Erectile Dysfunction: 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 brethren

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.

By the Numbers

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”.

Getting to the Point

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 is 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 brethren?

• 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.

A Step Back

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 blood flow 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 blood flow for a good erection, others cannot hold the blood in place (venous leak). This, of course, is only a very simplified description.

Other Options to Consider

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.

Penile Pumps

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 vacuum erection pump? Absolutely not. Here is the true skinny on Vaccum Erection 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 Vacuum 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.

What About Urethral Suppositories?

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 the 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 work 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 strikeouts.

Non-Surgical Treatments for ED

“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 differently 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.

Penile Implants

“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 scrotum 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 scrotum 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 married couples, it usually will restore their sex life and enhance 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.

Back to the Start

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

When to See a Urologist for ED

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