Because drug treatment is not effective in all cases, researchers in recent years have developed a number of procedures that relieve BPH symptoms but are less invasive than conventional surgery.

Transurethral microwave procedures. In 1996, the FDA approved a device that uses microwaves to heat and destroy excess prostate tissue. In the procedure called transurethral microwave thermotherapy (TUMT), the device sends computer-regulated microwaves through a catheter to heat selected portions of the prostate to at least 111 degrees Fahrenheit. A cooling system protects the urinary tract during the procedure.

The procedure takes about 1 hour and can be performed on an outpatient basis without general anesthesia. TUMT has not been reported to lead to erectile dysfunction or incontinence.

Although microwave therapy does not cure BPH, it reduces urinary frequency, urgency, straining, and intermittent flow. It does not correct the problem of incomplete emptying of the bladder. Ongoing research will determine any long-term effects of microwave therapy and who might benefit most from this therapy.

Transurethral needle ablation. Also in 1996, the FDA approved the minimally invasive transurethral needle ablation (TUNA) system for the treatment of BPH.

The TUNA system delivers low-level radiofrequency energy through twin needles to burn away a well-defined region of the enlarged prostate. Shields protect the urethra from heat damage. The TUNA system improves urine flow and relieves symptoms with fewer side effects when compared with transurethral resection of the prostate (TURP). No incontinence or impotence has been observed.

Water-induced thermotherapy. This therapy uses heated water to destroy excess tissue in the prostate. A catheter containing multiple shafts is positioned in the urethra so that a treatment balloon rests in the middle of the prostate. A computer controls the temperature of the water, which flows into the balloon and heats the surrounding prostate tissue. The system focuses the heat in a precise region of the prostate. Surrounding tissues in the urethra and bladder are protected. Destroyed tissue either escapes with urine through the urethra or is reabsorbed by the body.

High-intensity focused ultrasound. The use of ultrasound waves to destroy prostate tissue is still undergoing clinical trials in the United States. The FDA has not yet approved high-intensity focused ultrasound.

It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy.

As a man matures, the prostate goes through two main periods of growth. The first occurs early in puberty, when the prostate doubles in size. At around age 25, the gland begins to grow again. This second growth phase often results, years later, in BPH.

Though the prostate continues to grow during most of a man’s life, the enlargement doesn’t usually cause problems until late in life. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and as many as 90 percent in their seventies and eighties have some symptoms of BPH.

As the prostate enlarges, the layer of tissue surrounding it stops it from expanding, causing the gland to press against the urethra like a clamp on a garden hose. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH.

Many people feel uncomfortable talking about the prostate, since the gland plays a role in both sex and urination. Still, prostate enlargement is as common a part of aging as gray hair. As life expectancy rises, so does the occurrence of BPH. In the United States in 2000, there were 4.5 million visits to physicians for BPH.

Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases—such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease—account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience ED.

Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of erectile dysfunction. Smoking, being overweight, and avoiding exercise are possible causes of ED.

Also, surgery (especially radical prostate and bladder surgery for cancer) can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

In addition, many common medicines—blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug)—can produce ED as a side effect.

Experts believe that psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10 to 20 percent of ED cases. Men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, depression). Other possible causes are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as not enough testosterone.

Penile erection is mainly mediated by the parasympathetic nervous system, which when stimulated causes arterial dilation and relaxation of the cavernosal smooth muscle. The increased blood flow into the corpora cavernosa in association with reduced venous outflow results in penile rigidity.

Attention has recently been focused on the chemical mediators of erection. These include prostaglandin E, acetylcholine, vasoactive intestinal peptide and nitric oxide. The most physiologically important mediator is nitric oxide.2 This substance is released from nerve endings and vascular endothelium and functions by activating guanylate cyclase, which converts guanosine triphosphate to cyclic guanosine monophosphate (cGMP).3 cGMP becomes the secondary messenger that causes smooth muscle relaxation, resulting in venous engorgement and penile tumescence.

Erectile dysfunction is defined as the persistent inability to achieve or maintain penile erection sufficient for sexual intercourse. In the past, patients have underreported this problem because of embarrassment and the belief that little could be done to alleviate it. The availability and marketing of new therapies for erectile dysfunction have greatly increased public awareness of this problem.

An estimated 10 million to 20 million American men have some degree of erectile dysfunction, the incidence of which increases markedly with age. Between the ages of 40 and 70 years, the probability of complete erectile dysfunction triples from 5.1 percent to 15 percent.

