ED - Erectile Dysfunction (Started August 2005)

[Tim468]

I think that this shows that some of the ED associated with Peyronie's Disease can be considered "psychological", and not physiological. This is why giving such things a bit of time, and seeking professional help are worth doing, as well as seeing if one's own thinking is so negative as to "proram" failure into the equation.

Sadly, for many of us, it is also a fact of Peyronies Disease that our erections are not as firm or longlasting anymore.

Tim

[PainIsGrowth]

I was wondering if any members with the hinge or buckling symptoms have ever had any substantial improvements in condition.  My main concern with this hinge problem is drastic ED.  Specifically what medicines were helpful with it?  My hinge developed suddenly and seems to be the main symptom of my case, as I can feel no palpable plaque anywhere?  To the best of anyone's knowledge, is the hinge some sort of plaque or scar tissue that simply wraps all the way around the tunica?  Does it seem likely for this type of scar tissue damage to develop over a few day period.  My hinge could be best described as a making the penis feel floppy, and the whole penis flattens out if I rest my finger on the underside of it near the base.  I am currently trying pentox and arginine, but would appreciate any of thoughts on the progression of the hinge symptoms or possible treatments.      

[Liam]

Getting blood back to the hinged area would seem to be a good thing.  In that case the VED would be the tool of choice.  This is just my opinion.  I bet OLd Man would support it.

Liam

[kenno]

"Bringing Peyronie's Disease Out of the Dark Ages
Mark M. Newell Ph.D.
This year the American population reached the 300 million mark. The event occurs at a time when American and global medical science is making advances in technology and treatments that were simply unimaginable as little as twenty years ago. Yet, as most patients seeking care enjoy 21st century medicine, there is a significant portion of the American population – perhaps as many as 30,000,000 men, who have a condition that is largely, and erroneously, considered untreatable. The level of care most of these men receive is not much advanced from that given in the Sixteenth Century when the condition was first recorded! ..."

http://www.peyroniesassociation.org/staying_informed/commentary.php

[Liam]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17402321&query_hl=2

Isr Med Assoc J. 2007 Mar;9(3):143-6. Related Articles, Links  


Plasmid-based gene transfer for treatment of erectile dysfunction and overactive bladder: results of a phase I trial.

Melman A, Bar-Chama N, McCullough A, Davies K, Christ G.

Department of Urology, Albert Einstein College of Medicine, Bronx, NY 10461, USA. amelman@aecom.yu.edu

BACKGROUND: Ion Channel Innovations has developed a gene transfer product, hMaxi-K, and has begun clinical trials to investigate the effect of increased expression of Maxi-K channels in the smooth muscle of the penis or bladder in patients with erectile dysfunction and those with overactive bladder. The primary function of K channels is to modulate Ca++ influx through Ca-channels (i.e., L-type, voltage-dependent). The amount of Ca++ that enters the cell through these channels is a major determinant of the free intracellular calcium levels inside the smooth muscle cell, which in turn determines the degree of smooth muscle cell contraction. Increased Maxi-K channel activity is associated with smooth muscle cell relaxation, resulting in, for example, penile erection and detrussor muscle relaxation. A phase I clinical trial that used hMaxi-K has been completed and a similar trial to assess safety of the transfer for overactive bladder is about to begin. OBJECTIVES: To assess the safety and tolerability of escalating hMaxi-K doses by clinical evaluations and laboratory tests, and to measure efficacy objectives by means of the International Index of Erectile Function scale. METHODS: In the erectile dysfunction trial 11 patients with moderate to severe erectile dysfunction were given a single-dose corpus Cavernosum injection of hMaxi-K, a "naked" DNA plasmid carrying the human cDNA encoding for the gene for the alpha, or pore-forming, subunit of the human smooth muscle Maxi-K channel, hSlo. Three patients each were given 500, 1000, and 5000 pg and two patients were given 7500 microg doses of hMaxi-K and followed for 24 weeks. Patient responses were validated by partner responses. RESULTS: There were no serious adverse events and no dose-related adverse events attributed to gene transfer for any patient at any dose or study visit. No clinically significant changes from baseline were seen in physical evaluations (general and genitourinary), hematology, chemistry and hormone analyses, or in cardiac events evaluated by repeated electrocardiograms. Importantly, no plasmid was detected in the semen of patients at any time after the injections. Patients given the two highest doses of hMaxi-K had apparent sustained improvements in erectile function as indicated by improved IIEF-EF domain scores over the length of the study. One patient given 5000 microg and one given 7500 microg reported EF category improvements that were highly clinically significant and were also maintained through the 24 weeks of study. CONCLUSIONS: Efficacy conclusions cannot be drawn from results of a phase 1 trial with no control group. However, the promising primary safety outcomes of the study and preliminary indications of effectiveness provide evidence that hMaxi-K gene transfer is a viable approach to the treatment of erectile dysfunction and other smooth muscle diseases with targeted access.

Publication Types:
Research Support, Non-U.S. Gov't

PMID: 17402321 [PubMed - in process]  

[youngPD]

Hello everybody

First of all ,to state my case :I am 33 years old and unfortunately single,and have a pretty bad case of Peyronies Disease ,lots of areas with fibrosis, in a kind of "diffuse pattern". as a result ,I can't keep an erecion without a constant manual stimulation (and shrinkage as well).I have to say my Peyronies Disease started ,not similar to many other cases,with a sound of a "click" ,coming from below my left testicle during sex.from that time ,every time I masturbated I got kind of a strange feeling ,sometimes painfull ,below this testicle and soetimes along the penis.

My questions for you guys :

1.As I have a severe venous leak due to my Peyronies Disease ,does anyone of you ever heard of anything to enable sex in this condition ? I have heard opposite opinions regarding the VED : some said it may be helpful and some claimed it may cause more damage.
2.regarding the pentox - is it similar to the aspirin ? or even stronger ?
Has the Pentox ever brought about serious progress in ED ? if not , so what's the point to use it ? and do you know if it may be dangerous or not ?
Do you have any positive news about emerging new solutions coming up soon ?

3.How do you guys (the single young guys of you...) ,have managed to cope with the sharp change in your abilities and thus your lifestyle such as no more hooking at the bars or talking with the girls in each cafe place like I used to do ?
How did you manage to overcome the fear while trying to date with a new girlfriend with the new sexual condition - meaning the ED? how did it go with the sex ?

Thanks alot for helping

[Liam]

Constriction bands (penis ring) may prolong erection and allow for sexual relations.

No, aspirin and "pentox" are different.  Aspirin is an NAID and pentox is a Xanthine.  

Pentox has had some success in studies done.  There are more studies being conducted.  Use the search on this site.  There has been a TON written on this subject.

Welcome Back.

Liam

[PainIsGrowth]

This may seem like a question out of frustration, but here it goes.  I've read as much as I can about the venous leak or (veno-occlusive disorder) and I can't seem to find any indication that people have ever improved from this condition.  I know that ED which is caused from arterial hardening can sometimes be cured if physical fitness is greatly improved, and plaque that is damaging the arteries reverses.  I'm just wondering whats the deal with the venous leak.  It seems like the worst side effect from the peyronie's, that I have experienced.  Somehow the plaque in the penis tissue is interferring with the expansion of the tissue, which doesn't allow the veins to pinch off.  This makes the blood that rushes to the penis leak out faster than it should, so an erection never gets completely hard, and dies quickly without constant stimulation.  I'm wondering if it should be possible for this type of condition to ever improve, albeit slowly over time, if the internal plaque somehow resolves.  I have been contemplating a traction device to improve the slight curvature and major size loss, and read that Dr. Levine is conducting a clinical study on the device that seems promising.  I'm just wondering if a traction device theoretically could improve venous leak erectile dysfunction.  Just hypothesizing, if the device really does induce penile tissue growth from the constant tension, that new tissue should be free from plaque and healthy.  Wouldn't that new healthy tissue maybe increase the ratio of elastic tissue to scar tissue enough to improve ED?  I feel like i'm pulling at strings, but I'm trying to stay positive and look for possible leads.  
I know Levine is recommending the FastSize device, and the European studies used a device made by the SizeGenetics company (not 100% sure).  Anybody have recommendations between these two?

[Liam]

Just speculating, the traction may reshape the plaque, elongating and thinning it.  It seems plausible the ED could improve under these circumstances.  However, it could get worse or not change at all.  I am doubtful about regrowing new tissue, although, I don't discount it altogether.

I have convinced myself to try using mine again.  I have a $50.00 Ebay special.  I may break down and buy a fancy one.  The noose is the part that is the most uncomfortable.

We live in the gray area.

Liam

[Hawk]

Pain,

You ask some good questions.  I share some of your ignorance on these issues.  In fact I really question if anyone has in-depth complex answers to the complexity of ED issues.  I do have some thoughts and a few things I think I know.

Venous leakage:  It seems clear to me that venous leakage could be the result of at least a few different situations, each with a somewhat different solution.  I think the first thing we need is a clear, complete definition of venous leakage and its several causes.  Generally it only means that blood flows out of the penis as fast or faster than it flows in.  Since normal erection results from nitric oxide relaxing the arteries and allowing blood to rapidly flow into the penis, and since this enlargement is really what squeezes the veins and further seals them off, how much of your ED is really venous leakage?  How much of it is really reduced arterial inflow? The very fact that stimulation causes the process to work, makes me conclude that you have no venous leakage that is the result of plaque that is preventing veins from being squeezed.  You have no valve issues in the veins (I am not sure valves are ever a factor in venous leakage ED).  Under stimulation, the entire process works.  

This tells me that possibly you have a normal cascading series of events that goes something like:
Stimulation cause a barely adequate flow of blood to start an erection.
The veins get put under enough pressure to reduce outflow and you get more of an erection.
When the physical stimulation stops, the psychological stimulation is not adequate to maintain in flow.
Your erection reduces
Your anxiety level pushes more adrenalin (strong vaso-constricting erection killer) in to your blood.
The inflow reduces more and the veins are now decompressed to speed the outflow as the inflow reduces.

Your psychological distraction from sex (evaluating your erection, thinking of peyronies), and your adrenalin producing anxiety, probably contribute to undermining the process from beginning to end.

Now, ... I could be full of crap, but I for one cannot come up with any other theory that adequately explains your scenario and until I hear one, this is where I cast my vote.

Solutions:
Reduce anxiety thus reducing adrenalin
Assist arterial dilation with a minimal dose of an ED drug (Viagra, Cialis, Levitra, HGW, Arginine) in some combination.
Reduce outflow with a constriction ring.

Remember, just because a constriction ring works does not mean you have scar tissue causing the veins to leak.  It often just means that it gives the slow arterial inflow time to catch up and stay ahead of the process.

Also consider that is can loosely be said that we all have venous leakage every time every erection goes down.  That is not due to scar tissue placing support around the vein that prevents its constriction however.

Traction Devices I have read contrary opinions on whether stretching scar tissue on burn victims actually causes the tissue to stretch via producing more cells or via stretching the existing cells and making them thinner. it seems that this would be easy for experts to investigate and solve.  If it has not been solved then we also do not know which of these penis traction and the VED may do.  That is key to speculating on your traction and new tissue question.

[George999]

Interesting new research:

http://www.healthday.com/Article.asp?AID=605057

[PainIsGrowth]

This question will be mainly for those members of the forum with organic ED as a result of peyronie's or old age (old man!).  Let me start by saying, that after having a duplex penile ultrasound, I was diagnosed with having arterial insuffiency and a venous leak as a result of the priapism trauma I experienced.  The doctor rejected peyronie's even though I have new curvature in the flaccid and erect state now.  Mixed ED was the diagnosis, and I only partially respond to PDE5 inhibitors.  The thing is, since the incident, my sex drive has been minimal or nonexistant.  I'll try to be as specific as possible, but I hope I don't offend anyone with the details.  Prior to the injury, when I would fantasize about sex, or see an attractive female, it seemed like my penis somehow would send signals more easily to my brain.  My sex drive was raging, and it felt like I couldn't orgasm enough.  Now, its impossible for me to attain an erection just "thinking" about sex or looking at an attractive female.  Sex also no longer seems like the greatest urge to live for anymore.  Its still pleasurable, but I no longer feel like the young guy who thinks about sex 24 hours a day.  For some reason, I feel like there exists some kind of connection between having a healthy penis and having a strong libido.  This is where I would like people who have been living with real ED to try and retort here.  Specifically, guys on the forum who have had a prostatectomy and had their sexual nerves damaged!!!  I feel like the priapism damaged some of my nerves, because I'm just not responding to sexual inputs normally anymore.  Does having your penile nerves damaged change the way you think about sex, or your sex drives.  If it hasn't affected anyone elses's drive or libido, perhaps I'm just experiencing some sort of depressive slump that is affecting my drive.  But at the same time, I just think when you can't get an erection at will anymore, something that changes your physical body that much has to have an impact on your mental states as well.  Either way, I appreciate everyone's input.  

