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Review Article
Erectile dysfunction treatment and traditional medicine—can East
and West medicine coexist?
1 2 3,4
Joe K. C. Lee , Ronny B. W. Tan , Eric Chung
1 2
Department of Urology, National University Hospital, Singapore 119074, Singapore; Department of Urology, Tan Tock Seng Hospital, Singapore;
Lee Kong Chiang School of Medicine, Nanyang Technological University, Singapore – Imperial College, London, UK; 3Department of Urology,
4
Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; Andro Urology Centre, St Andrew’s War Memorial Hospital, Brisbane,
Australia
Contributions: (I) Conception and design: E Chung; (II) Administrative support: All authors; (III) Provision of study materials or patients: All authors;
(IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Associate Professor Eric Chung. Andro Urology Centre, Suite 3, 530 Boundary St, Spring Hill QLD 4000, Brisbane, Australia.
Email: ericchg@hotmail.com.
Abstract: Erectile dysfunction (ED) is a common sexual problem affecting many men irrespective of
cultures, beliefs and nationalities. While medical therapy for ED has been revolutionized by the advent
of oral phosphodiesterase type 5 inhibitors and intracavernosal injection of vasoactive agents, recent
technological advances such stem cell therapy, low intensity shock wave and newer generation of penile
prosthesis implant offer hope to men who do not respond to conventional medical therapy. In contrast,
traditional and complementary medicine (TCM) focuses on the restoration and better overall bodily
regulation with the use of various herbal and animal products as well as exercises to invigorate qi (energy) in
vital organs. Western medicine involves an analysis of ED symptom and underlying causes that contribute to
ED, while TCM emphases the concept of holism and harmonization of body organs to achieve natural sexual
life. The following article reviews our current understanding regarding the philosophical approach, and
evaluates the evidence surrounding various ED therapies between mainstream Western Medicine and TCM.
Keywords: Erectile dysfunction (ED); Western medicine; traditional and complementary medicine (TCM); herbal
products; Eastern medicine; qi (energy)
Submitted Oct 27, 2016. Accepted for publication Oct 30, 2016.
doi: 10.21037/tau.2016.11.13
View this article at: http://dx.doi.org/10.21037/tau.2016.11.13
Introduction bodily regulation with medicine to invigorate qi (energy)
Erectile dysfunction (ED) is defined as the persistent in vital organs such as kidney, spleen and liver; to enhance
inability to attain and maintain an erection that is sufficient physical fitness, increase sexual drive, stabilize the mind
to permit satisfactory sexual performance (1). The and improve the overall situation resulting in natural and
current pharmaco-therapeutic research in ED focuses on harmonious sexual life (3).
underlying endothelial dysfunction as the root cause for While Western medicine emphases the link between
ED and introduction of phosphodiesterase type 5 inhibitors cardiovascular function and ED, TCM places importance
to potentiate nitric oxide (NO) action and cavernosal on liver and kidney ailments as causative factor for
smooth muscle vasodilation, has revolutionized modern development of ED. Western medicine involves a step-wise
ED treatment over the past two decades (2). In contrast approach by targeting the relevant organ systems to treat
to Western Medicine, the traditional and complementary various clinical symptoms; but TCM focuses on restoring
medicine (TCM) aims at restoration and better overall the balance between various organs to achieve harmony
© Translational Andrology and Urology. All rights reserved. tau.amegroups.com Transl Androl Urol 2017;6(1):91-100
Lee et al. Erectile dysfunction treatment and traditional medicine
92
Table 1 Summary of current understanding and treatment strategies between Western medicine and TCM
Western medicine TCM
Basic understanding Health and disease as separate entities; Regulation of yin and yang; harmonization of body
understand pathogenesis elements
Yin and Yang of treatment Yin = anatomy; Yang = physiology Yin = blood; Yang = energy
Clinical approach Analytic; explore cause and effects of disorder Holistic; harmonize overall bodily function to treat disease
state
Underlying organ Cardiovascular risks and endothelial dysfunction Liver and kidney ailments
dysfunction
Treatment strategies Stepwise approach by target organ systems Restore balance for more natural and harmonious sex life
Medical and medicinal Oral PDE5 inhibitors; intracavernosal vasoactive Herbal products; animal derived products
products agents
Non-medical therapy Mechanical therapy: (I) VCD/VED; (II) PVS; (III) Exercise therapy: (I) Jelqing; (II) Qigong; (III) acupuncture
penile prosthesis; (IV) LIESWT; (V) penile cast
TCM, traditional and complementary medicine; PDE5, phosphodiesterase type 5; VCD, vacuum constriction device; VED, vacuum erection
device; PVS, penile vibratory stimulation; LIESWT, low intensity extracorporeal shock wave therapy.
