Surgical Treatment of Erectile Dysfunction

Exploring Your Treatment Options
Your doctor may suggest surgery to treat your erectile dysfunction or ED if other forms of therapy are not satisfactory.

Surgery is generally used to accomplish one of the following goals:

Implanting a prosthetic device within the penis, which causes an erection

Reconstructing the arteries within the penis to increase blood flow, which helps to facilitate an erection

Blocking off veins within the penis that allow blood to leave the penis, which helps to maintain an erection

Erectile Dysfunction: Penile Prosthesis

How does the penile implant work?
Is the penile implant noticeable?
What is sex like with the penile implant?
How effective are the penile implants?
Is the penile implant safe?

A penile prosthesis is another treatment option for men with erectile dysfunction. The simplest type of prosthesis consists of a pair of malleable rods surgically implanted within the erection chambers of the penis. Today, many men choose a hydraulic, inflatable prosthesis, which allows a man to have an erection whenever he chooses.

A penile implant is usually used when there is a clear medical cause for ED and when the problem is unlikely to resolve or improve naturally or with other medical treatments. Sometimes a penile prosthesis is implanted during surgery to reconstruct the penis when scarring has caused erections to curve.

How Does the Penile Prosthesis Work?

The inflatable penile prosthesis consists of two cylinders — a reservoir and a pump — which are placed surgically in the body. The two cylinders are inserted in the penis and connected by tubing to a separate reservoir of fluid. The reservoir is implanted under the groin muscles. A pump is also connected to the system and sits under the loose skin of the scrotal sac, between the testicles.

To inflate the prosthesis, the man presses on the pump. The pump transfers fluid from the reservoir to the cylinders in the penis, inflating them. Pressing on a deflation valve at the base of the pump returns the fluid to the reservoir, deflating the penis.

Is the Prosthesis Noticeable?

While men who have had the prosthesis surgery can see the small surgical scar where the bottom of the penis meets the scrotal sac, other people probably will be unable to tell that a man has an inflatable penile prosthesis. Most men would not be embarrassed in a locker room or public restroom, for example.

What Is Sex Like With the Prosthesis?

When the penis is inflated, the prosthesis makes the penis stiff and thick, similar to a natural erection. Most men rate the erection as shorter than their normal erection; however, newer models have cylinders that may increase the length, thickness, and stiffness of the penis.

A penile prosthesis does not change sensation on the skin of the penis or a man’s ability to reach orgasm. Ejaculation is not affected. Once a penile prosthesis is put in, however, it may destroy the natural erection reflex. Men usually cannot get an erection without inflating the implant. If the implant is removed, the man may never again have natural erections.

How Effective Are the Implants?

About 90%-95% of inflatable prosthesis implants produce erections suitable for intercourse. Satisfaction rates with the prosthesis are very high, and typically 80%-90% of men are satisfied with the results and say they would choose the surgery again.

Is the Implant Safe?

No surgery is totally free of possible complications. Complications associated with penile implants include:

Uncontrolled bleeding after the surgery possibly leading to re-operation
Infection
Scar tissue formation
Erosion (tissue around the implant may break down)
Mechanical failure

Semirigid or Malleable Rod Implants
With the semirigid or malleable rod implant, 2 matching cylinders are surgically implanted into the penis. To achieve an erection, you manually adjust the position of the penis. This implant provides enough rigidity for penetration and rarely breaks.

