ERECTILE DYSFUNCTION GP QUESTIONS

Questions from GP's answered by Dr. Tom Kelly of the Everyman Centre, Dublin.

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Question 1.
What surgical operations are available in Ireland for men with erectile dysfunction resistant to medical treatment?

Question 2.
What is the role for psychosexual counselling, if any, for erectile dysfunction now that we have such good medical treatments?

Question 3.
Considering erectile dysfunction treatments have a black market value, are there any ways to assess whether someone really needs it or not?

Question 4.
Should severe alcoholics, whose erectile dysfunction is probably related to their alcohol usage, be given medical treatments for erectile dysfunction?

Question 5.
Does medical treatment for ED help in premature ejaculation?

Question 6.
Apart from prescribing medication, how can a GP treat ED?

Question 1.
What surgical operations are available in Ireland for men with erectile dysfunction resistant to medical treatment?

Insertion of penile prostheses, both malleable and inflatable, are common surgical procedures used in Ireland for the treatment of ED ( erectile dysfunction).
Penile revascularisation, especially following pelvic trauma, is occasionally performed.
The most basic prosthesis is the semirigid rod  prosthesis which consists of two rodlike cylinders which are inserted in the corpora cavernosa. This prosthesis can be mechanically jointed or malleable and allows the penis to be manouvered into either a downward or an “erect” position.
This is generally the type of choice for men who are obese and those with limited manual dexterity.
Advantages of this type over the inflatables include easier placement, lower cost and a smaller risk of mechanical failure.
Disadvantages include higher risk of device erosion, less concealability and inability to increase the girth of the penis.
Inflatable devices consist of inflatable cylinders  and a fluid reservoir. The cylinders are inserted in the corpora cavernosa and the fluid reservoir is usually located in the scrotum. To achieve an erection the patient pumps the fluid from the reservoir into the cylinders. The pump can also be used to pump the fluid back into the reservoir.
Inflatable devices are more difficult to insert and carry a higher risk of infection.
Penile prostheses do not achieve the full length attained by natural erections.
Technical success rates and patient satisfaction rates are high though partner satisfaction rates are not so high.
About 25,000 prostheses are inserted annually worldwide.

Question 2.
What is the role for psychosexual counselling, if any, for erectile dysfunction now that we have such good medical treatments?

The majority of men under 50 years of age who present with ED will be found to have none of the following aetiological factors:- organic; psychiatric; drug use or post-operative.
They will not be suffering from true ED in the sense that they can achieve and maintain an erection in some circumstances. Typically these would include when they masturbate and occasionally on awakening.
The “ ED “ only occurs when having sex with a partner and it is primarily due to the fact that they do not experience sufficiently strong and sustained arousal, for whatever reason.
Most men recognise that even in a loving relationship where both partners are sexually attracted to one another that occasionally sex will be “low-key” and that it will be entirely appropriate that they don’t get a strong erection. They do not see it as a problem.
However, when it occurs on a regular or recurrent basis it is usually seen as problematic.
When a man (and ideally his partner) understands (or you help him to understand) that the problem relates to arousal issues, most will want to explore and deal with these. The process which follows is psychosexual counselling.
Some men, and/or their partners, will not want to explore these issues and will opt for medication instead.
Those who chose psychosexual counselling may do so for a number of reasons.
They understand that the source of the problem does not lie within their penis.
They want to solve the problem using their inner resources, if possible.
They want their partners to be involved since they too are affected.
They have an aversion to taking medication.
They want to put the problem to bed, so to speak, for once and for all.

Question 3.
Considering erectile dysfunction treatments have a black market value, are there any ways to assess whether someone really needs it or not?

Firstly, I doubt whether anyone who wants to sell ED medication on the black market would consult a doctor for a prescription when he could obtain what seems to be ED medication, in any amount he wants, through internet sites.
However, I think this question is primarily about the diagnosis of ED.
Suppose a man presents with ED and relates that he sometimes experiences erections on awakening; can achieve and maintain an erection during masturbation and also when engaged in “heavy petting”; but that he cannot maintain an erection for penetrative sex . This is a very common presentation, especially in young men. I can think of no way to independently, or objectively, verify the veracity of what he says.
If a man presents with a history of progressive loss of erectile capacity over a period of many months or years, including in relation to erections on awakening, such a history suggests an organic aetiology. Nevertheless, no matter what possible causative factors we find on further investigation, we cannot say with certainity that he suffers from ED.
So why would we carry out any further investigations? Primarily because ED of the progressive variety can be a marker for cardiovascular disease.
We may also detect a cause of ED which, when treated, reverses the ED, e.g, hypogonadism.
We may be called in a court of law to give evidence that supports or refutes a man’s or his partner’s claim that he suffers from ED.