[Old Man]

PainIsGrowth:

You are asking questions that have been around for many decades. I had a non-nerve sparing radical prostatectomy in 1995 since my prostate gland was very large. Cancer tumors covered about 75 percent of the total gland and had a very high overall cancer score. Surgery was the only viable option for me.

I had always had a very high libido all my life until the surgery. Of course, the first thought I had was that my "total sex life" was gone forever. Emotions were running very high and that also contributed to my inability to even get an erection even with the penile injections. So, the VED was added to my regimen and so far it works well for any and all sex.

Anyway, I am relating the above, (your should go back on the Peyronies Disease history thread and read the background for myself and others on this subject), so that you will not feel that you are alone with this problem. My best advice to you is to slow down, calm down your emotions and get a grip of what is happening in your case. Emotions can be very damaging to one's ego and personal life.

Now, with all that said, you should get the best medical help and follow the advice of the professionals who see your first hand. Give them the benefit of the doubt and accept their advice and try to follow it. I am not saying just blindly do that, but make sure you are getting the best pro advice.

Will be glad to discuss any problems further as they arise. Do wish you luck in your endeavor to satisfy your needs physicially.

Regards, Old Man

[Hawk]

Pain (a better abbreviation than PIG   )

I had a nerve sparing prostatectomy but many of my nerves were still lost.  That coupled with Peyronies Disease has left me with pretty significant ED.  For clarification however you made the following quote:

....guys on the forum who have had a prostatectomy and had their sexual nerves damaged

No "sexual" nerves are involved.  They are simply nerves that control arterial dilation when signaled by the brain.  They have no direct impact on sensation, orgasm, or desire.  Having said that, ED and Peyronies Disease can have a significant psychological impact.  Immediately after my prostatectomy when I was certain I would regain full function within 24 months, my desire, sexual activity, sensation, and drive were unaffected by the ED.  As that time period came and went, I developed Peyronies Disease in addition to the persistent ED.  At that point a pessimistic resolution to a permanent condition began to erode my drive and desire.  There is also a clear "use it or lose it" component.  If you surrender to sexual withdrawal an escalating cycle begins.

As an added point, an erection in itself becomes part of a positive cycle with sexual thoughts resulting in an erection, the erection then leading to more vivid sexual thoughts, and the erection even being very sensitive to minor tactile sensations such as normal movement, clothing, etc.

There is nothing wrong with realizing you are not in craving NEED of continual sex.  If you want to maintain desire however, You must work through the psychological aspects of ED and deliberately make the move to start the cycle with physical stimulation.   IE: Use it or lose it

[jon]

 IE: Use it or lose it

or as the kids say these days: find some strange.
And I've said it before, and it's been reinforced a number of times,for the most part, provided you can maintain an erection enough for intercourse, women aren't turned off by it. Honestly, I've been told by one of my female acquaintances that she had no idea until I told her. Just thought I was shaped a little differently. Now there are some out there will act like a bitch if you're not sporting a baseball bat in your trousers, but they're not worth giving a moments concern over.  

[PainIsGrowth]

I just got a prescription for trazadone to help with NTE's.  I have read through most of the posts on it, and unanimously it appears to be the best drug for healthy nightime erections.  Whats the longest amount of time anyone has been on it?  The priapism really scares me a bit, but I think there is greater risk if I don't get strong erections at night.  I have been trying full dose 20mg cialis, and that probably takes me to a 5 on whatever that erection scale is for NTE's.  Its super frustrating to have ED meds only work so so, and cost 10 bucks a pop.  The thing is, how safe do you think it is to take a pde5 inhibitor at the same time you are taking nightly trazadone, assuming you need one for a relationship?  Also, I read the theories that strong oxygenization through healthy NTE's can balance out the collagen/elastic ratio, and keep the penile tissues healthy.  But, has anyone who went from not getting good erections, then to using trazadone and getting great NTE's, seen any positive change in the appearance or feel of their penis?  Did it get to the point where you didn't need PDE5 inhibitors?  Thanks for the great advice on my past post guys.  I appreciate all of it.

[Liam]

Try 25 mg Viagra (not instead of trazadone).  You can cut a 100 mg in fourths.  Cheaper and works for me.  I have organic ED (much improved) from prostate surgery complicated by Peyronies Disease.  They hit at the same time.  OUCH!  I started a nightly 25mg dose before bed and woke up with an erection the first night.  It may also work for the intended purpose even at this dose.

When combining meds, its always best to check with your doctor and pharmacist.

[PainIsGrowth]

Here is a symptom I have experienced with peyronie's that I have not heard mentioned much on the forum.  When I achieve an erection with manual stimulation now, it is very wobbly at the base, and much less firm in the crural region.  If I clentch my PC and BC muscles I can keep it at center mast and firm temporarily, but it becomes extremely flexible and wobbly as soon as I let up the clentch.  Is this just a normal part of Erectile dysfunction, or is this plaque buildup in the lower crural region?  Even when I am at my maximal erection, the base part of the penis is completely bendable, and it never used to be like this.  Thrusting would be extremely difficult becuase it feels like there is nothing supporting the base.  
Second, this will probably sound strange to those who still get the feeling, but when I achieve and erection now, I don't get that erectical like sensation that usually proceeds a normal erection.  Its hard to describe in more specific scientific terms, but it used to feel like a tingly electrical rush of blood that no longer occurs during an erection and while the erection is maintained.  Would the reason for this be do to the venous leak I have been diagnosed with, or could it just be the smooth muscles cells are no longer relaxing the way they used to?  If someone who can only achieve an erection with a VED and tension ring is reading this, or other guys who have used a VED just for therapy, maybe its the same feeling achieving an erection in that manner.  It just doesn't feel as good, no other way to describe it.  Finally, if anyone has had the wobbly erection problem, and gotten over it over time, please let me know how you did it.    

[Tim468]

I found that 25 mg of trazadone did not do much for me. Viagra has helped with ED, but at the cost of headache. I have done well with cialis for intercourse without the side effects of viagra. I have found that the regular intake of horny goat weed at a fairly high dose (7 capsules at bedtime) helps with sex and NTE both. I like the HGW the best of all.

Tim

[Kimo]

Tim,,i used to have the bad headaches with viagra and runny nose and all that stuff, but i found after about 2 to 3 yrs all those symptoms stopped..I've been using viagra now for about 9 and a half years and i don't have any side effects at all anymore.....I also tried useing cialis and levitra and i liked those also, but have just stuck with the viagra because i think it works better for me....I think when i switch it will be to levitra....

Tim, with the nerve damage in my intestines from having a parasite a couple of years ago,,do you think the Horny Goat weed might be an irratant?  I would like to give it a try as i don't have any ins anymore to get viagra or levitra and would like to go with something natural anyway's.

Also, i tried the trazadone and it didn't do much for me either but put me in a fog every morning when i woke up,,,,,it did make me sleep well tho....

PainIsGrowth,,,,,,I know exactly what you are talking about,,loosing that feeling i called a tingling in the groin's,,,,,Mine stopped because of low testosterone....I don't know your age, but mine went away when i hit my 50's,,,,my testosterone went from a healthy 800 down to a level of 200 which is very low,,,,,I went on the testosterone patch and it helped real well,,," made me so horny, i couldn't stand my self,,doc had to lower the dose "......The feeling did come back after awhile, not as strong but it's there, so be patient...

Kimo

[Tim468]

Kimo, I have had no upset stomach-ache from HGW at all. I have used a fair amount too. I use Nature's Bounty, which has MACA added (which exerts a testosterone like effect, but not at all noticable by me). The HGW content is 500 mg, and the active incredient, icariin is at 10%. Since the biologic equivalency of icariin to viagra is something like 10=15%, I figured that each capsule is something like 5 mg of viagra - so I have tried up to ten capsules at a time.

The effect was not as striking as viagra (which at 100 mg causes a very hard erection, and at 50 mg works a bit less well), but there were few side effects. I was a little stuffy in my nose, had no headache, and tolerated the dose well.

I now take 5 to 7 capsules daily as a supplement most in the evening. I have noted that my NTE's are pretty good and my sexuality is a lot less stressed than before I tried anything (I had a fair amount of anxiety about erectile quality). So overall HGW is cheap and works well for me. I may yet try a higher dose - I go up cautiously when I try higher doses.

Tim

[Liam]

"The supposition for centuries was that oysters, clams and mussels have been thought to have aphrodisiac properties," said researcher George Fisher, a professor of chemistry from Barry University, in Miami Shores, Fla. "And they were eaten raw for that purpose."

Until recently, there was no scientific basis for that belief, Fisher added. But what he and his colleagues have discovered is that mussels, clams and oysters contain compounds that have been shown to be effective in releasing sexual hormones such as testosterone and estrogen. These compounds are D-aspartic acid and NMDA (N-methyl-D-aspartate).

Source:  http://health.msn.com/centers/mensexualhealth/articlepage.aspx?cp-documentid=100101156

[Liam]

This is an outline of everything to do with ED.  WOW!!!  Too big to post.

http://faculty.washington.edu/momus/PB/impotenc.htm

[Liam]

Found this while poking around the FDA site regarding Edex injections.  It is a pdf file and hard to copy and paste.  Look at pages 13 and 14 in particular.
"Local Adverse Reactions Reported by >1% of Patients"

http://www.fda.gov/medwatch/safety/2006/Jun_PIs/Edex_PI.pdf


n = 1065
                           n/%
Penile angulation - 72 (7)
Penile fibrosis - 52 (5)
Cavernous body fibrosis - 20 (2)
Peyronie's disease - 11 (1)

Total  15%

[Tim468]

Dr. Rose has more than data on erectile dysfunction:

http://faculty.washington.edu/momus/PB/tableofc.htm

[ninjagaiden]

Hi guys,

Liam, following your post of June 10th, I was wondering:

I'm not a really sex-driven person and I guess the less you use it, the more prone you are to get ED in the long run (ie, your "use it or lose it" motto) and as I told you before, I can perform sex and watch TV at the same time (well, not really, it's a way of speaking   . I had this problem since the start, (very frustrating sex life) and now I see that if I'm really "hard as rock" aroused, I get more pleasure, so maybe I have some ED problem (my nocturnal erections are not always convincing to me too)...

And in the past 2-3 years, I just can't masturbate (in order to "use it") without visual stimulation (xxx movies, you know what I mean ). If I try, I feel nothing and can't get a proper erection. Younger I could do this with only "thoughts", (mmm, the good old days) now, only with movies...

Could this be ED symptoms, or is it just because I have low sensitivity with my toy...
Also I usually can do it "only once", don't feel the urge for a second shot, and the next morning I usually feel as if I've run a marathon...

What do you think?
Maybe I should see a sexologist for the low sexual desire, at the same time as a urologist specialised in Peyronies Disease...

Also, are there natural supplements that I can take (no viagra or cialis for me now, I'm still too stubborn to start using these drugs) which WON'T HAVE SIDE EFFECTS ( I said it this time) on my testosterone level if I stop using them??
I know you're not doctors, but the doctors I asked are just laughing at me and want to prescribe conventional drugs... I want supplements to increase sex drive and erection firmness (can't be hard enough, right?  ). God I'm ashamed to ask such questions...

[antony]

Hello evrybody,

I don't know if i post in the good section, i'm french so quite complicated for me to understand evrything about the functionnement of the forum. (sorry if my english is not exellent too).Hope you will understand and be able to help me because i have a problem since 6 months that makes me mad.
I was given this adress of forum on another one which was about sexual exhaustion, i was told maybe here you could help me because my problem deals with fibrous tissus in erectile tissue that leads me to total impotence at the age of 25.(even if it doesnt sound like a typical peyronies disease in my case)

I just make a copy of what i sent on the other forum, (sorry if it's a little long)


I try to sum up: i'm 25 and have never had any sexual problem before , evrything was ok .

