ED Treatments in Secondary Care

Intracavernosal Prostaglandin Injections

Several alprostadil preparations are available and injection is now aided by a self injection pen. Intracavernosal injections work in a high proportion of patients, but require the preparedness to accept the injections and the dexterity to apply them.

Advantages:

Proved efficacy achieving good erections
(94% in users at home)
Rapidly effective
Suitable for most patients, few contraindications
Recovery of spontaneous erections in some patients
High patient and partner satisfaction

Disadvantages:

Invasive, requiring injection
Penile pain on injection (usually mild) is common
Needs initial tuition for use
Needs adequate manual dexterity and eyesight
Penile fibrosis in longterm use possible
Prolonged erections in <5% and priapism in 1%
Contraindicated in bleeding disorders + anticoagulation?

Transurethral Alprostadil (MUSE)

Alprostadil given transurethrally avoids the need for intracavernosal injection, but is overall less effective and has a higher incidence of penile pain leading to discontinuation of treatment. MUSE application is somewhat complex, requiring insertion after micturition, manual dexterity and good eyesight. Initial tuition is recommended (there is a patient video from the manufacturer). Longterm studies and follow-up have not been reported. It can be used in needlephobic and in anticoagulated patients.

Advantages:

Efficacy in providing erections in about 65%
Lower risk of priapism than intracavernosal injections
Suitable for needle phobia
Suitable for anticoagulated patients

Disadvantages:

Long term efficacy and side effects uncertain
Less effective than intracavernosal injections
Mild penile pain in 10-29%, (11% MUSE discontinuation)
Possible urethral discomfort + vaginal discomfort
Needs manual dexterity and good eyesight
Slower onset of action than intracavernosal alprostadil
Possible discomfort in lower limb varicosities

Vacuum Devices

A vacuum device consists of an external cylinder fitted over the penis to allow the air to be pumped out, resulting in engorgement of the penis with blood. A constriction ring is then fitted to the base of the penis to maintain this “erect” state. It is suitable for a wide range of patients with chronic or occasional ED, whatever the cause. Satisfaction rates with this are reported as varying widely, probably reflecting physicians enthusiasm and patient teaching to some extend. It probably works well in couples that jointly decide to use this method, although the method has some definite disadvantages. Vacuum pumps can be bought directly by mail order and are a single investment cost compared to ongoing costs of medication. Those patients wishing to try this method straight away can be given the list of manufacturers. Most patients may wish to try the method first and should be directed to the Urology department, where some dedicated pumps are available for patients to try.

Advantages:

Low incidence of side effects
Suitable for long term use
Suitable in failed oral therapy
Suitable in patients on nitrates
Single investment cost

Disadvantages:

Ontraindicated in bleeding disorders + anticoagulation
(probably suitable in most patients with antiplatelet therapy
[aspirin, clopidogrel, dipyridamole, NSAIDS],
Unless they easily get skin bruises)
Lack of spontaneity + cumbersome
Can be uncomfortable, ejaculation may be impaired
Pivoting at base of penis and “cold penis” for partner
Overall less satisfaction than with injection therapy suggested(Soderdahl)

Penile Prosthesis

This is third line treatment reserved for those who have failed other treatments, have contraindications to other treatments or decline other treatments. This has a high patient and partner satisfaction rate and is a very effective treatment. Penile prosthesis insertion will however irreversibly damage penile cavernosal tissues and a return to other treatment forms is subsequently impossible. In reality most patients wishing to undergo surgery for ED have nonfunctioning cavernosal tissues already. Technical success rates are high and the risk of infections is low with modern antibiotic covered prosthesis and prophylaxis.

Advantages: