Male sexual arousal is a complex interplay of hormones, nerves, blood vessels, muscles, and the brain.

Issues with any one of these factors can cause erectile dysfunction. In most cases, ED is a combination of psychological and physical factors. Erectile dysfunction can occur as a result of a number of physical and psychological factors, such as:

• Smoking cigarettes
• Excessive alcohol consumption
• Low testosterone
• Stress and anxiety
• Relationship problems

In many cases, erectile dysfunction has a physical cause. By conducting a thorough medical examination, we can identify conditions that can lead to ED, such as:

• Vascular disease (arteriosclerosis)
• Diabetes Mellitus
• Peyronie’s disease (curved penis)
• Kidney failure
• Hormone imbalances
• Drugs (prescription and over-the-counter)
• Neurological conditions
• Pelvic trauma (injury, surgery, or radiation)
• Venous leak

There is a direct link for many men between diabetes and erectile dysfunction. We can determine whether diabetes is affecting your reproductive health, and provide treatments that will allow you to resume a satisfying and healthy sex life. Diabetes mellitus (or simply, diabetes), is a group of diseases that interferes with the way your body uses blood sugar, or glucose. Diabetes results in too much glucose in the blood stream, which can lead to a range of health problems, including erectile dysfunction. It is estimated that men with diabetes can experience erectile dysfunction 10 to 15 years earlier than men who are not diabetic. If you are a man aged 45 or younger, and you are experiencing erectile dysfunction, it may be an early indicator of diabetes. Using the very latest in techniques and technology, we can diagnose any relationship you may be experiencing between diabetes and erectile dysfunction. Our practice is a leader in treating a range of men’s health issues, and can provide you with a solution that will help you to achieve confidence, health, and an enhanced quality of life.

A host of psychological issues can contribute to erectile dysfunction. These can include depression, performance anxiety, and stress. Mental health factors are usually secondary to physical causes of ED, so it is important to speak with a doctor if your symptoms persist or become more frequent.

We offer a full range of treatments for ED, allowing us to customize a plan to meet your unique health and lifestyle requirements:

• Oral Medication: Typically the first course of action, prescription medications with selective enzyme inhibitors can be very successful in treating ED. More commonly known by their brand names – Viagra®, Levitra®, Staxyn®, Cialis® and Stendra® – these medications are taken up to once a day. Patients need to consult a physician to ensure they can safely take these medications, and to discuss potential side effects.
• Surgical Procedures: Surgery can also help men overcome ED. Surgical treatment has a 95 percent satisfaction rate and can effectively treat conditions such as Peyronie’s Disease. A penile prosthesis can allow you to achieve an erection whenever you choose, for as long as you choose.
• Other Therapies: Patients who cannot take oral medications or undergo surgery may be candidates for a vacuum erection device, medicated urethral pellet (MUSE®), intraurethral gels, or penile injection therapy.

During your initial consultation and evaluation, we can determine the best treatment option for you. We will thoroughly explain your options so that you can make an informed decision.

About 30 percent of men suffer from this condition. Even men whose condition does not meet the medical definition of premature ejaculation – the inability to sustain sexual intercourse for more than 60 seconds prior to ejaculation – may wish to enhance their stamina. If premature ejaculation is affecting your quality of life, we can help you understand the cause of your condition and recommend an effective treatment.

To determine if premature ejaculation treatment can help you, we will ask a series of questions:

• What is the time frame in which you ejaculate?
• Do you ejaculate before you or your partner would prefer?
• Do you feel in control of your ejaculation?
• How long have you suffered with this condition? Some patients suffer with lifelong premature ejaculation, while others develop this issue later in life, or in specific circumstances.
• How often do you experience premature ejaculation? Generally, this condition is considered problematic if it occurs more than half of the time.

After reviewing your answers and your medical records, we may conduct a basic examination to determine which factors play a role in your condition.

