ED -WHEN THE LITTLE BLUE PILL DOES NOT WORK

If one thinks they have a problem because they have to use Viagra or one of its bretheren

in order to have successful intercourse, what if the pill does not work?   There lies a much

larger problem.  Here are some numbers to give you an idea of what I am speaking of.

If I were taking a board exam, I would answer that sixty-five percent of patients have successful

Intercourse with oral medications such as Viagra, Cialis, Levitra etc..  However, are you taking a board

exam right now?  Or when you are in bed with your partner?   I think we can conclude the answer is

“NO”.  What do I mean by this?  What is the definition of successful intercourse?  Usually that means

That the test subject was able to obtain an erection and maintain the erection long enough to

Complete “the proverbial act.”   My point is simple.   Successful intercourse for an adult film star and an

Obese diabetic sixty-five year old patient are two different things.  Furthermore, there are probably

Multiple variations of what each person may consider successful.  What I am getting at is that on paper

Oral medications are successful sixty-five of the time, however; the patient satisfaction rate is much

lower than sixty-five percent.  The patient satisfaction rate with oral medications is reported

to be fifty percent.  Why might patients not be satisfied with oral medications such as Viagra

or its bretheren?  It does not work.  It does not work well enough.  It does not change my

desire for sex.  It costs too much. My insurance should pay for it.  I get a severe headache.

I feel hungover.  I get stuffy.  I fell asleep and it wore off before I woke up the next morning.

I think I have probably heard most of the reasons patients are not satisfied with oral medications

For erectile dysfunction.  There are few times I think there is an advantage to being older or

In practice longer than most of my collegues and this is definitely one of them.  I hate to admit this

Fact, however; I have been in practice and treating erectile dysfunction well before oral medications

Were available.  That being said, I have a very good understanding of what is available when

Oral medications are not successful, and further what is truly successful and what is not.  I can assure

You my opinion most likely is much different than the average urologist on this point.

 

If we go back to answering board exam questions, thirty five percent of patients will not

Be successful when using oral medications for erectile dysfunction.  This can be for a multitude of

Reasons, however; to have a successful erection small arteries, veins and nerves have to be

Functioning properly for this to occur.   When one has a successful erection it can be compared

To filling a sink with water.  The water flow has to be strong enough to fill the sink up, and there has

To be some sort of drain plug present to hold the water in the sink.  For a successful erection

The bloodflow to the penis has to be strong enough to achieve an erection and to maintain the

Erection the blood has to be held in the penis long enough to keep the erection.  Some patients

Do not have enough bloodflow for a good erection, others cannot hold the blood in place

(venous leak).   This, of course, is only a very simplified description.

 

The good news is there are four or five treatments available when oral medications are not

successful. The bad news is many of these really are not all that successful.

There are over the counter medications available, however; if one of them really worked well for

a large number of patients, everyone would know about it.  Some of them are helpful some of the

time, however; for patients with a true problem I find most of these very unsuccessful.  First, if

these over the counter medications are tested at all it certainly is not with the same scrutiny

nor with patients with the same degree of pathology as patients with severe erectile dysfunction.

I have patients ask me about different over the counter medications every day and my answer usually

Is “I do not really know”.   Why?  There are no double blinded placebo controlled studies done on

over the counter medications.  Secondly, use your common sense.  Trust me on this one thing.  If there

was an over the counter medication that worked like a magic bullet……everyone would know about it.

Do you know of one?   Nor do I ……case closed.

What about “one of those there pumps, Doc?”   Usually they are asking about an external pump

Or more formally known as a “Vaccum Erection Device”.   Like with many treatments there is the good

news and the bad news.  The good news about a Vaccum Pump is they are very safe.  It is an external

device that is placed over the penis,  when pumped, this creates a vaccum and draws blood into the

penis and then a tight band is placed over the pump around the base of the penis to maintain the

erection.   I suppose the good news is that it is hard to do any serious damage to yourself as

long as one does not leave the constrictive band on too long.  When reading the medical literature

It states the patient success rate is around ninety percent.  To quote the lead singer from

Guns and Roses, Axyl Rose, “sometimes experience makes you wise.”  Luckily I have been treating

erectile dysfunction for longer than I want to admit, however; the good news for you as a reader is

I can give you the honest truth.  Think about how I described how a Vaccum Erection Device is

used.   Does it sound comfortable?   Absolutely not.  Are ninety percent of my patients satisfied with

A vaccum erection pump?  Absolutely not.  Here is the true skinny on Vaccum Ererction Device.

