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Treating Erectile Dysfunction — Without the Little Blue Pill

Non-pharmaceutical alternatives may be more effective

En español | If you watch TV or read magazines, you could easily conclude that men seeking treatment for erectile dysfunction (ED) have but one option: pills. The three dominant brands — Cialis, Levitra and Viagra — are locked in an expensive battle for men’s allegiances, and have, through their suggestive advertising, triggered both satire and controversy in the 14 years since the Food and Drug Administration approved Viagra.

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treating erectile dysfunction without the little blue pill or ed pills

Think about improving your heart health first before pursuing ED treatments. — Photo by Paul Bradbury/OJO Images/Getty Images

But steamy commercials aside, what if the pills don’t work for you, as is the case in 25 to 30 percent of men with ED, or they stop working after a few years — a common problem for men whose ED is caused by an underlying cardiovascular condition?   

“A lot of patients think that pills will give them complete restoration,” says Ajay Nehra, M.D., a urology professor at the Mayo Clinic College of Medicine in Rochester, Minn. But many patients instead find that even if they take the pills, they are “not the same” sexually as they were before the onset of their ED, he says.

If you are among the men who want — or need — to try other therapies for ED, here are the three main options, some of which are cheaper and more effective than the pills. All costs stated below will vary, depending on your insurance plan.  

Before pursuing ED treatments, though, bear in mind that improving heart health by losing weight, eating a healthier diet, exercising more and quitting smoking typically enhances erectile performance as well as one’s overall health. In addition, sex therapy counseling sessions can often ease or eradicate ED symptoms, if the underlying cause is psychological in nature, says Drogo Montague, M.D., director of the Center for Genitourinary Reconstruction at the Cleveland Clinic. 

1. Vacuum erection device (penis pump)

Penis pumps produce erections by drawing blood, via air suction, into the penis. The devices consist of a cylindrical tube, 12 to 18 inches long, connected by a small air hose to a hand pump (on many models this resembles the squeeze mechanism on a blood pressure monitor). Users place the tube over the penis then pump to produce an erection. They must then place an elastic band around the base of the penis to keep the blood there and maintain the erection.  

“Obviously this isn’t the most spontaneous thing,” says Tobias Kohler, M.D., assistant professor of urology at Southern Illinois University School of Medicine. “You can imagine someone having sex with a partner for the first time and pulling out this lunch box.”

While the pumps produce erections for 90 percent of users, most abandon it for other treatments, says Trinity J. Bivalacqua, M.D., assistant professor of urology and oncology at the Johns Hopkins Medical Institution.

The pumps are “very cumbersome and clumsy,” Bivalacqua says. Despite reliably producing erections, pumps have the lowest satisfaction rate of any erectile dysfunction treatments. “In my practice, most men who try it will say, ‘Not for me,’ ” he adds.

Insurers typically cover 80 percent of the roughly $500 cost for a prescription pump, leaving consumers with around $100 in out-of-pocket expenses.

If you opt for a pump, experts say it’s important to get one through a doctor’s prescription. The pumps sold in sex shops tend to be novelty items that don’t work and may even cause injuries.

Next: No. 2: Penile suppositories or injections. »

2. Penile suppositories or injections

These produce erections by injecting or inserting into the penis a drug that increases blood flow. Urethral suppositories, the size of a grain of rice, are inserted via the head of the penis; injections are self-administered near the base of the penis.

The actual insertion of the suppository into the penis isn’t painful, say experts. Nor is the injection itself — done with a very small, thin needle. “Both [methods] are around a 1.5 to 2 on a zero-to-10 pain scale,” Kohler says, “where zero is no pain and 10 is getting run over by a truck.”

The biggest complaint about these treatments is a burning sensation in the penis as the drug takes effect. The frequency, intensity and duration of that side effect vary by method and user but can, in some cases, be bad enough, Montague says, that “a man will get an erection but be too uncomfortable to use it.”