Evrtyhing started in February 2007, i had a little urinary problem and a sensation of cold in penis , it was diagnosed as a cysticis. Doctor gave me antibiotics for that.

During this time i had 3 intercourses in a night with a girl, with complete and hard erection , as usually, but the erection was with a lack of sensitivity and sensation (probably because of cysticis or antibiotics) .During the 3rd intercourse, the girl was on me and did a wrong lateral move, it hurted me on penis. But we could finish the intercourse. I didn't have any big haematoma or change of color of penis on the moment, just a pain.

I thouht it was nothing but the following days, it was still paintful ,then the loss of sensation and sentivity in penis increased a lot, my glan was totaly cold, and finally 2 weeks after, i lost ALL my erections (morning erections, night erections, reflex erections with girlfriend, etc, etc, i became totally impotent so young).
My penis size also teribly decreased (i had good size before the problem), penis shrunk and changed of form.
I could'nt have no more erection, so no sexual relation, and totally lost my sexual life.
I consulted some specialists who said it would go better, it was not serious, or said crap things (prostatisis, problem of pudendal nerve, etc etc) .
I made a penis echo doppler (for vascularisation of penis) and blood analyses which were normal.

I tried to take viagra or cialis, and saw thanks to the provoked erection ( by viagra or cialis), that my penis was now deformed (curvature on right side), really really smaller, there is a loss of elasticity in erectile tissues, as if corpus cavernosa couldn't grow up as before. The sides of my penis are now very hard and paintful, with no elasticity.

The last doctor i saw thinks i had a shock on tunica albuginea during the intercourse in February and sadly, the scar healing went in bad way, and made a scar tissue on erectile tissue, and that condamns erection!!! According to him, i have a fibrosis of erectile tissues!!And he can't do anything apparently. All that for that. Now i don't trust doctors anymore, and have really dark ideas.

I retried several sexual relations with viagra last month, but nothing is like before now, it's horible , and medicine seems to have no solution.

Nowadays , i have a very probably a fibrosis of erectile tissues of tunica albuginea.

Symptoms are:

-totally impotent
-loss of sensitivity and sensation in penis
-with viagra or cialis, erection isn't 'normal', with no elasticity, penis just becomes hard and paintful. Moreover the size is really smaller than before, and there is a little curvation on right side.
-at flaccid state, there is a torsion at basis of the penis. Moreoever, i can't stretch the penis when i pull on it (as if it was totally fibrosed).
-if i take medicine for erection, as soon as the penis becomes just a little hard, i have like a seminal liquid who goes out from urethra.
-when i touch my penis, the basis can blow up, but the middle is totally thin, like 'retracted'.
-my ejaculation doesn't go out strongly, in 'eject' and big quantity like before, but just like a small liquid which flows out without any force, and so without real orgasm, and i can't control the moment when it will flow (contrary to before).
- to finish, i have a sensation of 'dead penis', my sexual life is totaly destroyed, my man's life too, i am now in depression because of all that.

So it's like a damaged penis which didn't scared well, and that makes erectile tissue don't work.


Ok sorry for this long explanation.

Doctors don't told me i had a peyronie's disease, coz it's not a typical way to happen, my curvature is not so huge, and i was told it was quite rare to become totally impotent in one month because of a peyronies disease. Moreover at flaccid state, its visible that the form of penis changed and that i lost elasticity, but they didn't feel any nodule. (but not sure they are competent).

My questions are (because your forums seem to be really more developed and better that french ones):


1)has anyone here already have a problem like mine?

2)Do you know if there is a way to recover from impotence (vaccuum, hypertermia, etc,) in this precise case? (in fact my goal isnt to have non natural erections to have sexual intercourse, coz i tried that and its horrible now, the penis has become so hard that it hurts, the size has become to small, and i have no more pleasure, but my goal is to know if there is a way to 'destroy' a fibrous scar tissue in tunica albuginea, and to recover natural erections and size, even if its long, coz i not, i dont see the interest to stay like that from the age of 25 to the end of my life)

3)in the USA do you have any real oral treatment for this type of fibrosis tissue ? (fish oil, vitamine E , etc)

4)do you know if any radiologic test can preceisely show a fibrosis inside penis?

Thanks a lot to have taken time to read me, if anybody can help me or advice me, thanks... Hope my englis is clear.

Antony

[Tim468]

Dear Antony,

First off, I am really sorry that you have gone through such a terrible and frustrating experience. It sounds simply awful.

I cannot diagnose you over the internet, but it sounds like you have a BIG problem. My next post will be a reprint of a JAMA article on managing and evaluating erectile dysfunction - you may get some ideas from it. Also, there is an article referenced in the "Surgery" section that I posted that was written by a French surgeon. He MAY be a good person to go see.

It sounds like you have developed diffuse fibrosis in response to a non-specific injury. It sounds similar to what might happen to the corora cavernosa and tunica when one develops priapism (prolonged painful erection). In priapism, one potential outcome is development of a penis such as you describe (interestingly, that is not always the outcome of priapism - why not?).

You really need a very good evaluation. The ultrasound needs to be done with an injection of the penis with PGE2 to induce a firm erection (as firm as you can get). Then, the blood flow can be evaluated better. If there is evidence of fibrosis. I think that you would be a good candidate for going on Pentox, viagra (or vialis) and arginine for a LONG time (ie 2-3 years) to see if you can reverse this process. The diffuse fibrosis after priapism has been successfully treated in this way.

Finally, if you have a bad outcome (meaning erectile dysfunction and a densely fibrotic penis that does not heal), you wuold be a good candidate for a penile implant WITH grafting. See the reference below. Remember that although it is frightening to think of such things, it should remind you that at the end of this process, you should have back your sexuality - one way or another.

Tim

[Tim468]

JAMA. 2004;291:2994-3003.

INTRODUCTION  

DR BURNS: Mr G is a 66-year-old man with a history of hypertension and sleep apnea. He lives in a suburb of Boston with his wife and has commercial indemnity insurance.

Mr G first developed erectile dysfunction (ED) several years ago. Four months ago when he saw his primary care physician for a routine checkup, he asked about using sildenafil (Viagra). He noted decreased libido and difficulty attaining an erection. He had slight urinary urgency, but no difficulty initiating urination. He had no history of diabetes or cardiovascular disease. In the past, he had used a dental device to treat his sleep apnea but was no longer using one. His other past medical history was a colonic adenoma found on a screening colonoscopy in 2001. His medications were aspirin (81 mg daily), hydrochlorothiazide (12.5 mg daily), and ibuprofen (600 mg 4 times a day as needed). His wife had metastatic breast cancer and was doing well with maintenance therapy. He was working part-time and noted considerable stress due to a home renovation project.

On physical examination his blood pressure was 150/90 mm Hg; his heart rate was 76/min; his lungs were clear to auscultation; and his heart had regular rate and rhythm without murmurs, rubs, or gallops. The abdomen was soft and nontender, without organomegaly. Genitourinary examination revealed small soft testicles and a smooth firm prostate that was minimally enlarged without nodules. His pulses were bilaterally intact.

Laboratory evaluation for secondary causes of ED included the following values: prolactin (4.9 µg/L [reference range, 2-20 µg/L]), thyroid-stimulating hormone (1.7 mIU/mL [reference range, 0.27-4.2 mIU/mL]), total testosterone (505 ng/dL [17.5 nmol/L]; reference range, 270-1100 ng/dL [9.4-38.2 nmol/L]), free testosterone (1.0 ng/dL [0.03 nmol/L]; reference range, 1.5-3.5 ng/dL [0.05-0.12 nmol/L]), and prostate-specific antigen (PSA) (1.4 ng/mL [reference range, 0-4 ng/mL]).

Atenolol (25 mg daily) was added to improve his blood pressure control. He was given a prescription for sildenafil (50 mg to take as directed).

Two months later, Mr G was seen at a follow-up examination. At that visit, his blood pressure was well controlled with hydrochlorothiazide (12.5 mg) and atenolol (25 mg). He noticed no change in his sexual difficulties with the addition of atenolol. Mr G stated that after reading the patient information sheet about potential adverse effects of sildenafil, he decided not to take the medication. His primary care physician suggested that he see an endocrinologist or urologist about beginning testosterone replacement. Mr G is concerned about the potential adverse effects of testosterone therapy. He wonders about the pros and cons of the different treatment options for male sexual dysfunction.


MR G: HIS VIEW  

I'm not quite sure if it started when my wife was getting sick, but that's when it became more noticeable. Not the same desire, and physically it changed. The erection wasn't there. It becomes an embarrassment. That's how I felt about it. So you know, I really didn't say anything. I never investigated it. Maybe I'm from the old school that's very private. But the only thing that I ever knew that they would do is the implants, the Viagra [sildenafil], or the testosterone.

I think Viagra and the testosterone need to be better explained. It seems like they're always putting a mystery to it. The side effects can be a lot worse than what people tell you. They'll say, with Viagra, 10% of the people may have this side effect. But if you're among those 10%, wouldn't you like to know about it first? The only way that I found out about the side effects was I went to the drug store and asked for a printout as to what it does and how it works. Even the pharmacist said, "I don't know all the side effects, because some of them are so minuscule that they're not printed." But if you're affected by it, it makes a big difference.

I'm not very keen on taking medication. So I'd have to do quite a bit of thinking about it, you know. And right now, I'm undecided.


DR K: HIS VIEW  

Mr G actually came to me and asked me for a prescription for sildenafil. He said that he had a normal libido. It wasn't an issue of libido so much as initiating and maintaining erections. One thing that's happened as a result, I think, primarily because of advertising by the drug company that makes sildenafil, is that people come in and actually raise the issue much more easily than they used to.

In someone like this patient, particularly with a borderline low or a low free testosterone value, who probably would respond to either testosterone or sildenafil, what would Dr Morgentaler recommend? I'd like to know whether he thinks that every gentleman who is given a prescription for testosterone should get a prostate biopsy. I'd also like his opinion on whether primary care physicians should be managing much of this by themselves and when the urologist is particularly useful.


AT THE CROSSROADS: QUESTIONS FOR DR MORGENTALER


What is the definition of male sexual dysfunction? How prevalent is it? What are the causes and pathophysiology of ED? What evaluation should be undertaken for a man with sexual dysfunction? What are the medical treatment options? When should a patient be referred to a urologist for sexual dysfunction? What are the surgical treatment options and when should they be considered? What are the risks and benefits of each? What do you recommend for Mr G?

DR MORGENTALER: Mr G is a 66-year-old married man who presents with a history of diminished libido and ED of several years' duration. The onset of symptoms began when his wife became ill. The history suggests various possibilities regarding etiology: psychological (temporal relationship to wife's illness), vascular (age and hypertension as risk factors), or hormonal (low serum testosterone level). Although sildenafil was prescribed, Mr G never tried it. Mr G expressed concerns about the risks of treatment for sildenafil as well as for testosterone.

Mr G presents with a set of common, yet vexing problems for the primary care physician. What kind of evaluation is required for a man with sexual dysfunction? In a case such as this, how does the clinician decide whether to treat first for hypogonadism (low serum testosterone level) or ED, and how to balance risks vs benefits for treatment of a quality-of-life issue such as male sexual dysfunction?

Male Sexual Dysfunction

Male sexual dysfunction can be broadly separated into several major categories, as outlined in Box 1. The introduction of sildenafil, the first of the oral phosphodiesterase inhibitors, in 1998 has created widespread recognition of ED as a primary form of sexual dysfunction in men, and there is gathering interest as well in hypogonadism. However, there is far less awareness of ejaculatory disorders and of anatomical abnormalities of the penis such as Peyronie disease, an inflammatory condition of the penis that results in palpable plaque or curvature with erection.


Box 1. Classification of Male Sexual Dysfunction


It is of the utmost importance to distinguish which of these conditions is present when a man complains of sexual dysfunction, recognizing that more than one may be present in a given individual.1 This is particularly true in older men, since both ED and hypogonadism become increasingly prevalent with age. A common error is to assume that any sexual complaint in a man represents ED, which may lead to inappropriate and ineffective treatment.2 For example, sildenafil is generally not helpful for men with a primary complaint of diminished libido.3

Mr G presents with symptoms of both ED and diminished libido. Sildenafil, as a treatment for ED, may be a reasonable first step. However, successful treatment of patients like Mr G requires an approach that addresses both conditions. Participation by the partner is always encouraged and can be extremely useful; however, many men prefer to address their sexual dysfunction as a personal issue without involvement of their partner, and this wish must be respected.