First, they are uncomfortable.  Secondly, they work poorly, if at all.  Third, even if the constrictive

band works well enough to hold enough blood in your penis to maintain an erection and does not

hurt too much to use the erection, the anatomy of your penis does not end where it attaches to your

body wall.  The anatomy of the penis goes deep into the pelvis.  What does this mean for Vaccum

Erection Device user?   At best, your penis is firm from the constrictive device out, however;

The part that runs deep into your pelvis is a wet noodle.  Trust me on this, very few

patients use a Vaccum Pump successfully and even less are truly satisfied.  The partners of my

patient’s that have used a Vaccum Pump say the penis is very cold also (because of the

constricted blood flow).  Most women complain about the cold feeling, and really, who can

blame them? Occasionally a patient or two that utilizes a Vaccum Pump successfully, however;

most are happy they took my advice and did not spend the extra money for an automatic inflation

type of pump.  My saying about a Vaccum pump is “all my patients with erectile dysfunction have

one, none of my patients actually use them.  That is the true “skinny” on Vaccum Erection Device.

 

One of my best friends is one of the smartest people I have ever met.  When urethral suppositories

for erectile dysfunction went public he was very upset with me.   “Frank, why didn’t you tell me urethral

Suppositories were coming out and the company was going public!!!!”   My response was “because they

don’t work most of the time”.   Well, that really made him upset…….FRANK……WHO  CARES!!!  Do you

know what the stock is going to do???   As usual he was correct.  The stock initially shot up.  Then

spiraled downward faster than it initially went up.  The idea between urethral suppositories “MUSE”

Is it is a small dissolvable pellet that is placed in the urethra.  The penis is rolled between the

patient’s fingers to enhance the dissolution of the medication.  This then travels through the

Corpus Spongiosum to the Corpus Cavernosum (erectile tissue) and dilates the large blood vessels

that then fill with blood and create an excellent erection.   The good news is that with some

manipulation of the data by the statistician it looks pretty reasonable on paper.  The bad news is

In reality it maybe works for ten percent of patients.   I would say the majority it does not work well

at all.   It can cause severe hypotension (low blood pressure).  Further it causes varying degrees

of burning in the urethra as it dissolves.   For the most part I am talking about intolerable

burning when it dissolves.  I believe at this point very few urologists are still prescribing this

medication.  When it was being prescribed, even fewer patients used the medication successfully.

So far, unfortunately, between the over the counter medications, Vaccum erection device,

And MUSE (urethral suppositories) we are at what is known as “the hat trick” in baseball.

Three at bats……three strike outs.

 

“Doc……….what about all those advertisements for non-surgical erection?”

I will not mention the names of some of these clinics that advertise in the sports section

Of the paper, or golf magazines, however; they are talking about “injection therapy”.

Yes, injection therapy.  Yes, one has to stick their penis with a needle, and yes it means

more than one time.   That’s the unpleasant news.  There is some good news to go with

that.  If one can get past sticking a small diabetic needle into their penis, it actually can

work reasonably well for very motivated patients.  Once again, with the help of

statisticians it looks reasonably good on paper.  Furthermore, it does actually work

for some patients.  However, the medical literature quotes very high success rates.

Again they are talking about a satisfactory erection to “complete the proverbial act.”.

That being said, let me break this down for you into something that is more realistic

and understandable.  As a urologic surgeon, physician, etc.  I do not worry as much about

how a product works on paper and with the help of a statistician what is the P value etc.

What I really want to know is……did it work?  Did you like it?  Would you recommend it to

your best friend or brother?   Will you use it again?

So here is an example of how these injections really work for patients with erectile dysfunction.

