Erectile dysfunction commonly affects the ageing male. Its aetiologies are multi-factorial. There is a reduction in serum testosterone, as the man ages. There is a loss of libido for other reasons. The neurovascular supplies of the erectile corporal bodies of the penis also undergo deterioration. Patients who have diabetes, elevated lipids and vascular disease, are prone to penile arterial insufficiency. Diabetes, pelvic irradiation, prior pelvic surgery, all also affect the autonomic sacral nerve supply to the penis, which is yet another cause of erectile dysfunction. A full assessment is required by the Urologist, including a full history and physical examination with blood tests to include hormonal assays, blood sugar levels, blood profile, PSA and testosterone levels.
Duplex venous and arterial ultrasonography of penile erectile tissues can be performed. The initial management is through lifestyle modification, correction of high blood sugar and high lipid levels, with an increase in physical activity and exercise.
Tablets come in the form of drugs that increase blood flow into the penis and the well known trade names are Viagra and Cialis. Your Urologist must make sure you are suitable for these, as there are some medical contraindications.
Other causes of erectile dysfunction include trauma to the penis, causing a venous leak pathology. Peyronie’s calcified plaques cause initially a painful hard lump to be felt that then becomes a chronic painless state, however acts as a fulcrum within the firm tunica of the penis and causes a varying degree of bend in the penis.
This curvature when > 20–30°, may preclude intercourse, because the penis is no longer straight. The simplest and most effective way of dealing with this a Nesbitt’s ventral plication, which is a simple day surgical operation, which takes one hour under general anaesthesia and this allows for straightening of the penis, by way of permanent non-dissolving suture placement.
Prostate cancer surgery causes erectile dysfunction. Erectile rehabilitation is in the form of tablets and penile injections. Nerve sparing techniques at the time of robotic surgery allow preservation of erections. When tablets and injections fail, the final option is a permanent penile prosthesis. This is a three piece inflatable device, where inflatable rods are placed into the penis and replace the erectile spongy corporal tissues and these rods are connected to a retropubic normal saline reservoir, which are both then connected to a scrotal pump, placed in the dominant handed side of the scrotum. The patient is then on-demand able to access the scrotal pump, which moves fluid from the reservoir into the corporal penile rods, producing an erect penis, and this is said to have satisfaction and fulfilment rates well above 80%. Several sterilisation and antibiotic preparatory techniques are required in order to minimise infection, which can occur when implanting a prosthetic device.