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Erectile Dysfunction

Erectile dysfunction can happen most often when blood flow in the penis is limited or nerves are harmed. With stress or emotional reasons. As an early warning of a more serious illness, like: atherosclerosis (hardening or blocked arteries), heart disease, high blood pressure or high blood sugar from Diabetes.

What is Erectile Dysfunction?

Erectile dysfunction, or ED, is the most common sex problem that men report to their doctor. It affects as many as 30 million men.

ED is defined as trouble getting or keeping an erection that's firm enough for sex.

Though it's not rare for a man to have some problems with erections from time to time, ED that is progressive or happens routinely with sex is not normal, and it should be treated.

ED can happen:

Most often when blood flow in the penis is limited or nerves are harmed

With stress or emotional reasons

As an early warning of a more serious illness, like: atherosclerosis (hardening or blocked arteries), heart disease, high blood pressure or high blood sugar from Diabetes.

Finding the cause(s) of your ED will help treat the problem and help with your overall well-being. As a rule, what's good for your heart health is good for your sex health.

How Erections Work

During sexual arousal, nerves release chemicals that increase blood flow into the penis. Blood flows into two erection chambers in the penis, made of spongy muscle tissue (the corpus cavernosum). The corpus cavernosum chambers are not hollow.

Diagram of How Erections Work


During erection, the spongy tissues relax and trap blood. The blood pressure in the chambers makes the penis firm, causing an erection. When a man has an orgasm, a second set of nerve signals reach the penis and cause the muscular tissues in the penis to contract and blood is released back into a man's circulation and the erection comes down.

When you are not sexually aroused, the penis is soft and limp. Men may notice that the size of the penis varies with warmth, cold or worry; this is normal and reflects the balance of blood coming into and leaving the penis.

Updated June 2018


With Erectile Dysfunction (ED), it is hard to get or keep an erection that is firm enough for sex. When ED becomes a routine and bothersome problem, your primary care provider or a Urologist can help.

ED may be a major warning sign of cardiovascular disease indicating blockages are building in a man's vascular system. Some studies have shown men with ED are at significant risk of getting a heart attack, stroke or circulatory problems in the legs. ED also causes:

Low self-esteem


Distress for the man and his partner

If ED is affecting a man's well-being or his relationships, it should be treated. Treatment aims to fix or enhance erectile function, help circulatory health and help the quality of a man's life.

Updated June 2018


ED can result from health problems, emotional issues, or from both. Some known risk factors are:

Being over age 50

Having high blood sugar (Diabetes)

Having high blood pressure

Having cardiovascular disease

Having high cholesterol


Using drugs or drinking too much alcohol

Being obese

Lacking exercise

Even though ED becomes more common as men age, growing old is not always going to cause ED. Some men stay sexually functional into their 80s. ED can be an early sign of a more serious health problem. Finding and treating the reason for ED is a vital first step.

Physical Causes of ED

ED happens when:

There is not enough blood flows into the penis

Many health issues can reduce blood flow into the penis, such as hardened arteries, heart disease, high blood sugar (Diabetes) and smoking.

Many health issues can reduce blood flow into the penis, such as hardened arteries, heart disease, high blood sugar (Diabetes) and smoking.

The penis cannot trap blood during an erection

If blood does not stay in the penis, a man cannot keep an erection. This issue can happen at any age.

Nerve signals from the brain or spinal cord do not reach the penis

Certain diseases, injury or surgery in the pelvic area can harm nerves to the penis.

Diabetes can cause small vessel disease or nerve damage to the penis

Cancer treatments near the pelvis can affect the penis' functionality

Surgery and or radiation for cancers in the lower abdomen or pelvis can cause ED. Treating prostate, colon-rectal or bladder cancer often leaves men with ED. Cancer survivors should see a Urologist for sexual health concerns.

Drugs used to treat other health problems can negatively impact erections

Patients should talk about drug side effects with their primary care doctors.

Emotional Causes of ED

Normal sex needs the mind and body working together. Emotional or relationship problems can cause or worsen ED.

