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Benign Prostatic Hyperplasia (BPH)

What is BPH?

Getting older is inevitable, and it can be hard to accept the way our bodies change. For many older men, that often includes prostate enlargement and, for some, the urinary trouble that goes along with it.

The medical term for an enlarged prostate is benign prostatic hyperplasia (BPH). You might also hear the terms benign prostatic hypertrophy and benign prostate enlargement (BPE).

The prostate is a walnut-sized gland found beneath your bladder and in front of your rectum. It makes seminal fluid – the fluid that mixes with sperm when you ejaculate. Running directly through the prostate is the urethra, the tube that allows urine and semen to leave your body.

BPH might become aggravating, but overall, it’s not harmful

BPH becomes more common as you get older. According to UpToDate, an estimated 8% of men between the ages of 31 to 40 have an enlarged prostate. Over age 80, the rate is over 80%.

One word that should reassure you is benign. It might become aggravating, but overall, it’s not harmful. And BPH is not the same as prostate cancer. It is possible to have both an enlarged prostate and prostate cancer, but BPH on its own is very common and very treatable.

Symptoms of BPH

While BPH is benign, it can still have some frustrating symptoms, mostly urinary:

  • A more urgent and frequent need to urinate. That “gotta go” feeling might be stronger, and it might happen more often.
  • Frequent urination at night (nocturia). If you’re waking up every couple hours with the need to pee, that could be a sign of BPH.
  • Feeling like your bladder isn’t completely empty, even if the urine flow has stopped.
  • Straining during urination. You might feel like it takes more effort – or you have to push – in order to pee.
  • Weak urine flow or a flow that stops and starts. You might dribble or leak urine, too.
  • Bloody urine (hematuria)

BPH symptoms usually start when a man reaches his 50s

BPH symptoms usually start when a man reaches his 50s. However, not all men with BPH have symptoms. Some have no problems at all. Or if they do, the symptoms don’t bother them.

What happens when the prostate gland grows?

Basically, when the prostate gland gets bigger, it grows inward rather than outward. And this is why urination becomes a problem.

Recall that the urethra goes straight through the prostate gland. That new growth going inward can press against the urethra - squeezing it, if you will. This process narrows the path for urine flow, slowing it down or blocking it altogether.

Should you simply tolerate BPH symptoms, chalking them up to signs of aging? No. For one thing, there are a variety of treatments available, so there’s no reason to suffer with symptoms. Chances are, there’s a treatment that will work for you.

Secondly, not treating BPH can lead to other problems. Your BPH symptoms might worsen over time, eventually damaging your bladder or kidneys.

Diagnosis

Doctors diagnose BPH by taking a medical history and conducting a number of tests. You’ll be asked a lot of questions, and it’s important to be honest. The tests? Some can be uncomfortable. But they’re essential for ruling out other conditions that have similar symptoms:

  • Urethral stricture
  • Prostate cancer
  • Bladder cancer
  • Kidney or bladder stones
  • Overactive bladder
  • Neurogenic bladder

Your medical history

Your doctor will want to know about your family medical history and your own experiences with urinary tract infections and prostatitis (inflammation of the prostate). They will also ask you about any over-the-counter products and prescription medications you use. You might want to make a list of these before your appointment. If you use any herbal products or nutritional supplements, make sure you mention those.

The doctor might want to observe you urinating and will likely check your abdomen to see if there are signs of an enlarged bladder.

You might also be asked to complete a questionnaire called the AUA (American Urological Association) Prostate Symptom Index or another assessment tool.

Digital Rectal Exam (DRE)

This exam can be awkward. But it only takes a few minutes, and your doctor can get a lot of useful information.

During a DRE, your doctor will place a lubricated, gloved finger into your rectum. In this way, they doctor can actually feel your prostate gland and assess its size and its texture (lumps, hard spots, soft spots).

A DRE shouldn’t hurt, but you might feel a little uncomfortable. Take some deep breaths, knowing that it will be over soon.

Lab tests

  • Urine test (urinalysis). This test is straightforward: You pee into a cup. Your urine sample is then analyzed to see if there is anything unusual.
  • Blood tests. In your blood work, your doctor will check your PSA levels. PSA stands for prostate specific antigen. Patients with benign prostatic hyperplasia (BPH) or prostatitis may have larger amounts of PSA.

