Men’s Health

Associated Urologists of North Carolina

Urologists located in Apex, Cary, Clayton, Dunn, Raleigh & Wake Forest, NC

Understanding Erectile Dysfunction

Erectile Dysfunction (ED) is defined as the persistent inability to attain or maintain an erection sufficient for satisfactory sexual performance. It is a common medical condition affecting tens of millions of men globally, with prevalence increasing with age.

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Causes & Risk Factors

Erectile function relies on a complex interplay of vascular, neurological, hormonal, and psychological factors. ED is frequently an early marker for systemic cardiovascular disease. Some of the causes and risk factors include:

Vascular: Atherosclerosis, hypertension, hyperlipidemia, and diabetes mellitus impair penile arterial inflow and venous outflow.
Neurological: Parkinson’s disease, multiple sclerosis, spinal cord injury, or nerve injury following pelvic surgery (e.g., radical prostatectomy).
Hormonal: Hypogonadism (Low T), hyperprolactinemia, or thyroid dysfunction.
Lifestyle & Psychogenic: Smoking, obesity, sedentary lifestyle, stress, performance anxiety, and depression.

Diagnostic Evaluation

A comprehensive clinical workup helps identifies underlying etiology and directs targeted therapy:

Medical & Sexual History: Utilizing validated instruments such as the International Index of Erectile Function (IIEF).
Laboratory Testing: Morning total testosterone, fasting glucose/HbA1c, lipid panel, and serum creatinine.
Diagnostic Imaging: Penile Duplex Doppler Ultrasound (PDDU) following intracavernosal injection to evaluate arterial inflow and venous leak.

Treatment Modalities

Treatment follows a stepped-care approach tailored to patient preferences and severity:

Level	Treatment	Mechanism / Description
First-Line	Oral PDE5 Inhibitors	Sildenafil, Tadalafil, Vardenafil, and Avanafil
	Lifestyle Modifications	Weight loss, cardiovascular exercise, smoking cessation, and glycemic control.
Second-Line	Intracavernosal Injections (ICI)	Compounded vasoactive medications (Alprostadil, Bimix, Trimix) injected directly into the corpora cavernosa.
	Vacuum Erection Devices (VED)	Mechanical negative pressure devices that draw blood into the penis, held by a constriction ring.
Third-Line	Inflatable Penile Prosthesis (IPP)	Surgical placement of a three-piece hydraulic implant offering a definitive, permanent solution.

Peyronie’s Disease

Peyronie’s Disease (PD) is an acquired connective tissue disorder of the penis characterized by the formation of collagen plaques within the tunica albuginea. This leads to penile curvature, shortening, pain, and erectile deformity.

Disease Phases

Peyronie’s disease progresses through two distinct clinical phases:

Acute (Inflammatory) Phase: Typically lasts 6 to 12 months. Characterized by active plaque formation, painful erections, and evolving penile curvature.
Chronic (Stable) Phase: Pain generally resolves, and the degree of curvature and plaque calcification stabilizes for at least 3 months.

Treatment Options

Therapeutic intervention depends on the phase and degree of functional impairment:

Conservative Management: Penile traction therapy (PTT) and oral vacuum devices used during early phases to mitigate length loss and curvature progression.
Intralesional Injections: Collagenase Clostridium histolyticum (CCH) or interferon alpha-2b injected directly into stable plaques combined with mechanical modeling to disrupt fibrous tissue.
Surgical Reconstruction (For Chronic, Stable Disease):

- Tunica Albuginea Plication: For patients with adequate erectile function and mild/moderate curvature (<60°); shortens the longer (convex) side.
- Plaque Excision/Incision & Grafting: For severe curvature or complex hour-glass deformities in men with intact erectile function.
- Penile Prosthesis Placement: For men with coexisting severe ED and Peyronie’s disease, combined with manual modeling or plication.

Talk to your healthcare provider about what your best treatment options are based on disease phase.

Low Testosterone

Testosterone deficiency is a clinical syndrome resulting from failure of the testes to produce physiological levels of testosterone. It affects energy, metabolic function, bone density, and sexual health.

Classification & Etiology

Primary Hypogonadism (Testicular Failure): Low testosterone with elevated gonadotropins (LH and FSH). Causes include genetic conditions like Klinefelter syndrome, orchitis, testicular trauma, or chemotherapy.
Secondary Hypogonadism (Hypothalamic/Pituitary Dysfunction): Low testosterone with low or inappropriately normal LH/FSH. Causes include pituitary adenomas, hyperprolactinemia, severe obesity, type 2 diabetes, HIV/AIDS or chronic opioid/corticosteroid use.

Diagnostic Criteria

Diagnosis requires both clinical symptoms and laboratory confirmation:

Symptom Profile: Low libido, fatigue, decreased lean muscle mass, increased body fat, erectile dysfunction, depressive mood, and reduced bone mineral density.
Biochemical Testing: At least two separate early-morning (8:00 AM – 10:00 AM) fasting serum total testosterone measurements below 300 ng/dL, supplemented by free testosterone testing if SHBG abnormalities are suspected.

Testosterone Replacement Therapy (TRT) & Alternatives

TRT aims to restore serum testosterone to the mid-normal physiological range (400–700 ng/dL). It’s important to consider a therapy based on plans for fertility. Make sure to discuss this with your provider.

Types of testoterone supplementation include:

Intramuscular/Subcutaneous Injections: Testosterone Cypionate or Enanthate administered weekly or bi-weekly.
Transdermal Formulations: Daily gels or solution applications maintaining stable daily hormone levels.
Oral pills: Daily pills of testosterone taken at various doses to achieve steady state.
Subdermal Pellets: Long-acting pellets implanted subcutaneously every 3 to 6 months.
Fertility-Preserving Therapies: Human Chorionic Gonadotropin (hCG) or Selective Estrogen Receptor Modulators (SERMs like enclomiphene) to stimulate endogenous production without suppressing spermatogenesis.