Some emotional issues that can cause ED are:



Relationship conflicts

Stress at home or work

Stress from social, cultural or religious conflicts

Worry about sex performance

Updated June 2018


Finding the cause of your ED will help direct your treatment options.

Diagnosing ED starts with your health care provider asking questions about your heart and vascular health and your erection problem. Your provider may also give you a physical exam, order lab tests or refer you to a Urologist.

Health and ED History

Your doctor will ask you questions about your health history and lifestyle. It is of great value to share facts about drugs you take, or if you smoke or how much alcohol you drink. He/she will ask about recent stressors in your life. Speak openly with your doctor, so he/she can help you find the best choices for treatment

What Questions Will the Health Care Provider Ask?

Questions about your health:

What prescription drugs, over-the-counter drugs or supplements do you take?

Do you use recreational drugs?

Do you smoke?

How much alcohol do you drink?

Have you had surgery or radiation therapy in the pelvic area?

Do you have any urinary problems?

Do you have other health problems (treated or untreated)?

Questions About ED

Knowing about your history of ED will help your health provider learn if your problems are because of your desire for sex, erection function, ejaculation, or orgasm (climax). Some of these questions may seem private or even embarrassing. However, be assured that your doctor is a professional and your honest answers will help find the cause and best treatment for you.

Questions about your ED symptoms:

How long have you had these symptoms? Did they start slowly or all at once?

Do you wake up in the morning or during the night with an erection?

If you do have erections, how firm are they? Is penetration difficult?

Do your erections change at different times, like when going in a partner, during stimulation by mouth, or with masturbation?

Do you have problems with sex drive or arousal?

Do you have problems with ejaculation or orgasm (climax)?

How is this problem changing the way you enjoy sex?

Do you have painful with erections, feel a lump or bump in the penis or have penile curvature? These are signs of Peyronie's Disease which can be treated but calls for an expert in urology to assess and manage.

Questions About Stress and Emotional Health

Your health care provider may ask you questions about depression or anxiety. He or she may ask about problems in your relationship with a partner. Some health care providers may also ask if they may talk to your sex partner.

Are you often under a lot of stress, or has something recently upset you?

Do you have any anxiety, depression or other mental health issues?

Are you taking any drugs for your mental health?

How satisfied are you with your sex life? Has there been any changes lately?

How is your relationship with your partner? Has there been any changes lately?

Physical Exam

A physical exam checks your total health. Examination focusing on your genitals (penis and testicles) is often done to check for ED. Based on your age and risk factors, the exam may also focus on your heart and blood system: heart, peripheral pulses and blood pressure. Based on your age and family history your doctor may do a rectal exam to check the prostate. These tests are not painful. Most patients do not need a lot of testing before starting treatment.

Lab Tests

Your health care provider may order blood tests and collect a urine sample to look for health problems that cause ED.

Other Tests

Questionnaires are often used by health experts to rate your ability to initiate and keep erections, gauge your satisfaction with sex and help identify any problems with orgasm.

Advanced Erectile Function Tests

For some men with ED, specialized testing may be needed to guide treatment or re-assess you after a treatment fails.

Blood work to check Testosterone and other male hormones

Blood work to measure blood sugar (Diabetes)

Ultrasonography (penile Doppler) to check blood flow

A shot into the penis with a vascular stimulant to cause an erection

Pelvic x-rays like arteriography, MRI or CT scanning are rarely needed to check ED unless there is history of trauma or cancer

Nocturnal penile tumescence (NPT), an overnight test to check for sleep erection

Updated June 2018


The treatment for ED starts with taking care of your heart and vascular health. Your doctor may point out ‘risk factors' that can be changed or improved.

You may be asked to change certain food habits, stop smoking, increase workouts or stop using drugs or alcohol. You may be offered alternatives to the drugs you take. (Never stop or change prescription drugs without first talking to your health care provider.)

Your health care provider may also suggest treating emotional problems. These could stem from relationship conflicts, life's stressors, depression or anxiety from past problems with ED (performance anxiety).

The treatments below are available to treat ED directly.

