Q. I’m 59, and I’ve had difficulty getting an erection suitable for intercourse since I started taking antihypertensives about 20 years ago. I have also had four back surgeries (three procedures for herniated lumbar discs and a total lumbar fusion) that left me with some permanent nerve damage, causing foot drop and weakness in one leg. I have tried penile suppositories and injections. Although the injections were somewhat helpful, they were not ideal. Might an implant be my best option at this point? Should I see another urologist for an opinion?

A. You have pointed out two possible causes for your erectile dysfunction. However, before you try a penile prosthesis (implant), I think you need to have a better understanding of the problem.

To get an erection suitable for penetration you need three things. The first is good arteries and blood flow into the penis. The second is a good nerve supply to allow the arteries to dilate and turn the blood flow on. Lastly, there needs to be no outflow of blood through the veins during filling, to ensure a rigid erection. So, the problem may not be as simple as medication that decreases the filling of the penis or back surgery that might affect the nerves to the penis.

I think your doctor needs a diagnosis of what exactly is causing the problem — such as arterial insufficiency, neuropathy or a venous leak — before you accept a prosthesis. The reason is that some forms of arterial insufficiency are reversible, and neuropathies should respond to injection therapy like prostaglandin E1 (Caverject). By jumping right to a prosthesis, you miss the opportunity to restore the natural erections. In addition, the average time a prosthesis lasts is 7-10 years. At 59, you would be looking at several operations in your lifetime.

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