A wide variety of options exist for treating erectile dysfunction (ED). Treatments include psychological counseling, medications, mechanical devices, and surgery. The cause and severity of the ED are important factors in determining the best treatment or combination of treatments for the individual. If ED is the result of a medical condition, the cost of treatment may be covered by insurance.
Psychological counseling: Psychological counseling can help with ED that is caused by
stress, anxiety, or depression. ED can also cause these issues. The individual and their partner may be instructed to visit a sex therapist, psychologist, or psychiatrist with experience in treating sexual problems. Qualified therapists work with couples to reduce tension, improve sexual communication, and create realistic expectations for sex, all of which can improve symptoms of ED. Therapists also help the individual work through issues such as sexual abuse as a child. Psychological therapy may be effective along with medical or surgical treatment. However, medical and surgical treatment may not help someone with ED who is suffering from psychological causes.
Oral medications available to treat ED include sildenafil (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra®). The U.S. Food and Drug Administration (FDA) approved Viagra® in 1998, and it became the first oral medication for ED on the market. Since then, Levitra® and Cialis® have been approved, providing more options for oral therapy. These drugs are chemically known as phosphodiesterase-5 inhibitors (PDE-5). They enhance the effects of nitric oxide, a chemical messenger that relaxes smooth muscles in the penis. This increases the amount of blood flowing into the penis and allows an erection in response to sexual arousal and stimulation. These medications do not automatically produce an erection. Instead they allow an erection to occur after physical and psychological stimulation and arousal. Many men experience improvement in erectile function after taking these medications regardless of the cause of their impotence.
Generally, these medications are absorbed and processed rapidly by the body and are usually taken 30 minutes to one hour before intercourse. Cialis® has been reported in clinical trials to stay in the body longer than the others. It promotes erection within 30 minutes and enhances the ability to achieve erection for up to 36 hours.
Common side effects of phosphodiesterase inhibitors include headache, reddening of the face and neck (flushing), indigestion, and nasal congestion. Cialis® may cause muscle aches and back pain, which usually go away on their own within 48 hours.
Medications prescribed for the treatment of erectile dysfunction may cause significant side effects when mixed with certain heart drugs called nitrates, including nitroglycerin (Nitrostat®, Nitro-Bid®), isosorbide mononitrate (Imdur®), and isosorbide dinitrate (Isordil®). Nitrates are often prescribed to reduce chest pain, dilate the blood vessels, and lower blood pressure. Because ED medications also reduce blood pressure, combining these two types of medication can cause a dangerous drop in blood pressure. Experts do not recommend taking sildenafil (Viagra®), vardenafil (Levitra®), or tadalafil (Cialis®) if nitrates are used. If an individual has coronary heart disease (CHD) or has had a heart attack in recent months, be sure to check with a doctor before taking any of these drugs for erectile dysfunction. These drugs should also not be used along with alpha blockers.
Prostaglandin E1 (alprostadil): Two treatments involve using a drug called alprostadil (Muse®, Caverject®, Edex®). Alprostadil is a synthetic version of the hormone prostaglandin E1. This hormone helps relax smooth muscle tissue in the penis (corpus cavernosum), which enhances the blood flow needed for an erection. There are two ways to use alprostadil, including needle-injection therapy and intraurethral (into the urethra) therapy. With needle-injection, a needle is used to inject alprostadil (Caverject®, Edex®) into the base or side of the penis, performed at a doctor's office or hospital. This generally produces an erection in five to 20 minutes that lasts for about an hour. Because the injection goes directly into the spongy cylinders that fill with blood, alprostadil is an effective treatment for many men. And because the needle used is so fine, pain from the injection site is usually minor. Other side effects may include bleeding from the injection, prolonged erection, and formation of fibrous tissue at the injection site. It should not be used more than three times per week, and there must be at least 24 hours (one day) between each dose. The cost per injection can be expensive. Injecting a mixture of alprostadil and other prescribed drugs (including papaverine and phentolamine) may be a less expensive and more effective option. A risk of infection exists at the injection site, especially in immunocompromised individuals such as those with human immunodeficiency virus (HIV). Healthcare professionals recommend using care to protect the individual using Caverject® and their sexual partner, as blood from the injection site after could be a carrier of sexually transmitted diseases, such as HIV or hepatitis.
Medicated Urethral System for Erection (Muse®)
is a self-administered intraurethral (into the urethra or opening in penis) therapy. It involves using a disposable applicator to insert a tiny suppository, about half the size of a grain of rice, into the tip of the penis. The suppository, placed about two inches into the urethra, is absorbed by erectile tissue in the penis, increasing the blood flow and causing an erection. Although needles are not involved, this method may be painful or uncomfortable. Side effects may include pain, minor bleeding in the urethra, dizziness, and formation of fibrous (scar) tissue. Again, bleeding may occur during the use of this drug, so care should be taken by the individual using Muse® to protect themselves and their sexual partner.