ED Treatments

Non-invasive treatments are often tried first. Most of the best-known treatments for ED work well and are safe. Still, it helps to ask your health care provider about side effects that could result from each option:

Oral drugs or pills known as phosphodiesterase type-5 inhibitors are most often prescribed in the U.S. for ED (Viagra, Cialis, Levitra, Stendra)

Testosterone Therapy (when low testosterone is detected in blood testing)

Penile Injections (ICI, intracavernosal Alprostadil)

Intraurethral medication (IU, Alprostadil)

Vacuum Erection Devices

Penile Implants

Surgery to bypass penile artery damage for some younger men with a history of severe pelvic trauma. Penile vascular surgery is not recommended for older men with hardened arteries.

Oral Drugs (PDE5 inhibitors)

Drugs known as PDE type-5 inhibitors increase penile blood flow. These are the only oral agents approved in the U.S. by the Food and Drug Administration for the treatment of ED.

Viagra ® (sildenafil citrate)

Levitra ® (vardenafil HCl)

Cialis ® (tadalafil)

Stendra ® (avanafil)

Red Ring for natural use without DRUGS.

For best results, men with ED take these pills about an hour or two before having sex. The drugs require normal nerve function to the penis. PDE5 inhibitors improve on normal erectile responses helping blood flow into the penis. Use these drugs as directed. About 7 out of 10 men do well and have better erections. Response rates are lower for Diabetics and cancer patients.

If you are taking nitrates for your heart, you SHOULD NOT take any PDE5 inhibitors. Always speak with your health care provider before using a PDE5 inhibitor to learn how it might affect your health.

Most often, the side effects of PDE5 inhibitors are mild and often last just a short time. The most common side effects are:


Stuffy nose

Facial flushing

Muscle aches


In rare cases, the drug Viagra ® can cause blue-green shading to vision that lasts for a short time. In rare cases, the drug Cialis ® can cause or increase back pain or aching muscles in the back. In most cases, the side effects are linked to PDE5 inhibitor effects on other tissues in the body, meaning they are working to increase blood flow to your penis and at the same time impacting other vascular tissues in your body. These are not ‘allergic reactions'.

Testosterone Therapy

In those rare cases where a low sex drive and low blood levels of Testosterone are at fault for ED, Testosterone Therapy may fix normal erections or help when combined with ED drugs (PDE type 5 inhibitors).

Vacuum Erection Device

A vacuum erection device is a plastic tube that slips over the penis, making a seal with the skin of the body. A pump at the other end of the tube makes a low-pressure vacuum around the erectile tissue, which results in an erection. An elastic ring is then slipped onto the base of the penis. This holds the blood in the penis (and keeps it hard) for up to 30 minutes. With proper training, 75 out of 100 men can get a working erection using a vacuum erection device.

Diagram of an Erectile Dysfunction Vacuum


Intracavernosal (ICI) and Urethra (IU) Therapies

If oral drugs don't work, the drug Alprostadil is approved for use in men with ED. This drug comes in two forms, based on how it is to be used: intracavernosal injection (called "ICI") or through the urethra (called "IU therapy").

Self-Injection Therapy

Alprostadil is injected into the side of penis with a very fine needle. It's of great value to have the first shot in the doctor's office before doing this on your own. Self-injection lessons should be given in your doctor's office by an experienced professional. The success rate for getting an erection firm enough to have sex is as high as 85% with this treatment. Many men who do not respond to oral PDE5 inhibitors can be ‘rescued' with ICI.

ICI Alprostadil may be used as a mixture with two other drugs to treat ED. This combination therapy called "bimix or trimix" is stronger than alprostadil alone and has become standard treatment for ED. Only the Alprostadil ingredient is FDA approved for ED. The amount of each drug used can be changed based on the severity of your ED, by an experienced health professional. You will be trained by your health professional on how to inject, how much to inject and how to safely raise the drug's dosage if necessary.

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 a prolonged erection. Prolonged erections (>1 hour) can be reversed by a second injection (antidote) in the office.