Advantages of the semirigid or malleable rod implant include:

Simple surgery

Relatively few complications

No moving parts
Least expensive implant

70-80% success rate
Highly effective
The major drawbacks of the semirigid or malleable rod implant are:
Cosmetic appearance of the penis
Need for surgery

Destruction of the natural erectile mechanism when the device is implanted
Other disadvantages of the semirigid or malleable rod implant include:

Constant erection at all times

May be difficult to conceal

Does not increase the width of the penis

Risk of infection

Permanently alters or may injure erection bodies Most likely implant to cause pain or erode through the skin If unsuccessful, interferes with other treatments

Inflatable Implants
The inflatable implant consists of:

Two cylinders, surgically inserted into the penis

A pump, placed in the scrotum

A reservoir, contained either within the cylinders or in a separate reservoir placed beneath the tissue of the lower abdomen
With an inflatable implant, you squeeze the pump placed within the scrotum to inflate the cylinders. The pump moves fluid from the reservoir implanted in the lower abdomen to the cylinders implanted in the penis. The expansion of these cylinders creates an erection.
The inflatable implant generally remains functional for 7-10 years before a replacement typically is necessary. Most, if not all, companies offer lifetime warranties for both the parts and the components of these devices.

Although effective, some overall complications of the inflatable implant include:

Infections (2% of users)

Device malfunctions (4% of users)

Erosion of the device through the urethra or the skin (2% of users)

Painful erections (1% of users)

Two types of inflatable implants are available: a fully inflatable implant and a self-contained inflatable unitary implant.
Fully Inflatable Implants

Advantages of a fully inflatable implant include:

Mimics the natural process of rigidity-flaccidity

User controls the state of erection
Natural appearance
No concealment problems
Increases the width of the penis when activated
70-80% success rate
Highly effective
Disadvantages of a fully inflatable implant include:
Relatively high rate of mechanical failure
Risk of infection
Most expensive implant
Permanently alters or may injure erection bodies
If unsuccessful, interferes with other treatments
Self-Contained Inflatable Unitary Implants
Advantages of a self-contained inflatable unitary implant are:
Mimics the natural process of rigidity-flaccidity
User controls the state of erection
Natural appearance
No concealment problems
Simpler surgery than the fully inflatable implant
70-80% success rate
Highly effective
Disadvantages of a self-contained inflatable unitary implant include:
Sometimes difficult to activate this type of implant
Does not increase the width of the penis
Possible mechanical breakdowns
Risk of infection
Relatively expensive
Permanently alters or may injure erection bodies
If unsuccessful, interferes with other treatments
Vascular Reconstructive Surgery
Vascular reconstructive surgery is another surgical treatment option for men with erectile dysfunction.
Surgery to reconstruct the arteries within the penis can be performed. By increasing blood flow to the penis, a man is able to achieve or maintain an erection.
Surgery to block off the veins within the penis can be done. By blocking off these veins, blood is not allowed to leave the penis, which enables a man to achieve or maintain an erection.
Your doctor will discuss the benefits and risks of vascular reconstructive surgery with you and your sexual partner.

Advantages of vascular reconstructive surgery include:

Restores natural erections when successful
Natural appearance
No implant required
If unsuccessful, does not interfere with other treatments
It must be stressed that very few men are potential candidates for vascular reconstructive surgery. In addition, extensive testing is required of men prior to undergoing this type of surgery. Additionally, there are very few medical centers that have experience in the management of vascular surgery for erectile dysfunction.

Although moderately effective, with a 40-50% success rate, the long-term effectiveness of vascular reconstructive surgery is generally only 2 years or less. Also, vascular reconstructive surgery is very expensive and associated with a relatively high relapse rate.
Other disadvantages of vascular reconstructive surgery are:

Technically difficult surgery

Risk of infection, scar tissue formation with distortion of the penis, and painful erections

May cause shortening or numbness of the penis

Male impotence

When a man becomes sexually aroused, increased blood flow to the genital area readies the body for intercourse. The penis becomes enlarged and erect. In men with impotence (ED,Levitra Online), however, this physical response doesn’t happen as it should. And this isn’t just a one-time or occasional occurrence. In fact, occasional failure to become aroused or desiring sex less often than your partner is perfectly normal. Stress, fatigue and anxiety can affect the body’s response to sexual stimulation. The problem occurs when this lack of response happens persistently and on a regular basis for more than 25 percent of the time. With ED, intercourse is difficult or impossible. ED is not only a common problem, particularly among older men, but also it is undertreated. The Massachusetts Male Aging Study of middle-aged and older men showed 35 percent of men ages 40 to 70 years had complete ED, which was strongly related to age, health status and emotional function. According to the American Medical Association (AMA,Levitra Online), about 20 million American men, mostly older than 65, are affected. It is difficult to calculate an exact number because less than 10 percent seek treatment.

