many men are nervous about the injection at first (“needlephobia”), but once they learn the proper technique, satisfaction rates are high

• Safe when used correctly

Intracavernosal (IC) Injection Disadvantages 

• Cost

  • $21–$35

• Education required

• Adverse Effects: 

  • Penile pain

  • Fibrosis or scarring

  • Prolonged erection (priapism)

• Lack of spontaneity

  • Requires planning, the patient must prepare and inject before sexual activity (onset 5–20 min)

MUSE (Medicated Urethral System for Erection)

• Is a transurethral suppository form of alprostadil

  • Instead of injecting it, a tiny pellet is inserted into the urethra (the opening at the tip of the penis) using an applicator

• The alprostadil is absorbed through the urethral lining into nearby erectile tissue (corpora cavernosa), which causes vasodilation and erection

• Can be used up to twice in 24 hours

MUSE (Medicated Urethral System for Erection) Advantages

• Less invasive (no needle required)

• Better tolerated by patients who dislike injections

• Easier to administer once trained

MUSE (Medicated Urethral System for Erection) Disadvatages

• Penile pain

• Mild urethral discomfort or burning

• Dizziness

• Hypotension 

  • The patient should sit or lie down during administration to reduce dizziness risk

TU Alprostadil

• Inserted into the urethra → alprostadil is absorbed through the urethral lining → increases blood flow to the corpora cavernosa → erection

• Route: Intraurethral

• Onset: 5–10 minutes

• Duration: 30–60 minutes

TU Alprostadil Advantages

• Ease of use

• Lower risk of priapism (persistent and painful erection of the penis)

• No needles

  • Great option for patients with needle fear (needlephobia)

TU Alprostadil Disadvantages

• Cost

  • $22–$26 per dose

• Less effective than IC (intracavernosal) injection

  • Response rate is around 40–60%, lower than the 70–90% seen with injections

• Penile pain

• Lack of spontaneity

  • Still requires advance preparation and timing before sexual activity

• Manual dexterity issues

  • Patients with poor hand control, obesity, or those on anticoagulants (blood thinners) may find it hard or risky to insert safely

Patient Counselling w MUSE

• Insert immediately after urination

• Roll penis between your hands for 10 seconds

• Stand or walk for a few minutes after insertion

• No more than 2 doses in 24 hours

• Use condoms during intercourse

  • Prevents vaginal absorption of alprostadil in female partners, which can cause side effects

Yohimbine

• Is a herbal supplement that comes from the bark of a West African tree

• It works in the brain as a centrally acting α₂-antagonist, which may slightly increase blood flow and nerve signals related to arousal

• It is NOT FDA-approved to treat erectile dysfunction (ED)

• It’s sold as a dietary supplement or by prescription (brand: Yocon), but its effectiveness is not well proven

• It’s rarely prescribed because of limited benefit and more risks than safer ED drugs like PDE5 inhibitors

• Can cause anxiety, increased heart rate, high blood pressure, and insomnia due to its stimulant-like effects

• Not recommended by the American Urological Association (AUA) for ED treatment

Penile Implants 

• Three Piece Inflatable

• Semirigid Rods

Three Piece Inflatable

• Fluid reservoir 

  • Holds sterile saline; placed in the lower abdomen

• Pump

  • Located in the scrotum; the patient squeezes it to move the fluid

• Intracavernosal rods 

  • Hollow cylinders placed inside the penis

Semirigid Rods

• Always firm but bendable; can be positioned upward for intercourse and downward for concealment

Surgical Therapies

• Penile Prosthesis (Implant)

  • 80-90% satisfaction rate

• Penile Reconstruction

• Vascular Reconstruction