The causes of premature ejaculation can be:

• Biological: Systemic diseases or disorders, such as hyperthyroidism, can lead to premature ejaculation. If you have experienced a sudden onset of premature ejaculation, it is especially important to undergo a physical examination.
• Neurobiological: Your brain chemistry can result in rapid ejaculation. In particular, irregularities with the neurotransmitter serotonin can impact your sexual function.
• Genetic: Due to heredity, some patients’ bodies may simply be more sensitive to sexual stimulation.

There are also potential psychological causes for premature ejaculation. Relationship issues, depression, anxiety, or low self-esteem can interfere with your sexual performance. Unfortunately, suffering from premature ejaculation may cause or exacerbate these conditions, making the cycle difficult to break without appropriate care.

We provide three primary treatments for premature ejaculation:

• Topical Medications: When applied to your penis, these anesthetic substances desensitize the tissue, allowing you to delay ejaculation longer. We often prescribe these substances first. We typically recommend Promescent® from Absorption Pharmaceuticals.
• Oral Medications: If the source of your premature ejaculation is neurobiological, taking a low dose of antidepressants or specific pain medications (which influence the level of serotonin in your brain) may help. However, these drugs can cause side effects, including insomnia, dry mouth, vision issues, nausea, weight gain, or even erectile dysfunction.
• Behavioral Modifications: Changing the way you have sexual intercourse can allow you to delay ejaculation. We can explain the squeeze and start/stop techniques. However, these methods can interfere with sexual satisfaction and many men prefer alternative treatments.

We will help you determine which treatment or combination of treatments is best for your needs.

Which option is right for you?

Patch:

No longer recommended due to skin irritation.

• Androderm: Transdermal patches, in two different strengths:  2mg testosterone per 24-hour patch and 4mg testosterone per 24-hour patch.  The usual starting dose is one 4mg patch applied to skin daily.  Formerly used but no longer recommended due to skin irritation.

 Injectables:

Advantages include efficacy and patient satisfaction, dosing ranging from weekly to as infrequently as every 10 weeks, and low cost.  Disadvantages include increased fluctuation (peaks and valleys) in testosterone levels compared to daily dosing options and the requirement for needles and self-injection.

• Testosterone Cypionate (TC): 200mg testosterone per cc, which is injected into the muscle (IM).  Injections can be done in the clinic, or you can be taught by our nurse how to self-administer.  The usual starting dose is 1cc IM weekly to every other week.
• Testosterone Enanthate: 200mg testosterone per cc, which is injected into the muscle.  Some patients may experience less water retention than with TC.
• Testosterone Undecanoate (Aveed): 750mg in 3cc is injected into the muscle. Injections are performed in the clinic upon initiation, at 4 weeks, and then every 10 weeks.

Implantable:

The advantages of this therapy include convenience and decreased frequency of dosing.  As this requires a short office procedure, there are risks including bleeding, infection, and pellet extrusion in less than 1% of cases.

• Testopel (Subcutaneous Testosterone Pellets): This comes in cylindrically shaped pellets that are about the size of a grain of rice.  Each sterile pellet contains 75mg of testosterone.  The usual starting dose is 10-14 pellets implanted subcutaneously in the office under sterile conditions once every 3 months.

 Inhalable:

The advantages of this modality is that avoids needles, and implants. Additionally it cannot be passed from skin to skin contact between people.

• Natesto ( Inhalable Testosterone): After you blow your nose one can administer the gel by inhalation. It is recommended to apply one pump to each nostril three times daily.

Peyronie’s disease is an acquired inflammatory condition of the penis where a plaque (scar) develops under the skin of the penis leading to curvature, painful erections, and erectile dysfunction. The plaque consists of scar tissue that forms within the wall of the tissue called the tunica albuginea that surrounds the corpus cavernosum, which is the structure that fills with blood to create erections. When the plaque is large enough, it causes curvature of the penis that may be painful and may prevent intercourse. Also, the plaque may cause erections to be less rigid or difficult to maintain. Peyronie’s disease is common and may run in families, with an estimated 1% of all men having some degree of Peyronie’s disease.