A Second Sexual Revolution

The advent of oral contraceptives, coupled with the women's liberation movement in the 1960s, ushered in major changes in sexuality and sexual attitudes and has often been termed a "sexual revolution." The introduction of sildenafil in 1998 has created a second sexual revolution, not only because it is the first effective and safe oral medication for the treatment of ED, but also because it has widely affected social attitudes and behaviors regarding sexuality.1-2 Men, as well as women, are now much more likely to raise the topic of sexual dysfunction with their physicians, and it has become a common scenario for patients like Mr G to specifically request a prescription for Viagra (sildenafil) by name. Sexual dysfunction can lead to depression and a profoundly altered sense of self-esteem that negatively affects many relationships; increased awareness and treatment are thus to be greatly encouraged, due to the profound benefits in life satisfaction that may result.2

Epidemiology of ED

Erectile dysfunction is one of the most common chronic disorders affecting men and becomes increasingly prevalent with age. Data from the Massachusetts Male Aging study showed that 52% of men aged 40 to 70 years reported some degree of ED.4 A similar prevalence of ED has also been found in numerous countries worldwide, affecting greater than 40% of men older than 60 years of age in Finland,5 Italy,6 Japan,7 the United Kingdom,8 Australia,9 and Iran.10

Risk factors for ED include age, diabetes mellitus, hypertension, hyperlipidemia, coronary and peripheral vascular disease, smoking, obstructive voiding symptoms, obesity, renal failure, and alcoholism.4, 11 It is difficult to estimate the relative prevalence of these various etiologies, particularly since more than one may be a contributing factor for many affected men.

Medications are also a common contributing factor. The most common offenders include antihypertensive medications, digoxin, antidepressants, spironolactone, -adrenergic agents, and testosterone-lowering medications, such as gonadotropin-releasing hormone agonist/antagonists. New-onset ED associated with a new medication, or an increased dosage, suggests medication as the likely cause. However, this may occur on either a physical or psychogenic basis, since sexual function may be compromised by fears associated with beginning any new treatment, particularly related to cardiovascular health. For instance, the -blocker class of antihypertensives has generally been considered one of the most common causes of medication-induced ED.12 However, in a study of 96 men with newly diagnosed cardiovascular disease and without ED, 31% reported ED after beginning treatment with atenolol (50 mg) and being informed of its sexual adverse effects. In contrast, only 3% of men who were similarly treated reported ED when they were blinded as to the study drug.13 Nevertheless, the development of new or worsening sexual dysfunction of any type in temporal association with initiation of a new medication should prompt consideration of discontinuation of the medication. Treatment with a phosphodiesterase type 5 (PDE 5) inhibitor may be indicated depending on individual circumstances and the medical necessity of the new medication.

There is growing evidence that ED itself represents a risk factor for subsequent development of cardiovascular events, since it is often a manifestation of atherosclerotic disease.14-15

Pathophysiology of ED

Erection occurs as a coordinated event involving psychic arousal and increased arterial inflow to the corpora cavernosa of the penis in response to parasympathetic nerve signaling via the S2-4 nerve roots, together with trapping of blood within the corpora cavernosa via a veno-occlusive mechanism mediated by smooth muscle relaxation12 (Figure 1). Psychic arousal and sexual behavior is facilitated by androgen priming of the anterior hypothalamus/preoptic area.16 Flaccidity occurs in response to sympathetic influences. Corporal smooth muscle relaxation is mediated by the conversion of guanosine triphosphate (GTP) to cyclic guanine monophosphate (cGMP), under the influence of nitric oxide.17-18 The medications sildenafil, vardenafil, and tadalafil act by inhibiting the metabolism of cGMP by PDE 5, which is found almost exclusively in the corpora cavernosa.19



Erections may fail due to inadequate psychic arousal (eg, anxiety, depression); inadequate hormonal priming of sexual centers in the brain (eg, low testosterone); inadequate nerve signaling to the penile vessels (eg, spinal cord injury, multiple sclerosis, radical prostatectomy); arterial insufficiency (eg, atherosclerosis, vascular surgery, pelvic/perineal trauma); or impaired veno-occlusive ability within the corpora cavernosa (eg, radiation, Peyronie disease, atherosclerosis).1

Evaluation of the Man With ED

Face-to-face evaluation provides the best opportunity to explore the physical and psychological aspects of male sexual dysfunction and allows for identification of modifiable risk factors that may have an impact on general health, such as low serum testosterone level, diabetes mellitus, hypertension, hyperlipidemia, smoking, alcoholism, and depression. Creation of a therapeutic relationship may be critical for a successful outcome, since initial treatment attempts are often less than completely satisfactory.

The Sexual History. The primary goals of the sexual history are to identify the problem, assess its severity, and determine the degree to which the patient and/or his relationship has been affected. The diagnosis of ED is made by history alone and is defined by the inability to achieve or maintain an adequate erection for satisfactory sexual function.1 If ED is present, it is useful to try to determine whether the problem is likely to be organic (physical) or psychological in etiology, since this may influence treatment. Complicated psychosocial issues should be referred to a mental health professional. In Mr G's case, it is noteworthy that he describes his difficulties as occurring around the time of his wife's illness. This is not an uncommon presentation and suggests a psychological contribution to the sexual dysfunction. Some men may understandably feel hesitant or guilty about initiating sex when their partner has been ill, even when the partner encourages the activity.

I recommend a set of questions that are direct and nonjudgmental (Box 2).20 The use of clear terminology, such as the words "penis," "erection," and "orgasm," is helpful, particularly since this gives the patient the opportunity to use similar language without concern that he is using offensive terms. Two questions that have been particularly valuable in my experience are: "What happens when you try to have sex?" and "Is the penis usually hard enough to go inside your partner?"


The intermittent or sudden inability to have a firm erection suggests a psychogenic etiology. Low sexual desire suggests the diagnosis of hypogonadism, depression, or a medication effect. Inability to maintain an erection is most often due to poor veno-occlusive function of the penis, but it is helpful to ask whether softening of the penis happens before or after orgasm, since men with premature ejaculation may describe their symptoms similarly.1

Physical Examination. A directed physical examination should be performed for the man with sexual dysfunction. Specific items to be evaluated include assessment of general health, vigor, mood, and blood pressure. The presence of gynecomastia should be noted. The penis should be palpated to identify the presence of penile plaque, which is indicative of Peyronie disease. Testicular size and consistency should be noted, since small, soft testicles are associated with low serum testosterone level. Peripheral pulses should be evaluated. Neurological assessment should include a digital rectal examination (DRE), since nerve roots S2-4 mediate both erection and anal tone. The prostate should be assessed for size and for the presence of nodularity or asymmetry.

Diagnostic Tests. The goal of diagnostic testing in the primary care setting is to identify abnormalities that may contribute to sexual dysfunction, such as an endocrinopathy, or treatable medical conditions that may be associated with ED, such as diabetes and hyperlipidemia. For this reason, based on clinical experience, I recommend routinely performing the following blood tests in men who present with ED: hematocrit, glucose, total and free testosterone, prolactin, and a lipid profile. Tests of thyroid function and hemoglobin A1C are optional. The luteinizing hormone level should be measured if the history suggests hypogonadism. Men with penile curvature or premature ejaculation do not require diagnostic testing but should be referred to an appropriate specialist, usually a urologist. Testosterone levels should be considered in men with difficulty achieving orgasm unless their symptoms are clearly related to medications known to have this adverse effect, such as the serotonin reuptake inhibitor class of antidepressants.21

A variety of testosterone assays exist. Total testosterone has been used most frequently; however, since the majority of circulating testosterone is bound tightly to sex hormone–binding globulin and is not biologically functional, exclusive reliance on the total testosterone assay will result in underdiagnosis of hypogonadism. Although there is as yet no consensus regarding what serum level defines hypogonadism, values less than 300 ng/dL (10.4 nmol/L), and in some cases 350 ng/dL (12.1 nmol/L), are often used as an inclusion criterion for clinical trials. Unfortunately, the reference ranges for serum testosterone provided by many laboratories are overly generous at the lower range, resulting in categorization of too many results as normal when in fact they suggest hypogonadism.22 The measurement of bioavailable or free testosterone appears to be more useful. Although there is debate regarding the accuracy of the widely used analog assay for free testosterone,23 my experience is that it aids considerably in the identification of hypogonadal men who might benefit from treatment.24 There is no basis for the use of age-adjusted reference values for testosterone, since men of any age will experience similar symptoms at low testosterone levels.

More sophisticated tests, such as nocturnal penile tumescence and rigidity monitoring25-26 or penile Doppler ultrasound of the cavernosal arteries,27 can provide additional functional information but are not necessary in the initial evaluation.

Oral Phosphodiesterase Inhibitors

Treatment must be tailored to the individual. Some men may not desire treatment at all. Others, perhaps like Mr G, are interested primarily in gathering information about treatment options before initiating therapy.

The oral phosphodiesterase inhibitors—sildenafil, vardenafil, and tadalafil—represent first-line therapy for men with ED. Sildenafil and vardenafil have similar pharmacokinetic properties, with peak serum concentrations at approximately 1 hour and a half-life of 4 to 5 hours.3, 28 Tadalafil has a considerably longer half-life of approximately 18 hours, with evidence that erectile function continues to be enhanced for at least 36 hours.29 Although to date no head-to-head clinical trial results between these drugs have been published, their overall clinical efficacy appears to be fairly similar, with minor differences in results likely due to variations in the patient populations studied.3, 28, 30 For example, in a double-blind randomized study of 532 men, successful intercourse was achieved in 69% of men receiving 100 mg of sildenafil compared with 22% of men receiving placebo.3 In a study of 348 men using tadalafil (20 mg), 59% successfully reported intercourse at 36 hours, compared with 28% in the placebo group.30 And in a multicenter, double-blind, placebo-controlled trial, 69% of men receiving vardenafil (20 mg) successfully reported completing intercourse, compared with 22% receiving placebo.28

Approximately half of men with diabetes mellitus or more advanced coronary and peripheral vascular disease report benefit.31-32 A success rate of roughly 30% has been noted following radical prostatectomy.33 An attempt at treatment with oral agents is warranted only if the nerves have been spared, and even then, success is unlikely unless at least partial return of erections has occurred.

Patient education is critical for optimal response to sildenafil. This includes informing the patient to take the medication on an empty stomach and to time sexual activity so that it occurs within 1 to 6 hours, as well as explaining that sexual activity of some sort is necessary to obtain a positive effect. If an initial starting dose of 50 mg is ineffective, I recommend increasing the dosage immediately to 100 mg: nothing is gained by repeated attempts at a subtherapeutic dose. Similar instructions should be provided for vardenafil. However, instructions regarding the timing of intercourse may be considerably liberalized for tadalafil due to its prolonged duration of effect, although peak concentration occurs somewhat later, at 2 hours.

Limitations. Many men who fill prescriptions for sildenafil never refill them, and many others, like Mr G, receive a prescription but never fill it. Reasons for this include ambivalence about taking a medication for sex, cost, concerns regarding risk, and negative partner attitudes regarding sex or the medication. Many men and their partners believe that sexual activity should be natural and spontaneous, and they object to the planning required for successful use of oral medications. Still others may hope that their own sexual abilities will return with time or with resolution of personal problems.

Risks. The phosphodiesterase inhibitors have undergone extensive clinical study and have a fairly benign safety profile when taken as directed.3, 28, 30 The single important contraindication is the use of any nitrates, either on a chronic or intermittent basis, due to the potential for significant hypotension. Sildenafil also should not be taken within 4 hours of -adrenergic blockers,34 and vardenafil should not be used at all with them.35 The most common adverse effects are headache (15%), flushing (10%), nasal/sinus congestion (8%), dyspepsia (7%), and transient color vision changes (3%).3, 27, 29 Mr G should be reassured that priapism is extremely rare and treatable, and that he may safely take sildenafil in combination with his antihypertensive medications, atenolol and hydrochlorothiazide.36

Cardiovascular Effects. The relationship of PDE 5 inhibitors and cardiovascular health has been extensively studied. Daily administration of tadalafil (20 mg) for 26 weeks in healthy men or patients with mild ED resulted in blood pressure changes similar to those observed after placebo administration.37 Sildenafil studies have revealed a minor reduction in systolic and diastolic pressures of 2 to 8 mm Hg without appreciable change in heart rate.38

The cardiac effects of sildenafil during exercise in men with suspected coronary artery disease was studied in a randomized, double-blind, crossover study of 105 men with ED who underwent supine bicycle echocardiograms 1 hour after taking sildenafil or placebo. No negative effect of sildenafil was seen with regard to symptoms, exercise duration, or ischemia.39 Similar safety was noted in a double-blind single-dose crossover study using vardenafil (10 mg) or placebo in 41 men with stable exertional angina who underwent exercise tolerance testing.40 No differences were noted between vardenafil and placebo with regard to exercise time or time to first awareness of angina, but vardenafil did significantly prolong the time to ischemic threshold.

