Erectile Dysfunction | NAU Urology Specialists

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Erectile Dysfunction

 Peyronie’s Disease

Peyronie’s Disease often develops later in life and is distinct from other penile curvature conditions that are present from birth. Men often are shocked and embarrassed by the condition and do not seek treatment. Fortunately, this condition can be successfully managed and allow men to resume satisfying sexual intercourse.

The erectile mechanism of the penis consists of two long tubes called the corpora cavernosa that fill with blood during arousal. These tubes are covered by the tunica albuginea, a flexible but strong sheath that allows the penis to maintain its rigidity when erect. Penile curvature firms when part of the tunica albuginea becomes scarred and inflexible. This leads to an assymetry during an erection and a curvature in the direction of the scar of the tunica albuginea.

The most common curvature is upward, but men can experience curvature in any direction or even notice a point of their penis that is narrower than the rest, called an hour-glass deformity.

The amount of curvature, duration of the curvature and its impact on sexual intercourse are important considerations when deciding on treatment. The penis may appear to be normal when flacid so an examination of the penis while erect is often necessary. Photographs of the erect penis are helpful but many men will be examined after injection of an erectile agent into the penis to measure the curvature directly.

Phases of Peyronie’s Disease

There are generally considered two phases of Peyronie’s Disease, the immature and mature phases.

The Immature Phase generally occurs during the first year and is when the penis curvature is first noticed. This phase is characterized by inflammation and the degree of curvature can increase or resolve completely during this phase.

The classic ‘Peyronie’s Plaque’ can be felt as a thickening along the shaft of the penis and may be tender. Patients often report pain with erections.

The Mature Phase is considered to begin after the first year when the inflammation has subsided and the curvature is unlikely to change. There is usually no pain during this time and the plaque may be easier to feel. Surgical treatments are reserved for Peyronie’s disease that has entered the mature phase.

In addition to a thorough history and physical exam, an examination of the penis while erect and/or an ultrasound may be ordered during evaluation. In some cases labs will be ordered including a testosterone level.

Medical Treatment

Consists of several oral medications that are thought to help in reducing inflammation and leading to smaller, more flexible scar formation

Scientific evidence supportive of their use is limited and they are generally only used during the immature phase.

• Vitamin E (oral 1200u per day) is a widely used during the immature phase in the hopes of reducing the inflammation due to an anti-oxidant effect.
• Colchicine is a drug used to treat gout and may reduce inflammation by blocking the reproduction of inflammatory cells.
• Potaba (2 gm taken 6 times daily) is thought to help with the uptake of oxygen by the cells that form Peyronie’s plaque and reduce the amount of fibrosis (or scar tissue) that forms.
• Pentoxiphylline(400 mg three times/day) is a medication that is approved to reduce leg cramping due to blockage of the arteries to the leg but has been used by many physicians to improve the curvature in Peyronie’s patients during the immature phase.

Injections

Are used by many physicians as the first step in management during the mature phase. The following agents are injected directly into the Peyronie’s plaque. The injections occur directly through the skin, in the office after the penis is anesthetized. Most of the agents must be injected on several occasions over several weeks and is most effective when used with a penile straightening device.

• Verapamil is a calcium channel inhibitor used to treat hypertension. Injection into a Peyronie’s plaque is thought to alter the function of fibroblasts that are involved in the creation of scar tissue. Many patients will experience improvement in the degree of penile curvature after a course of verapamil injections. At North Austin Urology we generally recommend 12 injections performed every 10 days along with the use of a penile traction device. We will assist in securing insurance coverage as allowed for this treatment.
• Interferon can also be injected into a Peyronie’s plaque to achieve a similar response.

Surgical Treatment

Is appropriate for those patients whose penile curvature is leading to pain for the patient or his partner, or is preventing complete penetration. The Plication and Grafting surgical procedures described below are only appropriate for men who are able to achieve a rigid erection. The erection can be obtained with pharmacological assistance but must be of sufficient rigidity to allow for penetration. For men that are unable to obtain an erection, an implantable penile prosthesis is a more appropriate treatment.

Plication is a surgical procedure appropriate for patients in the mature phase of a Peyronie’s curvature and involves placing sutures in the penis to ‘curve’ the penis straight. This method is generally considered fairly straightforward and easily tolerated. Upward curvatures are corrected by placing sutures on the bottom surface of the penis. Curvatures to the right or left are similarly treated with sutures on the opposite side. This form of treatment is fairly simple and quick to perform but can result in shortening of the penis that may not be acceptable in some cases.

Grafts are appropriate in cases of more severe penile curvature where the penile shortening from a plications procedure would be unacceptable. The procedure involves cutting or removing the Peyronie’s plaque and placing a piece of artificial material to allow the penis to fill with blood. The purpose of a graft is to add tissue to the curved side of the penis. There are several different types of graft material available designed to provide strength and flexibility and induce little to no inflammation

The procedure is performed by carefully exposing the scar tissue under the skin of the penis, identifying and isolating the nerves that provide sensation to the head of the penis and placing the graft after either removing or incising the plaque. After the graft is sewn in place, an artificial erection is created to check the straightness of the penis.

