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Erectile dysfunction means a man is unable to maintain an erect penis sufficient for satisfactory sexual intercourse. It may have a psychological or a physical cause, either way it is distressing and may cause loss of confidence and self-esteem or depression, as well as relationship problems. There are several solutions, but recognising the problem and talking about it with your doctor are the first essential steps.
Many men have (often temporary) erection problems at times, and the likelihood increases with age. Estimates seem to be increasing as more careful studies are done and as men become more prepared to seek help. Some estimates indicate that about 40% of men over 40 will have erection problems. For some men erection problems occur suddenly but for most there is progressive difficulty. It may mean you are completely unable to get an erection, can get only a partial erection or can keep it for a short time.
The veins that allow blood to leave the penis are only so wide. During an erection, the blood vessels that let blood into the penis relax and widen (dilate). This lets more blood in – more than can escape – which causes the sponge-like tissues of the penis to swell and harden. Complex biological mechanisms are involved in allowing these blood vessels to relax and redirect blood to the penis. Your thoughts and senses (touch, hearing, smell and sight) influence a part of the brain that can trigger an erection. In addition, hormones and other substances determine how your nerves transmit ‘sexual signals’ and how blood vessels respond to the received signals. Arousing thoughts or nervous mechanisms (eg, touch reflexes) are two ways an erection is initiated.
Erectile dysfunction occurs when sexual stimulation or arousal (you may still ‘have the urge’) does not result in sufficient blood flow to the penis. For most men there is a physical or medical reason for this, for others the problem is psychological. Even when there is an initial physical reason, a man may still feel anxious about having sex, and this can compound the problem.
Recent illness, such as a heart attack, or injury to the brain or spinal cord can be a cause. Many other medical conditions can also lead to nerve damage or reduced blood supply to the penis – the most common of these is diabetes (men with diabetes are much more likely to have problems with erections). Other factors that can reduce blood flow to the penis include:
excess alcohol
smoking
narrowing of blood vessels caused by a high blood cholesterol level.
A wide range of drugs used to treat some health conditions (eg, heart failure, high blood pressure and depression) can also affect your ability to get an erection. If you are taking medication and have erectile dysfunction you should talk to your doctor about your drugs – there may be others without this side effect.
existing values or attitudes towards sex
stress, guilt, depression or fatigue
anxiety about your performance during sex
relationship problems (possible anger, power or control issues with your partner)
problems with intimacy and communication.
If you still have erections at times (eg, when you wake) this usually means psychological reasons are involved.
Most aging men manage to get erections, but only with more stimulation. It is up to each man to decide whether his erection is adequate. You can consider (with your partner) how important sexual intercourse is to your relationship – there are other aspects to intimacy, and not all couples require an active sex life to have a fulfilling relationship.
You can help yourself by cutting down on alcohol, stop smoking and reducing the stress in your life.
Tests by your doctor might include:
a physical examination, which may include the genitals and prostate gland
checking your medications for side effects
blood and urine tests for hormones, blood lipids, liver and kidney function and diabetes.
Many men are unhappy with their ability to get or maintain an erection, but only 5% of these men seek help. This is because men, in general, are unwilling to discuss their sex life, even when it is going well.
Understanding that erectile dysfunction could have a medical cause, just as asthma or arthritis do, can allow you to feel more at ease in mentioning it to your doctor. By opening up this discussion, which is confidential, your doctor can help you in a number of ways.
Your doctor can check your health and any current medications for likely side effects. If psychological reasons are suspected, your doctor can advise you on the appropriate action and help you access counselling services you (and your partner) may benefit from.
If your erection problems have a medical cause, your doctor can explain the treatment options, the techniques needed to make them work and their suitability for your needs in the light of your overall health.
Oral medications
The drugs sildenafil, tadalafil and vardenafil (also called PDE5 inhibitors) ‘prime’ the penis by allowing the blood vessels to relax, while another drug apomorphine acts by enhancing the brain’s response during arousal.
These tablets usually allow an erection to occur, but only when the man is stimulated or aroused. They can, however, cause headaches, dizziness and nausea, and PDE5 inhibitors can cause flushing or rarely some visual disturbance. Men with certain heart conditions or those taking nitrates for angina can’t use PDE5 inhibitors as this combination has proved fatal in some circumstances.
Self-injection
Injecting a prostaglandin drug into the base of the penis allows most men to get an erection, which may last beyond ejaculation. Some men may be put off by this method, but the injector devices are simple and convenient to use and the procedure is virtually painless.
Available treatments are summarised below. Your doctor can advise you on the benefits and drawbacks of each.
psychological counselling (whether or not there is a medical cause)
oral tablets
self-injection or penile insertion of a drug
vacuum pump devices
rigid or inflatable surgical penile implants
testosterone replacement (only for men with low levels of this hormone
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The first successful pharmacological treatment of erectile dysfunction was through penile injections of papaverine and phenoxybenzamine. To date, a number of medications have been used for this purpose, most commonly papaverine, phentolamine and alprostadil in isolation or as a mix for penis injection therapy.
Penile injections are administered by the patient himself just before sexual intercourse and they induce an erection within 5 minutes. The use of an injection mechanism similar to that for insulin injections makes administration easy and painless.