Other tests

  • Urodynamic tests measure the volume and pressure of urine in the bladder and evaluate the flow of urine.
  • Uroflowmetry tells the doctor how quickly – and to what extent - you can empty your bladder.
  • A pressure flow study can help your doctor determine how much blockage there is.
  • A post-void residual (PVR) test measures how much urine stays in your bladder after urination.
  • Ultrasonography creates images of your urinary tract to show any abnormalities. Your doctor can estimate the size of your prostate this way, too.

How is BPH treated?

If it turns out you have BPH, you have lots of treatment options. We’ll run through them here, but your doctor will help you decide which one is right for you.

Watchful Waiting

This is a “wait and see” approach. If you’re just starting to have symptoms, or if they’re not bothering you that much, you might not begin treatment right away. Instead, you and your doctor will keep an eye on things. If your symptoms get worse, you can look into other treatments. If they improve (and for some men they do), that’s even better.

While you’re waiting, you can take these steps to get some relief from urinary symptoms:

  • Watch your fluid intake. Skip that glass of water at bedtime or if you’re not sure where your next bathroom will be.
  • Caffeinated drinks (like coffee, tea, and soda) and alcohol can make you have to “go.” Cut back on these.
  • Try to empty your bladder before you going to bed or heading out. If you feel like it’s not completely empty, try again a few minutes later.
  • Avoid certain medications, like tranquilizers and over-the-counter cold remedies containing decongestants and antihistamines. These can worsen urinary symptoms.
  • Avoid spicy or salty foods.
  • Watch your weight and eat a healthy diet.

Medications

Generally, two types of medications are used to treat BPH:

Alpha blockers

If your doctor recommends medication, you’ll probably start with alpha blockers. These drugs open up your urine flow by relaxing smooth muscle tissue, taking some pressure off the urethra.

Examples include terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo).

Alpha blockers can have some side effects, such as headache, dizziness, low blood pressure, fatigue, weakness, and difficulty breathing.

Note: Erectile dysfunction (ED) drugs called phosphodiesterase type 5 (PDE5) inhibitors might interact with alpha blockers. Always check with your doctor if you’re thinking about taking these drugs together.

Alpha-reductase inhibitors

These drugs work by stopping prostate growth. It can take up to 6 months to see how well they work.

Examples include finasteride (Proscar) and dutasteride (Avodart).

Possible side effects are diminished libido, erection or ejaculation problems, depression, breast tenderness or enlargement, and reduced sperm count.

Note: If your partner is pregnant, she should never handle these drugs. Exposure can cause serious side effects for a developing fetus.

Combination Treatments

Some men, especially those with severe cases of BPH or very large prostates, take both alpha blockers and alpha-reductase inhibitors.

What about herbal treatments like saw palmetto?

You might have heard about herbal treatments, particularly one called saw palmetto. However, these aren’t usually recommended. Keep in mind that herbal treatments aren’t regulated by official agencies, like the FDA. And they can interfere with other medications you’re taking. If you’re thinking about any herbal remedies, always check with your doctor first!

Minimally Invasive and Surgical Treatments

If medications aren’t right for you, you doctor might recommend a minimally invasive treatment or surgery. Some of these procedures can be done right in your doctor’s office. Some require a hospital stay. Some men have temporary side effects, like erectile dysfunction (ED). Some men don’t. Your doctor will go over your options. Usually, treatment depends on the size of your prostate, the severity of your symptoms, and your overall health.

Keep in mind that the results of some treatment last longer than others. Ask your doctor if you might need another treatment down the road.

Prostatic Urethral Lift (PUL)

Some doctors call this technique Urolift®. With this procedure, you’ll have either local or general anesthesia. Your surgeon will then use a special needle to position special implants to hold prostate tissue back, away from your urethra. Most men go home the same day as a PUL procedure.

Transurethral Treatments

The word transurethral means “through the urethra.” In other words, excess prostate tissue is removed through your urethra. You might wonder how an enlarged prostate might be accessed through a tiny tube, but doctors use special equipment designed to fit. You’ll be given anesthesia, so you won’t feel a thing.

Transurethral Resection of the Prostate (TURP)

TURP is a common procedure. The AUA estimates that about 150,000 men in the United States undergo TURP every year.

For TURP, you’ll receive general anesthesia. During the procedure, an instrument called a resectoscope is inserted into your urethra. This device has an electrical loop at the end, which removes obstructing prostate tissue and seals blood vessels. An irrigating fluid is used to flush out the debris. Any remaining debris will pass through your urine.