Graft surgery is not appropriate for men that are unable to achieve a firm erection either naturally or with oral medications. For those patients, an inflatable penile prosthesis may be more appropriate.
For surgeons, please see my tips for using SIS grafts for Peyronie’s correction.

Penile Prosthesis is a silicone mechanical device that replaces the erectile mechanism of the penis. Two cylinders provide rigidity to the penis and is filled with fluid held in a reservoir by depressing a pump located in the scrotum. It is used for men with the most severe curvature and for men who cannot achieve a rigid erection. The prosthesis placement is a surgical procedure that can be performed on an outpatient basis.

 

 Premature Ejaculation

For an issue that one out of three men say they experience at some point in their lives, premature ejaculation (PE) is often steeped in unnecessary embarrassment. The fact is, this common complaint is typically not a cause for concern unless it’s happening nearly every time you engage in intercourse. Below we explain some of the symptoms to look for before coming in to see us about this issue, as well as how it is diagnosed and treated.

What Is Premature Ejaculation?

First, what exactly are we talking about here? Premature ejaculation happens when a man has an orgasm and ejaculates before he wants to or is ready to. In other words, the issue happens when he loses control of the timing of this outcome. Obviously, this can present problems in intimate sexual relationships, especially if a man cannot figure out the root cause of the issue. If it happens frequently enough, it could result in a medical diagnosis.

So why does this problem even happen to begin with? Well, there are a couple of reasons. For one, psychological issues can be primary factors in prematurely ejaculating. Stress — whether within the relationship or completely unrelated to it — can be a huge contributor to the issue. Nervousness or pressure, as well as ongoing depression, anxiety, or other mental health issues, can all cause PE as well.

But there are biological reasons for the issue that mean proneness to it can happen in certain men, and occasionally there are other physical problems at play that could mean a more serious medical diagnosis. 

Types of Premature Ejaculation

There are two phases to ejaculation: emission takes place when sperm moves to the prostate from the testicles, producing the semen. Expulsion happens when semen exits the penis due to muscle contraction that forces it out. 

There are two main categories doctors use to diagnose PE and discuss treatment options: 

Primary premature ejaculation — sometimes referred to as “lifelong” — is the diagnosis given when a man has always experienced this problem or has never had a significant portion of time pass where he has been able to engage in sex without prematurely ejaculating.

Secondary premature ejaculation — or “acquired” premature ejaculation — is the diagnosis when a man has developed the issue only recently, but has had normal patterns of control over orgasm and ejaculation during intercourse in the past.

Symptoms of Premature Ejaculation

Patients reporting ongoing problems with premature ejaculation typically present symptoms including:

  • Routine, ongoing patterns of uncontrolled ejaculation and the inability to stop it from happening
  • Routinely ejaculating within one minute of initial penetration
  • Decreased interest in sex or decreased sexual pleasure overall due to fear of premature ejaculation
  • Inability to connect intimately with a sexual partner, or avoidance of a partner, due to guilt, frustration, or shame surrounding premature ejaculation
  • Depression or low self esteem as a result of the issue

It is important to keep in mind that the criteria for ejaculation to be considered “premature” can vary from person to person, or from couple to couple. It is up to you and your partner to decide whether you both are satisfied or dissatisfied with the time it takes for orgasm and ejaculation to occur.

Tests and Treatment Options

If premature ejaculation is something you have been dealing with for some time, and has not gone away on its own, it may be time to schedule an appointment with a specialist. Urologists are uniquely qualified to quickly diagnose the issue and provide tailored treatment options. 

We start with a physical exam, a review of your medical history, and a series of questions to get more information about the issue and to rule out any more serious health problems. It is important to be as honest as possible during your appointment, especially when discussing any impact premature ejaculation might be having on your relationships or mental and emotional health. 

Lab tests are typically not necessary for patients presenting PE symptoms, but may be ordered if another issue is found during the examination. 

Once we determine that the issue is not related to another erectile dysfunction (ED) issue, we create a treatment plan to address the underlying cause. This could consist of behavioral methods that aim to increase your control over ejaculation, psychological therapy to address any relational problems and increase your confidence, or medications to help slow ejaculation. Often, the treatment plan will be a combination of methods to support the various contributing factors.

Medications for Premature Ejaculation

There are currently no FDA-approved drugs to treat premature ejaculation. However, several types of FDA-approved medications for other conditions or ailments can help men with a PE diagnosis.

SSRIs, or selective serotonin reuptake inhibitors — typically known as antidepressants — can help delay orgasm during intercourse.