A persistent concern among men and their partners is that sildenafil or its competitors might cause a myocardial infarction, based on early reports of sudden death reported in the lay press. An unquantified number of these anecdotal cases were clearly related to the contraindicated simultaneous use of nitrates. Nevertheless, the data regarding PDE 5 inhibitors and coronary artery disease have been reassuring. Cardiac catheterization for severe coronary artery disease was performed in 14 men before and 45 minutes following administration of sildenafil (100 mg), resulting in no negative hemodynamic effects.41 Moreover, an investigation of reports of sildenafil-associated deaths showed no difference from expected death rates,42 and the rate of cardiac events in England among users of sildenafil appeared to be no higher than that of the general population.43 Nevertheless, it must be recognized that sexual activity itself is associated with a small risk of myocardial infarction,44 and cardiovascular assessment should be considered prior to treatment of ED in any patient considered at increased risk for a cardiac event.

Since cardiovascular disease often coexists with ED, the Princeton Consensus Panel was convened to review existing data and provide recommendations regarding the treatment of sexual dysfunction in men with heart disease.45 Those recommendations indicate the need for no additional evaluation prior to treatment for men in a low-risk group, including those with controlled hypertension; mild, stable angina; history of uncomplicated myocardial infarction; and mild valvular disease. A high-risk group was identified in whom treatment of sexual dysfunction should be withheld until further safety data could be accumulated. This group included men with unstable or refractory angina, uncontrolled hypertension, high-grade congestive heart failure, myocardial infarction within the previous 2 weeks, high-risk arrhythmias, obstructive cardiomyopathy, and moderate to severe valvular disease. Men with intermediate risk, eg, those with moderate angina or recent myocardial infarction (<6 weeks), should undergo further cardiac evaluation before restratification into one of the other groups.

Other Treatment Options for ED

Treatment options for ED, benefits, and approximate costs are presented in Table 1. Penile injections with vasoactive medications are effective in 70% to 80% of patients, have an onset of action within 10 minutes, and are nearly painless.46-47 They represent the most common treatment for men who take nitrates or have had no success with phosphodiesterase inhibitors and are used by approximately 10% of men with ED. Alprostadil48-49 is most frequently prescribed but can cause an unpleasant burning sensation in about 20% of men. Papaverine and phentolamine can be used to avoid this problem or used in combination with alprostadil for greater efficacy.50 In a study of 615 cases of men using penile injection therapy, penile fibrosis was noted in 3%, and 4% of men experienced a prolonged erection, representing 0.3% of injections.47 Although less than half of men taught to use penile injection therapy continue to use this therapy for more than a few years,51 satisfaction rates among users are comparable to men who use sildenafil as therapy for ED.52



Intraurethral suppositories of alprostadil avoid penile injection but are less effective and require the use of a tourniquet at the base of the penis for optimal results.53 Initial treatment should occur in a health care environment with proper monitoring due to the rare occurrence of syncope.

Vacuum constriction devices offer a noninvasive yet mechanical treatment and is used by approximately 5% of men with ED.54 A plastic cylinder is placed around the penis and negative pressure is created, drawing blood into the penis. A tourniquet is placed at the penile base once adequate rigidity has been achieved, trapping blood within the corpora cavernosa. Some men find this treatment ideal, although many others find it cumbersome or unappealing.

Surgical implants remain a highly successful and satisfying treatment for men whose condition has failed oral therapy and find other treatment options unsatisfactory.55-56 Nevertheless, the number of procedures performed is relatively low compared with the estimated population of men with ED. A review of 372 cases using the AMS 700CX inflatable prosthesis (American Medical Systems Inc, Minnetonka, Minn) revealed 86% device reliability after 5 years, and 79% of men continued to use it for intercourse at least monthly.56 In a study of 434 patients implanted with the Mentor alpha-1 inflatable prosthesis (Mentor, Santa Barbara, Calif), functional results were similar, with patient satisfaction rates of greater than 80%, and partner satisfaction rates slightly lower than this.57 The appearance and sensation of the penis is quite natural, and psychologically, many men say they feel their problem has been "fixed" after placement of a penile prosthesis. The primary risks are device failure (2% at 2 years; 14% at 5 years) and infection in 2% to 3% of cases.55-56,58

Other Oral Therapies. Apomorphine is a centrally acting oral medication that has shown mild clinical efficacy in the treatment of ED,59 but is not available in the United States. Yohimbine is a plant-derived -adrenergic inhibitor with limited efficacy in the treatment of ED.60 Despite aggressive marketing, no data support the assertion that nutritional supplements, herbal therapies, or vitamins have any beneficial effect in the treatment of ED.1

Hypogonadism

When a man like Mr G presents with symptoms such as diminished libido and ED in association with a low serum testosterone level, the condition is termed hypogonadism.21 Other symptoms and signs of hypogonadism include depressed mood; reduced energy, muscle mass, and strength; reduced bone density; anemia; fatigue; and impaired cognition. Less well-recognized sexual symptoms of hypogonadism include difficulty achieving orgasm, diminished intensity of the orgasm, reduced sexual sensation in the penis, and reduced ejaculate volume.21

Hypogonadism is quite common, since testosterone levels decline 1% per year beginning around 40 years of age.61-62 Thus, the male population at risk for both ED and hypogonadism overlaps considerably. A major issue for clinicians caring for patients like Mr G is whether to first treat his ED, his hypogonadism, or both in combination. Treatment of hypogonadism results in reliable improvement in the symptoms of diminished libido and feelings of enhanced sexuality.63-64 However, ED itself may not respond as well, particularly in older men, due to coexisting vascular pathology.

Forms of Testosterone Supplementation. Forms of testosterone treatment include intramuscular injections every 1 to 3 weeks with testosterone esters (cypionate or enanthate) or topical daily treatments with gels or patches. Gels have become the favored mode of treatment for many patients due to their high efficacy in restoring physiological testosterone levels,65 ease of use, and infrequent skin irritation, the last representing a significant limitation in acceptance of the patches.66 Oral agents available in the United States all share a significant risk of hepatotoxicity,67 and their use is therefore discouraged. An informal survey of Boston pharmacies in April 2004 revealed a monthly treatment cost of approximately $220 for gels and $24 for injections.

Risks of Testosterone Treatment. Testosterone supplementation within the physiological range is generally well tolerated. Risks include erythrocytosis in as many as 50% of men receiving injections, but in only 5% of men using gels or patches.21 Gynecomastia, peripheral edema, exacerbation or de novo sleep apnea, acne, and mild weight gain occur in less than 2% of men.64 Testicular atrophy can occur, more prominently in younger men. In addition, men must be advised that fertility will be impaired while receiving exogenous testosterone due to negative feedback on pituitary gonadotrophins.68 Exacerbation of bladder outlet voiding symptoms is uncommon. Transdermal preparations are associated with local skin reactions in 3% to 5% of men using gels and as many as 40% of men using patches.21 There is no evidence that testosterone supplementation represents a risk for cardiovascular disease; on the contrary, some studies suggest that it may even be beneficial.69-71 Although testosterone treatment may reduce high-density lipoprotein cholesterol, total cholesterol is generally reduced as well, resulting in a neutral net effect.72 Liver toxicity does not seem to be associated with transdermal or intramuscular preparations of testosterone.21

One must also consider the risks of failing to treat men with hypogonadism. These may include depression, diminished sense of vitality, sexual dysfunction, anemia, and reduced bone mineral density.21

Testosterone and the Prostate

The greatest concern of clinicians regarding testosterone replacement therapy (TRT) is possible stimulation of an occult prostate cancer. This follows from the work of Huggins et al in the 1940s,73 who showed that prostate cancer was androgen-sensitive by following chemical markers in an uncontrolled study of 8 men with metastatic prostate cancer who underwent bilateral orchiectomy. Nevertheless, the limited clinical trials to date have shown a risk of prostate cancer in men undergoing TRT of approximately 1%, a rate not different from untreated men undergoing screening.74 Moreover, population-based studies have failed to demonstrate that men with higher levels of testosterone are at any increased risk of developing prostate cancer or that men with low testosterone levels are somehow protected against developing prostate cancer.75-78 Furthermore, only 1 of 20 hypogonadal men at high risk for prostate cancer based on a prior history of prostatic intraepithelial neoplasia developed cancer after 1 year of testosterone treatment,24 suggesting that TRT may not adversely affect progression of prostate cancer.

Who Should Be Referred for Prostate Biopsy in Association With TRT?

Men with an elevated PSA level or an abnormal DRE finding should undergo biopsy prior to initiation of TRT. Prostate biopsy should also be performed if the PSA rises above the normal range or the DRE becomes abnormal during treatment. There is ongoing debate whether the historical upper PSA threshold of 4.0 ng/mL should be lowered to 2.6 ng/mL.79-80 A rapid rise of PSA is a further indication for biopsy, since this may be a sign of prostate cancer as well. Bhasin and colleagues recommend biopsy for a rise of 1.0 ng/mL or greater within the first 6 months of treatment, and for any rise of 0.4 ng/mL per year after that time.74 Although most clinicians currently reserve prostate biopsy for the indications above, it has been my own practice to perform prostate biopsy prior to initiation of TRT in all men age 45 years or older, since 14% of hypogonadal men with a normal DRE and PSA less than 4.0 ng/mL have biopsy-detectable prostate cancer.81 There is evidence that high-grade prostate cancer, Gleason 8-10, is particularly associated with low testosterone.82

Once treatment has been initiated, men should be monitored with PSA and DRE, as well as hemoglobin or hematocrit, 2 to 3 times within the first year, and 1 to 2 times per year thereafter.21, 74

Who Should Treat the Man With ED?

Most men with ED can be effectively treated by their primary care physicians. Men with physical abnormalities of the penis, such as Peyronie disease, should be referred to a urologist. If oral medication fails or is contraindicated, then the man should be referred to a specialist in sexual dysfunction, which in most cases will be a urologist. Sexual problems related to hypogonadism may also be treated by the primary care physician or referred to a urologist or endocrinologist. Referral to a psychotherapist is indicated for significant personal or relationship issues that appear to be more complicated than a straightforward complaint of ED or low sexual desire.

The Competing Issues of Hypogonadism and ED

The 2 primary treatment options offered to Mr G, testosterone and sildenafil, have widely different actions. Sildenafil effectively improves blood flow to the penis, thus aiding erection, but has no direct effect on libido. Testosterone supplementation, on the other hand, has a wide variety of potential benefits, including improved erections, libido, mood, strength, and sense of well-being. Men who respond to TRT often report that they "feel normal again."

As a rule, I treat hypogonadal men with TRT first, since this may offer a more complete response than addressing ED alone. If ED does not respond to testosterone treatment, I then prescribe a PDE 5 inhibitor. If the man has experienced benefits from TRT, such as improved libido, he may continue both treatments together. If no symptomatic improvement resulted from TRT itself, it is my practice to discontinue it. However, some clinicians choose to continue treatment to address the metabolic effects of hypogonadism.

Recommendations for Mr G

I would first offer Mr G a trial of TRT in the form of a topical gel, adjusting dosage and mode of therapy as needed to achieve physiological testosterone levels. It is my own practice to perform prostate biopsy before initiating treatment because of the substantial prevalence of biopsy-detectable cancer in this population. However, this approach is impractical for nonurologists, and a reasonable alternative strategy is to monitor with PSA and DRE at 3, 6, and 12 months, reserving biopsy for worrisome changes. If Mr G noted improvement in ED and libido with testosterone supplementation, I would continue this treatment indefinitely. If he notices no benefit at all despite mid- to high-normal testosterone levels, I would discontinue the testosterone trial. I would then offer treatment with one of the oral PDE 5 inhibitors. If libido improves with TRT but ED persists, I would continue TRT and add a PDE 5 inhibitor to the treatment regimen.

