Always search FIRST for reversible causes of impotence. Impotence is potentially reversible in the following types of patients:

• Patients on medications for high blood pressure
• Patients on medicines for depression
• Patients who have endocrine problems, like thyroid or pituitary problems
• Patients who have partner conflict
• Patients who smoke cigarettes
• Patients who use recreational drugs; Alcohol, Marijuana, Cocaine, Heroin
• Patients who have an anatomical abnormality of their penis
• Men less than 45 years of age may have a correctable cause of vascular impotence

Please understand that every patient is different and what works with one man may not work with another.

Deciding on a Treatment for Impotence

Selecting a treatment for impotence is a personal decision that depends on the preferences of you and your partner. Try to learn as much as you can about each treatment option. Here are some questions to think about that may help you reach a decision:

• How effective and safe is the treatment?
• How does my partner feel about the treatment?
• Is it convenient and comfortable to use?
• Does it fit with my lifestyle?
• How much does the treatment cost?
• Will my insurance pay for some or all of it?

Sex and Your Heart

Your doctor will evaluate you to determine if you have a medical condition that might need attention before you receive any treatment for impotence. Because sex makes the heart work harder, sexual activity is not advisable for some men with certain heart problems. Some men have serious forms of heart disease, such as:

• A recent heart attack or stroke (within the past 2 or 3 months)
• Certain heart rhythm problems
• Severe (unstable) angina
• Untreated or severe high blood pressure
• Severe heart failure
• Severe heart valve disease (aortic stenosis)

Other men with heart problems also may need to be evaluated by a cardiologist to determine if it is safe for them to be sexually active and use any medication to treat their impotence.

Treatment Options:

There are essentially five ways to treat erectile dysfunction. These include oral medications, vacuum erection devices, injections, intra-urethral pellets and surgeries.

Oral Medications:

Viagra has truly revolutionized the treatment of erectile dysfunction. It is relatively effective and safe in approximately 60% of men. It is taken one hour prior to intercourse and will work only if a man has significant stimulation. In most patients it will result in a very rigid erection that is well maintained and satisfactory.

It is strictly contraindicated in all men who take nitrates (generally used for cardiac problems). It is also strictly contraindicated in men with retinitis pigmentosa.

Its side effects can include headaches, nausea, facial flushing or modest temporary visual changes including blurring, blue-green tinges and some increased intensity of light. It should not be taken with a fatty meal as this will delay its absorption.

Yohimbine is another oral medication and it predated Viagra. Its efficacy is controversial, although it is generally believed to produce modest improvement in erectile dysfunction. It must be taken three times each day chronically, not only prior to intercourse.

Vacuum Erection Devices

These devices are external and go over the penis. A seal is created between the device and the penis. The air in that space is removed and this creates a vacuum around the penis, which draws blood into the penis. A ring is then placed around the base of the penis, which holds the blood in, and the vacuum pump is removed. The patient will then maintain the erection while the ring is on and will have intercourse with the ring on. This method has proved effective. It is mostly used by older men in long-standing relationships.

Penile Injections

Penile injections are successful in 90-95% of patients (even in those cases where Viagra is not.) They result in a rapid onset of an erection and they are used immediately prior to intercourse. For most patients they produce an erection that is of increased rigidity and duration. Many patients who are not satisfied with results from Viagra use the injections with great success.

Injections are not painful. Most of the times they can be given with an auto-injector. Men describe this sensation as similar to that of a flick of a rubber band.

The three main medications used for injections are Alprostadil, Papaverine and Phentolamine. They can be used in various combinations. The Alprostadil is available in prescription form in kits. These include a vial of powdered medicine, a syringe with the fluid needed to diluted it and a self locking case of disposable needles.

MUSE

The Alprostadil may be made into a small pellet in high concentration. This is then placed, via an applicator, into the urethra, (the tube men from which men urinate and ejaculate). . The medication then diffuses through the urethral tissue into the blood stream and then into the erectile tissue. It has worked in many men, although in general it is less effective than injecting the same medication into the penis. Side effects may include urethral burning and lowering of blood pressure.

Surgeries

There are two classifications of surgeries:

• The most common is the insertion of a penile prosthesis of which there are several types. The most sophisticated are very natural in appearance. They are inserted through a small incision, usually in the scrotum. Two cylinders are placed into the penis itself near the erectile tissue. A small pump is placed into the scrotum and a reservoir placed under the abdominal wall. When the man wants an erection, he transfers the fluid via the pump from the reservoir into the erection chambers, thus getting a rigid, well-maintained erection. When he is finished with intercourse, he can deflate the prosthesis. Penile sensation and orgasmic ability are basically unchanged with this procedure. This procedure, though invasive, does have a very high patient satisfaction rate.

• A very small percentage of patients are candidates for penile re-vascularization. In this situation, when there is a blockage or damage to the penile artery it can be bypassed giving a better blood supply to the penis.

It is important to note that 30-40% of men for whom it is medically appropriate to prescribe Viagra will not respond adequately. Many do not have an erection rigid enough for intercourse. Others have difficulty in maintaining their erection through intercourse. For some there may be unpleasant side effects. When prescribing Viagra, all men should be informed that there are other options available if they are not truly satisfied with the results.