Author: Jared J Wallen, MD

A relentless learner striving for the best possible care for everyone.

Erectile Dysfunction & Vacuum Erection Device usage

A diagnosis of Erectile Dysfunction (ED) can be difficult to deal with, but together we will navigate treatment options. The process of erection, sexual intercourse, and, orgasm requires a highly coordinated response from the neurologic, vascular, psychologic, and sensory systems. The penis should be thought of as an inflatable rod and the cardiovascular (heart) system is the pump that inflates the rod. If the blood vessels in your heart are not functioning well, it is likely that blood vessels in your penis are not functioning well. Among many causes of ED are things like coronary artery disease, neural compromise from spinal problems or trauma, diabetes, smoking, drug use including alcohol and marijuana, etc.

If you are safe for sexual activity, this means that you can walk up at least 2 flights of stairs or at least 50-100 yards without getting winded, short of breath, chest pain, or dizziness then the 1st treatment option is an oral medication like sildenafil or tadalafil, the active ingredients in Viagra® and Cialis®, respectively. Certain populations such as diabetics, post pelvic surgery, smokers or those with Peyronie’s disease patients can commonly fail medical therapy for ED.

A 2nd treatment option is a Vacuum Erection Device (VED). Now you might be thinking… A vacuum WHAT device? This is a plastic tube that fits over the penis and is pressed against the skin surrounding the base of the penis and pubis. It then uses suction via a hand or battery-powered pump to pull blood into the phallus and cause engorgement. When it is used for sexual activity it is often used in conjunction with a penis ring that fits around the base of the penis to trap the blood in after the vacuum pulls the blood into the penis. The whole point is to fill the penis with blood and then trap it there for a temporary period of time just like the normal physiologic processes with an erection. This cannot be used with the ring for more than 30 minutes at a time. Patients have reported negative reviews in the past related to a somewhat wobbly base of the shaft of the penis where the ring is or the sensation of a cold glans penis. For sexual activity the VED must be used with the ring for most patients. Discuss with your doctor if you take anticoagulation medications (Coumadin, Aspirin, Plavix, Warfarin, Lovenox, etc.) as these can sometimes be prohibitive of use.

The 2nd (and more common in our practice) use for a VED can be maintaining penile length in the face of increasingly Severe ED. This is certainly used for patients who have  had prior prostate surgery or other radical pelvic surgery, but also any patient who has more severe erectile dysfunction in which the loss of nocturnal or stimulated erections occurs. Typically, nocturnal erections occur to engorge and stretch the penile tissue and revitalize the blood-filled capillaries with oxygen. In many more severe forms of ED loss of nocturnal erection occurs. In this case, setting the vacuum erection device is used 3-5 times per week for approximately 20-30 minutes at a time with NO penile ring. This is to cause engorgement in and stretching of the phallus. This is thought to be helpful because it can otherwise help to prevent shortening from decreased blood flow and the normal stretching of the tissues that occur with the erection process. Caution again should be advised for patients taking anticoagulant medications.

Stay tuned for further options beyond a VED as 2nd and 3rd line therapies for ED. Together we will find a cure to get that function and confidence back in your life.

Please call (813) 278-8850 for an appointment today! We have offices in Tampa and Brandon.

Prostate Cancer Screening and Your Sexual Health

The prostate is the very first “P” in the PP&T of the Urologic Triad of Men’s Health, which are the common problems of the prostate, penis, and testicles men have as they journey through life. The primary functions of the prostate are reproductive in nature, as the gland provides 30% of the ejaculate fluid that mixes with fluid from the seminal vesicles and sperm from the testes to form the entire ejaculate volume.

The prostate gland can cause a multitude of problems as men age. Common benign problems include enlarged prostate or BPH and infectious/inflammatory conditions such as prostatitis. An enlarged prostate can cause difficulty urinating due to the prostate’s location deep in the pelvis (pictured below). As you can see in the right portion of the picture the urethra (the tube men pee out of) runs right through the middle of the prostate. As men age the prostate continues to grow, while the bones of the pelvis limit the growth, which commonly results in an overgrowth of tissue that pinches the urethra tube closed. This results in a slow stream, frequency, and other urination symptoms. There are medical treatments, small office procedures (Rezum or Urolift), and surgeries (TURP, Greenlight, Simple Prostatectomy) that can treat these symptoms.