You’ll probably be in the hospital for about 3 days, and you’ll have a catheter to drain urine. During your recovery, you might have some initial discomfort, feel an urgent need to urinate, or have trouble controlling urination. Usually, these symptoms clear up before long.

Some men have sexual problems after TURP, and it might take a year for your sex life to get back to the way it was before the procedure. The most common issue is retrograde ejaculation, sometimes called “dry orgasm” or “dry climax.” You’ll still ejaculate and feel pleasure from orgasm. But semen will travel backward into your bladder instead of forward out of your penis. It eventually passes with your urine. Retrograde ejaculation is harmless, but if you wish to father a child, talk to your doctor first.

Transurethral Incision of the Prostate (TUIP)

If your prostate isn’t greatly enlarged, you might have a TUIP procedure.
Your surgeon will use a laser beam or electrical current to make small cuts in the bladder neck where the urethra joins the bladder, extending into the prostate. This reduces pressure on the urethra.

You might be in the hospital for about 3 days for TUIP, and you’ll probably have a catheter for a few days, too.

Urinary tract infections, retrograde ejaculation, and ED are possible side effects of TUIP, however most issues are temporary. Additional treatment might be necessary in a few years.

(Note: When a laser beam is used, TUIP might be called TULIP (transurethral ultrasound-guided laser incision of the prostate).

Transurethral Electroevaporation of the Prostate (TUVP)

With TUVP, a tool called a resectoscope is inserted into your urethra (after you receive anesthesia). This tool emits an electrical current to destroy prostate tissue. You’ll be in the hospital for one night.

Transurethral Water-Jet Ablation (TWJA)

As the name suggests, TWJA uses strong water jets to destroy extra tissue. It’s a fairly new procedure, and you’ll have general anesthesia. Your hospital stay will likely be just one night, and you’ll need a catheter for about two days. This approach is thought to have fewer sexual side effects.

Transurethral Microwave Thermotherapy (TUMT)

With TUMT, microwaves are used to heat prostate tissue and destroy it. (Don’t worry! There’s a cooling system in place that will protect your urinary tract.) You won’t need anesthesia for TUMT, and you’ll probably go home the same day.

Ablation of the Prostate

Ablation, in BPH terms, means “destroy” excess prostate tissue using electrical, heat, or laser energy. These procedures tend to have less bleeding, and could be more suitable for men with other health issues. Here are some examples:

  • Plasma vaporization (“button procedure”). Similar to TURP, but instead of an electrical loop at the end of the device, there are two electrodes.
  • Holmium laser enucleation of the prostate (HoLEP). This procedure is also similar to TURP, but uses a holmium laser. You might be in the hospital for a night. And you might experience incontinence afterward, but this usually gets better within 6 weeks.
  • Thulium laser enucleation of the prostate (ThuLEP). ThuLEP is similar to HoLEP described above, except a thulium laser is used.
  • Holmium laser ablation of the prostate (HoLAP). This procedure is also similar to HoLEP, but the laser vaporizes excess tissue.
  • Photoselective Vaporization of the Prostate (PVP). PVP uses a special high-energy laser to vaporize excess prostate tissue. The laser is delivered through an endoscope that’s inserted into your urethra.
    The procedure is performed on an outpatient basis, and you’ll likely go home within a few hours. You should still avoid strenuous exercise for 2 weeks afterward, though.
  • Convective water vapor ablation (CWVA). This technique uses the energy in water vapor (steam) to destroy excess prostate tissue. It’s a same-day procedure that can be done at your doctor’s office, though you might need to use a catheter for a few days afterward. Many men don’t have side effects.

Surgery

Simple prostatectomy

Men who have particularly large prostates or bladder damage may undergo simple prostatectomy - the surgical removal of prostate tissue. Unlike transurethral procedures, prostate tissue is removed through an incision. This incision might be in your lower abdomen (a suprapubic or retropubic prostatectomy). Another option for the location of the incision is your perineum (the area between your rectum and scrotum). This type is called a perineal prostatectomy.

Note: Simple prostatectomy is different from radical prostatectomy

(Note: Simple prostatectomy is different from radical prostatectomy, a procedure used to treat prostate cancer. With radical prostatectomy, the entire prostate gland is removed. Simple prostatectomy just removes a portion of it.)