and holistic approach to inner sense (4). The following and molecular levels. The deep understanding of the role of
article reviews our current understanding regarding cGMP-specific phosphodiesterase type 5 enzymes in ED and
the philosophical approach, and evaluates the evidence the use of phosphodiesterase-5 inhibitors in treatment of ED
surrounding various ED therapies between mainstream exemplifies the success of this approach.
Western medicine and TCM (see Table 1).
Pharmacotherapy: oral or intracavernous vasoactive agents
Western medicine The development of PDE5-inhibitors is a clear example
Principle of treatment of how Western medicine approached the problem of
ED differently from Eastern medicine. The erectogenic
In Western medicine approach, health and disease are effect of sildenafil (Viagra®) was discovered by accident
clearly divided entities. The emphasis is on protection of the when patients undergoing heart clinical trials reported
individual body from disease or how to replace the body’s better erections as a side effect after taking sildenafil. This
lost functions. Antibiotic therapy is used to combat harmful observation led to further elucidation of the NO/cGMP
bacteria during infections, exogenous synthetic hormones are signalling pathway and development of PDE5-inhibitors as
used to replace hormone-deficient individuals and artificial a first-line therapy in ED (5).
prostheses are applied when an organ loses its functions. This Currently, there are four PDE5-inhibitors namely
is very different from the holistic Eastern approach where the sildenafil, tadalafil, vardenafil and avanafil are approved for
treatment entity is taken as a whole, and the objective is to use in United States, with more expected to join the market.
seek harmony between different bodily systems. Udenafil and microdenafil are PDE5-inhibitors developed
When it comes to scientific development, in Western in Korea and Lodenafil carbonate from Brazil (6).
medicine, an analytic approach is often used to identify and For patients who failed oral medical therapy or unable
resolve medical challenges. A hypothesis is first derived through to tolerate the side effects, intracavernosal injection of
general observations of a phenomenon. A research plan is then vasoactive agents can often provide effective alternative.
carefully designed and data collected. Once sufficient data is Various vasoactive agents such as alprostadil, papaverine
collected, critical statistical evaluations are done and conclusions or phentolamine have been used either as single agent
are drawn (4). Every aspects of a disease entity are studied or combination agents to potentiate the NO release
from macroscopic to microscopic views, down to the cellular and cavernosal smooth muscle vasodilation. However,
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Translational Andrology and Urology, Vol 6, No 1 February 2017
93
intracavernosal injection therapy has high attrition rate and with oscillating discs that can provide excitation of afferent
can be associated pain especially with alprostadil injection (2). penile nerves at various regulated frequency and amplitudes.
The practice of isolating compounds and understanding its PVS has been utilised to activate the ejaculatory reflex for
pharmacological attributes before using it as a drug therapy patients with spinal cord injury above T10 seeking to collect
has been a strength of Western medicine. retrogradely ejaculated semen in fertility treatment (10).