Penile injections do not require any sexual stimulation to work (this means that erections will be achieved irrespective of sexual desire) and their efficacy rate is significantly higher than PDE-5 inhibitors. More importantly, patients have consistently reported harder erections and overall higher sexual satisfaction from the use of penile ejections compared to PDE5 inhibitors. On the other hand, taking an oral pill as opposed to administering an injection before intercourse is more acceptable for most patients. In summary, the advantages and disadvantages of penile injections compared to PDE-5 inhibitors are the following:
Advantages of penile injections compared to PDE-5 inhibitors
- Significantly higher efficiency rates irrespective of sexual stimulation and desire (up to 93%)
- Faster action time
- Stronger and more rigid erections even after ejaculation (1-2 hours duration)
- No reported side effects
Disadvantages of penile injections compared to PDE-5 inhibitors
- Administration is less comfortable
- Rarely there may be increased chance of topical side effects such as priapism (prolonged erection lasting more than four hours)
The type and dosage of injection therapy that will result in maximum responses are patient specific and will thus need to be evaluated during a consultation with Dr John J Ryan MD.
What is Caverject?
Caverject is a prescription-only erectile dysfunction treatment. It is given by injection and has an almost immediate effect, with most men able to get an erection within 5 to 20 minutes. Caverject contains the active ingredient alprostadil, a type of prostaglandin called prostaglandin E1, known to improve blood flow to the penis.
How does Caverject work?
The active ingredient in Caverject, alprostadil, is a man-made version of prostaglandin E1, a strong vasodilator – that means it widens blood vessels and can thin the blood. It helps erectile dysfunction by acting on the blood vessels in the penis to improve blood flow, making it easier to get an erection.
Caverject should make it easier to get an erection within 5 to 20 minutes of injecting the solution and lasts no more than one hour. If you’d like your erection to last longer, you should let your doctor know.
How effective is Caverject?
In a clinical study involving 13,792 Caverject injections, 87% resulted in an erection which was satisfactory for sexual activity. A further study found that 73% of those who used Caverject at home enjoyed satisfactory sex.
How to take Caverject
Caverject is available in 2 forms:
- Caverject dual chamber: turn the plunger to mix the solution and powder in the device
- Caverject vials: the powder will need to be mixed with the supplied solution before injecting
You will be advised by your Doctor Ryan how much Caverject solution you need to inject. Your doctor will monitor you closely to see how the dose is working. The usual starting dose is 1.25 mcg to 2.5 mcg. Most people find that a dose between 5 and 20 mcg is right but some people may need a higher dose.
You must not use more than 60 mcg of Caverject at once. To find the best solution for your circumstance, consult your doctor.
How to prepare the Caverject vial:
- You should begin by washing your hands with warm soapy water and drying them thoroughly.
- Prepare the vial: flip the plastic lid off of the vial and wipe the rubber top with one of the provided antiseptic pads.
- Fit the needle to the syringe: Hold the syringe and twist the white cap to break the seal. Remove the foil from the larger needle with the grey end, but keep the cover on. Join the needle to the syringe by turning the needle clockwise onto it . Remove the needle cover by pushing it away from the syringe with your thumb and finger.
- Mix the solution and powder: Push the needle through the rubber middle of the vial top. Press the plunger down to squirt all the solution onto the powder. Gently swirl the vial until all the powder has dissolved. If the powder doesn’t dissolve or is cloudy, do not use it.
- Fill the syringe: With the needle inserted, turn the vial upside down. Make sure the tip of the needle is below the liquid level. Gently pull the plunger to draw all the mixture into the syringe. Remove the needle from the vial.
- Change to the injecting needle: Gently twist the large needle off of the syringe by turning it anticlockwise. Remove the smaller injecting needle with the yellow end from its packaging, keeping the cover on. Twist the needle clockwise tightly onto the syringe. Remove the needle cover by pushing it away from the syringe with your thumb and finger.
- Set the dose: Gently tap the syringe to send any air bubbles to the top, then push the plunger to squeeze the air bubbles out, ensuring one drop of solution comes out the end of the needle. Continue pushing the plunger until it is at the right dose mark prescribed by your doctor.
How to inject Caverject:
- Get undressed and get in a comfortable position
- Take some time to relax yourself and your partner
- If your doctor has recommended using a second antiseptic pad, open it now
- Ensure the injection needle isn’t bent, if it is do not use it, attach a new needle instead
- Hold your penis from the front, with the first two fingers underneath close to your testicles and the thumb on top
- Gently squeeze your penis between your thumb and finger so that the injection site bulges out
- If your doctor has advised you to wipe the skin where the injection will be inserted, do it now and let it dry
- Firmly gripping your penis, use your free hand to push the needle straight into the skin on the soft, spongy tissue either side of the penis shaft
- Push the plunger firmly until all the liquid has been injected
- Remove the needle and press gently with the antiseptic pad or your thumb, massaging the penis to help spread the Caverject liquid
You shouldn’t use Caverject more than once in 24 hours or more than 3 times per week. You should also change the exact place and side you inject each time you use Caverject.