Erectile Dysfunction

Impotence or erectile dysfunction is defined as the inability to achieve or maintain an erection sufficient for sexual intercourse It also includes the inability to get an erection as a result of sexual stimulation or losing your erection prior to ejaculation.

Impotence or erectile dysfunction (ED) is a common treatable condition affecting up to 1 in 5 men in Singapore. It tends to be more common and more severe as one gets older.

Seventy-five percent of ED cases are physical in nature, not psychological. Relative blockage of the penile blood flow or problems with the nerves producing erections lie at the root of most problems.


Some men with erectile dysfunction may unknowingly have symptoms which affect penile blood flow and/or causes nerve damage. These symptoms are:

High Cholesterol

High Blood Pressure

Diabetes

Sometimes ED becomes the symptom through which such health problems are discovered. Patients with ED are usually screened for such risk factors before treatment of their erectile problems. Less common causes include:

Spinal problems

Radiation to the pelvic area

Surgery

Certain medications

Treatment for Erectile Dysfunction

1

Oral medication

Sildenifil (Viagra), Vardenifil (Levitra) or Tadalafil (Cialis) are phosphodiesterase 5 inhibitors. They are the first line of treatment and basically facilitate penile engorgement. Treatment is successful in up to 80% of cases. Patients on Oral Nitrates for heart conditions cannot take these pills and those in poor health should see a urologist before trying out such medications on their own. Those with nerve damage like diabetics and post pelvic surgical patients have a lower success rate.

2

Intra cavernosal injections

In those in whom oral medications don’t work, direct injection of a medication (PGE1) that causes blood vessel dilatation is an option. Patients will be taught to inject the medication using a minute needle to produce an erection when needed. Mild discomfort is experienced at the site of injection and an erection is produced in about 10 minutes.

3

Vacuum pump

In those with very poor penile blood flow or severe nerve damage, even injections may not work. A non surgical option is to use a vacuum pump to achieve penile engorgement so that penetration can be achieved. However the penis and glans may feel cold, the technique may be off putting and some manual dexterity is required.

4

Penile implant

nflatable rods are inserted into the working channels of the penis through an incision in the base of the scrotum. These rods are connected to a reservoir of fluid activated by a pump. This is manually activated when an erection is required.

Andropause

A progressive decline in male hormone (androgen) production is common in males after middle age. Known as "andropause" or " Androgen decline in the Aging Male (ADAM)", this syndrome is characterized by a decrease in blood levels of testosterone (androgen) as well as other hormones such as growth hormone, melatonin and DHEA.

Symptoms include fatigue, depression, decreased libido and alterations in mood, memory and cognition. Erectile problems per se are not related to declining testosterone levels but may be more a sign of vascular disease.

The clinical management of andropause requires an individualized approach. In some men, the main problem may be stress or lifestyle related, whereas in others, low male hormone levels may play an important role. In such cases, judicious supplementation of testosterone can be very effective. Close monitoring of blood counts, PSA and liver function is mandatory while on testosterone

Penile disorders and cosmetic correction

Circumcision

With a wealth of specialist training in paediatric surgery, we perform laser and conventional circumcision in children in addition to adults.

Penile deformity

Injudicious injection of silicon/oil/other foreign material for penile enlargement often results in a severely deformed appearance. We perform a 2 stage corrective procedure using surrounding penoscrotal skin that gives a more natural result than skin grafts.

Male factor infertility

Infertility is the inability to get pregnant after trying for at least 1 year without using birth control. About 15% of couples are infertile. About one-third of cases of infertility are caused by male factors alone. A combination of male and female factors causes about 20% of cases. Therefore, the male factor is at least partly responsible in about 50% of infertile couples.

It is important to consider the couple as a unit in evaluation and treatment and to proceed in a parallel manner until a problem is uncovered. There are many causes for infertility in a male. These may be related to previous infections, drugs, lifestyle factors, previous surgery, problems with ejaculation or testicular disorders. There are also certain rare medical and hormonal conditions that interfere with sperm quality and transport. Unfortunately, the cause of infertility is unknown (idiopathic) in up to 40% of men.

Your doctor will obtain your medical history, examine you and test your semen at least twice. A semen analysis can tell your doctor about your sperm count and sperm quality. Some basic hormone tests are also performed. More testing may be needed, depending on the results of this first evaluation.

More than one-half of cases of male infertility can be corrected. Treatment may help a couple get pregnant through normal sexual intercourse. Sometimes the man needs surgery to correct the problem that is causing his infertility. These include

  • Varicocelectomy

  • Vasovasostomy and Epididymovasostomy

  • Transurethral Resection of Ejaculatory Duct

  • Sperm retrieval

We provide a comprehensive service for the evaluation and treatment of male infertility. Consideration of the couples age and situation will influence management decisions.

MEDICAL TERMS

HOW DOES IMPOTENCE VACUUM PUMPS WORK?

Impotence vacuum pumps create an erection by using a plastic cylinder which is placed around the penis. A manual or electronic pump gradually withdraws the air from the cylinder, creating a vacuum and drawing blood into the penis. Once the penis is rigid, the cylinder is removed and an elasticized band (often referred to as a "tension ring") is applied to the base of the penis to prevent blood from flowing back into the body and to maintain the erection during intercourse.

The diagram on the right clearly demonstrates how an impotence vacuum pump works.



NOTE: The tension ring should never be left on for more than 30 minutes

VARICOCELECTOMY

A varicocele is a mass of enlarged and dilated veins that develops within the scrotum. These veins are blood vessels that drain the testicles. If the valves that regulate bloodflow from these veins are defective, blood does not circulate from the testicles efficiently, causing swelling in the veins above and behind the testicles with resulting warming of the testes. This warming effect can affect testicular growth and sperm quality. Sometimes patients experience a vague heaviness or discomfort in the affected scrotum. Many varicoceles do not cause symptoms and are discovered only when the patient sees a doctor for fertility issues.

Varicoceles are classified according to how visible they are. The more visible, the higher the grade and the more likely to have symptoms:

Subclinical: Not felt or seen by the doctor. Detected only by Dopppler ultrasound examination.

Grade 1: Felt when the patient strains hard but not otherwise visible
Grade 2: Can be felt without the patient straining hard but still not visible
Grade 3: Easily seen and felt. Commonly described as a “bag of worms”.

Varicocelectomy is the most common surgical procedure for infertility in males. This operation improves semen quality in about two-thirds of men and basically doubles the chance of conception. The operation is usually performed through a small groin incision as a dayprocedure. Laparoscopic varicocelectomy is also performed but has no clear cut advantage over a small inguinal incision. Complications following varicocelectomy include hydrocele formation, epididymitis, injury to the internal spermatic artery and persistent or recurrent scrotal varicoceles. Fortunately, this occurs in less than 3-5% of patients.

TRANSURETHRAL RESECTION OF EJACULATORY DUCT

Sometimes the exit site of the "sperm" transporting tube (vas deferens) is blocked. Under anesthesia they are inspected using a scope and then can be incised or unroofed. In select cases, this transurethral resection of the ejaculatory ducts has resulted in marked improvement in semen parameters, and pregnancies have been achieved.

SPERM RETRIEVAL

In cases where the blockage is not remediable and sperm can be retrieved for assisted reproduction.

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