Male Reproductive Prostate diagram

Another unfortunately common problem with the prostate as men get older is cancer. Prostate cancer is typically a disease of men 60 and older, however the trend seems to be younger patients being diagnosed. We have seen men as young as 40 being diagnosed, and even some patients in their late 40’s with advanced metastatic disease in our clinic. High-risk groups include men with a positive family history of prostate cancer and men with African American ancestry. Screening for cancer is one of the most effective ways we have to catch prostate cancer while it is localized in the gland and has not spread elsewhere. Screening consists of a blood test (PSA) and an experienced finger exam of the prostate to determine if there are abnormalities like firmness, nodules, or masses that would suggest cancer.

Screening is very important because prostate cancer usually does not cause any noticeable symptoms until it becomes locally advanced or spreads to other areas of the body.

The American Urological Association recommends screening for all men ages 55 to 70 with informed and shared decision making. For the high-risk patients screening should start at age 45. Screening should extend beyond 70 while the patient continues to be in good enough health to have a greater than 10-year life expectancy. Ultimately screening is very important because prostate cancer usually does not cause any noticeable symptoms until it becomes locally advanced or metastatic (spreads to other areas of body like the bones or pelvic lymph nodes) and because it allows us to detect and treat the cancer early. Screening is beneficial because we know 1 in 7 men will be diagnosed with prostate cancer and 1 in 40 will die from their disease. 30,000 men die each year due to prostate cancer. We do have effective treatments for these conditions including minimally invasive robotic surgery to remove the prostate and various forms of radiation. There are also many experimental treatments like HIFU, cryoablation, and focal therapy.

So, what does any of this have to do with your erections and ability to ejaculate? Well, as we said the prostate provides 30% of the ejaculate and it is an important part of the highway that carries semen out the end of the penis for the purposes of reproduction. Further, the nerves that control erections are on the outside portion of the prostate. What does this all mean? Well, if you have surgery to remove your prostate your vas deferens is usually cauterized and divided, and your prostate and seminal vesicles are removed. This means that highway for sperm to get into semen is blocked and the producers of 85% of the fluid of the ejaculate are gone. Further, sometimes when the disease is favorable (not outside the prostate and lower grade) we can spare the nerves on the outside by sweeping them away, but in the opposite situation where disease is advanced, the nerves are usually sacrificed to ensure removal of all the cancer.

Options for gentlemen with leaky veins in the penis as a result of prostate cancer treatment include high dose intracavernosal injection (ICI) therapy or outpatient surgery to place an inflatable penile implant.

Unfortunately, research shows that the 80/80 rule holds true regarding erections after a “nerve sparing” robotic radical prostatectomy. This means 80% of folks post-surgery will still not have erections hard enough for penetrative intercourse and 80% of the same group will fail medical erectile dysfunction therapy. The reason is men with ED as a result of pelvic surgery have leaky veins that prevent the blood from staying in the penis to cause erections. Remember, think of the penis as an inflatable rod. You need good blood flow and blood retention to create pressure and rigidity. If you have leaky veins it’s like having a hole in a tire. You can pump it up, but if there’s a leak, it isn’t going to stay up. Further, even if nerves are spared, common temporary paralysis can occur for up to 18 months. Leaky veins can be diagnosed with a doppler ultrasound of the penis. If you have leaky veins and want the ability to have penetrative intercourse, there are two treatment options: high dose intracavernosal injection therapy, or an outpatient surgery to place an inflatable penile implant (IPP). We recently published an article in the Journal of Sexual Medicine Reviews about patients who have had prior radical pelvic surgery (PRPS) and have IPP surgery that further explores these issues. Certainly, radiation to the prostate can have similar damaging effects, although they may be somewhat time delayed.

