Erectile Dysfunction Frequently Asked Questions

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ED (aka impotence) is defined as “the persistent inability to achieve or sustain an erection sufficient for satisfactory sexual intercourse.” This can be a total inability or inconsistent ability, or a tendency to sustain only brief erections.

Although it is common (at least 50% of men over 50 years old have some loss of function), it is NOT normal, no matter what the patient’s age.

Unfortunately, only 10% of men seek treatment and many (50%) discontinue treatment once they start it. This is because they are understandably embarrassed to raise this issue with their physicians and they may get inadequate information about the many treatments that are available to them.

It is even more unfortunate when you consider that it 1) affects the quality of life 2) makes men feel worse about their general health and 3) may be a symptom of an underlying disorder (for example, diabetes, cardiovascular disease, etc). Men do not realize that there are a variety of very satisfying treatments and there is no need to suffer in silence.

What are the causes of erectile dysfunction?

In the most basic analysis, an erection consists of blood flowing into the corpora cavernosa (AKA erection bodies) and being trapped there. A problem with either blood getting in or staying in causes ED.

Potential causes are many and include: vascular (high blood pressure, elevated cholesterol, diabetes, cardiovascular disease), diabetes, trauma (spinal cord injury or injury to the pelvis), neurologic disease (stroke, Parkinson’s disease), radiation to the pelvis (for prostate or rectal cancer), endocrine disease, surgery in the pelvis (radical prostatectomy, surgeries for rectal cancer or bladder cancer), medication side effects (especially medications used for high blood pressure), alcohol, tobacco, cocaine, etc.

Is ED just the man’s problem?

This is a “couples disease”. Even though the problem is not Psychologic (i.e. it’s not “all in your head”), ED causes depression, anxiety, loss of feelings of masculinity and self-esteem. This of course affects relationships and may set up a “vicious cycle” where the partner feels unattractive and so stops initiating intimacy, the man then feels unattractive, etc. This can be devastating to the couple. Very few couples can or want to give up their physical intimacy without any problems!

Is there treatment for ED?

Luckily, there are many good treatments. These include pills, injections, penile suppositories, vacuum devices, and surgery. Surgery provides the only cure but many men want to explore other options and may be very satisfied with them.

What about pills?

Currently, three pills are available (Viagra/sildenafil, Levitra/vardenafil, Cialis/tadalafil). They are all “phosphodiesterase inhibitors” which means they act by blocking a chemical that stops erections. Viagra was introduced in 1998 (the others in 2003) and revolutionized the way that men and their partners looked at ED. With all the press and media coverage of these medications, men realized that they had a real problem and became more open to talking about it.

Keys to using pills successfully

These medications all act as “amplifiers”, meaning that men still need foreplay and erotic thoughts to have an erection.

The pills may not work the 1st few times, so it is worth trying the pills several times before deciding that they do or don’t work.

The pills (especially Viagra) should not be taken after a large meal, as they will not absorb as well. They should be taken before a meal or after a snack.

Pill Safety

Generally these medications are safe. Side effects are common (around 30% of men have them) and include: headache, flushing (feeling hot), upset stomach, stuffy or runny nose, and back pain (especially Cialis).

These medications should NOT be used if you are taking (or have at home) nitroglycerin or medications containing nitrates (ask your doctor or pharmacist if you have a question about this), as the combination may cause a dangerous drop in blood pressure.

These medications should be used with caution if you are taking medications for enlarged prostate (BPH) such as flomax/tamsulosin, hytrin/terazosin, etc. Again, ask your doctor or pharmacist if you have questions about this or if you have any other less common medical conditions that would make you change the dosage of the pills.

You may hear about other pills that are available, such as yohimbine, Uprima, etc. These are not approved by the FDA and generally are not very effective.

What if pills don’t work?

If pills don’t work or if the patient cannot tolerate them, alternatives include injections, suppositories, vacuum devices, or surgery.

What are vacuums?

A vacuum device (VED) is an external device (not a drug) that goes over the penis. When pumped, it pulls blood into the penis then a special ring is placed over the base of the penis to keep it erect.

VEDs are generally safe (although there have been some very rare but serious complications) but unfortunately many men simply do not like them. They can only work well in the setting of a stable relationship and many men simply stop using them.

What about injections?

Drugs may be injected directly (using a tiny needle) into the penis. Several drugs and drug combinations are available, including alprostadil (Edex, Caverject), phentolamine, and papavarine (usually given in combination as Bimix or Trimix). The patient can usually get an erection within 5-10 minutes and it should last between 20 minutes to an hour.

Injections do require training and it may be tricky to get the right dose. We always do the first injection in clinic, which helps the patient learn to do it and also gives us a good idea about the dosing. Patients are usually anxious about it but are almost always surprised by how painless the injection is. The patient will be observed in clinic to make sure the erection goes down and, if necessary, the erection is reversed. If needed, the patient returns another day to try a different dose; on the second trip, patients do the injection themselves under our supervision. Some men do not require a second visit.

It is very important to alternate injecting the left and right side of the penis and to not use injections more than 3 times per week.

Although injections often work well, long-term use is not common.

What about suppositories?

Urethral suppositories (AKA MUSE) contain alprostadil (see “Injections”). The pellet is given via a delivery system into the urethra (urinary channel) and dissolves there. Similar to injections, we always give the first suppository in clinic to make sure there are no problems and that the patient is comfortable doing this.

Although the suppositories are appealing, effectiveness is relatively poor and overall satisfaction is relatively low. Additionally, the suppositories are quite expensive and this severely limits their use.