The management algorithm at the Sexual Medicine Program at Weill Cornell Medicine - New York Presbyterian Hospital proceeds in a stepwise manner in order to ensure comprehensive, state-of-the-art treatment in the management of erectile dysfunction (ED). This begins with first line therapy including management of associated medical conditions and psychological support combined with oral medical therapy. Second line therapy includes vacuum erection device therapy, penile injection therapy, and transurethral prostaglandin suppository administration. Third line therapy usually involves surgery with implantation of a penile prosthesis.
Oral Agents (Pills)
Avanafil (Stendra), Sildenafil (Viagra), Tadalafil (Cialis) and Vardenafil (Levitra, Staxyn) are called inhibitors of phosphodiesterase type 5 (PDE5-I) and they all work by the same mechanism. Viagra® was the first oral agent with proven benefit in the treatment of erectile dysfunction. Nowadays, there are several oral products which differ in time needed to achieve erection, effects of food intake on activity, and daily or on-demand use. This gives physicians and patients more flexibility in choosing the best type of medication to suit individual needs.
The advantage of medications in this group is their simplicity of use. Medications in this group help promote the development and maintenance of an erection. Stimulation is required for these medications to work. It is important to note that these medications do not affect sex drive or libido. Treatment with any of these PDE5 inhibitors allows approximately 65% of men to resume sexual intercourse. Headache, flushing, transient visual disturbances, back pain, and dyspepsia are the most common side effects.
Vacuum Erection Device
Vacuum erection devices, also known as vacuum constriction devices, have been utilized for improving erectile rigidity for over a century. Bruising, skin breakdown, and penile pain associated with the application of the constriction band are among possible side effects.
Intraurethral Agents (Suppositories)
Intra-urethral administration of alprostadil suppository (MUSE™) induces an erection sufficient for sexual intercourse in 30-40% of men. A pellet, the size of a grain of rice, is placed 1 inch into the urine channel following urination while the patient is standing. The reported side effects include pain and dizziness.
Injection therapy represents a cornerstone of ED therapy and remains the gold standard for medical therapy. To date, a number of medications have been used for this purpose, most commonly papaverine, phentolamine, and alprostadil. These medications have been administered in a variety of combinations with good effect. The success rate, defined by the production of an erection rigid enough for intercourse, has been in excess of 75%. Disadvantages include the more complex route of administration, potential for bleeding, bruising, penile fibrosis, and a higher incidence of priapism (albeit all uncommon side effects).
Penile Implant (Prosthesis) Surgery
Penile Implant (prosthesis) Surgery represents a safe and effective means of treating men with ED. Penile prosthesis has the highest satisfaction rates of all treatment options for erectile dysfunction. Patients who attempt, but dislike or fail to achieve, satisfactory results with pills, vacuum devices, suppositories or injections, are counseled about penile implant surgery.
Penile prostheses can be divided into two main categories: malleable (also known as non-hydraulic or semi-rigid) and inflatable (hydraulic). At our Sexual Medicine Program at Weill Cornell Medicine, 3-piece inflatable penile prostheses are the most commonly implanted. Three-piece inflatable implants have paired cylinders, a small scrotal pump, and a large-volume fluid reservoir (which is placed behind the abdominal wall muscles).
Prior to surgery, it is important that all patients receive appropriate education concerning the operative procedure and its associated risks and benefits. We also insist on all patients reading device literature and viewing a device video prior to committing to the procedure. Ensuring that the patient has realistic expectations prior to proceeding with implant surgery is essential to ensuring high postoperative satisfaction profiles. Patients are advised that the prosthesis will allow them to achieve a rigid erection on demand and will have no effect on their libido and will not lengthen their penis. Patients are also informed of infection rates (1-3%) and rates of re-operation second to device malfunction (15% within 8 years).
Penile implants offer the patient a very high level of satisfaction with spontaneity, consistency, and rigidity.