Nowadays, some prostatectomies are robot-assisted. However, this doesn’t mean that a robot is actually doing your surgery. Your surgeon is still in charge! However your surgeon guides the robot with a computer and follows the action on a monitor. This allows the surgeon to control the robot’s movements with great precision.

You’ll be in the hospital for a few days after an open prostatectomy. Once you’re home, you’ll need to take it easy and avoid any strenuous activity or lifting for a few additional weeks. Depending on the prostate size, many centers with robot-assisted laparoscopic techniques can now perform the surgery using the robot. The advantage of the latter is a shorter hospital stay and earlier recovery.

Some men have incontinence (urine leakage) or erection difficulties after prostatectomy. Your doctor can teach you how to do special exercises called Kegels to strengthen your pelvic floor muscles. Your doctor might also prescribe treatment for erectile dysfunction (ED).

Erectile dysfunction (ED) – you know the term. It's when a man can't get – or keep – an erection hard enough for satisfying sex. Your father or grandfather might have called it impotence, if they talked about it at all.

If you can't get an erection at all, no matter what, that's ED. But a partial erection – one that's not as firm as you'd like it to be – is ED too. Maybe it only happens once in a while. Or maybe it only happens in certain situations – like when you're with someone but not when you masturbate. It's all ED.

Understandably, men are typically concerned about ED. Your sex life is likely to suffer – or at least change quite a bit. Your sense of masculinity may be bruised. You may be worried about satisfying your partner. And what about your overall physical health?

Don't panic! ED is actually quite common. Most men experience is at some point in their lives. And often, it's very treatable.

The American Urological Association estimates that 30 million men have erectile dysfunction

How common is ED?

It's the most common sex problem men discuss with their doctors. The American Urological Association (AUA) estimates that 30 million men have ED.

ED is more common if you're older, but younger men get it, too. If you're not as healthy as you could be, the odds you'll be dealing with ED go up. If you have diabetes, heart disease, or kidney disease, you're at higher risk. Psychological issues, like depression and anxiety, can play a role as well.

Why can't I get (or keep) a strong erection?

Ideally, here's what happens to your penis when you get aroused: smooth muscle tissue relaxes and arteries widen. Additional blood starts to flow in. This extra blood makes your erection firm. Veins temporarily close, keeping the blood inside the penis until you ejaculate or the stimulation stops. Then the veins open up again and the blood flows back into your body.

ED is often a blood flow problem. The smooth muscle tissue might not relax or the arteries don't open enough. Or, arteries might be blocked by plaques, as is the case the atherosclerosis (hardening of the arteries), making it more difficult for blood to flow in. In some cases, veins don't constrict enough, so blood can't stay in the penis.

What causes ED?

There are a number of possibilities here:

Vascular disease

Vascular disease involves damage to your circulatory system – the arteries and veins which carry blood throughout your body. Remember, "hard" arteries are "clogged" with plaques that form on your artery walls. Vascular disease makes it harder for blood to flow through your blood vessels. Less blood flow typically means a softer erection.

This is a common way for vascular disease to lead to ED. Your risk for vascular disease increases as you get older. An estimated 50 to 60 percent of men over 60 have ED due to vascular disease.

You're more likely to face vascular disease if you have:

  • Diabetes
  • High blood pressure (hypertension)
  • High cholesterol
  • A history of smoking

Diabetes

When your blood sugar is too high, it can damage nerves and blood vessels throughout your body, including those needed for a firm erection. Your penis might not "get the message" from your brain to start an erection. And if an erection does get triggered, you might not have sufficient blood flow to keep it going. Diabetes is a huge ED risk factor. About 60 percent of men with diabetes have trouble with erections.

Drugs

Lots of medications men take have sexual side effects, which can include ED. If you take blood pressure drugs, heart medications, antidepressants, tranquilizers, or sedatives, you might see some changes in your erections. Over-the-counter meds that you buy at the pharmacy can have similar effects.

If you drink alcohol or use illicit drugs, you should watch your intake. These can cause ED, too.

Kidney and liver disease can affect your hormones and your sex life

Hormone imbalances

Most men know testosterone affects sexuality. It may surprise you though that it's pretty rare for low testosterone to cause ED or low sex drive. Still, it does happen. Check with your doctor.

Prolactin is another hormone to watch. Men with pituitary gland tumors may have too much prolactin, which in turn reduces testosterone levels.

