Erectile dysfunction (ED), once called impotence, is defined as the inability to get an erection or sustain an erection long enough to participate in sex.
ED is a very common condition affecting as many as 30 million American men. The incidence of erectile dysfunction increases as men get older.
About 5% of men aged 20-39, 17% of men in their 60s and nearly 70% or more of men in their 70s. In a study done in the UK, ED was one of the most common disorders in adult males affecting one in five men across the country. By 2025, 322 million men worldwide will be affected by ED.
Erectile function and an active sex life is important to a man’s well being and overall health. ED can cause both a psychological problem as well as a strain on a couple’s lifestyle and relationship. There are multiple treatments for this problem both non-invasive and invasive.
Lifestyle Changes
Lack of physical activity, obesity, poor dietary habits, and tobacco use are all major contributors to erectile dysfunction. Lifestyle changes can prevent further progression of ED or altogether prevent it from happening. The two most important modifications for ED are weight loss and smoking.
In a study of greater than 31000 men who were initially free of ED, as they became obese, there was a 40% increase in erectile dysfunction. Smoking has a negative relationship with ED. As smoking history cumulates, there is a significant increased risk of ED.
Physiology and Oral Medications
An erection starts with nerve stimulation which then releases nitric oxide. NO stimulates guanylate cyclase which converts to guanosine triphosphate into cyclic guanosine monophosphate. This then induces smooth muscle relaxation which allows the influx of blood into the penis for erection.
The molecule phosphodiesterase type 5 breaks down the cyclic guanosine monophosphate and allows the penis to return to the flaccid state. This is the site where most oral medications work.
These medications, (Viagra, Cialis, Levitra) inhibit the action of the PDE5 and keep the level of cGMP high and thus promoting and maintaining erections.
PDE5 inhibitors
- Viagra approved in 1998
- Cialis approved in 2003
- Levitra approved in 2003
- Stendra approved in 2012
Cialis is the only one of these drugs approved for daily use rather than an as needed basis. For these medications to work, there must be an intact nervous system. Therefore, in patients with diabetes, peripheral neuropathy and radical prostatectomy with nerve damage, these medications may not be effective.
Overall, these medications are dilators and should not be used in heart patients on nitrates or in patients taking alpha blockers for prostate enlargement or hypertension as the combination may cause significant hypotension.
Intracavernosal injections
This medication is injected into the lateral aspect of the penis. The common drug is prostaglandin E1 which stimulates cyclic adenosine monophosphate (cAMP) to cause smooth muscle relaxation and stimulate blood flow into the penis. PGE1 is monotherapy and FDA approved but is commonly mixed with papaverine and phentolamine and called Trimix. The use of this medicine is contraindicated in patients with history of recurrent priapism, Peyronie’s disease and bleeding disorders.
Suppositories
Similar to the medicine used in intracavernosal injections, the suppository form is inserted into the urethra. This mode is less effective than the injection route and can cause more pain.
Vacuum Erectile Devices
The vacuum assisted erectile device is placed over the penis and when pumped to create the vacuum, blood is pooled into the penis. Then, a band is placed at the base to maintain the erection and once removed, the penis returns to its flaccid state. This device is challenging to use for many patients. Also, the long-term use causes a decrease in penile sensation and cannot be used in patients on blood thinning medication.
Shockwave Therapy
Extracorporeal shockwave therapy is a newer treatment to improve blood vessel function in the penis. It is a potential treatment modality for patients with cardiovascular and other vessel diseases. Results of studies have shown improvement in penile blood flow which correlated to improved erections. Studies have also shown a decrease in the clinically effective response over time with this modality.
Platelet Rich Plasma
Platelet Rich Plasma is an autologous blood concentrate, rich in growth factors, cytokines and bio-active proteins, used in all fields of medicine to repair and rejuvenate tissue in the body.
Dr. Charles Runels of Fairhope, Alabama invented The Priapus Shot or P Shot in 2010. Named after the Greek god of fertility, The Priapus Shot is based on the idea that specific components of the blood can heal your bodies tissues. Dr Runels hypothesized that an erection results from increased blood flow to the penis causing it to become engorged. For that reason, treatments that would increase blood flow should improve erectile dysfunction. The Priapus Shot not only increases blood flow but also aids in the development of new blood vessels. Since the invention by Dr. Runels, the P Shot is being used worldwide for erectile dysfunction.
Research has proven the P Shot to be effective with virtually no side effects.
Studies
J Sexual Med 2021 May;18(5):926-935 PMID 33906807
Purpose: To conduct the first double blind, randomized, placebo-controlled trial assessing the efficacy and safety of PRP injections in patients with mild to moderate erectile dysfunction.
Conclusion: PRP intracavernosal injections may be a promising addition to the urologist’s armamentarium for the management of ED
Fron Reprod Health 2022 Aug 16;4:944765 PMID 36303622
Purpose: In this article, we review the evidence for intracavernosal injections of platelet rich plasma in the treatment of ED
Conclusion: In summary, only one randomized, placebo-controlled trial has been published to date regarding the use of PRP intracavernosal injections as monotherapy for ED. This study has shown an impressive response in erections in a highly selected cohort of men and offers an exciting new treatment for ED, a condition that to date, has had no treatment that may reverse the dysfunction.
Sexual Medicine Review 2020 Apr10(2); 341-352 PMID 34219010
Purpose: Erectile Dysfunction and Peyronie’s Disease are debilitating medical conditions affecting quality of life. Platelet Rich Plasma injections are one of the various emerging approaches proposed to treat these medical conditions.
To describe the evidence of the potential role of PRP injections in ED and PD.
Results: Eighteen articles met the inclusion criteria for review including 12 studies on the use of PRP in humans and 6 on the use of PRP in rat models. Ten studies reported on the efficacy of PRP in Ed exclusively, 7 in PD exclusively and one in both conditions. In humans, 6 and 3 studies showed promising results in ED and PD respectively. No major complications were noted.
