Treatment
Introduction
Treatment for erectile dysfunction depends on whether the problem is caused by psychological or physical factors, or a combination of these. Even if ere

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ctile dysfunction has a physical cause, it often has adverse psychological effects that make the problem worse and treatment more complicated. The following treatments have a reasonable chance of success:

• Oral medication.
• Medication you can inject or insert into the penis to get an erection.
• Alteration of existing medication for other conditions.
• Vacuum devices.
• Penile implants.
• Psychotherapy or behavioural therapy – even when the erection problem has physical causes.

The least invasive treatment should be considered first. Non-surgical treatments work for 60 to 70% of men and may make surgery unnecessary. Although treatments like injections are effective more than 80% of the time, up to 60% of men may eventually drop out of treatment. Sometimes, once men can get an erection again, they realise they have overestimated its importance in their relationships. They may decide that the nuisance or cost of the treatment is not worth the effort.

Home treatment
If you only experience occasional episodes of erectile dysfunction, you may be able to treat it at home without a doctor's help.

• Some of the causes of erection failure are within your control, such as stress, smoking, and alcohol use.
• Talk to your partner. Often sharing your worries about sexual performance with your partner can break a vicious cycle of anxiety. You may find out that your partner does not view the problem as seriously as you do. This may leave you freer to enjoy sexual activity instead of consciously tracking your performance.
• Make some time together to enjoy simple sensual pleasure, such as caressing and massaging without the goal of having sexual intercourse or even an erection. You may discover new kinds of sexual pleasure while you reserve intercourse for another occasion when you are more at ease.
• Sexual problems are often the result of underlying difficult feelings between you and your partner. Are you angry with him or her? Are you worried about rejection? Talk openly about these feelings and try to resolve conflicts. At the same time you might want to reassure your partner that erectile dysfunction very seldom arises from lack of sexual interest.
• Pelvic-floor exercises (similar to Kegel exercises) may be helpful in some men with erection problems. These exercises have no risks.
• Don't be embarrassed about seeking professional help if home strategies don’t help and erection problems are persistent and troublesome.

• Increase of blood flow into the penis (erection-producing medications)
• Reduction of performance anxiety by ensuring successful erections
• Adjustment or replacement of medication taken for other conditions. If such drugs affect your erections, your doctor may review them in an attempt to reduce side effects. Never adjust your dosage without consulting your doctor.
• Correction of abnormal hormone levels through testosterone replacement therapy. Abnormal hormone levels, however, are a rare cause of erection problems.

Vardenafil (Levitra), tadalafil (Cialis) and sildenafil (Viagra)

These prescription drugs, called PDE5 inhibitors, have become very popular. One of the benefits of this form of treatment is that it is taken before sexual intercourse and therefore don't interrupt the sexual act.

Alprostadil
Alprostadil (al-PROS-tuh-dil) is a synthetic form of the hormone prostaglandin E. This hormone helps relax smooth muscle tissue in the penis, which in turn allows blood to flow into the cylinders of sponge tissue, causing an erection. There are two ways to deliver the drug to the penis:

1. Injection into the penis (Caverjet)
The idea might make you flinch, but it’s not as scary or painful as it might sound. You use a very fine needle, which minimises pain, to inject the drug into the base or side of the penis five to 20 minutes before you want to start sexual activity. Once you’ve had some practice to get the technique and dose right, it’s easy. The erection lasts between 30 and 60 minutes. This medication (sold under the trade name of Caverjet) should not be used more than three times a week. As with any medication, there is some risk: repeated injections may cause internal scarring that can worsen impotence in about five percent of men. Another possible complication is that of an erection that does not abate for longer than four hours (priapism). Far from turning you into a sexual long-distance athlete, this condition can damage the penis permanently if it does not receive prompt medical attention. Fortunately, only about one percent of men who regularly use injections will experience this problem. Another possible side-effect is minor bleeding from the injection site.

Regular use of Caverjet can be difficult to afford at a cost of about R110 per use.

2. Muse
The Medicated Urethral System for Erection (Muse) uses a disposable applicator to squirt a pre-measured dose of alprostadil, about the size of half a grain of rice, into the opening at the tip of the penis. It may cause a little discomfort or pain. The technique is successful for about 60% of men. In addition to the medication, you may need to fit a rubber band around the base of your penis to help prevent blood draining out and loss of the erection. Side effects may include a little bleeding and scar tissue formation. The cost of Muse varies, depending on strength, between about R110 and R124 per use.

Apomorphine SL (Uprima)
Unlike Viagra which works directly on the penis, apomorphine has a central effect in the brain. Apomorphine stimulates dopamine receptors in an area of the brain that is important in the initiation of erection. This causes a cascade of events that eventually leads to an erection. Apomorphine SL has recently been approved for marketing in Europe at doses of 2 and 3 mg. Apomorphine is administered under the tongue and reaches its maximum effect in 15-20 minutes. The patient must drink some water before placing apomorphine under the tongue, to wet the mucosa of the throat and facilitate dissolution of the tablet (a process which takes 10 min). There is no interaction of apomorphine with food or alcohol, but the concomitant use of alcohol should be discouraged, as it is known to reduce erectile capacity.

• Some drugs are claimed to be effective, but have not been proven to be so in scientific studies. These include yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone.
• Medications may be used in conjunction with counselling, psychotherapy or psychiatric medication if your erectile problems have psychological causes.

Surgery

• A bendable rod can be implanted into the penis. This makes the penis rigid enough to have sex, yet leaves it flexible enough to be tucked away in your pants unobtrusively.
• A cylinder may be implanted that extends when fluid from a reservoir tucked under the abdominal muscle is pumped into it. This is done by manually squeezing a small pump that is connected to the reservoir and implanted into the scrotum.

While implants mean that you can avoid using drugs, they do require surgery and all the risks normally related to surgery: adverse reaction to anaesthesia, possible blood loss, and infection. About two percent of implants have to be removed as a result of infection. In five to 10% of cases there may be mechanical failure of the device, in which case a second operation is necessary for repair or removal. Urologists perform most penile implants, and cost can range from about R6 000 to more than R20 000, depending on the type of implant.

• Surgery to repair or remove blood vessels of the penis may be appropriate in the case of a young man who suffers erectile dysfunction as a result of injury, such as a car accident. In older men, it tends to be more difficult to repair damaged blood vessels, as damage may be extensive. These specialised blood vessel repair (revascularisation) operations should be done by specially trained urologic surgeons.

Other

• Vacuum devices are small pumps attached to a cylinder you fit around your penis. Air is pumped out of the cylinder to create a vacuum, and the lowered pressure increases blood flow into the penis. The blood is trapped by rolling a special rubber ring down to the base of the penis. More fashionable versions of these rings, made from metal or studded leather, can also be bought from sex shops, if it appeals to you to make the intervention less clinical in this way. The pumps are useful for all types of erection problems (physical, psychological, or a combination of both). Vacuum pumps are generally safe, simple to operate and can be used as often as desired. However, improper use can damage your penis and so they must be used under a doctor's care. While you may need to interrupt foreplay to use them, you can also incorporate use of the pump into erotic play, making it less medical and more natural.
• Psychotherapy is recommended for men whose erection problems are due to psychological causes. It may be used in conjunction with drug treatment or vacuum devices for erection problems that have both psychological and physical causes. The psychotherapist may use techniques aimed at reducing anxiety associated with sexual intercourse. Another goal is to work on the relationship between the partners by developing greater intimacy, trust and better sexual communication. Psychotherapy often involves special sex exercises for you and your partner to do at home.

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