Kidney and liver disease can also affect your hormones and your sex life.

Obesity

We all know obesity is a growing problem in the United States. Maybe you're struggling with your weight. You're not alone. In 2017-2018, the Centers for Disease Control and Prevention (CDC) reported that 42% of Americans were obese - in other words, they had a body mass index (BMI) of over 30. Carrying extra weight puts a lot of stress on your body. The result can be heart disease, diabetes, and yes, ED.

Neurologic conditions

Some neurologic conditions, like paraplegia and stroke, interrupt nerve impulses from the brain to the penis. In other words, the penis won't "know" that there's a reason to become erect. Other neurologic conditions, such as multiple sclerosis (MS), Parkinson's disease, and Alzheimer's disease can lead to ED, too.

Pelvic trauma, surgery, radiation therapy

If you've had pelvic surgery, radiation treatment for cancer, or trauma to the pelvic region or spinal cord, you might experience ED.

For example, if you have prostate cancer, you might have your prostate removed surgically. Unfortunately, the prostate is surrounded by nerves needed for erections. Surgeons do their best to keep as many nerves intact as they can (a technique called nerve-sparing). But many men still have some degree of ED afterward. The situation usually improves, but it takes time – sometimes up to 18 months.

The situation is similar if you have a radical cystectomy for bladder cancer.

Peyronie's disease

Men with Peyronie's disease have a noticeable curve to their erect penis due to areas of hardened scar tissue (plaques) that form just beneath the skin's surface. Some men with Peyronie's develop painful erections or ED.

Venous leak

Good blood flow into the penis is critical for a firm erection. But that's only half of the story. The blood needs to stay in place to keep a strong erection. Sometimes, there's a problem with the veins, and they can't keep the blood in. So it leaks back into your body. The result? A softer erection, or no erection at all.

Psychological and emotional issues

Stress and anxiety can have a huge impact on our health, including our sex lives. If you're worried about your relationship, your kids, your job, or just life in general, that might transfer to the bedroom.

Add in anxiety about ED and things can go downhill quickly. If you're in bed with your partner and worried about your performance, it's going to be tough to relax – and that's a recipe for ED.

Diagnosing ED

We know. It's tough for many men to talk with a doctor about the possibility of ED. But your doctor has heard it all. And talking with your doctor is the first step in doing something about the issue.

Your doctor will ask the usual questions about your medical history and your lifestyle. Do you smoke? How much exercise do you get? What's your diet like? Your doctor will also need some details about your erections. How often do you have trouble getting or staying firm? Can you get an erection in some situations (like when you masturbate), but not others? How has your sex drive been? Do you have any pain?

Again, your doctor has heard it all. Men are treated for ED every day. You want your treatment to be as effective as possible, so answer the questions with as much honesty and detail as you can muster.

Lab tests will probably be part of this too. You'll likely have blood and urine tests. They'll want to check how your liver, kidneys, and thyroid are working. You might even have an ultrasound to check your blood flow.

How Is ED Treated?

We've all seen the ads for ED drugs. But pills are only one way to treat ED. Treatments can even be combined. Work with your doctor to find the best approach. Again, the more information you provide and the more questions you ask, the more effective your treatment is likely to be.

Lifestyle changes and natural treatments

Sometimes, ED can be managed by simple lifestyle changes. For example, if you have diabetes, then controlling your blood sugar may improve your erections. Or, if you're taking a medication with sexual side effects, tweaking your prescription might help. (Never make medication changes on your own. Always check with your doctor.)

These basic changes are the first treatment options for many men:

  • Quit smoking. Your doctor can help tailor a smoking cessation plan that is right for you. You'll feel better. You'll look better. Your wallet will thank you.
  • If you use recreational drugs, stop. Your doctor can help you here, too.
  • Do you drink a lot? Does someone else in your life think you should cut back? Give it a try. Or stop completely. Again, your doctor can help you.
  • Exercise! It's the closest thing there is to a wonder drug. Start exercising (or increase your current effort even modestly) and you'll almost immediately lower your risk for health problems. Chances are you'll feel better too. You might lose a few pounds. Maybe your pants will fit a little better. Exercise doesn't have to be a grind to be effective. Play some basketball. Go for a bike ride. Walking is excellent exercise.
  • Change your diet. Think salads, fruits, and veggies. Whole grain breads and pastas. Soy, beans, seeds, nuts, olive oil, and cold-water fish (like salmon, tuna, sardines, halibut, and mackerel). Avoid fast food, processed foods, caffeine, and sugar.You don't have to make drastic changes all at once. Try a salad for lunch twice a week instead of drive through. Have an apple or a peach for dessert instead of that chocolate-chip cookie. Pour yourself a glass of flavored seltzer water instead of soda or fruit punch. Get a cookbook full of healthy recipes and experiment with foods you've never tried before. (This can be especially fun with your partner or friends.)

