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Surgery For ED

Surgery usually has one of three goals:

• to implant a device that can cause the penis to become erect
• to reconstruct arteries to increase blood flow to the penis
• to block off veins that allow blood to leak from the penile tissues

Implanted devices, known as prostheses, can restore erection in many men with ED.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see Figure 3). Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. The pump causes fluid to flow from a reservoir residing in the lower pelvis to two cylinders residing in the penis. Inflatable implants can expand the length and width of the penis to some degree. They also leave the penis in a more natural state than malleable implants do when not inflated.

Once a man has either a malleable or inflatable implant, he must use the device to have an erection. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have decreased in recent years because of technological advances.

With an inflatable implant, an erection is produced by squeezing a small pump implanted in the scrotum. The cylinders expand to create the erection.

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the groin or fracture of the pelvis. The procedure is usually unsuccessful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure-intentional blockage. Blocking off veins, called ligation, can reduce the leakage of blood that diminishes the rigidity of the penis during an erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

Retainer Medicine

Retainer medicine is practiced by physicians who have decided to drop out of all third party payer programs. These practitioners have offered a limited number of patients the opportunity to pay a fixed annual fee in exchange for premium services and amenities. Retainers doctors generally limit, by a drastic amount, the number of patients, which they will service. This makes the most sense for primary care physicians and those specialists who have ongoing and regular relationships with their patients. Many retainer practices also provide amenities which patients often do not get when Medicare or an insurer pays the doctor, including access to the physician’s cell phone, e-mail correspondence, same-day appointments, and plenty of face time during appointments. However, whatever the specifics of a particular practice may be, the key that defines “retainer medicine” is that the doctor works for the patient. It has become impossible in practical terms and in ethical terms for traditional primary care physicians to fight the pervasive pressures upon them to ration healthcare at the bedside. To escape this fate, they must become either specialists or a retainer practitioner. That is, primary care physicians must choose between remaining in a system that ruthlessly pushes them toward a practice of bedside rationing or, one way or another, getting out of traditional primary care medicine altogether. Retainer medicine restores the professional integrity of medical practice, and re-establishes a doctor-patient relationship in which the physician can again assume the duty of a true advocate. It is perhaps the only remaining means to restore the foundational medical ethic of always placing the patient first. Retainer fees let one practice handle more patients by phone or email.

How is ED diagnosed?

Patient History

A person's medical and sexual histories help define the degree and nature of ED. The medical history can disclose diseases that lead to ED, and a simple recounting of sexual activity might identify problems with sexual desire, erection, ejaculation, or orgasm.

Use of certain prescription or illegal drugs can suggest a chemical cause because drug effects are a frequent cause of ED.

Physical Examination

A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to physical touch, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics, such as unusual hair pattern or breast enlargement, can point to hormonal problems, which would mean the endocrine system is involved. The doctor might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem-for example, a penis that bends or curves when erect could be the result of Peyronie’s disease.

Laboratory Tests

Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of available testosterone in the blood can yield information about problems with the endocrine system and may explain why a patient has decreased sexual desire.

Other Tests

Monitoring erections that occur during sleep-nocturnal erections-can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than a psychological cause. Tests for nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be conducted for best results.

Psychosocial Examination

A psychosocial examination, using an interview and a questionnaire, can reveal psychological factors. A man's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

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What Else May Cause Sexuality Problems?

Surgery. Many of us worry about having any kind of surgery—it may be even more troubling when the breasts or genital area are involved. Most people do return to the kind of sex life they enjoyed before surgery.

Hysterectomy is surgery to remove a woman’s uterus. Often, when an older woman has a hysterectomy, the ovaries are also removed. The surgery can leave both men and women worried about their sex lives. If you’re afraid that a hysterectomy will change your sex life, talk with your gynecologist or surgeon.

Mastectomy is surgery to remove all or part of a woman’s breast. This surgery may cause some women to lose their sexual desire or their sense of being desired or feeling feminine. In addition to talking with your doctor, sometimes it is useful to talk with other women who have had this surgery. Programs like the American Cancer Society’s (ACS) “Reach to Recovery” can be helpful for both women and men. If you want your breast rebuilt (reconstruction), talk to your cancer doctor or surgeon.

Prostatectomy is surgery that removes all or part of a man’s prostate because of cancer or an enlarged prostate. It may cause urinary incontinence or ED. If removal of the prostate gland (radical prostatectomy) is needed, talk to your doctor before surgery about your concerns.

Medications. Some drugs can cause sexual problems. These include some blood pressure medicines, antihistamines, antidepressants, tranquilizers, appetite suppressants, drugs for mental problems, and ulcer drugs. Some can lead to ED or make it hard for men to ejaculate. Some drugs can reduce a woman’s sexual desire or cause vaginal dryness or difficulty with arousal and orgasm. Check with your doctor. She or he may prescribe a different drug without this side effect.

Alcohol. Too much alcohol can cause erection problems in men and delay orgasm in women.