Given Mr G's concerns regarding risks, I would reassure him that both testosterone and PDE 5 inhibitors have been widely studied and both appear to have good safety profiles. I would specifically add that sildenafil by itself has not been found to be dangerous for the heart, that it can be taken together with his antihypertensive medications, and that priapism is extremely rare and treatable. I would emphasize that he will require monitoring of his prostate and hematocrit indefinitely while receiving TRT. I would then encourage him to begin treatment if he wishes.

It is my own belief that the mission of physicians must include doing our best to improve the quality of life of our patients. Given the importance of sexuality in human life, I encourage clinicians to become knowledgeable in the area of male sexual dysfunction to ably assist their patients to experience full, satisfying, and loving lives.


QUESTIONS AND DISCUSSION  


A PHYSICIAN: You mentioned that sildenafil worked in 80% of psychogenic and 65% of organic cases of ED. What about placebo response in each group?

DR MORGENTALER: The placebo response depends greatly on the study population. Trials that include populations of men with psychogenic ED, as in the first published study of sildenafil, showed 80% efficacy for the highest dose of sildenafil for some measures, with a corresponding placebo response rate as high as 50%.3 Studies of men with more significant medical conditions demonstrate efficacy in 40% to 60%, with a placebo response rate of 10% to 15%.32

A PHYSICIAN: If a man has a nest of prostate cancer cells present on biopsy, would you still offer him testosterone therapy or would you recommend other treatments?

DR MORGENTALER: The single absolute contraindication to testosterone therapy is the presence of prostate cancer,74 and I would not offer testosterone therapy to a man with untreated prostate cancer. Historically, this contraindication has been extended to all men with a history of prostate cancer, with the thought that quiescent cancer cells may be stimulated by testosterone supplementation. But, in my opinion, a blanket contraindication doesn't make sense. We withhold testosterone therapy from hypogonadal men who underwent radical prostatectomy 5 to 10 years ago with an undetectable PSA level even though they are likely cured of their cancer. Why can't we treat them? If their own testosterone level were normal, no one would suggest these men should be castrated.

Another example is that we often give testosterone-lowering treatments to men as an adjunct to radiation therapy for prostate cancer. Afterward, testosterone levels typically return to normal, but not always. Even if those men are highly symptomatic, with hot flashes, low energy, and absent libido, we do not give testosterone because of their history of prostate cancer. But if their testosterone levels spontaneously returned to normal, we say that's fine. This is an artificial distinction. Why should we penalize the man who remains symptomatically hypogonadal?

A PHYSICIAN: Could you comment on the recreational use of sildenafil in men without ED?

DR MORGENTALER: The mythology of Viagra on the street is that it can turn any man into a sexual superstar.2 The ease of obtaining sildenafil via the Internet has essentially demedicalized PDE 5 inhibitors for a substantial number of men without ED who use it for recreational purposes. Some of my own patients without ED have reported that sildenafil provides them with greater rigidity and a shortened refractory interval. However, the effects of the recreational use of PDE 5 inhibitors have not been well studied. My major concern is the psychological impact of taking these medications for younger men who are not yet in a stable relationship. I have seen cases where men who lack for nothing except confidence secretly take sildenafil every time they go on a date, in the hope that it will help them please their partner. However, this can create obstacles for a solid intimate relationship. Apart from issues of authenticity, trust, and honesty, it seems to me that the key psychological cost of using sildenafil recreationally is that, by relying on a pharmacologic enhancement to his sexuality, a man loses an opportunity to achieve what we all look for in relationships—namely, to be loved and accepted for whom we really are.


AUTHOR INFORMATION    



Corresponding Author: Abraham Morgentaler, MD, Men's Health Boston, One Brookline Place, Suite 624, Brookline, MA 02445 (amorgent@yahoo.com).

This conference took place at the Medicine Grand Rounds of Beth Israel Deaconess Medical Center, Boston, Mass, on May 29, 2003.

Acknowledgment: We thank the patient and his doctor for sharing their stories with us.

Author Affiliation: Dr Morgentaler is Director, Men's Health Boston, and Associate Clinical Professor of Surgery (Urology), Harvard Medical School, Boston, Mass.


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Addendum: Useful Questions in the Sexual History

What actually happens when you try to have sex?
Is the penis ever firm enough to go inside your partner?
Does your penis ever become firm?
  Upon awakening?
  With masturbation?
How long has this been a problem?
Did anything happen, medically or socially, around the time that this problem began?
Any new medications around the time that the problem began?
What do you think is causing the problem?
How has this affected you? Your partner? Your relationship?
Are you interested in treating the problem?
Are you able to have an orgasm?
Is there any new curve when you have an erection?
What treatments, if any, have you tried so far?

[Tim468]

One can have radical surgery.

RECONFIGURATION OF THE SEVERELY FIBROTIC PENIS WITH A
PENILE IMPLANT
FRANCESCO MONTORSI, ANDREA SALONIA, TOMMASO MAGA, RENZO COLOMBO,
ANDREA CESTARI, GIORGIO GUAZZONI AND PATRIZIO RIGATTI

These surgeons are in Italy from the Department of Urology, University "Vita e Salute-San Raffaele," Milan, Italy.

No time to post the pictures (i have posted them before - one can search through my old posts). The make the severely shortened and fibrotic penis longer by adding grafts and making relaxing incisions before putting in the prosthesis. It is a last resort, but one should know that those who get this after struggling for a long time with other avenues have a very high satisfaction rate.

Tim

[antony]

Hello Tim, and thanks a lot for answers,

Yes, for sure its a BIG problem, and it's a terrible experience that can give you very, very dark ideas.
I'm 25, last year i was going out with a model and worked in music, some months later my life is destroyed, what happened between that two points? An unusual sexual accident, bad diagnosed by urologists, and now i am just told that i will stay impotent for rest of my life, juste makes me crazy.


'It sounds like you have developed diffuse fibrosis in response to a non-specific injury. It sounds similar to what might happen to the corora cavernosa and tunica when one develops priapism (prolonged painful erection). In priapism, one potential outcome is development of a penis such as you describe (interestingly, that is not always the outcome of priapism - why not?).'

>>>> yes it's exactly what i feel, and what last doctor i saw thinks too. (after....7months!!!!) , and when you say 'non specific injury', its totally that, because what i had doenst look typical, not a typical peyronie, not a priapism, not a very violent penile fracture.

Do you know if some vaccumm exercise can help with such a problem? Or oral medication? (i ask here coz i dont really trust doctors anymore now...one told me to do vaccum, the other told me it wasn't good)... and me, i stay in my condition...


Do you have the name of the french surgeon you speak about?

I tried to take cialis during last month two times a week. In my case, the problem is that the penis has changed of anatomy. I would say the cialis 'works', but the induced erection is now small, with curvature (not a big one, that's not the problem), paintful, with no sensation, and totally hard, with no elasticity in the penis. In fact my penis becomes very very hard and 'sticks itself' to the belly and navel (if you see the image), it doesnt go in 'normal direction' like before, i mean pointing right. There is definitely a big organic problem. It's for that reason i would like treating the fibrous tissue if it's possible, and not only take medicine like cialis or viagra, coz they are not very useful in my case.

What are pentox and arginine ? are they used with 'success' if following impotence due to priapism?(sorry if i haven't read the whole forum, its quite hard for me to understand evrything in english)

For sure i am looking for a very good evaluation, but lots of doctors are not competent here. About sexual problems, they first say its psychologic when you are young  (pffffffffff, i know it was organic), and finally when in my case they admitted it was fisical (just have to see the form of penis!!!, and the unpossibility to stretch it at flaccid state), they said it was too late and now can only give cialis or viagra pfffff i am so disgusted. So i dont know a doctor who could do it.

Do you know if things like fish oil or vitamine E can help?
Has anyone already experienced such a problem as mine?

To finish, i would defintely never accept a penile prothese. First because i cant accept that i went to doctor very soon at the beginning of problem and they let the problem go to total impotence. Secondly because i read some about prothese and it's horrible, it's totally mechanic, you have no more pleasure or what. I am young, not married, i liked enjoying life and go to see different girls, it's not as if i was with my wife and explain her that. And i am too young . And too expensive. Any way that's a solution i can't accept. My goal is to recover from the fibrous tissue. How could i become impotent in so few time? Disgusted.

Anyway thanks a lot for your answers and help. I'm in a such despair, i hope so much find a 'treatement' (to take 1 year to recover, or even more, would make me mad, but i could to that, because it's worth to do it, but if i am clearly said that i just can do nothing, useless to live it).

Thanks Tim,

Antony

[Liam]

What do you think?
Maybe I should see a sexologist for the low sexual desire, at the same time as a urologist specialised in Peyronies Disease...

Sound like a reasonable approach to me.  As far as supplements, many men swear by "horny goat weed" .  "Red Korean Ginseng" has good reviews, also.

[Tim468]

Antony,

I have learned to never say never. You should know that implants have a high satisfaction rate, and men can experience orgasm and good sensations, and it is not mechanical etc. Think of it this way. What if you struggled for3 years, or 5 years, or ten years and got no better? Would you then want to get a bigger and straighter penis that worked and pleased a woman and allowed you to have an orgasm with intercourse? I think the answer is yes. But you are not there now. That is OK - just understand that if you fail to improve, that you DO have an option that can restore you to a way to have back your sex life.

Having said that, I want to remind you that I wanted you to simply remember that you have other options to fall back on as you struggle with your feelings of despair.

Now, as for viagra or cialis... althoug it is hard, you really should go back to read some of the "highlights" on the "Newly Diagnosed Highlights " area. There you will see why we are saying that might be good for you.

The Viagra or Cialis is not intended to promote erection for fibrosis, but to promote healing. Getting harder erections is simply a good side effect! Rather, the viagra, and arginine promote what are called "nitric oxide" (also known as 'NO') biochemical pathways in the body. This will promote an anit-inflammatory healing, and allow recovery better than when such drugs are not given.

Pentoxifylline is designed to reduce the formation of transforming growth factor Beta-1 (TGF-Beta), which is a chemical in the body that promotes fibrosis. By blocking it's formation with pentoxifylline, you allow the fibrosis to gradually reverse.

So, using those medicines may allow a reversal of fortune for you over time. I would waste no time in digging up these articles and reading them and then finding a uroolgist who is willing to work with you.

Tim

Related articles:

Valente EG et al. (2003) L-arginine and phosphodiesterase (PDE) inhibitors counteract fibrosis in the Peyronie's fibrotic plaque and related fibroblast cultures. Nitric Oxide 9: 229–244

Schwartz EJ et al. (2004) Sildenafil preserves intracorporeal smooth muscle after radical retropubic prostatectomy. J Urol 171: 771–774

Rajfer J. Gore JL. Kaufman J. Gonzalez-Cadavid N. Case report: Avoidance of palpable corporal fibrosis due to priapism with upregulators of nitric oxide. [Case Reports. Journal Article] Journal of Sexual Medicine. 3(1):173-6, 2006 Jan.

Aslan A. Karaguzel G. Melikoglu M. Severe ischemia of the glans penis following circumcision: a successful treatment via pentoxifylline. [Case Reports. Journal Article. Research Support, Non-U.S. Gov't] International Journal of Urology. 12(7):705-7, 2005 Jul.

Evliyaolu Y. Kayrin L. Kaya B. Effect of pentoxifylline on veno-occlusive priapism-induced corporeal tissue lipid peroxidation in a rat model. [Journal Article] Urological Research. 25(2):143-7, 1997

[antony]

Tim,

yes i will ask to my urologist about pentox or other treatments VS fibrosis.
The fact is in 6 months i have seen a lot of doctors who did a lot of mistakes, and i have seen some of 'famous' ones who can now do nothing (it's their own words, 'just take cialis and see')....

For that reason such a despair :  1 'little' accident, 6months to know what i had, lots of doctors and mistakes, an impotence and retracted penis as a conclusion.

For the implants, you're right but i realy dont want of that.

I will try to read the highlights too .

Pentox and arginine have really healed people who had fibrous tissue after priapism?? here, urologists say that when you have fibrosis of erectile tissue after priapism, there is nothing to do, its for life.

Are the related articles you give me are on the forum or on the net?

Thank you.

Antony

[Hawk]

Antony,

I just want to let you know that I will be moving these posts to another topic since most of it really is not about erectile dysfunction, but I will leave them here for now because I want to be sure you see the posts.

