Methods to help with erections

Penile injections: Many urologists (doctors who specialize in conditions and diseases of the genitals and urinary tract) teach men to inject their penises with medicines that cause erections. A small needle is used to put the drug into the side of the shaft of the penis a few minutes before starting sex. The combination of sexual excitement and medicine helps to produce a firmer and longer-lasting erection.

Penile injections can have side effects. Because of this, the first injection is usually done in the doctor’s office. A few men may get an erection that will not go down. If this happens, the man needs to go to an emergency room right away for treatment. Some men develop scarring in the spongy tissue of the penis after repeated injections. Scarring is often not noticed by the man, but in severe cases can make erections permanently curved. The only way to treat bad scarring is surgery.

Urethral pellets: Another way of using the same drug used for penile injections is to have a man use an applicator to put a tiny pellet or microsuppository into his urethra (the opening at the tip of the penis). As the pellet melts, the drug is absorbed through the lining of the urethra and enters the spongy tissue of the penis. The man must urinate before putting in the pellet so that the urethral lining is moist. After the pellet is put in, the penis must be massaged to help absorb the pellet. This system may be easier than injections, but it does not always work as well and can cause the same kinds of side effects. Because the pellet may cause dizziness in some men, a test dose in the doctor’s office may be needed. It can cause some burning in the urethra, too. Bits of the pellet may also enter the partner during sex and cause burning, itching, or other discomfort.

Vacuum constriction devices: Another treatment, the vacuum constriction device (VCD), is less risky but may interrupt sex more than the drugs do. A man places a plastic cylinder over his penis and pumps out air to produce a vacuum around the outside of the penis. The suction draws blood into the inside of the penis, filling up the spongy tissue. When the penis is firm, the man takes the pump off and slips a stretchy band onto the base of his penis to help it stay erect. The band can be left on the penis for up to half an hour. Some men use the pump before starting sexual touching, but others find it works better after some foreplay has produced a partial erection. The erection from a vacuum device is usually firm, but may swivel at the base of the penis, which can limit comfortable positions for sex. It may take some practice to learn how to use a vacuum device. Most vacuum devices are prescribed by physicians, but the FDA has approved some that are available over the counter.

Vacuum devices, penile injection, and the urethral pellets have a success rate between 50% and 70%. When injections or a vacuum device is suggested, some sexual counseling can help a couple discuss their options and plan how to make the new treatment a comfortable part of their sex life.

Penile prostheses or implants

Surgery to implant a prosthesis in the penis was the first really successful treatment for medical erection problems. Over the past 30 years, many of these operations have been done, and they still work quite well to treat permanent erection problems. There are 3 main types of implants.

Semi-rigid rods: For the simplest type, 2 silicone rods are placed into the spongy tissue of the penis. The result is a penis that hangs about 45 degrees from the body and always stays about 80% erect. Since it is above the urethra, the prosthesis does not affect urination. Most semi-rigid prostheses are easily shaped. A thin metal core runs through each rod. When you bend the penis up or down to conceal it during non-sexual activities, it stays bent. With any of the semi-rigid prostheses, a man can avoid an obvious bulge at his crotch by wearing briefs made for athletics, with heavier than normal elastic in front.

Inflatable 3-part pump (multi-part pump): The inflatable penile prosthesis has 3 main parts, and it offers the choice of a soft or hard penis. It is a pump system placed entirely inside a man’s body. Two tough inflatable silicone cylinders are put inside the penis just as the rods are in the semi-rigid implant. A balloon-shaped reservoir (storage tank) that contains a mixture of salt water and x-ray dye is tucked behind the groin muscles. (The x-ray dye is used so that the system can easily be checked for problems after it is in place.) A pump is placed inside the loose skin of the scrotal sac. All the parts are connected with tubing.

Usually, the salt water stays in the reservoir, leaving the cylinders in the penis empty. From the outside, the penis looks the same as it normally does when not erect, except that it is always a little fuller. When you are ready for sex, you stiffen the penis by squeezing the pump under the skin of the scrotum several times. This pumps the salt water into the cylinders and inflates the penis as blood does in a natural erection. When you have finished sexual activity and no longer want an erection, you press a release valve on the bottom of the pump. The cylinders will deflate. The salt water then returns to its reservoir and your penis becomes soft.

Inflatable 2-part pump: A simpler 2-piece inflatable prosthesis is a cross between the semi-rigid and multiple part types. It has 2 cylinders that connect to a combined pump-and-reservoir unit that is placed in the scrotal sac. The 2-piece inflatable prosthesis cannot produce as long or thick an erection as the newest multi-part inflatable. When the penis is not inflated, it will be softer than with a semi-rigid prosthesis, but not as soft or small as with a multi-part inflatable.

Special things to think about before choosing an implant: Men in poor health are advised to try the semi-rigid or 2-piece inflatable types, since the surgery is minor and the risk of future problems is so low. A man who has superficial bladder tumors that keep coming back may need an inflatable prosthesis because the semi-rigid rods interfere with cystoscopy (a test that looks inside the bladder). A man who is physically active, either on the job or in his leisure time (jogging, playing tennis, riding), may be more pleased with an inflatable type, since it does not get in the way as much.

If you are seriously thinking about prosthesis surgery, you might read the chapters on medical and surgical treatments in the books listed in the “Additional resources” section. Implants carry some risk of complications, such as infection. Also, the devices with more parts are more prone to failure, which then requires a second surgery.

Learn as much as you can and ask your urologist questions about possible complications before making your decision. A man who is married or in a committed relationship should include his partner in any decision about implants. Your partner needs to understand the procedure and to have a chance to discuss any fears or questions with you and the doctor. You also must be realistic about what a prosthesis can and cannot do for you. Any penile prosthesis is just a mechanical stiffener for the penis. Having a penile implant cannot solve any other problems, such as low sexual desire, lack of sensation on the skin of the penis, or trouble reaching orgasm. It cannot turn a poor sexual relationship into a great one.

A couple needs to talk openly before they have sex after implant surgery. You may need to experiment with different kinds of touching or with different positions. Make sure you are truly excited before trying to have sex, rather than starting sex just because your penis is erect. Couples who have maintained mutual touching, even if an erection problem prevented penetration, tend to adjust more easily to the prosthesis.