The following information is designed as a basic introduction to possible causes of and treatments for ED. If you suspect a problem, talk with your doctor or other health care professional.

Causes

Once thought to be a psychological condition, most cases of ED are now known to have a physical cause, such as a disease, an injury or a side effect from a drug. Certain drugs can interfere with the nerve signals that cause an erection. Hardening of the arteries and high blood pressure can damage blood vessels and interfere with blood flow to the penis. Smoking is a major risk factor for these conditions as well as for ED. Diabetes can damage nerves and interfere with erection. Surgery for prostate cancer may cause ED. Other possible physical causes include alcoholism, liver failure, hormonal abnormalities (such as low testosterone,Levitra Online) and neurological disorders. In most cases of ED, even when there is also a definite physical cause, men may feel anxious, guilty or depressed, which can make the problem worse.

Treatments

The AMA estimates 95 percent of ED cases are treatable through one of the following measures.

Drug therapy: Viagra® (sildenafil,Levitra Online) was approved by the U.S. Food and Drug Administration in 1998. Taken an hour or so before sexual activity, it increases the concentration of a natural chemical in the penis that causes the blood vessels to dilate, which increases blood flow to the penis. Unlike injection therapy (see below,Levitra Onlin), it doesn’t cause an automatic erection. Rather, it works in response to sexual stimulation. However, sildenafil isn’t right for everyone. Men who have heart problems and take drugs that help widen the coronary arteries are not good candidates because the drug combination can lower blood pressure dangerously. Some men with hormonal imbalances may be helped by testosterone shots, or skin patches. In 2003 the FDA approved Levitra® (vardenafil) for the treatment of ED. The way it works is similar to sildenafil. The latest medication approved for impotence is Cialis® (tadalafil). It differs from the other two drugs only because its effects persist for 36 hours, rather than just a few hours.

Psychotherapy: Whether there is a physical cause or not, men may benefit from working with a therapist to learn techniques that can decrease anxiety associated with intercourse.Vacuum constriction device: This involves placing a plastic tube over the penis and pumping the air out of the tube, drawing blood into the penis and making it erect. An elastic band is placed around the base of the penis to maintain the erection.

Penile injection therapy: Medication injected directly into the side of the penis causes the blood vessels to widen and erection to occur.Intraurethral therapy: A soft pellet of medication is inserted into the urethra. Its absorption produces an erection.Surgery: Surgery may involve one of three procedures: implanting a device (prosthesis,Levitra Online) that can cause the penis to become erect; reconstructing arteries to increase blood flow to the penis; or repairing the veins within the penis that are failing to keep sufficient blood within the organ. Artery reconstructions and vein repairs have generally not given good long-term benefits.

All these treatments have different complications and side effects. So men should work with their doctors to determine what’s right for them.

Risk of blindness

In 2005, the Food and Drug Administration (FDA,Levitra Onlin) approved updated labeling for Cialis, Levitra and Viagra to reflect a small number of reports of sudden vision loss, attributed to NAION (non arteritic ischemic optic neuropathy), a condition where blood flow is blocked to the optic nerve. The FDA advises patients to stop taking these medicines, and call a doctor or health care provider right away if they have sudden or decreased vision loss in one or both eyes. Further, patients taking or considering taking these products should inform their health care professionals if they have ever had severe loss of vision, which might reflect a prior episode of NAION. Such patients are at an increased risk of developing NAION again.At this time, it is not possible to say if these medicines for impotence were the cause of the loss of sight or whether the problem is related to other factors such as high blood pressure or diabetes, or to a combination of these problems.