Sex therapy and counseling

If anxiety, depression, or another mental health issue is triggering your ED, your doctor might suggest counseling or sex therapy. Therapy can give you a chance to talk things over with a professional and learn some coping strategies. If you have a partner, you might bring them with you. Together, you can work on your communication and your relationship.

Pills

Yes, you've seen and heard commercials for ED drugs. In the United States, there are four oral medications used to treat ED: sildenafil (Viagra), vardenafil (Levitra), tadalafil (Levitra), and avanafil (Stendra).

They're called phosphodiesterase type 5 inhibitors – PDE5s inhibitors for short. And while they are all used a little differently, they work in similar ways, by relaxing smooth muscle tissue in your penis. Then, enough blood can flow in for a firmer erection.

Usually, men take PDE5 inhibitors about an hour or two before sex, but you should always follow your doctor's instructions.

PDE5 inhibitors are effective for about 70% of men, but they're not safe for everyone. Men who take nitrates for heart conditions should never take PDE5 inhibitors. Combining PDE5 inhibitors with nitrates can cause a dangerous drop in blood pressure. If you take nitrates, you will need to use a different ED treatment.

Pay attention to side effects of your ED medication

Are there side effects? Yes, there can be. Some men get headaches or muscle aches when they take these drugs. Others get a stuffy nose, a flushed face, or indigestion. For most men, these effects are mild.

Men who take Viagra might notice temporary vision changes, where things look like they're in a blue-green filter. If your visual acuity (how well you see) changes, you must stop taking the medication and inform your doctor immediately. Cialis users sometimes experience back pain.

If any side effects give you trouble, reach out to your doctor and ask whether another ED treatment is right for you.

Self-injections

The medical term for this approach is intracavernosal injection (ICI). The success rate for this method is about 85%, according to the American Urological Association (AUA). As with all medications, however, the response will depend on many different factors, including the severity of the condition and the medication dose.

If you take this route, you'll use a tiny needle to inject a medication called alprostadil into the side of your penis. Sometimes, other medications are mixed with alprostadil, so you might hear terms like bimix or trimix, depending on what is used. Ask your physician about the differences between these medications and how they work.

After the injection, an erection usually starts within 15 minutes and can last up to two hours. Don't be alarmed if your erection lasts a while after you ejaculate. That can happen.

However, if you have a rigid erection that lasts longer than 4 hours, head to your local emergency department. This condition is called priapism and you’ll want medical attention ASAP.

If you use ICI, make sure you space each injection at least 24 hours apart. Up to 3 injections a week should be safe but ask your doctor about the right plan for you. Using ICI too often can scar the penis, which can make erections more difficult later on.

The idea of giving yourself an injection in the penis might make you queasy, but lots of men manage their ED this way. Your doctor will teach you how to do it safely for effective results and minimal pain. Your partner can also be taught how to do it.

Urethral Suppositories (MUSE)

The drug alprostadil (also used in injections) can come in suppository form, too. With the MUSE intraurethral method, you place a pellet into your urethra – the tube that allows urine and semen to leave your body. An erection usually starts within 10 minutes, when the drug gets absorbed and moves from the urethra into the erection chambers, the corpora cavernosa. Typically, the erection lasts for 30 to 60 minutes.

As with self-injections, your doctor will show you how to use MUSE safely and effectively. Side effects may include pain in the penis, testicles, legs, and the area between the scrotum and rectum. Some men feel warmth or burning sensations in the urethra, and the penis might redden. There could be some minor bleeding, too, if you don't place the pellet correctly.

Testosterone therapy

If your testosterone levels are lower than normal (below 300 ng/dL), your doctor might suggest testosterone replacement therapy (TRT).

Testosterone is an important hormone for men. It drives male-typical characteristics like a lower voice and body hair distribution. It also drives your libido.