The Viberect is a vibratory stimulation handheld device
Mechanical and device-related therapy approved by FDA for treatment of ED. It is clamp-shaped
with two oscillating discs facing each other near the tips,
Various devices have been developed to enhance penile and the glans penis is placed between the two oscillating
erection without the common side effects of systemic discs to receive concurrent dorsal and ventral stimulation at
vasodilation associated with pharmacotherapy. In fact some adjustable frequencies and amplitudes.
of these devices have a longer history than modern ED In a study by Segal et al. (11), 4 out of 5 healthy individuals
medicine. were able to achieve tumescence beyond 60% maximum
®
rigidity when subjected to PVS using the Viberect alone,
Vacuum constriction and erection devices with no other external visual sexual stimulation. In a
The vacuum device is approved by USA Food and Drug randomized controlled study by Fode et al. (12) involving
Administration (FDA) for treatment of ED since 1982. 68 men who underwent nerve-sparing radical prostatectomy,
Vacuum therapy (VT) works by creating a negative 30 men who received PVS to the frenulum daily for 6 weeks,
®
pressure environment around the penis through the use of using the Ferticare vibrator, showed a trend towards better
a cylindrical housing attached to a pump mechanism, which erections. After 1 year, 53% in the PVS group had an IIEF
can be manually-operated or battery-operated. Vacuum score 18 compared with 32% in the control group, although
≥
draws mixed arterial and venous blood into the corporal no statistical achievement was achieved. The role of PVS in
bodies and distends the corporal sinusoids to create an penile rehabilitation is based on the postulation that PVS
erected penis. If a pre-loaded constriction band is applied provides early activation of the parasympathetic erectile
over the base of the penis to prevent outflow of blood and spinal centres at S2–S4 level, which result in early recovery of
maintain tumescence for intercourse, it is considered a the neuropraxic cavernosal nerves.
vacuum constriction device (VCD). It is recommended that
the constriction band be removed within 30 mins to return Low intensity extracorporeal shock wave therapy
the penis to its flaccid state, as prolonged application of the (LIESWT)
constriction band can compromise both arterial and venous The use of shock wave therapy has revolutionized the
blood flow (7). Some minor side effects associated with treatment of many aspects of medicine. High intensity
VCD are penile discomfort, coldness, numbness, bruising extracorporeal shockwave therapy has been used for the
and pain on ejaculation. Major side effects such as penile treatment of nephro-urolithiasis while medium intensity
skin necrosis, gangrene, urethral injury and Peyronie’s shockwave therapy is used by orthopaedic surgeons to treat
disease are very rare (8). joint pain as well as tendinitis. Low intensity shockwaves
The same device is considered a vacuum erectile device therapy was first noted to improve ischaemia-induced
(VED), when it is used to increase inflow of the blood to the myocardial dysfunction in animal studies when low intensity
penis without a constriction band. Regular use of VED in shockwaves were applied to porcine myocardium (13).
post-prostatectomy patient increases penile oxygenation and Shockwaves induces a localized stress on cell membranes
is accepted as a valid option in penile rehabilitation. Recent in the same way that shear stress affects endothelial cell
study reported transient increase in oxygenation to the membranes (14) and this triggers the release of angiogenic
glans penis and corporal bodies were detected by oximetry factors, such as increased NO production through
after VED was applied, providing proof for possible role for increased activity of endothelial NO synthase (eNOS) and
VED to counter the early penile hypoxia, cavernosal fibrosis neuronal NO synthase (nNOS), platelet-derived growth
and long-term ED after radical prostatectomy (9). factor (PDGF) and vascular endothelial growth factor
(VEGF) (15). These shockwaves also cause membrane
Penile vibratory stimulation (PVS) hyperpolarization (16), activation of the Ras signaling
Penile vibratory stimulator is a battery operated device pathway, non-enzymatic synthesis of NO and induction of
© Translational Andrology and Urology. All rights reserved. tau.amegroups.com Transl Androl Urol 2017;6(1):91-100
Lee et al. Erectile dysfunction treatment and traditional medicine
94
stress fibers and intercellular gaps (17). placement has allowed many of these men the option for
The pilot study by Vardi et al. (18) showed that LIESWT three-piece IPP placement (22). Technological advances
was effective in treating men with ED, suggesting a physiologic have improved mechanical reliability, reduced prosthesis
impact of LIESWT on cavernosal hemodynamics. The infection risk and offered excellent patient and partner
LIESWT is an effective penile rehabilitation tool that satisfaction rate (23).
