AboutArthur Goldstein, M.D. Expertise Any problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, impotency, etc.
Experience I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in male impotence and endourology.
Organizations American Medical Association, American Urological Association, American College of Surgeons
Question I am a 23 year old male currently taking no medication. I have been having issues with erectile dysfunction/impotence for a little over a year now. There have been many occasion where I have been completely unable to obtain an erection. Conversely, if I am able to obtain an erection it is very weak and requires constant physical stimulation to maintain it.
I have seen a urologist specifically regarding this issue who, along with an endocrinologist, have determined that my testosterone levels are abnormally high, my sex hormones are normal, and I do not have hypogonadism. I have also seen a sex therapist who suggested the use of bio-feedback to alleviate any underlying anxiety I may have about my situation in the hope that it would in turn alleviate my impotence.
This therapy coupled with cialis seemed to help somewhat. During the course of therapy and with cialis I was able to perform sexually at a satisfactory level several times. Since then, however, I have reverted to having the same issues. I am only able to obtain a lazy erection with physical stimulation. Mental and visual stimuli do absolutely nothing. I have begun to suspect that I may have a blood flow issue. However, the urologist I was seeing was less than helpful when I suggested the use of a doppler ultrasound. His reaction was to tell me that he knew of nowhere I could have the test administered and that I would need to search for it along with filling the scripts for the procedure itself and the caverject. Feeling hopeless I never went any further with the idea and continue to suffer from the same symptoms.
My questions are, is it worth attempting to move forward with the ultrasound? I have read that if there is a bloodflow issue there is no real fix for it and if bloodflow is normal I am still stuck in the same position. Also, upon reviewing my case is there any other suggestion you could make as to why a 23 year old generally healthy male would be having this problem? I am at a total loss.
Answer Anders, you could have a blood flow issue. This may be in the form of a venous leak or inadequate arterial flow from the internal pudendal artery. Information obtained from a duplex doppler flow of the penis would be helpful. Sometimes additional tests such as a corpus cavernosogram are needed to further define the problem. Vascular problems can sometimes be corrected depending the specific pathology. If your urologist is not cooperative, I suggest a second opinion. The tests mentioned above should be available at most radiology facilities. To follow are two "macros" I have written on ED and venous leakage that should be informative for you.
There are many causes for erectile dysfunction (ED). The most common diseases associated with this disorder are vascular conditions (ie atherosclesosis – “hardening of the arteries” and abnormal varicose veins inside the penis - so called "venous leak") and diabetes. Some others include hormone imbalances, neurologic pathology, local penile diseases (ie Peyronie’s disease), smoking, obesity, alcoholism, prostatitis, prostate surgery, certain medications, "recreational drugs", trauma to pelvic nerves or vasculature and chronic perineal pressure from overly aggressive bike or horse back riding. A variety of emotional disturbances (most commonly depression or performance anxiety) can also cause or be a significant factor in those suffering from ED. Very commonly, the etiology is multifactoral. As a result, consultation with a urologist skilled in the evaluation and treatment of ED is recommended.
In addition to a history and physical examination, specialized tests may be indicated to find a cause. Some of the commonly ordered studies include routine blood tests, hormone levels, and penile duplex color ultrasound.
If a correctable cause is found, specific treatment is instituted. If the condition is irreversible, most men today can still be restored to normal functionality with the numerous treatments available including oral medications in the class of PDE5 inhibitors (ie Viagra, Levitra, and Cialis), vacuum erection devices (VEDs), confidence rings (for those with a pure venous leakage), penile injections (ie Edex, Caverject), urethral suppositories (Muse) and penile prosthetic surgery. PDE5 inhibitors (in proper dosage which varies with the individual) have shown success in about 80% of patients. Side effects may include headaches, flushing, heart- burn, nasal congestion, visual disturbances, dizziness, etc. These drugs are contraindicated in patients with coronary artery disease who take nitrates (ie nitroglycerine) as some deaths have occurred in this group. There is also the potential for a severe drop in blood pressure if PDE5 inhibitors are used in patients who take alpha- blockers (ie Hytrin, Cardura, etc.) or are hypertensive. It is now a recommendation that not more than 25 mgm of Viagra be used within 4 hours of taking an alpha blocker Several other types of medication may alter the blood level of PDE5 inhibitors possibly leading to significant side effects. Other contraindications include certain types of liver and visual disorders (ie retinitis pigmentosa). PDE5 inhibitors have been noted to cause abnormal liver function tests in some otherwise normal men. Because of this, although PDE5 inhibitors are well tolerated by most, they should only be taken with caution and under the supervision of a physician. All 3 of the PDE5 inhibitors available in the USA have about the same success rate. If one fails to respond to the initial dose, it should be increased until either tolerance or the desired effect is obtained.
The way one takes the PDE5 inhibitors may significantly affect their action. The following should guide you in their administration. Cialis can be taken without regard to meals but takes 2-4 hours before it works, although the beneficial effect lasts about 18 hours. The dose is 10-20 mgm. Viagra and Levitra have an onset of action in 30-60 minutes and last about 4 hours. The absorption of these 2 medications can be adversely affected by diet, especially a diet high in fat. Therefore, it is best to take these an hour or 2 after meals. About 60% of patients who fail to respond to maximum doses of one of the PDE5 inhibitors. respond favorably to another and, in the absence of side effects, this is worth trying.
The penis is composed of three cylindrical bodies called corpora. The single corpus spongiosum contains the urinary canal (urethra) and the paired corpora cavernosa are the erectile bodies. The latter each contain an artery that supplies blood and they are surrounded by an elastic membrane. The corpora cavernosa contain vascular spaces that have the ability to expand with the inflow of arterial blood. The act of having an erection is dependent on many factors. In its most basic form, however, sexual arousal (touch, thought, dreams, etc.) stimulate the nervous system to send information to the penis. This causes the vascular resistance in the corpora to decrease allowing arterial blood to flow in much easier. Simultaneously, the outer elastic membrane stretches to accommodate the increased blood in the penis and an erection occurs. While arterial blood is flowing into the penis, the veins of the penis tend to let the blood escape back into the circulation. Normally, the pressure inside the corpora increases to a critical level, the corpora swells and passively compresses the veins, thus shutting off the outflow temporarily. However, abnormal venous drainage can be present either congenitally or develop spontaneously over time. In such a case, the blood may flow out of the penis too fast during attempted erection resulting in no or only partial tumescence. This is called a “venous leak”.
The venous leak can be identified by performing a penile duplex color ultrasound or by a special x-ray of the the penis called a corpous cavernosogram. The latter is an invasive test and not usually performed unless one is considering surgical repair. Although the later is an option, the success rate is disappointing. The simplest therapy is to use a thick expandable device called a confidence ring. These come in various diameters and strengths. They help to compress the veins but do not affect the arterial inflow. The ring is stretched and placed over the penis to its base just before attempting sex. They should not be left on for more than 30 minutes because of potential comprise of blood flow. Another option, is the use of medication to allow blood to more easily flow into the corpora. These agents are oral medications in the class of PDE5 inhibitors (ie Viagra, Levitra, and Cialis), penile injections (ie Edex, Caverject), and urethral suppositories (Muse). They may be successful alone or combined with a confidence ring. Good luck.