Hormone replacement therapy: For the small number of men who have testosterone deficiency, testosterone replacement therapy may be an option. While it is fairly well established that testosterone plays a role in libido (sexual desire), its role in ED remains unclear. ED occurs in men with normal or moderately low levels of testosterone, so it cannot be concluded that testosterone is the primary modulator of erectile function. However, among men diagnosed with hypogonadism, a condition characterized by abnormally low testosterone, erections do improve after testosterone replacement. For these men with ED, testosterone therapy is recommended to restore erectile function.
Testosterone replacement therapy has also been recommended as a second-line approach to treatment of ED when prescription medications alone have failed and when prostate cancer has been ruled out. However, testosterone may increase the growth of prostate cancer and is not used in individuals with this disease or an enlarged prostate (benign prostatic hyperplasia or BPH).
Yohimbine: Yohimbine comes from the bark of the Pausinystalia yohimbe tree. Yohimbine hydrochloride is a standardized form of yohimbine that is available as a prescription drug in the United States, and has been reported in human studies to be effective in the treatment of male impotence. Yohimbine hydrochloride (HCL) has also been used for the treatment of sexual side effects caused by some antidepressants (selective serotonin reuptake inhibitors), female hyposexual (low sexual desire) disorder, as a blood pressure boosting agent, and xerostomia (dry mouth due to lack of saliva).Yohimbine HCL improves erections for 10-20% of men. It stimulates the parasympathetic nervous system, which is linked to erection, and may increase libido (sexual desire). It is necessary to take the medication for six to eight weeks before determining whether it will work or not. Yohimbine HCL has a stimulatory effect and side effects include elevated heart rate and blood pressure, mild dizziness, nervousness, and irritability.
This treatment involves the use of an external vacuum and one or more rubber bands (tension rings). To begin, a hollow plastic tube is placed over the penis. This tube is available by prescription or through various vendors. Then a hand pump is used to create a vacuum in the tube that pulls blood into the penis. Once an adequate erection is achieved (usually one to three minutes), a tension ring is slipped around the base of the penis to maintain the erection. The vacuum device is then removed. The erection typically lasts long enough for a couple to have sexual intercourse. The ring can be left in place for 25 to 30 minutes. The tension ring is removed after intercourse.
Vascular surgery: This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery may also be used to correct erectile dysfunction caused by vascular blockages such as atherosclerosis (hardening of the arteries) or tumors. The goal of this treatment is to correct a blockage of blood flow to the penis so that erections can occur naturally; however, long-term success of this surgery is unclear. Complications are minimal and include abdominal or scrotal pain/swelling and occasional temporary numbness on the top surface of the penis. Abstinence from sexual activity involving the erect penis is recommended for the first six weeks after the operation.
This treatment involves surgically placing a device into the two sides of the penis, allowing erection to occur as often and for as long as desired. These implants consist of either an inflatable device or semi-rigid rods made from silicone or polyurethane. This treatment is often expensive and is usually not recommended until other methods have been considered or tried first. Penile implants are also sometimes used to treat Peyronie's disease, a disorder that causes bent or painful erections. As with any surgery, there is a risk of complications such as infection. Most men go home within 24 hours of surgery. Although new penile implant designs are very reliable and may last a lifetime, they can malfunction. For example, in some semi-rigid devices, internal parts can break down over time, leading to a prosthesis malfunction. In inflatable devices, fluid can leak or the valve or pump device can fail. Surgery is necessary to repair or replace a broken implant. Penile implants do not usually affect urination, sex drive, orgasm, or ejaculation.
A consideration before implanting a device into the penis is that implants cause an erection, but they do not increase sexual desire or sensation. A penile implant will be shorter than the natural erection. Some partners feel that sexual pleasure is diminished by their lack of involvement in creating an erection. This surgery is permanent. If the implant is removed, the patient will not be able to get an erection. There may be reduced sensation in the head of the penis. In some men, this improves when they also take phosphodiesterase type 5 inhibitors, such as sildenafil (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra®).
Unclear or conflicting scientific evidence
Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today it is widely used throughout the world and is one of the main pillars of Chinese medicine. It involves the insertion of needles in various point of the body to help move the "chi" or energy. A few clinical studies have suggested that acupuncture may help individuals suffering from erectile dysfunction (ED). The results found that acupuncture can be an effective treatment option in more than two-thirds of patients with ED caused by psychological factors including stress, anxiety, and depression.