The exact cause of Peyronie’s disease is unknown, but it is likely that a genetic predisposition to abnormal scar tissue formation is an underlying cause. In some men, Peyronie’s disease is caused by trauma to the penis, for example, sudden and painful bending during intercourse.. Peyronie’s disease can be associated with abnormal scar tissue formation in the plantar fascia of the foot (Ledderhose’s disease), the eardrum (tympanosclerosis), or the palm of the hand (Dupuytren’s contracture). Low testosterone, or hypogonadism, is also commonly seen in men with Peyronie’s disease, which may pre­dispose to poor wound healing and inflammation.

Symptoms and diagnosis of Peyronie’s Disease

Peyronie’s disease often begins with the sudden onset of curvature to the erect penis, which may be initially painful. Peyronie’s disease may present with the new onset of erectile dysfunction. You or your doctor may notice an abnormal hardening or calcification of the tissue below the skin along the shaft of your penis. The plaque commonly occurs on the upper side of the penis near the base, but can also form on the bottom or side of the penis. In some men, the plaque occurs around the entire penis. The condition is usually asymptomatic in the flaccid state.

During erection, there may be:

• A bend in the penis
• Penile pain from the erection or pain during intercourse
• Pain with intercourse for the sexual partner
• Difficulty with penetration
• Shortening of the penis
• Inability to maintain the erection
• Narrowing of a portion of the penile shaft, which is called an “hourglass deformity”

Ultrasound can be used to evaluate the size of the plaque, the degree of penile curvature and severity of associated erectile dysfunction. To perform this ultrasound study, medicine is injected into the penis to produce an erection (see attached). A painless ultrasound probe is used to determine the plaque volume, degree of curvature, arterial blood flow into the penis, and the ability of the veins to keep this blood from exiting the penis. This information is used to develop an individualized treatment plan.

Treatments for Peyronie’s Disease

A combination of oral medications and/or penile injections may improve the symptoms Peyronie’s Disease. A vacuum erection device (VED) may be beneficial to improve penile length or aid with erections if venous leak erectile dysfunction is detected on ultrasound. For a small percentage of men, the curvature can improve over time with or with­out treatment.

Oral Medications:

The following medications may alleviate some symptoms or slow the progression of Peyronie’s disease:

• Trental (pentoxifylline)
• L-Arginine
• Vitamin E
• Daily phosphodiesterase inhibitor (e.g., Viagra®/Cialis®)

Penile Injections:

Injections of medication directly into the penile plaque are an option that may benefit some men. Traditional intralesional injection therapies include verapamil and interferon. Xiaflex®, an intralesional injection therapy made from collagenase clostridium histolyticum, offers certain men a potential decrease in curvature and symptoms with a simple office procedure. Xiaflex® is an option for men with stable Peyronie’s disease, intact erectile function, and a curvature between 30 and 90 degrees. Xiaflex® consists of a series of one to four 2-day injection cycles in combination with modeling therapy (bending) by the clinician.

Surgical Repair:

Surgical treatment is typically reserved for men with a severe penile curvature or erectile dysfunction that prevents intercourse. The main goal of surgery is to straighten the penis enough to restore satisfactory sexual function.

Surgical procedures for men with severe curvature but preserved erection function may include:

• Plication: This procedure involves placement of nonabsorbable sutures into the tissues of the penis opposite the curve. Although it causes some shortening of the erect penis, it has the lowest risk of subsequent erectile dysfunction.

• Incision and grafting: In this procedure, the Peyronie’s plaque is incised and replaced with a graft.

