Jeff Brady: Probably ten year ago there were no good, real good therapies for erectile dysfunction certainly no good oral therapies. We did have intracavernosal injection which is where you would inject a medication into the penis with a needle to get erections. That worked well, but obviously people are not excited about placing a needle into the penis.
Steven Brooks: We are in a remarkable time. In the last ten years, we have seen dramatic steps forward. Really up until the introduction of Viagra, there were no truly effective medical therapies. With the introduction of Viagra and now it's associated medications, we have seen shift in how erectile dysfunction is treated.
Jeff Brady: Pfizer have initially developed Viagra, so BENEFIL as a coronary artery drug. It was used to try and dilate the blood vessels to the heart so that that would improve blood flow to the heart and decrease angina. Unfortunately it do not work very well for men, but they had an interesting side effect that Pfizer has obviously marketed very differently. When pathergy patients had better erections, it didn't work very well for the heart, but it helped their erections.
One problem that they did have is that patients would not turn in their medications and some patients actually broke into the Infirmary to get their medications, it still is a medication.
Steven Brooks: An erection involves a very intricate cascade of events. You need a visual stimulation, you need the mechanical stimulation, so that there are definite cerebral triggers that are involved in sustaining an erection when a patient is awake during the course of the day. There is a cascade of chemicals that are released, something called Nitric Oxide which then stimulates another chemical called Cyclic GMP and the presence of the Cyclic GMP causes the muscle fibers within the erectile tissue of the penis to relax.
Jeff Brady: What these medicines do to foster the phosphodiesterase inhibitors. They black that breakdown of that signal to have an erection so we have an erection that last longer and usually is a bit better.
Steven Brooks: All these medications work, give or take within 30 minutes to an hour of taking the medication, it's very important that you-- if you simple take the medication and wait for an erection or if you just have visual cues, you are going to be disappointed. You need manual and physical stimulation to get these, this cascade of events to occur. But we typically suggest to take it 30 minutes to an hour before you engage in relations and that would apply the all three of those medications.
Jeff Brady: Levitra and Cialis are in the same classification as Viagra, but they are some what different in their Pharmacogenetics. So what that means that, the amount that is absorbed, the strength that it binds to the receptor and the length that is in the body and hactive is different. For Levitra it may act a little bit more quickly may be in a half hour and last for that 4 to 5 hours.
Steven Brooks: I believe efficacy is so much similar with some caveats. Levitra there are some studies that suggest that may be a little bit more effective in diabetics, but overall efficacy is similar.
Jeff Brady: There are lot of different ways we can measure erections, we can measure the pressure in the erectile body itself and not everybody going to do that so there are fairly subjective and they are based on patient questionnaires so whenever 100% certain who is better than the other, but using at least patient information how we get a good idea.
Steven Brooks: The most typical side effects are indigestion or dyspepsia, flushing, stuff nose, headache, blurry vision or bluish vision. And it's a Cialis has a slightly greater incidence of back pain and muscular aching, but here to it's -- they are all typically less than 10% and I don't mean to infer that you are going to have all the side effects and it's tremendously variable. Some patients have absolutely no side effects or just will have a combination with the side effects I just mentioned.
Jeff Brady: Now we know people who have significant coronary artery disease or use nitric glycerin or nitrates should not use these medicines.
Steven Brooks: And always like to give the analogy, it's perhaps a better analogy for the Northern climates, but an older gentleman who has been set in Ontario fall (ph), this is the first snow fall of the winter and he takes his shovel and he goes out and he shovels his drive way. The exertion and the activity of shoveling the driveway causes him to have a heart attack.
Well, it's not a shovel that was harmful or dangerous and that's the anology I use when discussing these medications. It's not the medication that predisposes the patient to a cardiac event or a myocardial infarction, it's their underlying heart disease that does so. These drugs are actually extraordinarily safe. They have been studied extensively and in healthy patients their should be no concerns in that regard.
In order men enlargement of the prostate and Voiding dysfunction very often co-exist with the erectile dysfunction because after all the two conditions afflict in older population, so they can concurrent and then in this regard there is some concern regarding the use of Levitra, Viagra and Cialis as well as the more commonly used medication for enlarged prostates.
Jeff Brady: Hormone replacement therapies are where a man have Hypogonadism or a low testosterone that can effect libido and erectile function and if men have low testosterone we can replace the testosterone to try to get them to more normal level so their libido returns and they improve their erectile ability. We can do that with pills, with shots, with patches or gels. The pills are not very effective, in fact the side effects are very significant. They create hepatic or liver toxicity so we don't use them here in the United States.
The shots are not very convenient and they give you a dose once a month which is a super dose and then the troph levels are very low levels at the end of your cycle. The ideal way to replace this would be every day either place a patch or a gel on the skin and that will deliver the medication in the morning and then slowly taper off in the evening which is the normal pattern that men have about throughout their life and we can do that pretty effectively now.