L-arginine: L-arginine, or arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Early studies found that men with low nitrate levels (a cause of ED) in their blood or urine may find arginine supplements to be useful for managing erectile dysfunction (ED). A randomized, controlled clinical trial reported improvements in patients with ED following use of a combination of L-arginine, glutamate, and yohimbine hydrochloride. Notably, yohimbine hydrochloride is an U.S. Food and Drug Administration (FDA) approved drug therapy for ED, and the effects caused by arginine alone in this combination therapy are difficult to determine. It is not clear what doses of arginine may be safe or effective in treating this condition, and comparisons have not been made with other agents used for ED. Larger, high-quality studies are needed. L-arginine is generally safe in recommended dosages, although drug interactions may be seen, especially with drugs to lower high blood pressure.
Coleus: Coleus (Coleus forskohlii) has been used in Asian traditional medicine for over 2,000 years. A component of coleus, called forskolin, was studied in humans in addition to prostaglandin E1, a drug commonly used in erectile dysfunction. Positive effects were seen with the forskolin and progstaglandin when the prostaglandin alone did not work for ED. Caution is advised when taking coleus supplements, as numerous adverse effects including drug interactions with blood pressure lowering medications are possible.
DHEA or dehydroepiandosterone:
is an endogenous hormone (made in the human body) secreted by the adrenal gland. DHEA serves as forerunner to male sex hormones (androgens) and female sex hormones (estrogens). DHEA levels in the body begin to decrease after age 30. Although some human studies report positive benefits on erectile dysfunction and sexual function while using DHEA in both men and women, better research is necessary before a clear conclusion can be drawn. Caution is advised when taking DHEA supplements, as numerous adverse effects including drug interactions are possible.
Ginkgo: Ginkgo (Ginkgo biloba) has been used medicinally for thousands of years, and is one of the top selling herbs in the United States. Ginkgo is commonly used for decreased blood flow. Ginkgo has been reported in animal and human models as having vascular (blood vessel) relaxant properties, which may act on corpus cavernosum tissue of the penis and improve penile blood flow in patients with ED . Ginkgo has also been reported to be effective in antidepressant-induced sexual dysfunction. Ginkgo may increase the chances of bleeding in sensitive individuals, such as those taking blood thinning drugs like warfarin (Coumadin®).
Ginseng: Asian ginseng, or Panax ginseng, has been used for more than 2,000 years in Chinese medicine for various health conditions. Preliminary evidence from one study indicates that ginseng may be effective in improving the signs and symptoms of ED. It is not clear what doses may be safe or effective. Well-conducted studies are needed to confirm the results.
L-carnitine: L-carnitine, carnitine, or acetyl-L-carnitine, is an amino acid (building block for proteins). High concentrations of carnitine are found in muscle tissue. Preliminary studies suggest that addition of acetyl-L-carnitine (in combination with propionyl-L-carnitine, another form of carnitine) helped sildenafil (Viagra®) work better for patients with ED. However, more rigorous trials should be performed. Caution is advised when taking L-carnitine supplements, as adverse effects including drug interactions are possible.
Maca: Maca (Lepidium meyenii) is a vegetable that has been cultivated as a root crop for at least 2,000 years. It can be found wild in Peru, Bolivia, Paraguay, and Argentina, but has primarily been cultivated in the highlands of the Peruvian Andes. Traditionally in Peru, maca has been used as an aphrodisiac to increase sexual desire. Maca could improve sexual desire in healthy men independent of changes in mood, or serum testosterone (male hormone), and estradiol (female hormone) levels. Higher quality studies are needed in this area, in both men and women.
Muira puama: Muira puama (Ptychopetalum olacoides) has long been used by Brazilian native people as a treatment for impotence (erectile dysfunction). Relaxation of the corpus cavernosum can be related to penile erection. Three preliminary case-series suggest usefulness. Well-designed human trials of muira puama, as well as safety data, are necessary.
Pycnogenol: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster ssp. atlantica), which is grown in coastal south-west France. Pycnogenol® has protective effect on blood vessels. Pycnogenol®, in combination with L-arginine, may cause an improvement in sexual function in men with ED. It is not known what effect each of the individual compounds may have directly on this condition. Further research is needed. Caution is advised when taking Pycnogenol®, as it may increase the chances of bleeding in sensitive individuals, such as those taking blood thinning drugs like warfarin (Coumadin®).
A simple way to improve erectile dysfunction (ED) is to introduce lifestyle changes. For some men, adopting a healthier lifestyle by quitting smoking, exercising regularly, and/or reducing stress may be all that is needed to find relief. For others, adopting these lifestyle changes in addition to other treatments, such as medicines or surgery, can further help. Some tips on preventing symptoms of ED include limiting or avoiding the use of alcohol and other recreational drugs (marijuana, cocaine), quitting smoking, exercising regularly (at least 30 minutes daily), reducing stress, getting enough sleep (eight hours a night), dealing with anxiety or depression (through counseling and medication), and seeing a doctor for regular checkups and medical screening tests.
Although it may be uneasy to talk about, ED is a treatable condition and should be discussed with a healthcare professional.