Pay very close attention to what Tim is saying.  I think it is VERY unlikely that you can just go to your doctor and "ask about pentox".  You must educate yourself thoroughly about its use with Cialis or Viagra to treat Peyronies Disease. You must take documentation.  You must present this in a way the doctor will take you seriously and without offense.  You also must prepare for the fact that even then he may refuse and you will be going to yet another doctor.

You have time, and you have options.  Be calm, relax, think positive.  Life is not over.

The articles Tim ended his post with are on the internet.

Also please start by reading this on the forum https://www.peyroniesforum.net/index.php/topic,440.0.html

Hawk

[antony]

Hello Hawk,

i didnt know where to post exactly, but my problem deals with impotence , fibrosis, so i thought it was in erectile dysfunction. In fact it's a little like a peyronies disease with total impotence.

Yes you're right about the doctor. The problem is, as i explained, that i saw lots of them, at the begining they didn't take it seriously (they said it was a prostatisis, nothing, psy, etc etc). Now they tell me its very serious. So i am no more really patient with them, and don't really trust them anymore. The sexologist who works with me now wants to make me use vaccumm during 3 months, i was nearly to try when my generalist doctor told me it wasn't good, and adressed me to another specialist (i have apointment in... the end of november). So i think they made me lose enough time ; so if a treatment can help and they didn't suggest it , i will speak to them about it. I can't stay like that. The problem is already very very serious in itself , with bad consequences, but the worst is that ... they suggest me absolutely nothing (exept the one with vaccumm).
So if treatments with positive results were seen here for fibrosis of erectile tissues , i have to speak to the doctor about them.

Being relax, you know, i was at the begining. But i've heard that during 6 months ('no panic', 'it will be better', 'cool', etc etc, coz for doctors it's easy to say. I stayed cool some months, and i saw the situation was decreasing. Now i'm told that i will stay impotent , so hard to stay cool. I even post on american forums!!) Don't know who would be relax with all my symptoms and my life break in so few time.

I will read your link , and try to find articles Tim mention on internet. (french ones say there is nothing to do with fibrosis).

Antony

[George999]

Antony,

Just a couple of comments.  First of all, Pentox has been used to tried different types of fibrosis with some degree of success.  Secondly, I suspect that your Sexologist might well know more about the vacuum therapy than your general doctor.  A gentle application of vacuum would be more likely to be helpful in my opinion (I am not a doctor) than harmful.  So these are two potentially useful approaches.  But, at this point, a few more months is not likely to make a whole lot of difference on the effectiveness of treatment.  BUT, a few more months can make a lot of difference on the impression you can make on the doctor as to your degree of knowledge on the subject.  And that is VERY important.  You need to carefully study the use of the generic drug Pentox and also the use and concept of the VED (Vacuum Erection Device).  You need to know the course of treatment you want to pursue and you need to be able to provide your doctor with convincing evidence that this course of treatment might be effective.  It really sounds to me like the Sexologist is on the right track here, so perhaps you need to give him/her the opportunity to help you further.  But, in any case, you will need to discuss this further with your general doctor and enlist him on your side in this project.  Most doctors DO respond to legitimate research, so the more of that you have in hand when you go to the office, the better.  And the more you learn about fibrosis in general and those strategies that might work against it,  the better equipped you will be to deal with this over the long term.  Both Tim and Hawk are giving you excellent advice.  Take your time and learn, learn, learn.  And don't let yourself be disabled by depression.  There really IS more to life than sex.  But the more attention you pay to building up your general health with a good diet and healthy exercise, the better prepared you will be to potentially get rid of this monster.  I wish you the very best.

God bless you,

George

[ninjagaiden]

Hi guys!

Antony, I do think that before you make a bad move (talking about dark things, I don't think it's about coffee or chocolate), think twice and take time to search for solutions.
You've been to comedian-doctors like there are some many as it seems...
In France (at least north of France), they know close to nothing about Peyronies Disease, just talk about "corrective" surgery, or "just wait and see"... Very frustrating isn't it?

Now, forget about these comedians, take time to find a urologist interested in Peyronies Disease. Ask him directly over the phone if you can, don't waste time and money with guys specialized in urinary leaks...

If you need to just talk in order to feel better, you can send private messages to me or the veterans of this forum, they've been through tough s..t too, (we're babies here, they know more than us) so they can help you raise you head.

In the meantime, don't do anything stupid, talk about this whenever you need (here we keep it private, right guys ? ) and do activities that you enjoy the most (music if it's what you like). I think some doctors are searching for solutions, stuff that might not help you recover full  use of your penis right now, but some techniques may give you back a part of your sex life, and then in a few years, who knows? They'll find a cure.

So keep your head up and do things that you enjoy, or I'll find your house and will kick your ass!  

Smile my friend  I know it's hard, but you're just too young to give up now.  

[Liam]

The last doctor i saw thinks i had a shock on tunica albuginea during the intercourse in February and sadly, the scar healing went in bad way, and made a scar tissue on erectile tissue, and that condamns erection!!! According to him, i have a fibrosis of erectile tissues!!And he can't do anything apparently. All that for that. Now i don't trust doctors anymore, and have really dark ideas.

Does this doctor think you will heal?  Does this doctor think you will have normal sex in the future?  Here is a site about penile fracture (broken penis) and other trauma to the penis.  Try to Google penis fracture.  I'm sure there are sites in French, too.  Go to a doctor for dark thoughts (depression).  Medicine will help that.    My favorite is Wellbutrin, but they have other "flavors", too.  Good Luck!

http://www.emedicine.com/med/topic3415.htm  - the part about fracture skips around    You will have to scroll down the page.

[antony]

Hello guys ,

thanks a lot for your comments, really.

To GEORGES, i think i will defintely ask to my doctor about pentox. A french doctor was making research about fibrosis and i have read she used that for treating fibrosis -but not penis fibrosis, it was in order to treat post-surgery fibrosis, i have mailed her to ask her if it was the same principle for penis.
Maybe the vaccumm can help too efectively. You're right telling that the sexologist probably knows more than the generalist doctor, but i saw so many crap specialists in so few time that now my trust in them is very low.
In fact at flaccid state (99% of time now i am impotent), there is like a torsion at basis of penis, probably the blood can't circul normally and lead to the fibrosis of tissues.
Few months more are maybe 'not a lot' at the point where i am, but each day which goes is harder. As i told, the worst is not to have this problem if there was a common and well known way to heal it, the worst is that it seems there is so few to do, and what can i try like vaccum or pentox, i am totally not sure it will do something, and that i will recover. I've tried some diferents treatments since the begining (antibiotics for a prostatisis i didnt have, medical chinese herbs, cialis, anxiolitics, each time it should 'heal' me , but in fact it did about nothing).
After, when you say 'there is really more to life than sex'... Ah, it's too long to explain. for me it was 'a part of the balance', to stay stable. The 'side' with girls had a very important part in my life, i was also working in music band like 'sexy music' ,that speaks about a lot of parties, sex, relationships between guys and girls, etc, so i had t give up everything in so few time. I lost work, girlfriend, projects, confidence, and these olidays(this one is not the main thing), and probably my... life. And sure, there is not only sex in life, i could stay some time without having sex it was ok, but there is a diference between 'chosing not having sex', and 'dont have the possibility because i've become fisically importent...' Imagine, just later for having a wife and family... I'm just 25...
Anyway, i lost evrything in that problem, i don't want to move you to pity , not my goal, not my behaviour, but just hope i can do something to heal .
Anyway thanks a lot for your encouragement.


To NINJA GAIDEN (it was a video game if i remember well): thanks too for your post, you know the story now, and you know why i have so dark ideas. (lol dark things in my mind are darker than coffee or chocolate...)After, maybe it's a matter of age, way of life, personality, area where you live, etc, etc, the way how you react.
As for me, to become impotent was the worst thing that could happen, even in a nightmare i couldnt think that. I have ever had lots of muddles, quite rough and very speed life, some hard or sad moments, its ok, no problem, I can manage and recover very quickly. Every body has its dificulties. But this one... One night you make love, you feel something serious and bad hapened in your penis, nobody takes you seriously, especially doctors -, and few months later you have lost everything in your life.... (i can't sum up all what i tried, did, consulted, wasted my money for NOTHING in only 6 months, its not believable -you could make a film or book, 'how to go from the top to the hell in so few time'). So, even being proud, i admit without any problem that this thing is too hard for me.

i totally see what you mean speaking about 'comedian doctors'. And yes, the 'wait and see' of french doctors i saw... I was like: 'wait and see what? wait i become definitely impotent??? ' Go to hell these doctors, i prefer one who admits that it's serious but he doesn't really know what to do, than the ones who say 'wait, it will be ok, and give you... nothing'.

Concerning the urologist, i think i continue with the sexologist i see at the moment, but i don't know if i have to find one in 'peyronies disease' coz in fact, it looks like a lot a peyronie disease but not sure that its a typical one (or if it is, i am in the crap becoz i read on all french sites that when you become impotent because of peyronies disease, you will never recover. You can recover from curvature, from erectile pain, but not impotence caused by this illness.) My case looks like a lot, but my fibrosis of erectile tissues doesn't come from a peyronies disease i think (at least no doctor told me that, even if they said so much crap). Sure i have wasted enough time and money in the ones that make you do  urinary analyses when you speak about total impotence, no sensitivity in penis, hardeness of penis , deformation and fibrosis....

Thank you a lot for your recomfort, but for sure, can't continue my activities,especially music, and have stopped smiling. Anyway , about finding a treatment, i'm looking for all what i can, but concerning the 'mind' , it's too hard .

But i thank you , and good luck to find my house for kicking ass lol, haven't you heard in riots of november 2005, that it's dangerous to come in some areas now, it has become like Compton or Harlem here loool.


To LIAM: No, this doctor is about sure about what i have, but said to me he can do nothing. Just adviced me to another 'famous' doctor, i have apointment at the end of november, and this one will probably tell me he can do nothing, so waiting for these apointments that only make me waste few money i have now, are useless. He told me , just like that, 'hope in some years you will have a normal sex life again' (before that crap problem, i had never had even one small problem concerning sex).
I've read the french sites about penis fracture, they all say that you need a surgery very quiclky in order to avoid consequences like impotence precisely, curvature or pain in penis.... But during my intercourse, i had a big pain when the girl did wrong move, but no visible haematoma, so when i visited doctor because i had pain, he said 'it's nothing, it will go better soon'... you know the following of the story.
I can read about american articles on penis fracture, but i think this problem is 'international', they will probably say that, once it has bad scared, in a bad way, you're elasticity in erection is condamned for erver and need a penile protesis....

I saw recently a doctor for my dark thoughts, even if i don't like so much this type of doctors or medicine (its the 1st time i am confronted to that) , i made effort. But no medicine like anti depressor will make me forget what happened, and happens , to me... Maybe i should ask for the tarazadone i read about here?

Thanks for your message and the link.

Antony

[ninjagaiden]

Antony,

> ninja gaiden was indeed a video game  

You need to find a way to think about something else (ha ha, you must be reaaally having fun reading this advice ) I know it's hard thinking about something else and I can't imagine your situation, having "just" a 45° bent and a couple of other sensitivity / hardness problems that spoil the fun of a normal sex life. And of course, I have the same questions about the future, family, kids, can't imagine a bright future too.

You had hard times, I had my share too, and not small stuff that people usually complain about, but I know that this is the most shattering experience I'm living now. It pretty spoils my activities too.

But we have to wait at least a few years and try some options before thinking about giving up. You can't give up so soon, try for a 4-5 years to see what can be done.

I would not recommend the use of antidepressant in general, but in your case, take it because you're at the bottom at the moment. As time goes by, you'll have more time to think more "clearly" and look for solutions.

Unless you tried all, you can't give up. Don't make anything stupid ok?
Talk here, send messages as much as you want, we'll pay attention to you. But you have to talk about this in order to feel a little better.

Let the pride on a shelf cause in this case, not talking will bring you down.
Theses problems are too serious to be kept to oneself, but talk to people  who are in the same boat, only them can understand (to my point of view).

Take you medication + go to a psychologist in order to get advice to get out of this depression.

Keep us informed about you because we don't want you to think you're alone.


And if music hurts, do something else (sport, anything) that will help you smile. Keep us informed please.

