Hi, my name is Dr. Caroline Waller, and I’m a urologist at UCLA at the Northridge campus, and I’m here today to give to you a webinar discussing erectile dysfunction, so if you’d like to join the conversation you can find us on Twitter using #UCLAMDChat. So, erectile dysfunction 101 is the name of the presentation. What we’ll go over is how erectile dysfunction, or ED, occurs, what the risks are for developing erectile dysfunction, followed by the non-surgical treatments, and then these surgical treatments for erectile dysfunction. So, how ED occurs. Well, let’s start off with a definition. So, erectile dysfunction is the inability to attain or maintain a penile erection sufficient for satisfactory sexual performance. Now, it doesn’t mean that if you have trouble with erections from time to time that you have necessarily erectile dysfunction, it’s more when this becomes an ongoing problem. It’s starting to affect your confidence, your stress level, or your relationship. That’s when erectile dysfunction can be problematic. So, the graph below is from the Massachusetts male aging study, and this basically shows us that as you age, your risk of erectile dysfunction increases. So, aging is the single greatest risk factor. Next, moving on to the anatomy of the penis, what we see here are the paired corpora cavernosa right here, which are the erectile bodies under the influence of neurotransmitters that cause nitric oxide release and smooth muscle relaxation. These bodies fill with blood. As these corporal bodies fill with blood, the tunica albuginea, which is kind of the rigid structure around it, can compress the small veins that drain the penis, and thus the penis becomes elongated and more rigid, achieving a full erection. After orgasm, the smooth muscle then contracts, and the blood is allowed to leave the penis, and the penis then decreases in length and girth until it becomes flaccid. So, different types of erections. There’s psychogenic erection, which has to do with audio-visual arousal, reflexogenic, when there’s stimulation by touch, and then finally nocturnal, when during rapid eye movement sleep there are erections. The bottom part of the screen shows the neurotransmitter cascade, so this just tells us how nitric oxide is released from the cavernosa nerves and how it increases cyclic GMP. Then, to increase the smooth muscle relaxation, that guides and drives corporal body filling for erections. So, you know there are multiple risks for developing erectile dysfunction, and that has to do because arousal is a very complex process that involves your brain, your hormones, your nerves, your blood vessels, and even your penis and anatomy, so it can be affected from a variety of reasons, and so we’ll review these. First is psychosocial erectile dysfunction, so if a man is having troubles with his relationship, or if there is performance anxiety, stress, depression, or anxiety, as well as psychiatric disorders, these things can affect the ability to achieve an erection and sustain an erection. Next, neurological causes for erectile dysfunction include Parkinson’s disease, stroke, and dementia. Vasculogenic erectile dysfunction has to do with poor arterial blood flow to fill the penis, also known as arterial insufficiency, and then there can be also a problem where the blood is not allowed to sustain the erection, and there’s venous leak that contributes to erection trouble. Next, there are several drugs that are notorious for causing erectile dysfunction. The first and foremost is our blood pressure medications. Diuretics and beta blockers both are known to cause problems with erections. Next class of drugs includes the antidepressants or antipsychotic medications listed here, and then additionally medications that are used to suppress the testosterone levels. Things like leuprolide for advanced prostate cancer treatment, or even finasteride to shrink the prostate, can affect erectile function also. Alcohol and tobacco smoking also can cause erectile dysfunction. Here are some lists of some traumatic causes for erectile dysfunction. Pelvic fracture, penile fracture, pelvic radiation, these things can affect either the blood vessels or the nerves that control erections. Priapism is a situation where you have a sustained erection lasting more than 4 hours that is painful. By having priaprism, there can be endothelial damage to the blood vessels that control erections. You can have a spinal cord injury, as well as neuropathy from chronic bicycle riding can affect your ability to have erections. The final category are surgeries associated with erectile dysfunction, that includes radical retropubic prostatectomy as well as aorto-iliac vascular surgery and proctocolectomy. Now, here are some endocrine or hormonal reasons for erectile dysfunction. The first one is low testosterone, or hypogonadism, as well as thyroid disorders in hyperprolactinemia. Both of these influence the testosterone secretion and therefore cause erection trouble. Other diseases, diabetes, atherosclerosis, chronic renal failure, and chronic liver failure all are related to ED. So, some of the tests that your physician may do to diagnose erectile dysfunction, first and foremost, is a physical exam. Inspecting the genitalia, looking for any history of trauma. Next could be blood tests that are ordered not only to investigate for low testosterone, but also to search for other comorbidities that may be influencing the development of erectile dysfunction. Oftentimes by observing, say, uncontrolled diabetes, or after surgeries, sometimes erectile dysfunction can be treated. An ultrasound may be performed. This is to look at the blood flow to the penis as well as an overnight erection test, and the overnight erection test is to understand whether there are erections that are happening at night. This may show us that the penis is functional and that other causes for erectile dysfunction may be psychologic in origin. So, let’s move on to the more interesting treatments. So, we’ll start off with non-surgical treatments. There are many oral medications that you’ve probably seen, a whole host of commercials on the television. They are PDE-5 inhibitors. That’s their class, and the names of the medications include Sildenafil, or Viagra, Vardenafil, or Levitra, and Tadafil, or Cialis. These drugs augment the sexual response so that you have to be sexually stimulated in order for the drugs to work. They usually are effective one hour after taking the medication, and they typically work for about 4 hours, especially for Sildenafil and Vardenafil. The last one, Cialis, or Tadalafil, has an extended half-life, and so that allows for daily dosing. Some oral medications can be affected by the food you eat, so it’s