Penile rehab protocol for ED post prostate cancer treatment consists of PDE-5 oral medications and use of a vacuum erection device to promote blood flow and tissue elasticity.

We typically recommend a specific penile rehab protocol for ED after prostate cancer treatment starting at around 4-6 weeks as the patient heals. This consists of oral medications and a vacuum erection device (VED) to promote blood flow to the penis and stretching out the penile tissue. We prescribe daily, low-dose oral PDE-5 inhibitors such as 5 mg tadalafil lozenges (Cialis) or 20 mg sildenafil tablets (Viagra). We also ask patients to use a VED for 30 minutes a day WITHOUT the constrictive ring to stretch out the penile tissue and bring beneficial blood and nutrients into the penis. Patients with the best outcomes continue on PDE-5 inhibitors regardless if they produce an erection sufficient for intercourse. Some patients continue using PDE-5 medication even after penile implant surgery for the purposes of engorgement of the penile glans which the implant device doesn’t do. VED use is certainly important if the patient is no longer experiencing nocturnal erections because these are the typical benefits and presumed purpose of nocturnal erections. We also recommend max dose PDE-5 Inhibitors, 20mg tadalafil or 100mg sildenafil, twice weekly. If these interventions do not produce a satisfactory erection for intercourse, the doppler ultrasound of the penis combined with penile injection is the next step to further look at the blood flow to the penis. High dose penile injections can be used if oral medications do not produce satisfactory results, although some men may discontinue this treatment option due to the discomfort, inconvenient use, and a risk of scar tissue formation. If these interventions don’t produce satisfactory results or if they aren’t appealing to your lifestyle, then the Inflatable penile implant is an option that will provide satisfaction and up to 80% functionality 15 years post-surgery.

I hope you better understand just how important the prostate is in the Urologic Triad of Men’s Health. We’re here to help you deal with any and all problems men experience as they age and look forward to serving you, your family, and friends.

Peyronie’s Disease: Surgical Treatment Options

A diagnosis of Peyronie’s Disease (PD) can be difficult to deal with, but together we will navigate treatment options.

Think of the penis as an inflatable rod. It has two internal, side by side ‘cylinders’ called the corpora cavernosa positioned from the tip of the penis to the back portion of the pelvis. When a healthy man is aroused the cylinders fill with blood, the ‘rod’ inflates and becomes erect. As the arteries become engorged, the veins are compressed so blood is trapped in the penis and the penis remains erect. The penis typically regresses back to a flaccid state with lack of stimulation, sympathetic overdrive, or normal post ejaculatory physiology.

Peyronie's Disease Treatment

Around each cylinder is a very strong fascial layer like the fascia that keeps your abdominal contents inside you. This layer, called the tunica albuginea, is where PD occurs. During the erection process the scar tissue (plaque) associated with Peyronie’s prevents stretching and expansion in the area of plaque on the corpora causing a curvature, hourglass deformity, or another deformity when the penis is erect.

The corpora have two layers; one is circular on the inside and the other is longitudinal on the outside. Where the plaque occurs and in which layer it occurs determines the type of deformity. Of note these severe deformities are found when the penis is fully erect and typically not in a flaccid state. However even in the flaccid state we are able to palpate (feel) areas of plaque, especially if it’s calcified.

Peyronie's Disease Treatment

PD is a scar tissue disorder that occurs in 10% of men and is more prevalent as men reach middle age. PD can also be a contributing factor to erectile dysfunction because the scar tissue can cause ‘venous leak ED.’ PD scarring may prevent the venous (blood vessel) valves from closing well enough to keep the blood in the penis from flowing back into the body’s circulatory system. The result of a venous leak is loss of the erection prior to the completion of sexual intercourse.

PD can certainly cause distress, physical and psychological pain, and impede a man’s ability to have intercourse or to participate in all forms of sexual activity.

The goal of any PD treatment is to achieve a ‘functional penis’ which means a penis as straight as possible with good erectile function. Obviously, if in the process of fixing your curvature and / or hourglass or other deformity we don’t want to harm your ability to have an erection.