We are talking about “EDEX”  “Caverject”  “Trimix”  “Quadmix”  “Bimix”.  The good news is a small

bottle of some of these mixtures may last you between ten to twenty uses per bottle and one bottle

Is about the cost of one Viagra pill.  So injection therapy, for the most part is much more cost effective.

That being said, I break down the true success rate somewhat different than how the literature

reports the success rate.  First, how many patients do you think will absolutely not consider sticking

a needle in their penis?   A very conservative estimate is about fifty percent will no way even try

this right off the bat.   Of the patients that do try injections, probably half of those have discomfort

and will not try it again after the test dose.  Of the twenty five percent of the patients we have left,

half of them cannot really stick a needle in their penis and inject the medication successfully.

Now we are at about 12.5 % of the patients that actually can use the medication.  A handful of

those patients will develop what is known as  “priapism”  (their erection will  not go away) and

wind up in the emergency room and have to get a second erection to make their now unwanted

erection go away.   Of the remaining patients that actually use the medication successfully, most drop

out after two years because of pain, scar tissue, bruising, etc.

All that being said, injection therapy does work.  However, injection therapy is not used successfully

by a large number of patients with erectile dysfunction.

 

“Doc……..one of my friends said he has this internal pump thing that you put in and he said

You really took care of him and I need to see you!!!   What is he talking about????

The best news is that I saved the best for last.  There is a light at the end of the tunnel.

What this patient’s friend is talking about is a “PENILE   IMPLANT”  or inflatable penile prosthesis.

A penile implant actually does work.  These actually have a patient satisfaction rate of 92-96%.

The far majority of my Christmas Cards come from my patients that I have put in a penile implant.

What if I told you that patients with a penile implant like these because you really could not tell

a patient had an implant if you saw him in a gym locker room.  They look completely natural when

flaccid.  When one wants an erection there is a small pump concealed in the scrotom next to your

testicle that you pump which transfers fluid into the implant which gives you an excellent

erection every time, stays hard as long as you want, stays hard as long as your partner wants,

does not change the feeling for you or your partner, you can have sex normally, orgasm normally,

when you are done you push a button on the pump and it goes back down into the flaccid state.

It is placed through a small opening between the penis and scrotom as an outpatient.  You can

go home the same day.  It is covered by Medicare and most insurance companies.  All true.

I generally will see patients the next day in the office and again in a few weeks to begin cycling the

Implant (teaching you to pump it up and down).  For the married couples it usually will restore their

sex life and enhances their relationship once again.  For single men, let’s say they usually do not

have any shortage of home cooked meals because they get invited to dinner very frequently.

Why this is usually not mentioned by most urologists is that only approx. 7% of urologic surgeons

are trained to place penile implants and most that are do not place very many of these.

Luckily in my residency program many years ago we did them very frequently, and I continued

down this path in my own practice.  That being said, most urologists do not do the place many of these

and never bring them up in conversation with their patients.  Lastly, most urologists

are taught to look at penile implants and erectile dysfunction as more of a last resort.

My philosophy on erectile dysfunction is somewhat different.  I think if Viagra or one of its

bretheren works for you without significant side effects you should use it.  However, if you are

one of the 35% of patients that does not respond to oral medications, then why would I recommend

something to you I know is not gonna be successful for you?   If patients do not respond to

oral medications and the cause of their erectile dysfunction may improve in the future, then I

may recommend injection therapy.  If, however; a patient does not respond to oral medications

and their erectile dysfunction is a permanent problem like diabetes, vascular disease, then

I will usually recommend a permanent solution such as a penile implant.

A penile implant has the highest patient satisfaction rate amongst all therapies available, it is a

permenant solution, and very successful when implanted by a urologist that performs many of these

procedures like myself.

Fortunately, there is hope and very good treatment available for patient’s that do not respond

to oral medications for erectile dysfunction.  I highly recommend seeing a urologist that is well

versed in penile implant and prosthetic urologic surgery.  Urologist that do a large number of

these procedures are the most successful at placing penile implants, and further usually have

significantly more experience in treatment of erectile dysfunction in general.

