Surgical Management of Erectile Dysfunction

Scientists once believed erectile dysfunction (ED) — was a problem only of the mind and not of the body. But recent data suggest a physical (or organic) cause in more than half of all cases, especially those involving older men. In any case, experts believe it affects up to 30 million American men. But what is involved in impotence and what is available to correct it? The following information should help you talk to your urologist about this frustrating issue, and some of the options — including vascular surgery — that may help solve it.

What happens under normal conditions?

The internal structure of the penis includes two cylinder-shaped chambers, the corpora cavernosa. Filled with spongy tissue containing smooth muscles, fibrous tissue, veins and arteries, these chambers run the length of the organ and are surrounded by a membrane cover, called the tunica albuginea. The urethra, the channel through which urine and semen exit the body, is located on the underside of the corpora cavernosa and is surrounded by spongy tissue. The longest part of the penis is the shaft, which ends in the glans. The meatus is the opening at the end of the urethra.

Erection is the culmination of a complex set of physical, sensory and mental events, involving both the nervous and vascular systems. It begins when physical or psychological stimulation (arousal) causes neurotransmitters or impulses in the brain (chemicals such as dopamine, acetylcholine and nitric oxide) to tell the muscles of the corpora cavernosa to relax, allowing blood to fill the organ's tiny open spaces. As the tunica's fibrous or elastic tissues trap the blood, the penis engorges, or increases, in an erection. When stimulation finally ends, usually after ejaculation, pressure inside the organ decreases, as the muscles contract. Blood then flows from the penis and the penis returns to its normal shape and size.

What is erectile dysfunction (ED)?

Erectile dysfunction refers to the inability of a man to attain and maintain an erection sufficient for intercourse. It occurs when there is reduced blood flow to the penis or nerve damage, both of which can be triggered by a variety of factors. Scientists once believed that ED was an emotional issue alone. But today they know that physical factors are just as important as psychological triggers — stress, marital/family discord, job instability, depression and performance anxiety — in provoking this problem. It is important to note that hundreds of medications can also contribute to impotence while they fight allergic reactions, high blood pressure, ulcers, fungal infections, anxiety, depression and psychoses.

Who is at risk for erectile dysfunction (ED)?

A man is at risk if they suffer from:

Vascular diseases: Hardening or narrowing of arteries, often associated with high cholesterol, can also restrict blood flow to the penis, particularly if you are over 60. Because smoking can lead to any of the factors responsible for vascular problems — such as high blood pressure — it is probably an important factor in both arterial disease (atherosclerosis) and ED.

Neurologic disorders: Spinal cord diseases or injuries, brain injuries, multiple sclerosis, Parkinson's disease and other progressive diseases can interrupt nerve impulses to and from the brain. Diabetes poses both neurological and vascular problems because it damages small blood vessels and nerves throughout the body, impairing the impulses and blood flow necessary for an erection.

Other conditions/illnesses: In addition, other chronic illnesses such as cancer and well as hormonal imbalances and penile disorders can disrupt the nerve impulses and blood flow necessary for normal erections.

What are the symptoms of erectile dysfunction (ED)?

Failing to achieve and/or sustain an erection is the primary sign of erectile dysfunction. But diagnosing the specific cause and prescribing appropriate treatment usually require a variety of tests, beginning with a complete history and physical examination.

Your doctor may order additional laboratory tests to assess any conditions that may be interfering with normal erectile function, particularly arterial flow to the penis. A blood test, for instance, is normally used to reveal blood lipids and triglycerides, both of which indicate atherosclerosis if elevated. A urinalysis identifies protein and glucose levels that can suggest diabetes.

While these analyses focus on your chemical status, erectile function tests are the principal tools your doctor will use to tell how the blood vessels, nerves, muscles and other tissues of your penis and pelvic region are working. Among them, penile nerve function tests — squeezing the head of the penis and measuring various responses — can determine if there is sufficient sensation in the penis. Nocturnal penile tumescence (NPT), or healthy involuntary erections during sleep, may rule out psychological issues and instead suggest nerve function or blood supply problems.

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An imaging technique called duplex ultrasound may also be used. It monitors the behavior of moving structures and might provide some of the best data since it can evaluate blood flow, vein leaks, scarring of erectile tissue and some signs of atherosclerosis. During the test, an erection may be produced by injecting the stimulator prostaglandin into the body and then measuring vessel expansion and penile blood pressures, both of which are compared to the limp penis. In either case, duplex ultrasound can illustrate a specific blood vessel disease that may rule out a need for vascular surgery.

How is erectile dysfunction (ED) surgically treated?

The past several decades have ushered in a new treatment era for erectile dysfunction. Because of the advent of many advances, today urologists are helping millions of impotent men perform better and longer.

Penile prostheses: Surgically implanted devices to ensure stiffness have become highly reliable therapeutic solutions. Vacuum constriction devices have proven to be safe alternatives in stiffening the penis by drawing blood into the organ with a pump and holding it with an "occluding band." Penile injection therapy is a relatively quick and effective way to send vasoactive drugs directly into the corpora cavernosa where they expand the vessels, relax the tissue and increase blood flow for an erection. Furthermore, sildenafil citrate has become the treatment of choice for millions of men who have experienced the drug's ability to boost levels of cyclic guanosine monophosphate (cGMP), a chemical factor in metabolism responsible for relaxing blood vessels.

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Last updated: 10/05

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