MEDICAL TREATMENTS

There are many oral and injectable forms of medications that can help correct mild to moderate curvature or restore erection rigidity, however in more severe cases of curvature or if the patient has Peyronie’s and erectile dysfunction surgery can be indicated.

SURGICAL OPTIONS

There are 3 types of surgical procedures typically done for PD, alone or in combination:

  • Penile plication
  • Incision or excision of plaque and grafting
  • Placement of penile prosthesis alone, with modeling, with internal incision of plaque (the ‘scratch’ technique), or with incision or excision of plaque and grafting

PENILE PLICATION

During penile plication the surgeon uses sutures underneath skin on the opposite side of the curvature to create an opposing tension to correct the curvature. This surgery is most often done if the patients’ erectile function is good and oral or injectable PD treatments have failed to correct the deformity. The primary patient concern with this procedure is the risk of some loss of penile length as a result of plication surgery.

The rendering below illustrates the theory of plication. The blue dotted line represents sutures placed by the surgeon under the skin and into the corpus cavernosum on the opposite side of the maximum curvature. The red arrow represents the length of corpora tissue bunched together when the suture is tied down by the surgeon. Typically, the corpora spongiosum is lifted away from the corpora cavernoma’s surface first and not included in the sutures, and there would be smaller distance of corpora included in each stitch to limit the loss of length. This rendering has been simplified for ease of understanding.

Peyronie's Disease Treatment

The sequential bunching of tissue to counteract the plaque that’s causing curvature is what causes a risk of length loss. A more severe curvature requires more sutures and likely results in more penile length loss.

INCISION OR EXCISION OF PLAQUE AND GRAFTING

Incision or excision of plaque and grafting surgery requires more skill and is reserved for patients with severe deformity and / or erection issues. A ‘relaxing’ incision or incisions are made in the area of maximum curvature to ‘release’ the scar tissue deformity, or in more severe cases the scar tissue is removed in a larger section. After this is performed, a graft material is placed to ‘patch’ the area of the resulting gap or imperfection. The graft may be sewn in place or special self-adherent grafts can be used.

The biggest risk with this type of surgery is if in the process of correcting the deformity by cutting and removing the plaque we impact erectile function, penile sensation, or alter other functions in the area. One way to describe how this procedure could cause ED is to compare it to patching a tire. Think of the corpora cavernosa as the rubber on the outside of the tire. If we cut out a section or make an incision in the rubber and apply an external patch to the area (which is not done to tires) it would be very hard to obtain a tight seal that will hold pressures as high as 50 psi in the case of the tire, or 120 mmHg for the corpora. Due to these possible outcomes, incision or excision of plaque and grafting surgery is commonly performed in combination with placement of an inflatable penile prosthesis.

PLACEMENT OF PENILE PROSTHESIS

Outpatient surgery to place either an inflatable or semi-rigid (bendable rod) penile implant may be indicated for patients with severe curvature, erectile dysfunction, or risks of surgical complications. These devices are permanent prosthetic implants that provide ‘on-demand’ erectile function by pumping up the inflatable type by hand through the skin of the scrotum, or bending the semi-rigid type into position.

Penile prosthetic devices are not visible after surgical placement and healing and can function up to 20 years without issue. This surgery requires patients to stop taking anticoagulation medications and have appropriate surgical clearance. The risks of implant surgery may include bleeding, infection (1-2% of patients during the healing process), and in rare cases erosion of the implant, device malfunction, need for revision surgery, pain, cosmetic dissatisfaction, perforation of the urethra, or severe bowel/bladder/vascular injuries.

It should be noted that the device provides erectile function, but the function is somewhat different than natural erections given that there is a prosthetic in place.

Penile Implant

The inflatable devices tend to be more common as they offer both the erect and flaccid states of a natural penis. One important thing to understand is that a penis with implant in the flaccid state will look more ‘pronounced’ than a penis without an implant in the flaccid state because the device is taking up space even when not inflated.