Some anaesthetic creams can help “numb” the penis and might be prescribed to be applied before sex. Numbing sprays are another option for penis desensitization, which can help with PE.

If premature ejaculation is negatively affecting your sexual relationships or you find yourself avoiding intimacy with a partner due to an ongoing struggle with the issue, give us a call. We can get you in to see one of our specialists and find a treatment option that works for you.

 Delayed or Absent Orgasm

In the category of erectile dysfunction (ED) issues, which account for a large portion of the reasons patients come to see us, one particular ailment is quite common. Delayed or absent orgasm — or absent ejaculation — can be troubling for many men and can seriously impact their intimate relationships. There are a variety of causes and contributing factors to this issue, and there are nuances within the diagnosis itself. Read on to learn more about this condition.

What Is Delayed or Absent Orgasm?

Delayed or absent orgasm in men could mean one of the following:

  • A man is unable to reach orgasm at all
  • A man is able to reach orgasm only after at least 30 minutes of sexual penetration
  • A man is able to reach orgasm but does not ejaculate — or emit semen from the tip of the penis — during climax

Some men experience delayed or absent orgasm all the time, whether through solo masturbation or through any type of stimulation with a sexual partner. Others experience this issue only during sexual activity with a partner, but are able to climax and ejaculate normally when masturbating alone. Occasionally, men are unable to orgasm or ejaculate during intercourse, but are able to climax during other types of stimulation, such as oral or anal intercourse.

Like premature ejaculation (PE), which can negatively impact relationships because a man is unable to control or delay ejaculation, the inability to orgasm or ejaculate can cause similar and even additional relational issues. Besides the mental or emotional distress that can be placed on either partner, there is also the possibility of physical injury or irritation of the sex organs during intercourse.

Additionally, couples who are trying to conceive may be especially distressed if the male partner is unable to reach orgasm or emit semen during.

Types of Delayed or Absent Orgasm

Like premature ejaculation, there are different types of delayed or absent orgasm diagnoses:

Lifelong delayed ejaculation means the patient has experienced the problem from puberty.

Acquired delayed ejaculation is the diagnosis when the problem is new or recent, but the patient has experienced normal sexual function in the past.

Additionally, there are two other categories given to this issue, based on historical criteria:

Generalized delayed ejaculation means the issue happens always or almost always, regardless of circumstance, partner, or types of stimulation.

Situational delayed ejaculation refers to delayed or absent ejaculation that happens only during certain circumstances. When a patient is able to ejaculate while masturbating solo, but not during intercourse with a partner, for instance, this is considered situational delayed ejaculation. If a patient can ejaculate during certain types of sexual stimulation but not penetration, this is also considered situational.

If the issue has been going on for more than six months, it is usually grounds for a delayed ejaculation diagnosis.

Causes of Delayed or Absent Orgasm

Just like premature ejaculation, delayed or absent ejaculation or orgasm can have a variety of psychological or physical causes. Sometimes, there are multiple contributing factors that combined together manifest as a delayed ejaculation issue.

Of course, issues within the relationship itself can be the cause. Also, men with a past history of mental or emotional health issues such as depression or anxiety can be more prone to delayed or absent orgasm. Often, though, other lifestyle choices or patterns may account for the issue. 

Chronic stress can be a main contributing factor, as can the use of alcohol or recreational drugs. Men who take antidepressants, painkillers, blood pressure regulation drugs, or other types of medication may have trouble reaching orgasm. Excessive masturbation can contribute to the issue as well.

Sometimes, nerve damage caused by injury, surgery, stroke, or other health issues like multiple sclerosis (MS) or diabetes can cause delayed or absent orgasm.

Tests and Treatment Options

A specialist can diagnose the issue and help discover whether its causes are physical or psychological, and can create a tailored treatment plan from there. Typically, delayed ejaculation is caused by a combination of factors, as well as the ongoing and increasing anxiety about the problem itself, so a treatment plan is customized for the patient to address these different areas.

As a urology practice, we can not only determine the underlying causes, but can rule out any other medical issues that could mean something more serious. With urine or blood tests, we can get a snapshot of your current levels to ensure there is no infection or hormonal imbalance. 

It is important to be as upfront as possible when giving the doctor your medical history and answering questions about your experience with delayed or absent orgasm. In order to treat the problem effectively, we will need to know accurate information about your lifestyle and current circumstances. With this questionnaire and a physical exam, plus any additional necessary tests, we can get to the root of the issue and work with you to solve it.

We may prescribe certain medications, but typically delayed or absent orgasm is treated with a combination of lifestyle changes and alterations to sexual activity. Therapy is also frequently an effective treatment option for men suffering from this issue.

If you have been experiencing issues with delayed orgasm or ejaculation, or have been unable to climax at all, for a period of more than six months, make an appointment to see one of our doctors. We can work with you on this issue so your sexual functioning becomes more optimal.

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