 

 

If one thinks they have a problem because they have to use Viagra or one of its bretheren

in order to have successful intercourse, what if the pill does not work?   There lies a much

larger problem.  Here are some numbers to give you an idea of what I am speaking of.

If I were taking a board exam, I would answer that sixty-five percent of patients have successful

Intercourse with oral medications such as Viagra, Cialis, Levitra etc..  However, are you taking a board

exam right now?  Or when you are in bed with your partner?   I think we can conclude the answer is

“NO”.  What do I mean by this?  What is the definition of successful intercourse?  Usually that means

That the test subject was able to obtain an erection and maintain the erection long enough to

Complete “the proverbial act.”   My point is simple.   Successful intercourse for an adult film star and an

Obese diabetic sixty-five year old patient are two different things.  Furthermore, there are probably

Multiple variations of what each person may consider successful.  What I am getting at is that on paper

Oral medications are successful sixty-five of the time, however; the patient satisfaction rate is much

lower than sixty-five percent.  The patient satisfaction rate with oral medications is reported

to be fifty percent.  Why might patients not be satisfied with oral medications such as Viagra

or its bretheren?  It does not work.  It does not work well enough.  It does not change my

desire for sex.  It costs too much. My insurance should pay for it.  I get a severe headache.

I feel hungover.  I get stuffy.  I fell asleep and it wore off before I woke up the next morning.

I think I have probably heard most of the reasons patients are not satisfied with oral medications

For erectile dysfunction.  There are few times I think there is an advantage to being older or

In practice longer than most of my collegues and this is definitely one of them.  I hate to admit this

Fact, however; I have been in practice and treating erectile dysfunction well before oral medications

Were available.  That being said, I have a very good understanding of what is available when

Oral medications are not successful, and further what is truly successful and what is not.  I can assure

You my opinion most likely is much different than the average urologist on this point.

 

If we go back to answering board exam questions, thirty five percent of patients will not

Be successful when using oral medications for erectile dysfunction.  This can be for a multitude of

Reasons, however; to have a successful erection small arteries, veins and nerves have to be

Functioning properly for this to occur.   When one has a successful erection it can be compared

To filling a sink with water.  The water flow has to be strong enough to fill the sink up, and there has

To be some sort of drain plug present to hold the water in the sink.  For a successful erection

The bloodflow to the penis has to be strong enough to achieve an erection and to maintain the

Erection the blood has to be held in the penis long enough to keep the erection.  Some patients

Do not have enough bloodflow for a good erection, others cannot hold the blood in place

(venous leak).   This, of course, is only a very simplified description.

 

The good news is there are four or five treatments available when oral medications are not

successful. The bad news is many of these really are not all that successful.

There are over the counter medications available, however; if one of them really worked well for

a large number of patients, everyone would know about it.  Some of them are helpful some of the

time, however; for patients with a true problem I find most of these very unsuccessful.  First, if

these over the counter medications are tested at all it certainly is not with the same scrutiny

nor with patients with the same degree of pathology as patients with severe erectile dysfunction.

I have patients ask me about different over the counter medications every day and my answer usually

Is “I do not really know”.   Why?  There are no double blinded placebo controlled studies done on

over the counter medications.  Secondly, use your common sense.  Trust me on this one thing.  If there

was an over the counter medication that worked like a magic bullet……everyone would know about it.

Do you know of one?   Nor do I ……case closed.

What about “one of those there pumps, Doc?”   Usually they are asking about an external pump

Or more formally known as a “Vaccum Erection Device”.   Like with many treatments there is the good

news and the bad news.  The good news about a Vaccum Pump is they are very safe.  It is an external

device that is placed over the penis,  when pumped, this creates a vaccum and draws blood into the

penis and then a tight band is placed over the pump around the base of the penis to maintain the

erection.   I suppose the good news is that it is hard to do any serious damage to yourself as

long as one does not leave the constrictive band on too long.  When reading the medical literature

It states the patient success rate is around ninety percent.  To quote the lead singer from

Guns and Roses, Axyl Rose, “sometimes experience makes you wise.”  Luckily I have been treating

erectile dysfunction for longer than I want to admit, however; the good news for you as a reader is

I can give you the honest truth.  Think about how I described how a Vaccum Erection Device is

used.   Does it sound comfortable?   Absolutely not.  Are ninety percent of my patients satisfied with

A vaccum erection pump?  Absolutely not.  Here is the true skinny on Vaccum Ererction Device.