Question 4.
Should severe alcoholics, whose erectile dysfunction is probably related to their alcohol usage, be given medical treatments for erectile dysfunction?

Certainly, if it is safe to do so.
Oral medications for ED should not be prescribed to men with severe liver disease. In cases of moderate and mild liver disease a low dose should be prescribed initially. If a higher dose is needed a careful individual risk/benefit evaluation should be undertaken by the prescribing doctor.
Liver disease is not a contraindication to the use of Prostaglandin E1 intracorporeal or intraurethral therapies.
Because hypotension is sometimes associated with the use of ED medication and is also associated with alcohol abuse, it would be prudent to advise all men using ED medication of this possibility.

Question 5.
Does medical treatment for ED help in premature ejaculation?

Many well conducted studies have found that ED medical treatments are beneficial in the treatment of premature ejaculation.

There are several mechanisms of action that may explain this.
There is some evidence that the ejaculatory latency time may be dependent on the duration of erection so an increase in the duration of erection may result in prolonged ejaculatory time.
ED oral medication may inhibit the contractile responses of the seminal vesicles, vas deferens, prostate, urethra and even the skeletal muscles. Type 5 phosphodiesterase activity has been reported in the prostate, seminal vesicles and skeletal muscles. PDE -5 inhibitors have been shown to exhibit a direct inhibitory action on the smooth muscle of the vas deferens.
These drugs have also been shown to induce a state of peripheral analgesia in animals. This effect could be instrumental in alleviating the penile hypersensitivity  that is reported in some men with premature ejaculation.
Some men use ED medication to treat premature ejaculation in a similar way to the use of masturbation. Many men find that if they masturbate to ejaculation a few hours or so before sex with a partner that they will not come as quickly, as they would otherwise, with the partner.
Similarly, some men find that ED oral medication enables them to have sex again, after a relatively short period, and that they last longer the second time round.

Question 6.
Apart from prescribing medication, how can a GP treat ED?

Most men presenting to a GP complaining of ED will probably give a history of the problem arising only in the context of a sexual relationship in which they desire penetrative sex. In other words they will experience erections when they masturbate, occasionally on awakening and, perhaps, during “foreplay”. Some of these men will not experience an erection at any stage of sexual intimacy. Others will lose their erection when they feel it is the appropriate time for penetration. In both situations they are afraid that they will fail to get or maintain an erection. They fear “failure” because there is a prior history of such. Consequently, their arousal level plummets and they fail to achieve or fail to sustain their erection.
By the time they consult the GP they will probably be avoiding sex with a partner. If they are in a relationship, you may well find that there has been  little discussion between the partners but much tension. Their partners may be feeling angry, unloved and rejected. They invariably think that it is their “fault” – “I don’t turn him on”; “I’m not attractive anymore” and so on.
Many sufferers, mainly young, will have little insight into the nature of the problem. Where the patient is inexperienced and not in a relationship, the GP can, in a relatively short period , provide education and reassurance. For example, it may be clear that the young man expects to “perform” in inappropriate circumstances or with inappropriate partners. He may be reacting to peer pressure – real or perceived. He may need reassurance that there is nothing wrong with his penis.
Where the patient is in a relationship the GP can provide an opportunity for both to air their attitudes, beliefs and feelings about the situation and thus clear the way to do whatever is needed to treat the ED. Again, education and reassurance may be all that is required.
Most men in this situation will have lost sexual confidence, will be over-thinking during sex and will be unable “to go with the flow”.
If the man and his partner are willing there are a number of “exercises” they can do to overcome his performance anxiety.
Initially, whenever they become sexually intimate they both pretend he doesn’t have a penis. This may have the effect of reducing his performance anxiety and preventing him and his partner focussing  on erections. It may be helpful for him to wear boxer shorts at this stage. If and when this enables them to relax and “live in the moment”, he will begin to maintain arousal and, consequently, erections.
When such progress has been sustained on five or six consecutive occasions he then dispenses with the boxers. Touching of his penis is then incorporated into sexual intimacy but penetrative sex is avoided. At this and every other stage his penis is never touched with the express intention of producing an erection. The emphasis is always on pleasure, intimacy and arousal.
When this approach maintains arousal on another five or six occasions they may then incorporate some degree of penetration. This I call “teasing” penetration. With this approach shallow, short-lived penetration is included on a number of occasions during sexual intimacy but is never the end-point. The depth and duration of penetration is gradually increased with each encounter. When this approach is successful the man will inevitably start doing his own thing without fear or anxiety.