Psychological Therapy

Our first approach to treat ED is psychological. If the cause of Erectile Dysfunction is psychogenic, the psychological therapy is of most importance in the treatment of ED. Psychological treatment helps to integrate the treatment into the sexual relationship and resolve psychological issues such as performance anxiety, porn induced ED, negative thoughts, low self-confidence, guilt, intimacy issues and communication problems between partners. Psychological Therapy can prevent the recurrence of the sexual problem after treatment because men learn to manage their dysfunctional response patterns associated with ED.

Couple Counseling:- If ED results from problem in relationship it is unlikely to resolve until these problems are addressed. For this Relationship counseling is necessary. It can be difficult to talk to your partner about ED, but it often helps you to get rid of ED.Speaking to your partner about ED and involving them in the process to overcome it is an important part of the therapy to a more satisfying sexual relationship.

CBT:- Cognitive Behavioural Therapy is a talking therapy that can help you manage problems by changing how you think about things and your behaviour. CBT is an effective approach in managing ED. By learning to understand yourself, your thought patterns, and your responses, you can effectively change them to help resolve your problems.

Meditation:- Meditation is the best way to boost your mental abilities. It brings peace of mind. Meditation is very helpful in the management of psychogenic ED.

Sex Therapy

Sex therapy can be regarded as a specific type of psychotherapy, focusing specifically on sexual experiences.Sex therapy for ED may or may not include:
Investigating body-mind connectedness and interoceptive awareness.

Developing mind/body skills to manage anxiety and source inside of oneself for arousal.

Evaluating if any of the partner is depending on being a viewer of erotic sources for sexual arousal, such as pornography.

Understanding if masturbation habits that shape sexual arousal may not be conducive to arousal or functioning with a partner.

Assessing whether one is considering sexuality as a “performance” and is very orgasm-focused, rather than enjoyment.

Identifying relational communication problems.

Sensate focussing, slowly increasing senses of arousal, focussing on sexual stimulation and magnifying it.

Medicines

A. Allopathic Medicines:- Some medicines provides erection during sexual activities, these medicines are PDE5 Inhibitors i.e. Phosphodiesterase type 5 Inhibitors.These medicines prevents degradation of cGMP into GTP, by deactivating PDE5 enzyme. Hence concentration of cGMP remains high and penile muscles relaxation continues. We should not take these medicines without the advice of a Sexologist. PDE5 Inhibitors are strictly contraindicated in the patient taking Nitrates. Some of them are:

• Sildenafil:- Viagra 50 or 100mg.
• Tadalafil:- Cialis 5,10 or 20mg.
• Vardenafil:- Levitra 10 or 20mg.
• Avanafil:- Stendra 100 or 200mg

B. Herbal Medicines:- Herbal medicines are safest from all other medicines, having no side effects and ability gained last longer for many years. These medicines also work in a similar way by inhibiting pde5 enzyme, but because herbal medicines are used as a whole part,its active gradient increases rigidity of penis and other part counteracts the side effect. So,there is no side effect of a herbal medicine. Sexologists uses Many Herbs to treat ED. They uses different-different combinations of these herbs, depending upon the root cause of the ED and inner nature of patient. We customises medicine of every patient and every patient gets distinct medicine. No two patients have similar medicines,even having same kind of ED. Some of these herbs are:

• Ashwagandha
• Shatavari
• Kaunch Bees
• Swet Musli
• Kali Musli
• Akarkara
• Ginseng
• Yohimbine

Intracavernosal Injections (ICIs)

Intracavernosal Injections(ICI) Medicines in ICIs are Alprostadil, Papaverine, Phentolamine and Atropine. These are some prostaglandins. These Injected in the cavernosal chamber of penis. Injection on lateral base of penis to prevent neuro-vascular system dorsally,and urethra ventrally. Caverject is the famous brand uses medicines as Bimix which contains Papaverine and Phentolamine, Trimix which contains Alprostadil,Papaverine and Phentolamine, Qudmix which contains Alprostadil,Papaverine,Phentolamine and Atropine.

These medicines activates enzyme AC i.e. Adenylyl Cyclase and Inhibits enzyme PDE2,3,4. And increases relaxation of smooth muscles of penis and acts as vasodilators. Some side effects are also seen with these injections, such as Priapism- Sustained prolonged erection, Bruising, Fibrosis, Pain, Peyronie Disease.