Most physicians suggest that treatments proceed from least to most invasive. For some men, making a few healthy lifestyle changes may solve the problem. Quitting smoking, losing excess weight, and increasing physical activity may help some men regain sexual function.

Cutting back on any drugs with harmful side effects is considered next. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of blood pressure medicine.

Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.

Psychotherapy

Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient’s partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED from physical causes is being treated.

Drug Therapy

Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved Viagra, the first pill to treat ED. Since that time, vardenafil hydrochloride (Levitra) and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness.

Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.

While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body’s ability to use the drug. Levitra is also available in a 2.5 mg dose.

None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also, tell your doctor if you take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. Your doctor may need to adjust your ED prescription. Taking a PDE inhibitor and an alpha-blocker at the same time (within 4 hours) can cause a sudden drop in blood pressure.

Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs—including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone—are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient’s believing that an improvement will occur.

Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Patient History

Medical and sexual histories help define the degree and nature of ED. A medical history can disclose diseases that lead to ED, while a simple recounting of sexual activity might distinguish among problems with sexual desire, erection, ejaculation, or orgasm.

Using certain prescription or illegal drugs can suggest a chemical cause, since drug effects account for 25 percent of ED cases. Cutting back on or substituting certain medications can often alleviate the problem.

Physical Examination

A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to touching, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics, such as hair pattern or breast enlargement, can point to hormonal problems, which would mean that the endocrine system is involved. The examiner might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem—for example, a penis that bends or curves when erect could be the result of Peyronie’s disease.

Laboratory Tests

Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of free testosterone in the blood can yield information about problems with the endocrine system and is indicated especially in patients with decreased sexual desire.

Other Tests

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than psychological cause. Tests of nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be applied for best results.

Psychosocial Examination

A psychosocial examination, using an interview and a questionnaire, reveals psychological factors. A man’s sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

The history should include the frequency and duration of symptoms, the presence or absence of morning erections and the quality of the relationship with the sexual partner. The sudden onset of erectile dysfunction in association with normal morning erections or a poor relationship suggests psychogenic impotence.

A detailed medical history may reveal that the disorder is due to a chronic disease such as atherosclerosis, hypertension or diabetes mellitus. Inquiry about decreased libido and symptoms of hypothyroidism or hyperthyroidism may reveal a reversible cause.

Because as many as 25 percent of cases of erectile dysfunction are due to medication side effects, the patient’s drug therapy should be reviewed. Common pharmacologic causes of this disorder include antihypertensive drugs, most notably the centrally acting agents, beta blockers and diuretics. Antipsychotic and antidepressant drugs are also frequently implicated. Other drugs that can cause erectile dysfunction include spironolactone (Aldactone), cimetidine (Tagamet) and finasteride (Proscar). Excessive alcohol intake, heroin use and cigarette smoking are also known causes.

During the physical examination, signs of hypogonadism, such as gynecomastia or the loss of axillary and pubic hair, should be noted.  The genital examination should include an evaluation of the size and consistency of the testes. The penis should be examined for any fibrosis and plaques indicative of Peyronie’s disease.  Finally, the bulbocavernosus and cremasteric reflexes should be assessed to eliminate a neurologic cause of the erectile dysfunction. The bulbocavernosus reflex is elicited by squeezing the glans penis while observing for contraction of the external anal sphincter. This may be visualized or felt during a digital rectal examination.

Though erectile dysfunction is distressing, it isn’t life threatening. But heart disease can be. Erectile dysfunction — trouble keeping an erection sufficient for sex — can be an early warning sign of heart disease. Understanding the connections between erectile dysfunction and heart health can help you recognize signs and symptoms of heart disease early on. Likewise, if you have heart disease, getting the right treatment can help you maintain or improve erectile function. Factors linked to heart disease that can cause erectile dysfunction include:

* Atherosclerosis. This damaging process reduces blood flow to your heart and contributes to coronary artery disease. It can also affect the blood vessels to the penis, causing erectile dysfunction. Conversely, if you’re having trouble with erections, it could be a sign that your heart is also at risk.
* Medications. Some prescriptions that men take to protect their hearts can cause erectile dysfunction. Additionally, medications that are often prescribed for erectile dysfunction may not be safe when combined with certain heart medications.
* Depression and anxiety. Researchers have found a connection between depression, heart disease and erectile dysfunction. Feeling anxious can also lead to erectile dysfunction. If you have heart disease, you may worry that having sex could trigger a heart attack.

