Erectile Dysfunction


Erectile Dysfunction or Impotence (E.D.)


Definition of E.D. is:


“The inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance”

If you suffer from E.D., you are not alone. It is estimated that 20-30 million men in the U.S. suffer from E.D. It affects 5% of men at age 40, and between 15% and 25% by age 65. However, some studies have shown that some degree of ED affects 40% of men in their 40’s, 50% of men in their 50’s, 60% of men in their 60’s, and so on.


ED reduces quality of life. It may cause:


-loss of self-esteem
-poor self-image
-increased anxiety with one’s sexual partner
-Performance anxiety

* (NIH Consensus Development Panel on Impotence, JAMA 1993).



Anatomy and Physiology of Erections:


- The penis is made of three cylindrical parts: o 2 paired cylinders that fill with blood o 1 cylinder that contains the urethra

These three become engorged with blood during an Erection, but most of the rigidity comes from the Paired larger cylinders (corporal bodies)



There are many diseases associated with E.D. including:


- diabetes

- low testosterone

- hypertension(high blood pressure)
- hyperlipidemia and hypercholesterolemia

- heart disease
- peripheral vascular disease
- stroke
- depression


Many medical treatments cause E.D.:



-  surgery to remove the prostate, bladder, or colon

-  vascular bypass surgery

-  pelvic radiation therapy

-  pelvic fractures or injuries

-  prolonged competition bicycle riding


Some lifestyle choices can lead to E.D.:


-  smoking

-  drug abuse (marijuana, cocaine, amphetamine, narcotics)

-  excessive alcohol consumption

-  excessive stress or anxiety


Many prescribed medications can cause E.D.:


-  Beta blockers (atenolol, metoprolol, labetalol)

-  Diuretics (HCTZ, lasix



Treatment Options


Lifestyle modification


If you smoke, stop smoking. Smoking causes vascular disease, which increases your risk for ED. Also, nicotine is a vasoconstrictor meaning it causes the blood vessels to the penis to constrict, which in turn leads to less blood flow to the penis for erections.

If you drink alcohol, try drinking no more than 1 or 2 alcoholic beverages per day. A small amount of alcohol can be beneficial by decreasing anxiety and inhibitions. Excessive alcohol consumption can lead to higher estrogen levels which can lead to lower testosterone, a male hormone essential for normal libido and erections.

If you experience a lot of anxiety from work, relationship, financial problems, find a way to reduce your stress level. Stress and anxiety leads to increased levels of catecholamines. These hormones cause constriction of the blood vessels and can decrease erection quality and duration.

Regular exercise has been shown to improve sexual function and enjoyment. If you are overweight, try to lose weight. Studies on overweight men show that the visible length of the penis increases an inch for every 30 lbs of weight loss.


Psychosexual counseling


Some men suffer from performance anxiety. It is common for a man who is starting to experience some mild ED to become overly focused on it. This leads to the vicious cycle of anxiety leading to worse performance, which leads to more performance anxiety. There are highly trained specialists who can help men overcome this problem.


Pills (Viagra, Levitra, Cialis, Stendra, Staxyn)


Viagra was introduced in 1998. Levitra and Cialis soon followed. Recently, two now competitors have arrived on the market: Stendra (avanafil) and Staxyn (vardenafil, like Levitra, but dissolves on the tongue instead of swallowing). These drugs have revolutionized the treatment of ED. They work by blocking the molecule in the penis that signals to end an erection. This leads to better quality and longer lasting erections. But it only works if you have some ability to get an erection. If you get no erections at all, not even a partial one, these drugs are unlikely to work. Also, these drugs will not work in the absence of stimulation. You should think of them as an amplification of your natural erection ability.


Certain patients should not use these medications. Anyone who is taking nitrates should not use Viagra. Some of the common medications with nitrates are nitroglycerin pills (Nitrostat, Nitrobid), nitroglycerin patches (Deponit, Minitran, Nitro-Dur, Nitrodisc, Transderm-Nitro), nitroglycerin spray (Nitrolingual), nitroglycerin ointment (Nitro-bid, Nitrol), isosorbide dinitrate (Isordil, Sorbitrate), and isosorbide mononitrate (ISMO, Monoket). If you take any of these medications, DO NOT TAKE VIAGRA, LEVITRA, OR CIALIS. They may cause your blood pressure to drop dangerously low if taken with nitrates.

