 Hi, my name is William Brandt, I'm a urologist here at the University of Utah, the Division of Urology, Center for Reconstructive Urology and Men's Health. We've had another segment where we talk about erectile dysfunction in general, and what I want to talk more about today are the treatments for erectile dysfunction. Obviously, this is a sensitive subject, and I am going to have some props here, so we do recommend this for the more mature viewer, although we won't show anything too explicit. So what are the treatments in general? I'm going to cover these first before we get to the specifics, but in general, there is medical-type treatments and non-medical treatments. The medical treatments that most people familiar with are the pills such as Viagra, Levitra, Silas. There's other kinds of medical treatments such as injections and suppositories, and then there's non-medical treatments such as the vacuum device or penile prostheses, and we'll cover each of these in turn. So what happens, a lot of men ask, if you don't do anything, let's say you just have erectile dysfunction and you just don't do anything. Well, what happens, unfortunately, is that the penis, like a lot of other things in the body, is a use it or lose it organ, and just like a body builder who stops lifting weights, they're going to shrink and atrophy, and the penis is no different. So for example, men who've had prostate cancer surgery and have had the prostate removed and have profound erectile dysfunction as a result, they find an average of about two centimeter loss, and the longer they go without erections, they tend to lose some more size as well. So we do not recommend doing nothing if you want to preserve erectile size, and this has been true in animal studies and human studies. So the pills are the thing that I think most people are familiar with. Viagra was introduced to the common market in the late 90s, and then Silas and Levitra came out in 2003, and they do work pretty well. So if you look at studies that look at how much they improve the erection, about 80% of men will say that their erections are improved, versus about a quarter of men who are just taking a sugar pill or a placebo. Now if you ask the question, how many men are able to have successful intercourse, of course that's not as good as 80%, because you can't just have a better erection, you have to have an erection that sustains long enough for intercourse, and is hard enough for intercourse, but it's still pretty reasonable. Now the medications are not for everyone. There are certain medications that will not allow a man to take one of these pills for ED, such as certain medications that are used for high blood pressure. That can be dangerous. Additionally, about 30% of men have side effects from using these pills, whether it's headache, or feeling flushed, or nasal congestion, but only about 5% of men stop using the pills as a result of that. And there are some keys to using these pills successfully. They are amplifiers, they are not magic pills, so we always tell men if you take these pills and go watch a baseball game, you will not have an erection unless you love baseball. Another key element is that they work best if you have an empty stomach, so you take the pills either before dinner or after a snack, but not after a big meal. And the third thing is often they don't work the first couple times, so you have to try them several times before you even decide whether they're worth it for you or not. So one option for patients, if the pills are unsuccessful, is to use what's called a vacuum device. A vacuum device is not a drug at all, it's a mechanical object. And I brought with me models of this. This is just one older model, there are many variations on this, but you can see this has a plastic cylinder and a pump. And if I put the plastic cylinder on my hand, for example, and I start squeezing this, it's going to start creating a vacuum down here. So if the man's penis is in here, it'll start drawing in blood, and then there's this, which is like a fancy rubber band that goes around the base of the penis to hold the blood in. Now, this, because it's not a drug, does not have any drug side effects, and that's a positive thing. They're also relatively inexpensive, insurances usually cover them, and they work fairly well if a man can get the hang of it. The downside is unfortunately it's so unnatural. It's a very unnatural way to have an erection. The erection itself is not normal arterial blood, and so sometimes the patient will complain that the erection feels sort of cold, the partner will complain that the erection feels cold, the penis may have abnormal coloration, maybe blood vessels are burst, and so forth, and overall unfortunately the success rate is not very high, only at about 20%. So another alternative for medication is to do what's called injection therapy, and I brought this model that shows that the erection bodies are on the sides here and here, and they communicate with each other. And so if a man takes a pill, of course the drug goes everywhere in their body including their penis, but if they want to get a drug in very efficiently then they can draw it up, and you can see this is a very tiny needle, this is used for diabetics as an insulin syringe, and they can place it right in the erection body on the side, this is not painful, they put it right in, they inject the drug, and they take it out. The drug diffuses throughout the penis, and so it gives a very natural erection usually in about five minutes, and so men are very happy with that. The