Atherosclerosis: Where erectile dysfunction and heart disease meet

Atherosclerosis, a buildup of plaques in arteries, can prevent enough blood flow from reaching your heart, legs and brain — and your penis. If atherosclerosis has made your arteries in one part of your body narrow and stiff, arteries elsewhere in your body are probably also affected. When atherosclerosis affects blood flow to your penis, the blood can’t sufficiently fill the penis to allow a suitable erection.

The same factors that raise your risk of atherosclerosis in the arteries in your penis also increase your chances of heart disease. Because the arteries supplying your penis are smaller than the ones to your heart, symptoms may first show up as erectile dysfunction. If you haven’t been diagnosed with heart problems, consider erectile dysfunction a wake-up call. It could be a warning sign that the blood vessels feeding your heart might also be in trouble.
Risk factors for heart disease and erectile dysfunction

A number of risk factors can contribute to both heart disease and erectile dysfunction. They include:

* Diabetes. Men who have diabetes have more problems getting an erection than do men who don’t have diabetes. The problem is partially due to the diabetes-related damage to blood vessels that supply the penis.
* Obesity. Overweight men are more likely to have heart disease and erectile dysfunction.
* High cholesterol. A high level of low-density lipoprotein (LDL, or “bad”) cholesterol contributes to atherosclerosis in blood vessels, raising the risk of erectile dysfunction.
* Smoking. Smoking cigarettes raises your risk of developing atherosclerosis. Not only does smoking increase your chances of heart disease, but it can make you nearly twice as likely to develop erectile dysfunction.
* High blood pressure. Over time, high blood pressure damages the lining of your arteries and accelerates the process of atherosclerosis — which can lead to heart disease and erectile dysfunction.

Medications and erectile dysfunction

Some medications that treat heart disease can make you more likely to develop erectile dysfunction. These include:

* High blood pressure medications such as clonidine (Catapres), and beta blockers such as metoprolol (Lopressor)
* Diuretics such as spironolactone (Aldactone), used for high blood pressure as well as heart failure

Although you can’t stop taking your medications, there may be other drug options that are less likely to cause erectile dysfunction. Discuss your symptoms and potential options with your doctor.
Erectile dysfunction medications and nitrates: A dangerous mix

Medications prescribed for treatment of erectile dysfunction may cause significant side effects when mixed with certain heart drugs called nitrates.

Nitrates are often prescribed to reduce chest pain, dilate the blood vessels and lower blood pressure. Because erectile dysfunction medications, such as sildenafil (Viagra), also reduce blood pressure, combining these two types of medication can cause a dangerous drop in blood pressure.

Do not take sildenafil (Viagra), vardenafil (Levitra) or tadalafil (Cialis) if you use nitrate medications (NitroBid, Nitro-Dur, Imdur, others) for chest pain.

If you have coronary artery disease or have had a heart attack in recent months, check with your doctor before you begin taking any of these drugs for erectile dysfunction.
Anxiety: The worry of heart disease and sex

Men who’ve had a heart attack or surgery to treat their heart disease are often anxious about resuming an active sex life. However, intercourse seldom causes heart attacks. Sexual activity with your usual partner in a familiar setting doesn’t lead to a particularly high blood pressure level or heart rate. Even if you’re at high risk of having a heart attack, weekly sexual activity only slightly raises the risk. Talk to your doctor about when you can resume sexual activity after you’ve had heart problems or surgery.
Depression, heart disease and erectile dysfunction

There’s mounting evidence that depression is associated with an increased chance of having heart problems — and erectile dysfunction. Work with your doctor to make sure you’re getting the right treatment if you’re feeling down. Treatment can help alleviate erectile dysfunction and may prevent heart problems.

Depression is treated with counseling and medications. Although treating depression can help with erectile dysfunction, some antidepressants have sexual side effects. If you do have bothersome sexual side effects, you may need to try another antidepressant. Your doctor can also decrease the dose or add another medication to offset the effects of the antidepressant on erectile dysfunction.
Is your erectile dysfunction linked to heart disease?

Seeing your doctor for erectile dysfunction may have a silver lining. It could be a tip-off that you have underlying health problems linked to heart disease that need to be checked out and treated. If your doctor thinks you may be at risk for heart disease, making simple lifestyle changes may be enough to help keep your heart healthy — and improve your ability to have an erection. If you have more serious signs and symptoms of heart disease, you may further tests or treatments.