But in some cases, men's bodies don't produce enough testosterone. Also, men's testosterone levels naturally drop as they get older. It's a normal part of aging.

Your doctor might start you on TRT if you have other symptoms of testosterone deficiency, like low sex drive, depressed mood, or fatigue. You'll follow up with your doctor periodically to see how well it's going.

Don’t get duped! You might find over-the-counter products that claim to contain testosterone to improve sexual performance. Lots of men think about trying these on their own, without seeing a doctor. But it’s essential for your doctor to measure your testosterone levels and monitor them over time. Your doctor may also want to conduct other important blood tests.

Testosterone should always be taken by prescription. Think about it. Do you really want to trust your sexual health to the convenience store on the corner or a shady website?

Vacuum erection devices (VEDs)

If you don't do well with medications – or can't take them – you might try a VED, a simple mechanical tool. As the name suggests, a VED triggers an erection by using a vacuum to bring blood to your penis.

The basic components of a VED are a plastic tube, a small hand pump, and a rubber O-ring. Here's how they work together:

  • When you're ready to have an erection, you place your penis into the plastic tube, and hold it close to your body.
  • Next, run the hand pump for about one to three minutes.
  • Once your penis is fully erect, you place the O-ring around the base of your penis to keep the blood inside.
  • From there, you can remove the tube and have intercourse.
  • When you're done, remove the O-ring.

VEDs have their pros and cons. On the pro side, they can be used at any VEDs have their pros and cons. On the pro side, they can be used at any time, so you can always be ready for sex. You don’t need to take any medication, and there’s no surgery involved. And if used properly, about 75% of men have success, according to the AUA. Your doctor will show you how to use it. Again, for any individual patient, the response depends on the severity of the condition and many other factors that your doctor can discuss with you.

On the con side, VEDs can be a little cumbersome. They take about 5 to 10 minutes to set up, which means you and your partner will have to take a short break during lovemaking so you can get an erection started. Some couples find this interruption less than romantic, and it might take away some of the excitement and spontaneity.

Other drawbacks to the VED: Your erection might look a bit floppy because there's no erection/additional blood stored between the O-ring and your body. Some men find that their ejaculation feels different. You could feel some coldness or numbness in your penis, too.

Note: Sometimes, a man's body shape makes it difficult to use a VED. Also, men who have problems with blood clotting and those who use blood thinners shouldn't use VEDs.

Revascularization surgery

Younger men with ED caused by pelvic trauma may benefit from revascularization surgery. This process involves using an artery from the abdomen to create a “bypass” in the penis.

Revascularization is a very uncommon and specialized surgery that is ideal for young men, often trauma patients, who do not have general vascular disease since the “new” connection needs to be “atherosclerosis free” to be able to bring blood to the penis.

Penile implants (prostheses)

What, exactly, is an implant? It's a device that's surgically implanted into your penis and helps you create an erection on demand.

Implants come in two types:

  • Malleable implants are semi-rigid bendable rods, usually made from silicone. When you want an erection, you simply move your penis into an upward position. When you're finished with sex, you can move it back down.
  • Inflatable implants are cylinders that fill with fluid to create an erection. You control the timing by using a special pump that is also surgically implanted, usually in your scrotum. You can start an erection with just the press of a button. After sex, you can push the same button to deflate the cylinders.

Getting an implant is a big decision. Once you have one, there's no going back. That's because the rods or cylinders replace two chambers in the penis called the corpora cavernosa. These are the chambers that normally fill with blood during an erection. During implant surgery, the corpora cavernosa are removed completely.

Implant surgery is fairly straightforward. Chances are, you'll spend a night in the hospital, although you might go home the same day. You'll probably have some pain, bruising, and swelling for a few weeks. Your doctor will give you special instructions about lifting things and exercising. You'll need to wait about 8 weeks before having sex again.

Like any surgery, implants have risks. You might develop an infection. There's also a slim chance that the device will malfunction, and you might need surgery again to fix the problem. However, most men with implants have successful, satisfying sex lives for many years after surgery.

Implants do have high satisfaction rates among men and their partners. In fact, some partners might not even know you have an implant. And orgasm should feel the same.

How about supplements?

Some men find it helpful to take supplements and herbs, but your mileage may vary. No matter what, always check in with your doctor before taking any product. Supplements aren't regulated by the FDA the way drugs are, and you might not know how a product will interact with other health conditions or medications.

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