Penile Prosthesis:

For men with Peyronie’s disease and erectile dysfunction not responsive to conservative treatment options, implantation of a penile prosthesis is the best option. A penile prosthesis completely cures the disorder by restoring sexual function, a straight penis, and one’s confidence. Performed through a small hidden penoscrotal incision, a penile implant is invisible in your body while producing a completely natural erection and sexual experience. Sensation, orgasm, ejaculation, and urination are unaffected. The prosthesis has the highest success rate of all the treatments for Peyronie’s disease and erectile dysfunction, and over 90% of men and their partners have reported satisfaction after the procedure. There are two main types of penile prosthesis: inflatable and malleable. An inflatable penile prosthesis consists of 3 components that allows for a normal flaccid state, and then inflation through a scrotal pump produces a rigid state. A malleable penile prosthesis exists in a permanent semirigid state that bends downwards for dressing and bends upwards for sexual activity.

Following radial pelvic surgery such as prostatectomy or cystectomy, approximately 30% of patients have erectile dysfunction secondary to vascular and neurogenic causes. Although the cavernosal nerves are preserved during a surgery, a majority of men suffer from neuropraxia or nerve paralysis, which may last from months to years. Nerve injury can independently lead to vascular injury and penile scarring. Scarring within penile tissue can be a major cause of erectile dysfunction in men undergoing pelvic surgery.

Penile rehabilitation is the use of any device, pharmacologic agent, or intervention to promote male sexual function both before and after surgery. This includes girth, length, curvature, and longevity of erections. Beyond radical prostatectomy, penile rehabilitation should also be considered for Peyronie’s disease, penile fracture, after priapism, after cystectomy, and pelvic trauma.

Timing is extremely important with early initiation resulting in improved outcomes. The concept of penile rehabilitation is to increase blood flow and oxygen to penis and thus prevent scarring and permanent damage to the penis. It is important to take this proactive approach because many times the scarring that occurs in penis after a pelvic surgery is irreversible.

This Penile Rehabilitation Program can take up to a year, with therapy being initiated prior to your surgery. In order to better understand your pre-operative erectile function, we will be using objective and subjective measurements. Objective measurements will include an ultrasound of the penis, which is a test to assess anatomy (length, curvature), blood flow and record baseline function. Subjectively, you and your female partner (if applicable) will be asked to complete several questionnaires assessing sexual function. Understanding, and possibly treating, your female partner’s current sexual function can have a significant impact on your recovery of erectile function. A few blood tests, including testosterone levels, will also be taken. After surgery, these same tests and procedures will be performed in order to assess your progress and overall erectile function.

There are many medications that can he used to prevent penile scarring. Daily Cialis® (tadalafil) is very effective in preserving erectile function. Two weeks prior to surgery you will be asked to start taking 5mg of Cialis® every day. In one

study, men taking these types of medications after a bilateral nerve sparing radical prostatectomy were almost 7 times more likely to have spontaneous erections than men taking placebo after 48 weeks following prostate surgery (Brock G et al. Urology 2015).

One month after surgery you will also be asked to use a vacuum erection device (VED) on a daily basis to help increase blood flow and oxygen to the penis. The use of a vacuum erection device (VED) on a daily basis has been shown to increase blood flow and oxygen to the penis as well as preserve penile length.

Three months after surgery, if your erections are not sufficient for intercourse, you will be given the option to initiate penile injection therapy. This involves inserting a small needle into the side of the penis and injecting a medication that increases the blood flow into the penis.

If medical therapy is ineffective, men have the option of penile prosthesis. This device has revolutionized the treatment of erectile dysfunction. Satisfaction rates have been greater than 95% from both the male patients and their partners.

Prior to surgery:

• Cialis® 5mg every day.
• Penile duplex evaluation.
• Blood hormone evaluation.
• Sex therapy evaluation if indicated.

After surgery:

• Resume Cialis® 5mg every day starting 7 days after surgery.

1 month after surgery:

• Check PSA; if undetectable, consider replacing testosterone if low.
• Cialis® 5mg every day + Viagra 100 mg prior to intercourse.
• Start vacuum erection device 10 min/day.

4 months after surgery:

• Consider penile injection therapy 2-3 x/week, if above regimen not effective.
• Blood hormone evaluation.

Follow up at 8 and 12 months