 

Furthermore, with an inflatable prosthesis the transition between flaccid and erect states is operator dependent due to the manual pump. A semi-rigid device tends to be a better option for a man that is desiring erectile function but has poor manual dexterity. Placement of an implant should correct erectile dysfunction without changing the ability to ejaculate, achieve orgasm, or changing penile sensation. An Implanted Penile Prosthesis (IPP) can be used in the following settings for Peyronie’s:

Penile Prosthesis Placement Alone

If the curvature is less than 30 degrees and pre-op erectile function is poor, placing an IPP can be indicated for correction of curvature and maximum rigidity. Remember the goal is a mostly straight, rigid erection.

Penile Prosthesis Plus Modeling

In instances of more severe curvature the surgeon may combine placement of a penile prosthesis with specific ‘modeling’ maneuvers to stretch the penis in the opposite direction of curvature to help release the curve. These maneuvers are similar to stretching exercises patients are given during the treatment of PD with injection therapy and are done by the surgeon during the implant surgery. Sometimes patients are instructed by their surgeon to perform stretching exercises when fully healed from the implant surgery. In these cases the patient will inflate their device to create a rigid erection and preform the exercises to help further correct their curvature. This should only be done at the direction of your physician.

Penile Prosthesis Plus Internal Incision of Plaque

The ‘scratch technique,’ developed by Dr. Paul Perito, may be combined with the placement of a penile prosthesis. In this case, the surgeon will make small ‘scratches’ or incisions in the area of plaque to weaken the scar tissue and allow the prosthesis be more effective at straightening the penis. Because of the way this technique is performed, it is exclusively performed in combination with penile prosthesis surgery.

Penile Prosthesis Plus Incision or Excision of Plaque and Grafting

This technique is described above and often performed in combination with placement of a penile prosthesis to ensure post-surgery erectile function is satisfactory for sexual activity.

We sincerely hope that after reading this blog you have greatly increased your understanding of what options may be available from a surgical standpoint to treat your PD and correct your deformity while still maintaining or replacing your erectile function.

View the original article here. 

 

Dr Wallen’s Tips for Your Best Life

11 Tips to be Healthier and Happier

  • 40 mins of cardiovascular activity 5 days a week
    • Walking, jogging, swimming, biking, etc
    • Yoga or stretching should be emphasized especially as we age
    • As we get older it can also be helpful to do pelvic strengthening exercises
  • Plant Based Diet
    • YES ALL FRUITS AND VEGGIES!!!
    • At the very least mostly plant based with fish and chicken as preferable sources of lean white meats
    • Organic meats and produce preferable
  • 8-10 bottles of water a day
    • More if you are in hot, dry climate
  • 4 oz of lemon juice in your water daily
    • 1 oz mixed in a glass of water
    • 4 (1) oz shots of lemon juice with water chaser
  • Low Salt and Sugar diet
  • Turmeric or Curcumin supplements OTC
  • +/- Multivitamin
  • Use Sunblock 30-50+ SPF and protective sun wear
  • Visit your Dentist every 6-12 months
  • Remove the NEGATIVE:
    • Alcohol, Tobacco, Marijuana, and other drugs
    • Gambling
    • Sex and Pornography addictions
  • Cancer screening for men:
    • Testicular Cancer:
      • 15-45 year old Men should be performing self-exams of the Testicles monthly in the shower and if they have questions they should see a Urologist.
    • Prostate Cancer:
      • Men whom have a (++) Family History or African American ancestry should have screening with a PSA blood test and DRE (finger exam of Prostate) once a year starting at age 40-45 years old until they are over age 70 or have less than a 10-15 year life expectancy.
      • Men who DO NOT have a family history or African American ancestry would start screening with a PSA blood test and a DRE once a year starting at age 55, then as above.
    • Colon Cancer:
      • Men age 45-50 depending on family history should have screening colonoscopy then further as directed by their Gastroenterologist.

Write down your goals. Chase them. Achieve them. Repeat.

Thanks,

Jared J. Wallen MD