Intraurethral Suppository

There are some prostaglandins used as a suppository to treat the Erectile Dysfunction. Doctors places these suppository or pellet in the urethra through a system called MUSE i.e. medicated transurethral system for erection. Prostaglandin used is Alprostadil. It is available in strength of 125 mcg,250 mcg, 500 mcg or 1000 mcg. Initial dose is 125mcg. Regular use have side effects. Alprostadil increases blood flow by relaxation of smooth muscles of cavernosum.

Platelets Rich Plasma Therapy(PRP)

This is very useful therapy to treat Erectile Dysfunction. It regenerate the vascular tissues of penis, thereby increases the blood flow. Patient’s own blood prepares PRP by centrifugation and separation of blood contents. From platelets rich plasma injection is prepared and this injection is known as PRP Injection. This PRP Injection is injected into the corpora cavernosum of lateral base of penis. P-Shot i.e. Priapus Shot is a type of PRP Injection. This therapy also have some side effects like, fibrosis, bruising,and pain.

Androgen Replacement Therapy

Where the causing factor of Erectile Dysfunction is deficiency of testosterone, Androgen Replacement Therapy(ART) is helpful. We knows it as Hormone Replacement Therapy also i.e. HRT. If testosterone levels falls below 300 ng/dL than ART helps to restore testosterone. Testosterone and its derivatives are present in the form of injections, tablets, capsules or patches to treat the patient. These androgens increases overall blood flow of body and temporary increase in libido. Although this therapy have some side effects such as Decreased Libido in long run, weight gain, deep vein thrombosis, heart diseases, and cancerous in nature. There are some form of ART:-

Transdermal Patches:- Androderm and Testoderm.

Topical Gels:- Androgel,Testim, applied topically.

Nasal Gels:- Natesto, pumped into each nostrils.

Injections:- Testosterone Enanthate, Testosterone cypionate, Testosterone Propionate.

Oral Pills:- Testosterone Undecanoate, Methyltestosterone.

Implants:- Testopel (Long acting implant lasts 3-6 months), an pellet implanted in soft tissue which slowly release testosterone.

Stem Cells Therapy

Stem cell therapy is the newest approach in the management of Erectile Dysfunction. All other tissues develops from stem cells. The source of stem cells are umbilical cord or bone marrow. Stem cells therapy can improve erectile function through neovascularization and nerve regeneration.Different types of stem cells are Totipotent stem cells, Pluripotent stem cells, Multipotent stem cells, Oligopotent stem cells, and Unipotent stem cells. Treatment of ED is carried out by using mesenchymal stem cells, derived from bone marrow or foetal stem cells, given in the form of intravenous injection in the penis.

Penile Vacuum Pump

Vacuum Erection Devices (VED) are the devices used to achieve the erection by creating vacuum in the cylinder. This device contains a cylinder which has gradation on it, a pump to create vacuum, and some rubber rings. Penis remains in cylinder and as vacuum increases penis erects. To prevent backflow of blood rubber ring is there at the base of penis. We should use quality VED, as local vacuum pump may not create enough vacuum to erect the penis. Patient must use VED in the direction of a Sexologist. The device may be difficult to use in some patients with buried penis and having fatty lower abdomen. VED may cause little pain and penile sensation problem due to continuous use of constricting rings. The device can be manual or electronic.

Shockwave Therapy

Shockwave Therapy is the new approach in the management of erectile dysfunction. Li-ESWT i.e. Low Intensity Extracorporeal Shock Wave Therapy is used to treat ED. Shockwaves are acoustic waves that carry energy and can be targeted and focused noninvasively to affect penile tissues. When Li-ESWs, which are relatively weak but focused, targeted to deep tissues of penis, causes mechanical stress and microtrauma. This promotes a process called angiogenesis. It results in increased vascularization of penile tissue.

LI-ESWT stimulates the production of angiogenesis-related growth factors, such as 1.Endothelial nitric oxide synthase (eNOS) and 2.Vascular endothelial growth factor (VEGF), and endothelial cell proliferation factors, such as 3.Proliferating cell nuclear antigen (PCNA).

LI-ESWT induces neovascularization, which improves blood supply and treat ED. According to Treatment Protocol we gives total of 1500 SWs.In first three weeks, two treatment session per week, then three weeks of no treatment, then again three weeks of two treatment session per week.

The Energy Flux Density (EFD) of SWs would be 0.09 mJ/mm square.There are 12 treatment session in 9 weeks. Every focused point receives 25 Shockwaves in each session.