Suppositories “were developed so men wouldn’t have to use needles,” Bivalacqua says. They contain the drug alprostadil (also known as prostaglandin E1) and are sold under the brand name Muse. If they are going to work, it takes about five to 10 minutes. However, Muse produces erections in only 30 to 40 percent of patients, usually those with mild ED, because some of the drug is absorbed systemically and diverted from its function of opening penile arteries to allow more blood to flow in. The out-of-pocket cost is around $20 to $30 per suppository.

For men who don’t mind needles, injections come in various formulations: alprostadil alone; a two-drug combo called bi-mix, which can either be alprostadil mixed with phentolamine or phentolamine mixed with papaverine; and tri-mix, a three-drug mixture of phentolamine, papaverine and a low dose of alprostadil. 

Of these formulations, alprostadil alone carries the highest reported rate (50 percent of users) of burning and pain; in bi-mix users the rate of burning is around 10 percent, and in tri-mix users it drops to less than 3 percent of users, says Nehra. “And that improves dramatically over time as men get used to the injection,” he adds.

Because the burning side effect is triggered by alprostadil, the formulations with the least alprostadil — tri-mix and certain versions of bi-mix — could work for men who experience burning with the single-drug formula. But some men might choose alprostadil alone because the multi-drug cocktails can cost more and must be dispensed by a compounding pharmacy — one that is authorized to mix medications on site — which could mean the added hassle of a long drive to pick up the drug.

Some injectable formulations need to be refrigerated — yet another reason many men steer away from the needle option. Among ED treatments, injections are also the most common cause of extended erections — rigidity lasting more than four hours, also called priapism — which afflict about 3 to 7 percent of users, Kohler says. That condition, while easily treated with an adrenaline shot, requires urgent attention at a clinic or hospital. The cost of this ED treatment is $2 to $5 per injection.

Next: No. 3: Surgically implanted prostheses. »

3. Surgically implanted prostheses

A surgically implanted prosthesis can virtually guarantee erections on demand. “Overall, these have the highest satisfaction for both the patient and his partner,” Nehra says.

Ninety-five percent of prostheses implanted in men in the United States are pump-and-chamber devices in which the man activates a pump — via a discrete subdermal push button in the scrotum — that fills his penis with sterile saline from a reservoir implanted along with the pump.

The other 5 percent of prostheses are either pump devices in which the saline is permanently in the prosthesis, not in a separate reservoir (urologists may recommend this for men who have had multiple surgeries); or a pair of semi-rigid, malleable rods implanted in the penis, which render it hard at all times. The patient manually shifts the penis into an erect position for sex.

With the pumps, erections last until the user hits the deflate button, which Kohler says “doesn’t happen” accidentally. He adds that pump prostheses “are locker-room proof: Nobody can see that you have one.” (Obviously, this is not the case with the always-on malleable rod option.) Implanted pumps are reliable, experts say, with more than 90 percent of the devices working for 12 to 15 years. 

The downside to these prostheses includes the standard risks of surgery, the very low risk of infection — less than 2 percent in most patients, slightly higher in diabetics — and a slight drop in penis length versus a natural erection or other ED treatments. Also, unlike with other methods, any hope for a natural erection is abolished once a pump is implanted. The cost for surgical options varies, and insurance coverage is typically good.

All of the above treatments preserve men’s sensation in the penis and ability to achieve orgasm.

Choosing the treatment that is best for you comes down to preference and efficacy. Montague cites a study that surveyed three groups of men, all of whom were successfully using an ED treatment. One group was on oral medications, one was using injections and a third had surgically implanted pumps. The most satisfied users were those with the implanted prostheses.

Once implanted, the pumps become “part of their body,” Montague explains. “No out-of-pocket cost per use. Predictable response. Works every time.” Pills, even when they work, might be less effective if you’ve had more than a couple drinks or are out of sorts for other reasons. Injections are slightly more reliable than pills but, Montague says, are still subject to variability.

Originally published April 2012

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