While most men occasionally experience difficulty achieving and maintaining an erection, about one in 10 men (more than 18 million) in the United States experience erectile dysfunction (i.e., chronic impotence). Despite this high prevalence, less than 10 percent of men affected by this condition seek treatment. Erectile dysfuntion is not a normal part of aging although the prevalence is higher among older men.

About 70 percent of all cases of erectile dysfunction are caused by diseases such as diabetes, kidney disease, alcoholism, atherosclerosis and heart disease. An estimated 35 to 50 percent of men with diabetes experience erectile dysfunction. Other causes of erectile dysfunction include surgery (e.g., prostate surgery) which can injury nerves and arteries near the penis. Erectil dysfuntion may occur as a side effect of many common medications (e.g., high blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and ulcer drugs.

About 10 to 20 percent of the cases of erectile dysfunction are caused by psychological factors that include stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure. If nocturnal erections continue to occur, then psychological causes are more likely

Erectile dysfunction can be devastating. Luckily, 90 percent of erectile dysfunction patients can be treated successfully. Initial treatment of erectile dysfunction is directed towards correcting any medical of problems that may contribute to erection failure. About 30% of men with erectile dysfunction have undiagnosed conditions such as diabetes, hypertension, heart disease or cancer of the prostate (Butler, 1998). Medications (e.g., methyldopa, propranolol for high blood pressure, or alcohol) are a common cause of erectile dysfunction and simply changing to another medicaiton is often effective. Lifestyle changes (e.g., reducing alcohol intake or lowering stress) may also help.

Treatment

Treatment of erectile dysfunction can include drug therapy, vacuum constriction devices; penile prostheses, and vascular surgery. Some of the most common drug therapies are described below:

* Drug Therapies

Oral Medication (e.g. Viagra) is the newest and most exciting treatment. Viagra is the first oral medication that can cause an erection within 1 hour after taking it. It works by preventing blood from leaving the penis which results in an erection. Viagra is effective in men with erectile dysfunction related to conditions that include diabetes, hypertension, protatectomy, heart disease, and depression. Viagra can be dangerous for those with low blood pressure, myocardial ischemia, kidney or liver disease, or patients on drugs such as erythromycin, tagamet or nitroglycerine. Viagra has become very popular, but it is also very expensive. Only 26 of the Medicaid programs and one-half of health maintenance organizations currently pay for this medication.

Intracavernosal Injection. Injecting vasodilator drugs (e.g. papaverine, Regitine, Caverject) into the cavernosal body of the penis can increase blood flow and produce an erection within minutes that can last up to 2 hours. These drugs may cause priapism (a persistant erection) and other side effects such as pain, nodules and hypotension (low blood pressure).

Urethral Suppositories (e.g. Muse) mimic natural prostaglandins and cause relaxation of the smooth muscles. This allows the corpus cavernosum of the penis to vasodilate and an erection to occur. The effect occurs within 5 to 10 minutes and can last up to 1 hour.

NEW YORK (Reuters Health) - A new study shows that a substantial minority of men receiving so-called androgen deprivation therapy, or ADT, for prostate cancer experience erectile dysfunction (ED). However, many respond well to ED therapy, doctors from Memphis have found.

Men with advanced prostate cancer may be given ADT to stop their production of testosterone, which may drive tumor growth.

ED is “grossly underreported” by men treated with ADT, Dr. Ithaar H. Derweesh told Reuters Health. Moreover, “studies that have been reported in the literature have tended to focus on decreased libido (sex drive) and have not examined the issue of erectile dysfunction per se.”

Given that there is a lack of information on the prevalence of ED and the response to its treatment in patients receiving ADT, Derweesh and colleagues at the University of Tennessee Health Science Center studied 395 men treated with ADT at their institution over a period of about 15 years. The average age of the men was 71.7 years and the men were followed for more than 7 years.

During that time, 14.4 percent of men reported ED, they report, and 70 percent of these men had “new-onset” ED.

According to Derweesh and colleagues, 47 percent of men with ED responded successfully to ED treatment, most often with drugs such as Viagra.

“We demonstrate for the first time in a large series,” Derweesh noted, that these types of drugs are effective in the treatment of ED caused by androgen deprivation therapy.