The most common side effects reported in clinical trials of these medications are headache, flushing, heartburn, nasal congestion, vision disturbance (temporary blue-green color blindness or blue haze), backache, and stomach upset. In general, the side effects are uncommon and usually mild if they do occur.

These medications need a little time to work. Take one pill 30 to 60 minutes before sexual activity. It may be effective for up to 4 hours after taking the pill. They should be used no more often than once per day (Cialis no more than once in 48 hours). Although advertising indicates to call you doctor immediately should your erection last more than 4 hours, this side effect is very rare.


Vacuum pumps


These devices are a mechanical solution to ED. These devices are called vacuum erection devices (VED’s). They work by creating a vacuum around the penis. The vacuum pulls blood into the penis, creating an erection. A constricting ring is then used to keep the erection. For some patients, the VED is a great solution to their ED, while avoiding the potential side effects of medication. However, some men complain of pain or decreased sensation while using the constricting ring that keeps blood in the penis. Others report their wives complain of discomfort from the constricting ring. They can be cumbersome to use and some patients find it necessary to re-use the vacuum device several times during intercourse in order to complete their love- making. Drop-out rates are high.


Medications Injected into the Penis (Edex, Caverject)

Caverject (Alprostadil)

  • -  injected directly into the penis

  • -  results in dilation of the blood vessels

  • -  increases blood flow into the penis

  • -  creates an erection that lasts from 20 min to several hours

-  most men achieve erections with an injection (75-95%)



  • -  it is often painful (not the needle, but the medicine as it causes dilation)

  • -  does not work on every man (5-25% fail to get erection)

  • -  cumbersome

  • -  some men get an erection lasting longer than 4 hours

    o erections lasting longer than 6 hours can cause permanent damage to the penis and must be treated with an antidote injection or surgery

  • -  costly (usually $25-30 per dose)


Urethral Suppositories (Muse)

  • -  Developed as an alternative to needle injections

  • -  Medication (Alprostadil) is in pellet form

  • -  An applicator is used to insert pellet into urethra

  • -  Medication is absorbed into the penis

  • -  Creates blood vessel dilation and erection

  • -  Easier to use than needle



  • -  Some men have pain in the urethra and penis

  • -  Not as effective as injections (40-65%)

  • -  Can cause prolonged erection (over 4 hours)

  • -  Can cause fibrosis of the inside of the penis over time

  • -  Costly ($25-30 per dose)


Penile implants (the Internal Penis Pump)


There are two basic types of penis implants: Semi-rigid and Inflatable

Semi-Rigid penile consist of bendable rods with a silicone plastic coating. Think of a goose-neck lamp. These are best for patients who have limited manual dexterity (such as from severe arthritis). The penis is always full. It is bent down when not in use, and bent upward when it is to be used. It is harder to conceal and looks less natural than an inflatable implant.


Inflatable penile prosthesis (also called the internal penile pump) consists of a pair of inflatable cylinders implanted into the penis, a pump placed in the scrotum between the two testicles, and a reservoir to contain saline (salt water) used to inflate the penis.


The implant is inserted through a 1 inch incision at the junction between the penis and scrotum.
It is almost always done as an outpatient.
The procedure takes about 1 hour in the operating room.


  • -  the implant cures E.D.

  • -  restores a normal rigid erection

  • -  can be inflated within a few seconds

  • -  will remain rigid for as long as desired

  • -  will remain erect even after the man has an orgasm

  • -  can be used as often as the man likes

  • -  restores a man’s confidence in his sex life

  • -  high patient and partner satisfaction rates (over 90%)

  • -  is concealable (some men report their female partners don’t know)

  • -  covered by medicare and most insurance companies

  • -  will not affect the man’s sensation

  • -  will not affect the man’s ability to have an orgasm


  • -  small risk of infection (1-3%)

  • -  small risk of mechanical failure (5% over a 5 year period)

  • -  requires anesthesia

  • -  some bruising and discomfort after during healing after surgery

Sexual Health Inventory for Men
A five item questionnaire to assess erectile function
Sexual Health Inventory for Men.pdf
Adobe Acrobat document [64.1 KB]