Men who have penile erections lasting longer than two to four hours should seek Emergency Room care. Priapism is a prolonged erection, lasting longer than four hours. It is very painful. Failure to undo priapism will lead to permanent penile damage and untreatable ED.

Intraurethral (IU) Therapy

For IU therapy, a tiny medicated pellet of the drug, Alprostadil, is placed in the urethra (the tube that carries urine out of your body). Using the drug this way means you don't have to give yourself a shot, unfortunately it may not work as well as ICI. Like ICI therapy, IU Alprostadil should be tested in the office, before home usage.

The most common side effects of IU alprostadil are a burning feeling in the penis. If an erection lasts for over four hours, it will need medical attention to make it go down.

Surgical Treatment

The main surgical treatment of ED involves insertion of a penile implant (also called penile prostheses). Because penile vascular surgery is not recommended for aging males who have failed oral PDE5 inhibitors, ICI or IU therapies, implants are the next step for these patients. Although placement of a penile implant is a surgery which carries risks, they have the highest rates of success and satisfaction among ED treatment options.

Penile implants are devices that are placed fully inside your body. They make a stiff penis that lets you have normal sex. This is an excellent choice to improve uninterrupted intimacy and makes relations more spontaneous.

There are two types of penile implants.

Semi rigid Implant (Bendable)

The simplest kind of implant is made from two easy-to-bend rods that are most often made of silicone. These silicone rods give the man's penis the firmness needed for sexual penetration. The implant can be bent downward for peeing or upward for sex.

Inflatable Implant

With an inflatable implant, fluid-filled cylinders are placed lengthwise in the penis. Tubing joins these cylinders to a pump placed inside the scrotum (between the testicles). When the pump is engaged, pressure in the cylinders inflate the penis and makes it stiff. Inflatable implants make a normal looking erection and are natural feeling for your partner. Your surgeon may suggest a lubricant for your partner. With the implant, men can control firmness and, sometimes, the size of the erection. Implants allows a couple to be spontaneously intimate. There is generally no change to a man's feeling or orgasm.

Penile Implant


What is the Surgery Like?

Penile implants are most often placed under anaesthesia. If a patient has a systemic, skin, or urinary tract infection, this surgery should be postponed until all infections are treated. If a man is on blood thinners, then he may need to talk with a medical expert about stopping the medications for elective surgery and healing.

Most often, one small surgical cut is made. The cut is either above the penis where it joins the belly, or under the penis where it joins the scrotum. No tissue is removed. Blood loss is typically small. A patient will either go home on the same day or spend one night in the hospital.

Recovery Time after Penile Implants:

Most men will feel pain and will feel better with a narcotic pain-relief drug for one to two weeks. After the first week, over- the-counter pain drugs (such as acetaminophen or ibuprofen) may be substituted for narcotic pain drugs.

Discomfort, bruising and swelling after the surgery will last for a few weeks.

For the first month, men should limit their physical activity. The surgeon will explain when and how much exercise to do during the healing period.

Men most often start having sex with their penile implants by eight weeks after surgery. If there is persisting swelling or pain, the use of the implant may be delayed. The surgeon or health care expert in the surgeon's office will talk about how to inflate and deflate the implant.

There are risks to prosthetic surgery and patients are counselled before the procedure. If there is a post-operative infection, the implant will likely be removed. The devices are reliable, but in the case of mechanical malfunction, the device or a part of the device will need to be replaced surgically. If a penile prosthesis is removed, other non-surgical treatments may no longer work.

Most men with penile implants and their partners say that they're satisfied with the results, and they return to more spontaneous intimacy.

It was first developed by Vincent Marie Mondat in the early 1800s (McLaren, 2007) and is still in wide use 200 years later (Lue et al., 2004). The pump works by applying negative pressure to the penis to increase corporal blood flow and result in an erection (Jonas, 2001)

Occurs when a man can't get or keep an erection firm enough for sexual intercourse.

Erectile dysfunction can be a sign of a physical or psychological condition. It can cause stress, relationship strain, and low self-confidence.