[antony]

Hello ninja ,

Thanks for moral help, you know since the begining i try to think about something else, but the problem of a 'illness' like that is that it's 'on you', you can go evrywhere, do what you want, you have it 'inside you', and that's terrible.
I supose that a 45° bent, and sensitivity/hardness problems are already really hard to support, (by the way how it happened to you?), so imagine that at my age i become totally impotent and that medicines like ciallis dont work so much, and the erectile tissues have become totally fibrosed, because of... such a 'little thing', a night when a girl made a F^@$!ng bad move during intercourse at the top of me...(i would have prefered to be amonk pfff). And it was not a typical penile fracture, and not a peyronie, but worse consequences than both of them... The shock i received was hard but not so terrible, and now my man's life is finished, and i am too young for that.And of course i'm scared about future, wife, kids,too, and to have lost all what i liked, and to stay some years like that, like a dependant person because i stopped job.
When i know some men of 70year old who complain because they lose a little their erection and feel losing their virility, it makes me mad...

I was told that maybe in 5-6 years tunica albuginea could be put in 'culture' in order to repair it , and to insert the new one in good form into the penis. But it's not sure, trials are just done on animals, and anyway, 7 months like that were so horrible, i can't imagine 6 years.

I will go to see the doctor to speak about the anti depressor who can help night erection , 'trazadone', if it can make both anti depressor, and help for erection, could be something helpful? Anyway , i am against medicine like anti depressor too, but maybe don't have the choice now you're right.

I believe , like you, that only people who have the same thing can really understand.

The problem is, (according to me), speaking about the problem helps on the moment, but don't heal you (if we could speak to people who would have healed, it would be better), and not speaking is horrible to stay like that alone with your problem and dark ideas.

I would be more optimistic if some medicine would directly help on restaure the tissues... (will definitely speak about pentox to the sexologist). How it doesnt exist in 2007??? Knowing the importance that sex has in a mans life and human life in general (according to me)

Anyway thanks you for recomfort, but i can't be sure of doing nothing 'stupid', coz my life has been too much broken by this crap (i can't enter in detail, but i lost so much in so few time).

Good luck to you too.

[ninjagaiden]

Hi Antony,

I'll quote you on 2 points:

When i know some men of 70year old who complain because they lose a little their erection and feel losing their virility, it makes me mad...

I've been witnessing some situations like that, and you just want to knock the guy out... It's usually people who have never been living hard times (like serious diseases) in their life. And it's also unfair for us young guys, but life is not fair.

My best friend told me lately that sometimes, he "comes" prematurely, and that's a problem to him... (man, you're gonna make me cry  !)
Because of a frustrated mood, I only replied: "Mate, If you knew... you would think you're the happiest man on earth". He asked why and I just replied, "never mind."
No need talking to people who don't live the same stuff.
>>>Even if talking doesn't cure the problem, not talking just make it worse.


With all the "sligth" problems I had in the past + this one, now I consider that life is like a poker game in which you have to make the best with the cards you've been given... Even if you have crappy cards...

Sometimes I think about kids with cancer and sick disease like (sorry no translation) mucoviscidose... Why them also?

But there's no need asking why, it's life and if God exists, (sorry for the US guys, I know religion is important to you), He's not here to help people out. He's an observer... But no point talking about religion, sorry.

Just wanted to say that when you say :

I would be more optimistic if some medicine would directly help on restaure the tissues... (will definitely speak about pentox to the sexologist). How it doesnt exist in 2007??? Knowing the importance that sex has in a mans life and human life in general (according to me)

Sex life is not a priority (not my point of view of course), AIDS and Cancer are...
For us it's a priority cause we're affected by it...

But I do think that they'll come up with drugs and treatment (collagenase maybe?) to help you out.
Take the drugs (cialis or viagra) if it can help restore night erections (it might take some time, but you never know).
A depressed mood will also ruin your erections (I know that!, when I feel down, the rest of me is feeling down too  ) so either take anti depressants (check which ones to take 1st, cause some might ruin the erections I think  ) or find activities to bring your mood upwards...

I think you should talk to Hawk, Liam and Old man in order to get more advice cause they are more experienced than me.

I know it's hard to get this stuff out of your mind (I don't know if it's possible, but when I do some things I like doing, it takes my mind away (at least 50% of it   ) from my problems.
"Keep busy" as they say...

I live bad times psychologically too, but the more you think, the more it hurts, (good old vicious circle) so keep busy.

In any case, any time, you can talk I'm here (private message or not).
And don't give up now, I said take 4-5 years to see if it improves or not. No matter what. You're a man, you have to consider this stuff as a battle, and you're a damn warrior .
A man can take anything.

Ok, over with the "Rocky" stuff...I know it doesn't help much, but you have to take this philosophy for the 4-5 years to come at least. Even if you think it's too hard, grind your teeth and keep fighting. At least a few years. Then you'll see what are your options.

Sorry for the basic imagery, but that's the only thing that works on me. I know it's hard taking the comments of other people who are healthy and lead a normal life and still complain... And some girls won't be nice too, but you have to avoid the bad company for a while. Keep close to the people that cheer you up or make you happy.

Also, regarding girls: as long as you have this problem, stay away from the "Paris Hilton" kind of girls, they won't bring you up. I know that some people (a small %age of the human beings) have absolutely no desire for sex. I think they're called "the angels" or stg like that. Search on the forums or meetic stuff for such a girl. Say you look for a girl with no sex drive. Be direct, no need to explain why.
It can catch the attention of a girl in this situation and she'll bring you more support than a girl who needs sex. It'll cheer you up to be loved for other reasons that your "thing", and you'll take your treatment in the meantime and you'll wait for the erections to come back. There must be a way.

And when it works again, you'll give her a good "slapping" shag to change her opinion about sex   and you'll think about us who told you to keep fighting, see what I mean?  

I know it sounds silly, but I think finding such a girl could do some good to your mind and heart.


And to conclude,
I know it's hard to take, but you'll take it. And you'll find a way.

4-5 years, that's all I ask you to take before doing anything silly.

Don't isolate yourself, that's not good either. Just keep the good people around you, say "bye bye" to the bad influence people. That's the only way you can bear this s..t for the next 4-5 years.

[Old Man]

Ninja:

Well said my young friend! Your advice and wisdom in this matter is very far beyond your years. Just practice what you are preaching and the rest will come easy. Keep up the good work!!!

Regards, Old Man (Almost 78 now)

[ninjagaiden]

Hi Old man, I hope Antony and the others will keep walking on no matter what happens.
Yes, I'll practice what I said, that means taking 4-5 years (till I'm 30 or so) to see what I can do to improve the situation, hopefully there will be more treatments for that problem in the years to come.

In the meatime, I'll work in order to live a bit "in the fast lane" (that means make money and achieve some dreams like travelling, owing a Mustang (the car, not the horse   ), or any other silly dream that I may want to achieve. Helping others of course is important in my daily life, because it brings some satisfaction. You help others too (as you told me in another post) so you know what I mean...

Sometimes my mom asks me "why do you never relax? You go to your work, then you spend your evenings + weekends in renovating a house (+ the house I live in I should add   ), you haven't taken any holidays  for the past 3 years..."
I just can't tell her why. She already had a tough life like that  (long story, includes her own history + living with my dad, which is really not easy) and I just want to make money in order to make her gifts, and buy her whatever she would need. That + my own dreams to achieve is the reason why I don't stop...

Yes, I probably could do without the Mustang or the trips to Asia / USA, but I guess in our situation we need to "escape" from reality from time to time. That's why I'm working so hard to get the money now... and not in 10 years.
And if I become desperate enough   I might do a few months stay in a shaolin temple...I know they accept occidentals now... I've got crazy dreams, but it seems I need to achieve them all, just because of this problem... Otherwise I might have done just one or two... It's just that if I deceided to do stg silly in the future (you know... ), even in 5,10,20 years or later, I just would like to think before I do that : "I've done and seen things that most people I know never experienced, so I had a nice life after all...".

You know what I mean? But we're not there yet, don't worry    
I'll fight. And I'll try to encourage people around me as much as I can.
Bye, thanks for your support!!!

[antony]

Hello man,

thanks for your message. You look more 'courageous' than me on that point... Wait until 30 , leaving the last 5/6 years of 'yougness' with such a destroying problem, just sounds impossible for me.
Anyway, i know you're right on what you say, but i am just honest enough to reconize that i agree 100% with what you tell me, but i can't apply it ...
Anyway i will write to you a PM and explain you how i see the things and why.
Sad that no 'effective treatment' exists for the problem. For the 'moral' part, we'll speak together, even if one again you're right , but, as for me, i can't see things like that.
Speak to you soon.

[Tim468]

Dear Antony,

At some point you may chose to stop feeling sorry for yourself and take more action. Some of us have offered you advice on methods that have helped us get better. Not all methods work, but by taking steps we learn what does work and what does not.

At this point, it appears that your anger and sadness is preventing you from taking proper care of yourself, or moving forward. And yet, you have taken steps previously. When we hit hurdles in life, we either stop or we take them. I hope that you are able to see that if you help yourself, your depression will improve.

Tim

Oh - and by the way - to be perfectly blunt..  I was sexually active by 13, and had had many more lovers than most men by the age of thirty. I did that with Peyronie's Disease for most of that time. I pleased women and had a great time - in fact, the disease gave me ultimately a disease of the spirit as I tried to prove my sexual prowess. You can be whomever you want to be. If you want to remain in pain emotionally, then do so. If you want to heal, then start that journey. But every man here has the same disease that you have, and we are not all complaining about how down we are - we are working on getting better. It is not easy work, but it is worth it. I hope - very much so - that you can come to see that.

[antony]

Hello Tim,

the only fact is i dont stay like that without doing anything, i have taken the problem at the beginning, and if i would have been well diagnosed, i wouldn't be there now.
We don't have the same thing because you have a peyronie disease and it's not what i have. My problem is not only a curvature during erection, or a pain , but of being impotent, and probably for definitive.
I think it's understable to be depressive when you learn that at my age. Of course, i have the curvature and the pain TOO, but the main fact is that even with medicine , i cant really have normal erections. Moreover , the penis is always cold, it's horrible sensation,, and i have an ejaculatory problem too. I can go where i want, i have the problem on me, and not only at some moments, its always cold, painful, have changed form, really smaller and so impotent.
If i now complain, it's because doctors i saw clearly told me they could do nothing exept giving cialis or viagra.
I would prefer have a peyronie disease , than total impotence.
Anyway i continue searching, i saw lots of doctors, i take medicine for depression, i spoke about my problem, so i do what i can do. But the fact is that the problem is just getting worse....
Anyway i will ask about pentox, try some vaccuum, and continue treating depression, and i dont see what i can do more...

[Liam]

It is good for depression and does not intefere with sexual function  

C'est bon!

[Tim468]

Antony,

You should consider - strongly - taking pentox at a dose of 400 three times a day, L-arginine at a dose of 2000-6000 mg a day, and viagra or similar at a dose of 25-50 a day (again this is not for erection but for antifibrotic activity). You should get going with a VED. Consider a better evaluation with measurement of testosterone levels, and you should definitely get injected to see if your penis can get hard AT ALL (in other words, regardless of your feelings and emotions).

According to the limited  data available for men in similar positions as you, it has taken up to two years to recover - but that is if they do the therapy.

Finally, as I mentioned before, there are surgical reconstructions available for young men whose penis - for whatever reason - has failed. Right now, that may seem impossible or unacceptable. But if all else failed me, I would go for that in a heartbeat. But only after all else had failed.

So, you say that you will "ask about" pentox, but I suggest that you READ about it using the articles that I posted for you over two weeks ago. I am sorry to sound so blunt - for I have great feelings of empathy and sorrow for what you have suffered. But I have also suffered, as have many men here who can no longer have intercourse either. You are not alone. Instead of listing how many ways in which you are different (and therefore "worse") I hope you can start to see how you are not so isolated or alone. You are not the only guy whose life is altered in a way that is depressing and frustrating. Yet you will see, along with the depression, signs of hope and optimism here as well - and that is not because they "don't have it as bad as you". It is due to doing the work of recovery that we must all do to heal our hearts. And if you listen long enough you will also hear the words of the women who love men despite their failure to have a perfect penis any more.

You can heal either medically or surgically - that is a fact - though it may entail spending time and money and feeling sad. But for now, it may be of more help to get going on the "recovery" part of what you are facing.

Tim

Some responses to this post were moved to the "Psychological Component" topic.  Click the link below to go to those posts.