downside of it is what you would expect, is that men who are feeling frisky, you know, grab a needle and put it in their penis, it's not the most natural thing that comes to mind, and that's the big reason for dropout, and the dropout is about 50% if you look at it over a few years. So as another option for those who are either needle phobic or don't want to use a needle, you can use what's called urethral suppository. This is a suppository that goes directly into the urinary channel here, and I brought an example of this with me. There's a little cap that goes off, the medication is placed after the patient urinates directly in, and this is hit to deposit the medication, then it's wiggled out, and it leaves the pill in here, and then that works, it diffuses well there. The plus side of this is that it avoids needles, which is great, and it's very easy to use. The downside is it's very expensive, and there's a certain amount of penile pain that can accompany the drug dissolving, about 30% of men have had prostatectomy experience that. It doesn't work quite as efficiently as the injections do. You can imagine another problem with either this or the injections is that the man has to have very good hand function. He has to be able to see pretty well, and he can't be too fat because he has to be able to see what he's doing, and you can't have him miss. So what about for men who don't have success with these other modalities, or who are just unhappy using them, they don't tolerate the needle, etc. Well another option is what's called a penile prosthesis. These prostheses have been around since the early 70s, and there are several different types. Each prosthesis is a device that stays within the body, and in that sense it's totally concealed, and looks very natural. The simplest kind, I have a puppet here really that I'm going to use as a model, but the simplest kind is what we call a semi-rigid. So it's not exactly rigid, and it's not exactly flaccid. It's a little hard to conceal, but it's rigid enough to have intercourse. For men who have very poor hand function, or who want the simplest kind of procedure, this is a very nice way to go about this. For men who want a more natural feeling correction, there is one called a three-piece device, and I have a different puppet here that shows this, and what it is is there are there are hydraulic cylinders within the penis, and there's a pump in here like a third testicle, and there's a reservoir fluid that's hidden in the abdomen, so when the man wants to have an erection, they just pump on this, and this model doesn't work quite as well, but you can see the fluid starting to go in, they can get a very strong erection. When this is pumped up all the way, it's just as rigid and feels just as natural as a normal erection, and you see it's very rigid here, and when the man has had enough, there's a little button they hit, also in the scrotum, there's no external parts, they hit it, it gets out the fluid, and all the fluid comes out, and they go back to being flaccid. So the positive side of these prostheses is they've been around for a long time, we have lots of clinical data on them, certainly from the point of view of naturalness, these are internal, there's no issues with spontaneity or no stuff to use, and people like them very much, they're very discreet, if you were in the shower, if you had one of these inflatable ones at the gym, no one would notice that you had anything like this, you could even be on the swim team with this, and if you look at this graphic that compares the satisfaction rates of prostheses versus other modalities of treating erectile dysfunction, the prostheses do win with satisfaction, at least 90%, more like 95%, injections more like 40%, pills about 50%. Now the the pros of these prosthetics, they've been around for a long time, since the early 70s, we have tons of clinical data on them, they're totally internal and the man has full control of them, and so they're perfect in terms of discretion and spontaneity. Like everything else, they have downsides, and the downsides are basically three things. Number one is they are mechanical objects, and so if you give them 10-15 years, they're going to break and need to be replaced, which can be done but is another procedure. Number two is, and the thing we worry about the most, is infection. Like any foreign object, like a knee replacement or a hip replacement, these things, if they get infected, the bacteria live on the device and the device has to be removed at least temporarily in order to get the infection to resolve. Now luckily the infection rates for penile prosthetics are very low at about 1% or less, but they're still not 0%, so we worry about that. And the third thing has to do with patient expectations. If a guy comes in and says, but doc, I used to be this big, we say, well first of all, your memory is terrible, but second of all, no matter what size it was, that's not what this prosthetic or any other treatment for rectilus function can give you. It can just restore a function. So if a guy thinks this is a penile lengthening procedure, it is not that. It's not going to do anything other than restore a good function. And if a man thinks of that realistically, they'll be very happy, and if they don't, then they probably will not. So in this segment, we've tried to review some of the treatments for rectilus function. If you suffer from this problem personally, I encourage you to talk to your healthcare professional or contact us, and we're happy to help you. Thank you very much for your time.