The main symptom is a man's inability to get or keep an erection firm enough for sexual intercourse.

Patients suffering from erectile dysfunction should first be evaluated for any underlying physical and psychological conditions. If treatment of the underlying conditions doesn't help, medications and assistive devices, such as pumps, can be prescribed.

Erectile dysfunction (ED) is a significant problem, with over 150 million men in the US and 18 – 30 million in Germany affected. Although the disease is considered a benign disorder, it may have a dramatic impact on the quality of life of many men as well as their sexual partners. ED often results in anxiety, depression and lack of self-esteem and selfconfidence, which in themselves can perpetuate the disorder.

An important figure in the history of ED is Regnier de Graaf, who, in 1668 discovered that the injection of saline into the penile blood vessels of cadavers could induce an erection.3 Francois de la Peyronie is known for his original description of Peyronie’s disease in 1743, with the assumption at the time that he was himself a sufferer of the disease. In 1863, Eckhard published the first studies of an electrically induced penile erection in a dog (Figure 1).4 The French neurologist Charles Edouard BrownSe´quard put forward the theoretical links between hormone production and the ageing process. As early as 1869, he considered injecting semen into the blood of older men in order to increase mental and physical performance. Indeed, the first animal experiments on this theme were performed in 1875. At the age of 72, he experimented on himself by subcutaneously injecting animal testicular extract.

During the course of 10 injections he reported an increase in physical and mental powers as well as an improved ‘jet of urine’ and the ‘power of defaecation’. The pre-therapeutic state was resumed 4 weeks after treatment discontinuation. It is assumed that what Brown-Se´quard experienced was indeed a placebo effect due to the low level of androgen he injected. Nevertheless, such experiments introduced the idea of androgen therapy to modern medicine. Rejuvenation was clearly an important issue in ageing males. Another notable advocate of this procedure was the Russian, Serge Voronoff. Working in Paris, he was one of the first to transplant testicular tissue from a monkey into a human reproductive gland in 1920. In order to have the best long-term results, he only transplanted segments of the donor testis. He reported that hormonal secretion lasted for 1 to 2 y and then slowly decreased due to increasing fibrosis of the grafted tissue.6 Other historical landmarks for ED therapy include the reporting in 1908 by Frank Lydston of over 100 dorsal vein ligation procedures, with the realisation of the role of the vascular system in penile erection.7 The first vacuum device was patented by Otto Lederer in 1913, but this had previously been proposed by Muschenbrack, who described air pumps in 1694. Interestingly, the patented device is very similar to modern day equipment. Nicolai Bogoras reported the first total phalloplasty in 1936 following amputation of the penis

What is the success rate of erectile dysfunction?

The success rate for getting an erection firm enough to have sex is as high as 85% with this treatment. Many men who do not respond to oral PDE5 inhibitors can be 'rescued' with ICI. ICI Alprostadil may be used as a mixture with two other drugs to treat ED.

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Can a man recover from erectile dysfunction?

In many cases, yes, erectile dysfunction can be reversed. A study published in the Journal of Sexual Medicine found a remission rate of 29 percent after 5 years. It is important to note that even when ED cannot be cured, the right treatment can reduce or eliminate symptoms.

Which erectile dysfunction Cannot be cured?

Incurable causes of ED

Any problem affecting nerves in the body can also interrupt the nerve messages between the penis and the brain, including: injuries to the spinal cord or brain, Parkinson's disease, Alzheimer's disease, multiple sclerosis, or strokes. There are no cures yet for these conditions

Why is my erection not as strong as it used to be?

The blood vessels in the penis are smaller than arteries in other parts of your body, so any problems like blockages, blood vessel dilation issues, or hormone imbalances will sometimes show up as erectile dysfunction (or less firm erections) before something more serious like a heart attack or stroke

At what age does a man start to have erectile dysfunction?

Doctor's Response. The most common sexual problem in men as they age is erectile dysfunction (ED). In general, the younger a man is, the better his sexual function will be. About 40% of men are affected by erectile dysfunction at age 40, and nearly 70% of men are affected by ED by the time they turn 70.