Erectile Dysfunction

Erectile Dysfunction

With ED, it is difficult or impossible to achieve or maintain an erection firm enough to complete intercourse. Sometimes, the erection is hard enough but becomes soft before penetration or shortly thereafter. About 30 million men in the US are affected by ED.

When it happens to a younger man, say in his 20s-30s, it could be an early sign of arterial disease or heart disease. This young man should be screened for early coronary heart disease. Most men will start noticing a decrease in the quality of his erections starting in his 30s-40s but tends to be a very slow process.

While some men are still sexually active  into their 70s and 80s, many will experience ED starting in their 50s-60s.

For most men experiencing ED, it is usually due to a combinations of issues such as:

  • Aging
  • High Blood Pressure
  • Diabetes
  • High Cholesterol
  • Smoking
  • Arterial Disease
  • Side effect of Prostate Cancer Treatment
  • Side Effect of Medications
  • Venous Leak
  • Low Testosterone
  • Heart disease


Usually, the first option to try is pills and if it does not work, more complex alternatives are tried next.


These are known as PDE-5 inhibitors and include Viagra (Sildenafil), Cialis (Tadalafil) and Levitra (Vardenafil).  They work by increasing the blood flow into the penis and are a reasonable first option. Viagra and Levitra have a 4 hour window of opportunity,  should be taken at least one hour before attempting intercourse and work better when taken on an empty stomach.These drugs will facilitate an erection if there is sexual stimulus. 

Cialis (Tadalafil) has a 36 hour window of opportunity and should be taken at least 2-4 hrs before intercourse. Some men report better results the following day.  Cialis does not require to be taken on an empty stomach.

A common question is which of these drugs is the best?  The answer is whichever one works the best and with  least degree of side affects for you.

 Common side effects include headache, flushing, runny nose, stomach pain, back pain (Cialis),and indigestion. Lower doses are used for individuals with liver and/or kidney disease. 

You should not take a PDE-5 inhibitor if you have angina and/or taking a nitrate.

Some men report great results initially, but unfortunately, many will notice that after a few years the drug loses its efficacy. At that point, it is time to try the next option(s).

External Vacuum Device

This consists of a clear cylinder into which the man places his penis and a vacuum pump  helps extend and bring blood to the penis , achieving an erection. The pump can be manually or battery operated. The battery operated tends to be easier to operate and likely has a higher success rate.

It is a simple and non-invasive alternative effective in about 70% of men.


Self-injection Therapy

Alprostadil (Caverjet, Edex) is injected into the side of penis with a very fine needle. It is best to have the first shot in the doctor’s office before doing this on your own. The dosing and the technique is very important for success and safety.  The success rate is as high as 85% .

Intracavernosal Injections (ICI) may be used as a single drug (Alprostadil) or as a mixture of three drugs (Papaverine, Phentolamine and Prostaglandin). This combination therapy called trimix tends to work better than a single drug inject able.

ICI therapy often produces a reliable erection, which comes down after 20-30 minutes or with climax. Since the ICI erection is not regulated by your penile nerves, you should not be surprised if the erection lasts after orgasm. The most common side effect of ICI therapy is PRIAPISM,  a painful erection lasting more than 4 hours.

Men who develop priapism should go to the emergency room to seek chemical or surgical reversal of this prolonged erection. If allowed to last longer than 4 hrs, priapism will lead to permanent penile damage and worsening ED.

Penile Prosthesis