COLOGNE, GERMANY, November 17, 2003 — Results of a new clinical study indicate that most men with erectile dysfunction (ED) prefer the new PDE5-inhibitor drugs to sildenafil (Viagra) and of these, nearly one-half of men prefer Levitra Online (Levitra)(1), the product most recently approved in Europe and the United States. The direct comparison study is being presented for the first time today at the 6th Congress of the European Society for Sexual Medicine (ESSM) in Istanbul.In terms of overall preference, most men rated Levitra Online as the preferred option (47%) compared with tadalafil (19%) or sildenafil (34%) at the recommended starting dose. Levitra Online was also the preferred option at the maximum dose (43% compared to 40% taldalafil, 17% sildenafil). “These findings highlight the benefit of having new alternatives to treat ED. This is one of the first studies to compare all three PDE5-inhibitors, and our initial results show that the majority of men who have tried all three drugs preferred the newer agents to sildenafil, and of these, more men preferred Levitra Online,” said Frank Sommer, MD, lead study investigator. Dr Sommer is consultant at the Department of Urology, University Medical Centre, Cologne.In the prospective, placebo-controlled, crossover multicentre study, men in a stable heterosexual relationship who had ED for 6 months received sildenafil (Viagra), tadalafil (Cialis), Levitra Online (Levitra) and placebo in a randomised sequence, with a one week wash-out period between treatments. The study consisted of two separate trials of maximum dose (100mg sildenafil, 20mg tadalafil, 20mg Levitra Online; 86 men) and recommended starting dose (50mg sildenafil, 10mg tadalafil, 10mg Levitra Online; 47 men). Efficacy was measured using benchmark International Index of Erectile Function (IIEF) and Global Assessment Questionnaire (GAQ) endpoints. Patient satisfaction and preference were also assessed. Men were also asked cite the reasons for their preference of different treatment options:

* Of those who preferred Levitra Online, the two reasons most commonly cited by patients were hardness of erection (89% at maximum dose, 90% at starting dose) and ease of getting an erection (84% at maximum dose, 86% at starting dose).
* Among those who preferred tadalafil, duration of erection was most commonly quoted (88% at maximum dose, 89% at starting dose).
* Those who preferred sildenafil, did so because of its lesser side effects (60% at maximum dose, 56% at starting dose).

All three PDE5-inhibitors were significantly more effective than placebo in achieving an erection with vaginal penetration and maintaining an erection to completion of intercourse, but Levitra Online performed better than the two other PDE5-inhibitors at both doses.”These results show that Levitra Online is preferred on the key variables necessary for success and satisfaction — ease of getting an erection and hardness of erection,” said Dr Sommer. “Physicians should consider all the available options to ensure that patients receive the treatment that best meets their needs.”

References:

(1) Sommer F, Mathers M, Klotz T et al. Which PDE5-inhibitor do patients prefer? A comparative randomised multicenter study of sildenafil, taldalafil and Levitra Online. Presented at the 6th Congress of the European Society of Sexual Medicine, Istanbul, Turkey, November 2003.

(2) Jardin A, Wagner G, Khoury S et al. Recommendations of the 1st International Consultation on Erectile Dysfunction. Co-sponsored by the World Health Organization (WHO), International Consultation on Urological Diseases (ICUD) and Societe Internationale d’Urologie (SIU) and held July 1-3, 1999, Paris. 2000, p 713.

(3) Feldman HA, Goldstein I, Hatzichristou DG et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994; 151:54-61.

(4) Aytac IA, McKinlay JB, Krane RI. The likely worldwide increase of erectile dysfunction between 1995 and 2025 and some possible policy consequences. BJU Int 1999;84:50-56.

(5) Southgate J. New rivals to Viagra expand the market. Scrip World
Pharmaceutical News, 2002.