The approach to Erectile Dysfunction

Erectile Dysfunction (ED) affects men of all ages and is an important issue at the men’s health clinic.

There are two important questions in this order of priority for men:

  • What  can I do about it? Treatments usually work whatever the cause!
  • What is the Cause of The ED?

First-off, do you need to do anything about your ED?

Physical causes of Erectile Dysfunction

You know that erections need a good blood flow, and that a poor quality erection indicates that blood is not filling the penis.

An erection requires relaxation of the arterial blood supply to the penis, and the blood vessels of the ‘corpus cavernosum’ that fill during an erection.

Erectile dysfunction in older guys is often linked to narrowing of the the penile arteries caused by ‘furring of the arteries’ (atherosclerososis). In other words, the causes of ED are the same as those cause cardiovascular disease, namely:

  • High blood cholesterol (lipids)
  • High blood pressure
  • Diabetes – around 50% of men with Type 2 diabetes develop ED within 10 years of diagnosis.
  • Smoking
  • Obesity

Endothelial dysfunction appears to be the final common pathway for ‘organic’ Erectile Dysfunction. This is a technical way of saying that the internal lining of the blood vessels are not working properly.

Men with ED are at higher risk of cardiovascular events than men without ED. Cardiovascular risk factors may of course be managed or treated.

Prostate enlargement is associated with ED.

Low Testosterone may cause a low libido and erectile dysfunction. Around 25% of men with ED have low testosterone.

Testosterone directly affects erections through a variety of different mechanisms having affects on the structure and function of the cavernosal nerves, phosphodiesterase type 5, nitric oxide synthase expression, and corporal smooth muscle cell growth.

Testosterone should generally be checked in men with ED and low libido, poor response to therapy, or with Type 2 Diabetes.

Psychological Causes

Performance anxiety often contributes to ED. Unfortunately, worrying about losing an erection will often cause that feared outcome. General anxiety, stress or depression may occasionally be the cause of the problem.

Which routine tests might be needed?

The following blood tests may be indicated:

  • Testosterone (Other hormone tests may be indicated when there are other pointers to a hormonal problem)
  • Fasting lipids, Glucose, Full Blood Count
  • Routine biochemistry

What can be done about my erectile dysfunction?

This is the whole point of the exercise! Thankfully there are some very effective treatments.

Treatments for erectile dysfunction involve taking a tablet, using a gel or self-administering an injection. The doctor wants you to get good results and will help you to choose the most cost-effective option.

Underlying causes will need treatment. Testosterone replacement therapy is indicated in only a small number of men with ED.

Which tablets used to treat Erectile Dysfunction?

You have heard of  ‘the blue pill’ Viagra which is a class of medication called a ‘PDE5 inhibitors’ and works by relaxing the blood vessels in the penis. Other brands include ®Levitra and ®Cialis. These treatments are a good starting point because they are safe & usually well tolerated.

The brands differ in:

  • Cost (generic viagra is the cheapest)
  • Speed of onset (®Levitra / Vardenafil is probably the fastest acting commercially available in Australia)
  • How long they last for (®Cialis lasts the longest)

Viagra is available as affordable generic sildenafil. ®Cialis is soon to be released in Australia as generic Tadalfil.

The main issue with Sildenafil (®Viagra) is that it needs to be taken a full hour before sex for it to work properly.

We are able to offer scripts for a variety of compounded PDE5 inhibitors. These are available through specialized pharmacies and offer the following advantages:

  • Cost per dose is often considerably cheaper – even down to around $4 per dose
  • Avanafil is not available any other way in Australia
  • Combination of PDE5 inhibitors that optimize both speed of onset with length of action

The compounded versions are made in Australia and should be of a very high quality. Having said that, some guys prefer the factory-made TGA-approved products such as ®Cialis.

What about Gel?

Gel or injections contain Vasodilators which work by opening up the blood vessels in the penis. The Gels are a  great alternative to those who are not willing to injection the medication with a needle. Gels are, however, a little less effective in men with more severe ED.

The Gels are inserted into the tip of the penis with an applicator. The Gel package consists of 10 x pre-filled tapered syringes. Insert the blunt tip of the syringe into the opening of the penis and gently depress the plunger. Keep the tip of the penis closed off with your thumb/index finger or the syringe to keep the medication inside the urethra. Use your other hand to squeeze and relax the whole penis repeatedly over 2-3 minutes. This will spread the medicine around the inside of the urethra and encourage absorption of the medication into the Corpus Cavernosa.

An erection follow after around 15 minutes.

What would I do that for?

Most guys are understandably reluctant to embark on giving yourself the injection directly into the side of the penis with an ultrafine needle.  However, injection therapy is the most successful non-surgical treatment of erectile dysfunction. You probably won’t even feel the needle. The best advice is to just ‘forget’ that a needle is involved, and enjoy the results.

If injections didn’t work then there would be no demand for them!

Erection follows within around 15 minutes of the injection – voila!

The ‘upside’ of the injections usually outweigh the risks which include:

  • Fibrosis (hardening just under the skin) that occurs in around 1 in 20 men after prolonged therapy.
  • A  Prolonged erection (Priapism) lasting 4 hours or more is an emergency. Priapism is most likely to occur when the dose is too high and occurs also in around 1 in 20 men. A normal erection will not last more than 1 hour.

Priapism is by far the most feared side effect of penile injectables. After all, who wants to go to the nearest ED with an erection? The risk of priapism is very low with the following precautions:

  • Dose titration: ‘Start low, go slow’
  • Limit yourself to 3 injections per week
  • Don’t use an erection pill and injectable at the same time
  • Have a ‘priapism pack’ at home – just in case. You kick the plan into action after around 1 hour.

Which injectable should I use?

®Caverject is the branded injection of Prostaglandin E1. ®Caverject impulse  is an all-in-one syringe which does not require separate mixing.  The product is an excellent starting point for men who are reluctant to self-inject. The product is really easy to use, pharmaceutical grade, and single-use. There are times when the product is difficult to source in Australia.

A men’s health clinic will offer a full range of compounded injections. What is the difference between compounded injections and ®Caverject Impulse? Let’s run through the main features of compounded injectables.

  • Compounded penile injectables are ‘made’ by a specialist compounding pharmacy.
  • Ingredients are typically a mixture of Prostaglandin E1 and several vasodilators which include Phentolamine, Papaverine, and occasionally Atropine or Aviptadil.
  • The injections are presented in a multi-dose vial from which you draw up the dose required. For example, a 5ml vial injected at 0.5ml doses will last for 10 erections.
  • The dose is adjusted to give you the result you want. The dose is not adjusted beyond the dose that gives an an erection lasting for 1 hr.
  • Concentration of products in the vials is tailored to your requirements.

Men who experience burning or pain as a side effect may be fine with the non-prostaglandin injections.

What can I expect at the clinic?

Your first appointment allows for a full assessment of the issues. The outcome may include a prescription that you source from a range of standard or compounding pharmacies. We make a point in separating the ‘sale’ of a pharmaceutical product from its supply. In other words, there is no conflict of interest. However, we do ‘shop around’ and will offer to forward a script directly to a cost-effective compounding pharmacy that provides next day delivery.

Injectables require a 2nd appointment for instruction and supervision.

Scripts are provided with a repeat prescription.

Telehealth is also available.

WRITTEN BY: Richard Beatty
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