Exercise

We have to maintain the blood flow at the time of sexual activity to treat the ED. Regular exercise, yoga, physical workout helps to maintain the blood flow. We can choose any kind of regular physical activity such as running, jogging, Brisk Walk, simple walking etc. In my opinion Brisk Walk is the best option, as running and jogging causes jerking movements on the knee, which may cause pain later in the age of 60.

Kegel Exercises are also good option to maintain the blood flow in pelvic floor muscles. Rich blood flow in coccygeus muscles helps to treat erectile dysfunction. Kegel exercise must be done in perfect way to gain results from kegel. Patients do kegel after watching some clips on u-tube may not getting results they expect, because they are not doing it in the way it should be. Movements in the abdominal muscles,legs muscles and buttock muscles while doing kegel lowers the results of kegel. So before doing kegel we must consult a sexologist.

Modifying Lifestyle

In the management of erectile dysfunction modified lifestyle has a major role. Some habits causes hindrance to get rid of ED. We should evaluate our lifestyle and should avoid those habits causing reduction in blood flow.
Stop smoking:- Smoking causes constriction in blood vessels and reduces blood flow in the body. To treat ED we must stop smoking.

Excessive Drinking:- Excess alcohol depresses our nervous system and reduces body blood flow. Drinkers are advised to avoid alcohol in order to have better sex life.

Drug addiction:- Any kind of addiction whether of opium or medical drugs damages the nervous system. Avoid any kind of addiction to cure erectile dysfunction.

Junk Food:- To eat junk food at the time of conventional food time can lowers our energy level. Junk foods are of no nutritional value. Fatty and spicy food should be avoided.

Awaking overnight:- Night is for rest. Patient should have sleep of 8 hours in night. Awaking overnight is never good for our blood flow.

Drink Plenty of Fluids:- To wash out toxins of our body we should drink 3-4 L of water daily. We should add freshly prepared juices and soaps to our diet. Canned and packaged juice should be avoided, they contains preservative added in it.

Penile Implants

When treatment with medicines is not possible then Penile Prosthesis comes first to consider for the management of Erectile Dysfunction. These prosthesis are surgically implanted into the penis to obtain erection. This surgery is irreversible, as the penile tissues alters permanently and normal physiological erections does not occurs after surgery. Two types of Implants are there, Malleable Penile Implants and Inflatable Penile Implants.

Malleable Penile Implants:- These implants are silicone rubber with a central metallic core. The advantages of malleable devices are that they are easy to implant, easy to operate, and have minimal risk of failure. Disadvantage of these semi-rigid devices is that the penis is never fully rigid nor fully flaccid,interfere with urination, and difficult to conceal. Genesis and Spectra are brands of malleable penile implants.

Two Piece Inflatable Penile Implants:- This prosthesis consists of two cylinders and a scrotal pump. Proximal part of cylinders contains Reservoir. Detumescence can be done by bending the penis at midpoint. Ambicor is the brand of two piece implant.

Three Piece Inflatable Penile Implants:- It consists of two cylinders, a scrotal pump and a reservoir of saline. Penile shaft receives Cylinders, pump in the scrotum and reservoir is in suprapubic space. Three-piece prostheses provide excellent rigidity when erect and natural appearance when flaccid. AMS 700 and Titan are the brands of three piece inflatable penile implants. Infection is the most common complication of penile implant surgery.

Surgery

When the cause of Erectile Dysfunction is Arterial insufficiency or Venous Leak, sexologists recommends Penile Surgery. After diagnosis and confirmation of arterial insufficiency in the findings of penile doppler and pudendal arteriogram, sexologists suggests Penile Arterial Bypass Surgery. Revascularization and Arterialization are the procedures performed in the surgery to obtain normal function.

Arterial Revascularization:– When epigastric artery is anastomoses with dorsal penile artery.

Arterialization:- When epigastric artery is anastomoses with deep dorsal vein.

Venous Surgery:- No recommendation of Venus surgery.

Specialised Food for ED

To increase the blood flow of body there are some food, which will help to treat ED.

Grams:- In addition to proteins grams increases testosterone.

Fenugreek:- Increases testosterone.

Cinnamon:- Increases testosterone.

Walnuts:- Increases testosterone.

Dates:- Khajoor also increases testosterone.

Dark Chocolates:- Sex mood elevators.

Yohimbine

L-arginine

Ginseng

Ginkgo biloba

Horny goat weed

DHEA