First, they are uncomfortable.  Secondly, they work poorly, if at all.  Third, even if the constrictive

band works well enough to hold enough blood in your penis to maintain an erection and does not

hurt too much to use the erection, the anatomy of your penis does not end where it attaches to your

body wall.  The anatomy of the penis goes deep into the pelvis.  What does this mean for Vaccum

Erection Device user?   At best, your penis is firm from the constrictive device out, however;

The part that runs deep into your pelvis is a wet noodle.  Trust me on this, very few

patients use a Vaccum Pump successfully and even less are truly satisfied.  The partners of my

patient’s that have used a Vaccum Pump say the penis is very cold also (because of the

constricted blood flow).  Most women complain about the cold feeling, and really, who can

blame them? Occasionally a patient or two that utilizes a Vaccum Pump successfully, however;

most are happy they took my advice and did not spend the extra money for an automatic inflation

type of pump.  My saying about a Vaccum pump is “all my patients with erectile dysfunction have

one, none of my patients actually use them.  That is the true “skinny” on Vaccum Erection Device.

 

One of my best friends is one of the smartest people I have ever met.  When urethral suppositories

for erectile dysfunction went public he was very upset with me.   “Frank, why didn’t you tell me urethral

Suppositories were coming out and the company was going public!!!!”   My response was “because they

don’t work most of the time”.   Well, that really made him upset…….FRANK……WHO  CARES!!!  Do you

know what the stock is going to do???   As usual he was correct.  The stock initially shot up.  Then

spiraled downward faster than it initially went up.  The idea between urethral suppositories “MUSE”

Is it is a small dissolvable pellet that is placed in the urethra.  The penis is rolled between the

patient’s fingers to enhance the dissolution of the medication.  This then travels through the

Corpus Spongiosum to the Corpus Cavernosum (erectile tissue) and dilates the large blood vessels

that then fill with blood and create an excellent erection.   The good news is that with some

manipulation of the data by the statistician it looks pretty reasonable on paper.  The bad news is

In reality it maybe works for ten percent of patients.   I would say the majority it does not work well

at all.   It can cause severe hypotension (low blood pressure).  Further it causes varying degrees

of burning in the urethra as it dissolves.   For the most part I am talking about intolerable

burning when it dissolves.  I believe at this point very few urologists are still prescribing this

medication.  When it was being prescribed, even fewer patients used the medication successfully.

So far, unfortunately, between the over the counter medications, Vaccum erection device,

And MUSE (urethral suppositories) we are at what is known as “the hat trick” in baseball.

Three at bats……three strike outs.

 

“Doc……….what about all those advertisements for non-surgical erection?”

I will not mention the names of some of these clinics that advertise in the sports section

Of the paper, or golf magazines, however; they are talking about “injection therapy”.

Yes, injection therapy.  Yes, one has to stick their penis with a needle, and yes it means

more than one time.   That’s the unpleasant news.  There is some good news to go with

that.  If one can get past sticking a small diabetic needle into their penis, it actually can

work reasonably well for very motivated patients.  Once again, with the help of

statisticians it looks reasonably good on paper.  Furthermore, it does actually work

for some patients.  However, the medical literature quotes very high success rates.

Again they are talking about a satisfactory erection to “complete the proverbial act.”.

That being said, let me break this down for you into something that is more realistic

and understandable.  As a urologic surgeon, physician, etc.  I do not worry as much about

how a product works on paper and with the help of a statistician what is the P value etc.

What I really want to know is……did it work?  Did you like it?  Would you recommend it to

your best friend or brother?   Will you use it again?

So here is an example of how these injections really work for patients with erectile dysfunction.