Steven Brooks: This is an example of a penile vacuum pump. This is a cylinder that is placed over the flaccid penis, prior to placing the pump over the penis, a rubber band is placed on one end of the cylinder. This is then placed over the flaccid penis and you create suction. You create an air tight seal and then with a pumping motion you create a vacuum by withdrawing the air from the cylinder and with that because of the negative pressure, the penis becomes erect and then when you achieved an erection you slip the rubber band off the device on to the base of the penis to contain the blood, it is somewhat awkward. It can be somewhat uncomfortable, but it is actually a very safe method and alternative for patients with erectile dysfunction.
Jeff Brady: I think it's a good option for couples who have been together for a long period time. Some people do consider the contraption -- young single person that would not be obviously an ideal option for you, but I think for couples who have been together for a long period of time, it's an effective therapy that's not totally invasive without any new medications.
Steven Brooks: This is an example of an inflatable penile prosthesis. It's a silicon device that's surgically implanted through a small incision. Implantation in good hand takes about 45 minutes to an hour and there is a relatively quick recovery of about a week or so. This again an example of an inflatable prosthesis. That means this prosthesis can be inflated when the patient wants to be sexually active and deflated. So that no one else is aware that there is a prosthesis in place, it's more physiological and more natural than a implant that's always erect.
It involves pump that is placed in the scrotum. It's two cylinders that are placed in the penis and a reservoir which is tucked away in the abdomen. Of course none of this is exposed once it's implanted and in the deflated state, one would be hard pressed to ever imagine that some one has an implant.
Jeff Brady: Man usually choose that type of a device, an inflatable device because if they want to go say at the men's club and have a shower no body know that they have this device in place. The advantage is that they will have an erection within 10 to 20 seconds when they want to have an erection. it is reliable. It's spontaneous and it's probably one of more natural ways to have an erection in that women will not know the difference. It is a reliable form of therapy, it is spontaneous and it does work very well.
Steven Brooks: In contrast to inflatable prosthesis, there are something called the malleable prosthesis which consist of two rods that are somewhat rigid, but not completely so. I like to say it has the consistency of a metal hanger. These are simpler to implant, but are not as natural in appearance and that the patient will always be erect. Because they are some what malleable the patient can shift it out of the way to one side or the other, so it's of course is not necessarily a prominent in a forward position.
Jeff Brady: It's a very high satisfactory for men who have Inflatable Penile Prosthesis, over 90%, which is higher the most of the other therapies. I think you have to educate or patients have to be educated well to be satisfied and if you have your patients properly educated and motivated then a prosthesis is a good option for them.
Steven Brooks: Here is the implant where the cylinders are deflated. When the patient wishes to inflate the prosthesis he activates the pump with a series of compressions, transferring fluid from the reservoir to the cylinders and as you can see the implant becomes erect and considerable rigidity can be obtained and maintained for as long as the patient wishes and then when he is completed his activity and he wishes to deflate the prosthesis, there is the deactivation button that is compressed, the water is transferred back from the cylinders to the reservoir and the implant becomes deflated.
Jeff Brady: Patients so use injection therapy not as much as they used to. Diabetics are more likely to use this as Viagra, Levitra, Cialis may not be as effective for them. Those meant the injectable medications are much more effective. Diabetics are used to using needle so they may be opt to use that. So still used but not as much as in the past.
MUSE stands for Medicated Urethral Suppositories and what that is a compound that is made into a palette that is placed into the distal part of the urethra, the very end where men urinate from. That palette is then dissolved and the medicine goes from the urethra to the erectile bodies to dilate the blood vessels again to cause an erection.
It is a recently effective therapy for men with mild erectile dysfunction and it is not working well for men with significant erectile dysfunction. There is a penile revascularization that is rarely used today. It is mainly for young patients who have trauma to the pelvis or chronic perinea trauma. The success rates are about 66%, but in today's age we rarely do those now a days. There is a venous ligation surgery which not very many people do anymore because it's such a very low success rates.
From early studies from mid 1990s that probably only 10 to 20% men sought treatment for erectile dysfunction. Now that the new medicines oral medicines are released, we think it's probably higher, but we still think that only 50% of men really seek treatment may be because of an embarrassment or fear of failure. So there are some more men who can benefit from treatment that we have.
Steve Brooks: When should a man seek attention for his erectile dysfunction? When he feels he has a problem when he is not satisfied with the quality or length or duration or his erection?
Jeff Brady: I think that there is a hope and I want all men who have erectile dysfunction know there is a hope and we can almost always help them have erections whether it's with a medicine or with a pill, with an injection, with a vacuum pump or prosthesis. There are always ways that we can help them get back to that sexual relationship that they used to have and even with the pills if you fail the pills, there are often ways that we use combination of therapies whether it's combination medications, combinations of pills and pumps, we can help them get back to having better erections when they were younger.
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