important to not eat a greasy or fatty meal before taking Sildenafil or Vardenafil, as this will decrease the efficacy of these drugs. The side effects are listed here. Headache, facial flushing, stuffy nose, upset stomach. The important contraindication is if you are taking nitrates for angina or chest pain, you cannot take this class of medications because it could cause an unsafe dip in your blood pressure. Also if you are taking alpha blockers, you should wait until you are stable in terms of your alpha blocker regimen before adding one of these PDE-5 inhibitors. Moving on to mechanical devices. Here is the vacuum erection device, and it’s basically a hollow tube that’s placed over the penis. This can be hand powered or battery powered, and what it does is actually to suck air out of the tube, and that way the vacuum pulls blood, filling the corporal bodies of the penis. Then the erection is held in place using a tension ring, and then after sexual performance the tension ring is removed. Generally, you can leave the ring in place for about 20 to 30 minutes, otherwise you may have some side effects, including penile numbness, or coldness, bruising, or blocked ejaculation, and it’s important to wait, you know, at least an hour before using the vacuum erection device again. Next up is intraurethral suppositories. The name of it is called Alprostadil, or MUSE. It’s a suppository that’s placed with a special applicator in the tip of the penis. This is delivered about 2 inches into the penis, and within about 5 to 20 minutes, you can develop an erection. The side effects are that it can cause pain inside the urethra, with typically burning quality pain. It can cause minor bleeding in the urethra, as well as dizziness or formation of fibrous tissue inside the penis. It’s pretty effective, about 70% successful. Next is the self-injection. I’ve listed here some of the medicines that are used to deliver inside the corpora cavernosa, and you can see how a needle is used to directly administer the medication to the active area. The first dose should be supervised with the physician, and the things to watch out for that are side effects are prolonged erection, or priapism, lasting more than 4 hours, as well as bleeding or the formation of fibrous tissue. Moving along to surgical treatments. So there is the penile implant. This is a surgically placed device that basically takes away all natural erections, and instead you have an inflatable or a semi-rigid rod inside the corporal bodies. The device is made out of typically silicone or polyurethane, and there are several different types of penile implants. The first thing–the one-piece malleable, which just has the cylinders. These cylinders are moldable or malleable, so that you can point it up to the sky when you need, you know, to have an erection or, you know, to the horizon when it’s no longer needed. It’s more or less kind of like a pipe cleaner set of ball and socket joints that enables good malleability of the cylinder. This other two inflatable devices. There’s a two-piece and a three-piece. Two-piece has a set of cylinders and a pump. The three-piece also has a reservoir, and you can see how the pump sits in the scrotum here, and it’s used to send water from a reservoir to fill the corporal cylinders, and that causes an erection. Once the erection is through, then there’s a release mechanism that sends the water back to the reservoir to achieve a flaccid state. This is great because it allows for spontaneity. You don’t need any erections–you don’t need any erection medicines or injections. However, it is a device, and it does involve surgery, as all the parts are internal. The side effects are that there can be pain, mechanical malfunctions, such that the device may have to be replaced, or individual parts repaired over time. There can be a devastating infection which actually would necessitate the total removal of the device and need major surgery, so what are some things that you can do about erectile dysfunction in the meantime? It’s important to quit smoking, to lose weight, to get regular exercise. If you do have alcohol or drug problems, too, you know, please get treatment for those. Work through any relationship issues that may be affecting the psychosocial aspects to erection quality, and then finally to contact your doctor and go in for an evaluation. Erectile dysfunction can be kind of an awkward subject, but it is so important. It’s a part of every man’s quality of life, and so by contacting a doctor, you may be able to discover other things wrong with your health that can be fixed, or you can work through a strategy of finding one of these treatments that may be a solution for you. So, thank you for your attention, so now we’re going to take some questions. Okay, so the first question is, “What are the symptoms of erectile dysfunction?” Well, the symptoms are that you have difficulty achieving erection, where there can be a kind of a soft quality to the penis during erections, or you may not have enough of rigidity to actually achieve sexual penetration. Those are the symptoms of erectile dysfunction. The second question is, “Can men under age 30 have erectile dysfunction?” Actually, yes, they can, and studies have shown about 1 in 5 men over the age of 20 can have erectile dysfunction, so that includes the age group from 20 to 30. Although it is more common as a man ages, it definitely can happen starting at age 20. “Does erectile dysfunction mean that I am infertile?” is the next question. That’s a good question. No, it doesn’t mean that you are necessarily infertile. The production of sperm is separate from the erection of the penis, and so you may have ejaculate that can be stimulated in the office, or you may also be a candidate for other types of sperm retrieval techniques in order to make sure that your semen is fine. Next question is, “What are the natural treatments for erectile dysfunction?” Well, a lot of the natural treatments do have a thing called yohimbine. It’s a medicine that increases your libido and erection quality. However, placebo-controlled studies have shown that it is really no different than a simple sugar pill, so I would suggest not using herbal or over-the-counter remedies and instead seeing a qualified urologist or your medical provider about treatment. “Is impotence the same thing as a rectal dysfunction?” Yes, they are the same name. Okay, well, that concludes our talk. I think that that those are the last of the questions. So I appreciate your attention, and I encourage you to find someone to talk about erectile dysfunction if it is bothering you. You can find more information on the UCLA urology website, and you can find a urology provider of your choice. Thank you.