improves erectile function and potentially reverses underlying
ED. Recent meta-analysis (19) of 14 studies showed that Penile cast
LiESWT could significantly improve the International The use of penile support device such as penile cast worn
Index of Erectile Function (IIEF) [mean difference: 2.00; externally during intercourse has been tried to provide
95% confidence interval (CI), 0.99–3.00; P<0.0001] and length and rigidity to the penile shaft (24). Each device can
Erection Hardness Score (EHS) (risk difference: 0.16; 95% be customised to the patient’s penile size and provided an
CI, 0.04–0.29; P=0.01). In addition, the therapeutic efficacy option for patients who are seeking non-pharmaceutical/
was noted to last for at least 3 months. LiESWT has been non-invasive treatment, or have end-organ failure who may
cited to a potential cure for ED, unlike other well established not be candidates for, or unable to afford, penile prosthesis
non-surgical methods of treatment (i.e., PDE5i, ICI and implant.
VED) being on demand treatments.
Penile prosthesis implant Regenerative medicine
Penile prosthesis implant remains the most effective and Following the breakthrough in ED treatment using PDE5-
permanent treatment for ED. Penile prosthesis implants can inhibitors, Western medicine has now moved on to a new
be broadly divided into malleable and inflatable prostheses (20). frontier of regenerative medicine, with stem cell and gene
Malleable penile prosthesis, also known as semi-rigid therapy leading the way (25). There is a practical need
prosthesis, does not allow for (physiological) flaccid state for novel therapy as a significant portion of diabetic or
of the penis. The patient can bend the prosthesis upwards post-prostatectomy ED patients do not respond to oral
for sexual intercourse and downwards for concealment. pharmacotherapy. To date, stem cells derived from different
Although the angle of prosthesis concealment has improved sites including adipose tissue-derived stem cells, bone
with recent devices, however due to the constant rigid state marrow mesenchymal stem cells and muscle-derived stem
of the penis, they are still less comfortable compared to cells have been investigated using animal models for ED, to
their inflatable counterparts, are more likely to cause social study their effects on neural, vascular, endothelial or smooth
embarrassment and associated with higher risk of implant muscle regeneration (25,26).
erosions (21). However, malleable prosthesis still has its In a prospective human phase 1 open-label and single-arm
place for the treatment of ED as these implants are easier study reported by Haahr et al. (27), 17 men with refractory post
to handle, easier to place and would benefit patients with radical prostatectomy ED were given a single intracavernosal
impaired manual dexterity. injection of autologous adipose-derived regenerative cells
There are currently two models of the inflatable penile (ADRCs) freshly isolated after a liposuction. The procedures
prosthesis (IPP), namely, the two-piece IPP vs. the three- were well-tolerated and over a 6-month follow-up period,
piece IPP. The three-piece IPP consists of a pair of corporal 8 of 17 men showed improvement of their erectile function.
cylinders, a scrotal pump and an abdominal reservoir filled In time to come, regenerative therapy with adjuncts may
with saline. Owing to the presence of the reservoir, the be a treatment option for patients with medical refractory
corporal cylinders can be completely deflated to give the ED.
patient the physiological flaccid state when not in use, and
likewise a maximally turgid state when inflated (21). The
two-piece IPP lacks an abdominal reservoir and is often Eastern medicine
offered in patients with whom placement of reservoir is Principle of treatment
challenging or not possible such as following radical cysto-
prostatectomy with orthotopic ileal neobladder creation, Sexual dysfunction has been evaluated in ancient literature
or patients who had previous open book fracture of the of TCM in terms of subjective sensation and the actual
pelvis with metal implants. The concept of ectopic reservoir sexual performance (3). In TCM, methods and matters
© Translational Andrology and Urology. All rights reserved. tau.amegroups.com Transl Androl Urol 2017;6(1):91-100
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