We are talking about “EDEX”  “Caverject”  “Trimix”  “Quadmix”  “Bimix”.  The good news is a small

bottle of some of these mixtures may last you between ten to twenty uses per bottle and one bottle

Is about the cost of one Viagra pill.  So injection therapy, for the most part is much more cost effective.

That being said, I break down the true success rate somewhat different than how the literature

reports the success rate.  First, how many patients do you think will absolutely not consider sticking

a needle in their penis?   A very conservative estimate is about fifty percent will no way even try

this right off the bat.   Of the patients that do try injections, probably half of those have discomfort

and will not try it again after the test dose.  Of the twenty five percent of the patients we have left,

half of them cannot really stick a needle in their penis and inject the medication successfully.

Now we are at about 12.5 % of the patients that actually can use the medication.  A handful of

those patients will develop what is known as  “priapism”  (their erection will  not go away) and

wind up in the emergency room and have to get a second erection to make their now unwanted

erection go away.   Of the remaining patients that actually use the medication successfully, most drop

out after two years because of pain, scar tissue, bruising, etc.

All that being said, injection therapy does work.  However, injection therapy is not used successfully

by a large number of patients with erectile dysfunction.

 

“Doc……..one of my friends said he has this internal pump thing that you put in and he said

You really took care of him and I need to see you!!!   What is he talking about????

The best news is that I saved the best for last.  There is a light at the end of the tunnel.

What this patient’s friend is talking about is a “PENILE   IMPLANT”  or inflatable penile prosthesis.

A penile implant actually does work.  These actually have a patient satisfaction rate of 92-96%.

The far majority of my Christmas Cards come from my patients that I have put in a penile implant.

What if I told you that patients with a penile implant like these because you really could not tell

a patient had an implant if you saw him in a gym locker room.  They look completely natural when

flaccid.  When one wants an erection there is a small pump concealed in the scrotom next to your

testicle that you pump which transfers fluid into the implant which gives you an excellent

erection every time, stays hard as long as you want, stays hard as long as your partner wants,

does not change the feeling for you or your partner, you can have sex normally, orgasm normally,

when you are done you push a button on the pump and it goes back down into the flaccid state.

It is placed through a small opening between the penis and scrotom as an outpatient.  You can

go home the same day.  It is covered by Medicare and most insurance companies.  All true.

I generally will see patients the next day in the office and again in a few weeks to begin cycling the

Implant (teaching you to pump it up and down).  For the married couples it usually will restore their

sex life and enhances their relationship once again.  For single men, let’s say they usually do not

have any shortage of home cooked meals because they get invited to dinner very frequently.

Why this is usually not mentioned by most urologists is that only approx. 7% of urologic surgeons

are trained to place penile implants and most that are do not place very many of these.

Luckily in my residency program many years ago we did them very frequently, and I continued

down this path in my own practice.  That being said, most urologists do not do the place many of these

and never bring them up in conversation with their patients.  Lastly, most urologists

are taught to look at penile implants and erectile dysfunction as more of a last resort.

My philosophy on erectile dysfunction is somewhat different.  I think if Viagra or one of its

bretheren works for you without significant side effects you should use it.  However, if you are

one of the 35% of patients that does not respond to oral medications, then why would I recommend

something to you I know is not gonna be successful for you?   If patients do not respond to

oral medications and the cause of their erectile dysfunction may improve in the future, then I

may recommend injection therapy.  If, however; a patient does not respond to oral medications

and their erectile dysfunction is a permanent problem like diabetes, vascular disease, then

I will usually recommend a permanent solution such as a penile implant.

A penile implant has the highest patient satisfaction rate amongst all therapies available, it is a

permenant solution, and very successful when implanted by a urologist that performs many of these

procedures like myself.

Fortunately, there is hope and very good treatment available for patient’s that do not respond

to oral medications for erectile dysfunction.  I highly recommend seeing a urologist that is well

versed in penile implant and prosthetic urologic surgery.  Urologist that do a large number of

these procedures are the most successful at placing penile implants, and further usually have

significantly more experience in treatment of erectile dysfunction in general.