Erectile dysfunction (ED) is a surprisingly common ailment, affecting around 50% of men in the UK between the ages of 40 and 70. Given its prevalence, one might think treatment would be easy and straightforward; however, many men find that this is not the case. Since ED can be caused by a combination of factors, pinpointing the cause is the first step in treating erectile dysfunction. For some men their medication is the culprit, and ED can be remedied by changing the dosage or substituting the medication for another drug. If the problem is relationship troubles, therapy can be effective.
If the cause isn’t clear-cut, however, men have many different options to explore to help reduce or reverse symptoms.
Speak with your partner
Your spouse or sexual partner should absolutely be included in conversations about your sexual health. While this may be a difficult conversation to have, it is very important that you do so. Choose a time when you are both comfortable and relaxed and have an open and honest dialogue about what has been going on. This is the time to discuss possible causes and courses of treatment. Keep in mind that your partner may be feeling just as anxious as you are – worried that you find them less attractive or have fallen out of love with them. Reassure them that this is not the case and that the two of you can work through this together.
If it has been weeks, months, or even years since you’ve had sex, it can be difficult to broach the subject and both of you may a bit nervous when it comes time to “do the deed”. Remember to take your time and appreciate each other. And keep in mind that not all sexual acts require an erection! Oral sex, massage, and caressing are all intimate acts that can be enjoyed without an erection. Achieving orgasm without an erection is possible.
If the cause of your erectile dysfunction is due to a psychological or emotional difficulty, counselling with a sex therapist may be just what the doctor ordered. Ask your GP for a referral to a licensed sex therapist. As with any type of therapist, it is perfectly acceptable to “shop around” until you find someone you feel comfortable discussing problems with. If performance anxiety is an issue due to “failed” sexual encounters, the therapist may work with you and your partner on some relaxation techniques. Being open with your partner and a therapist about your feelings and experiences lessens the stigma some men feel about erectile dysfunction.
If the thought of seeing a therapist makes you uncomfortable, there are self-help resources available for you and your partner to utilise. Self-help books and DVDs often focus on therapeutic techniques used by sex therapists.
Upon the introduction of Viagra (sildenafil) in 1998, doctors had a revolutionary new way to help men with erectile dysfunction. The “little blue pill” took the world by storm, and quickly inspired other drugs that worked in very similar ways. Today, we have Cialis (tadalafil), Spedra (avanafil), and Levitra (vardenafil), as well as a low-dose version of Cialis approved for daily use. This class of drugs, known as PDE5 inhibitors, work to block the enzyme PDE5, which is responsible for breaking down cyclic guanosine monophosphate, a chemical that brings about erections. This allows the penis to fill with blood and stay erect long enough for sexual intercourse. The drugs are not to be confused with aphrodisiacs, which increase sexual desire. If you are not sexually aroused, PDE5 inhibitors will not help you develop an erection.
Since Viagra has been on the market longest, there is more research, compared to the other drugs, on its efficacy. The popularity of Viagra has the numbers to back it up: 83% of men have been able to have sexual intercourse at least once since taking the drug.
All medications have side effects, and PDE5 inhibitors are no exception. Most side effects are mild and last only a short time, including headaches (the most common side effect), redness of the face, nasal congestion, upset stomach, muscle pain, and urinary tract infections. Rarely, some men may experience vision changes like blurriness, sensitivity to light, and a blue tint to their vision. In most cases, these changes are mild and temporary.
Not every man is a good candidate for PDE5 inhibitors. If you take nitrates, alpha blockers, or certain heartburn medicines containing cimetidine (Tagamet), you should begin with a lower dosage of the ED drug or, in some cases, avoid it altogether. If you are on any type of medication, talk with your doctor about any possible drug interactions.
Statins are used to prevent heart attacks by keeping your cholesterol under control. Because they work to help blood vessels dilate properly, blood flow is improved throughout the body. Obviously, blood flow to the penis is critical for achieving an erection, so men with cholesterol issues may be good candidates for this type of treatment.
This form of treatment may seem like cruel and unusual punishment, but it is highly effective. The injection is administered in the side of the penis with a small needle, and results happen fairly quickly (between 5 and 20 minutes after the injection). The drugs used in injections work to relax the smooth muscle tissue and allow blood flow into the corpora cavernosa, producing an erection. Side effects are generally mild and include discomfort, bruising, and scarring. Rare complications include a drop in blood pressure and priapism (an erection that lasts longer than it should). Your doctor will prescribe the lowest effective dosage to minimise side effects.
An alternative to injections, medicated urethral system for erection, or MUSE, is equally effective and offers an option for men who are squeamish about injections. A small plastic applicator is inserted into the tip of the penis and dispenses a tiny pellet into the urethra. The medication is quickly absorbed and dilates the arteries of the corpora cavernosa. As with injections, MUSE can cause low blood pressure, so the lowest effective dose should be prescribed.
Yohimbe has long been used in Africa to treat impotence. The bark of the plant seems to have an effect on blood flow to the penis, so a drug called Yocon (yohimbine hydrochloride) was developed as the first FDA-approved drug for erectile dysfunction. While not as effective as PDE5 inhibitors (about 40% of men reported improvement in their symptoms), Yocon is a good option for men who cannot take PDE5 inhibitor drugs. The main side effect of yohimbine is insomnia, but can also include increased heart rate, high blood pressure, dizziness, nervousness, and irritability. Beware of yohimbe bark supplements, as these are not regulated and may only contain trace amounts of yohimbine. Ask your doctor about potential drug interactions before beginning a yohimbine regimen, and always take the proper dosage of prescription Yocon.
Testosterone is the hormone produced by the testicles that gives men their male characteristics, including facial hair, low voice, and musculature. By this logic, low levels of testosterone can be responsible for erectile dysfunction. While this is true in some cases, men diagnosed with hypogonadism (low testosterone) do not necessarily suffer from erectile dysfunction, and men with normal testosterone levels can develop ED. It is important that your doctor measure the levels of testosterone in your blood, as levels can fluctuate depending on diet and medication. Even if you have low testosterone, therapy is difficult to get. You must meet strict criteria for hypogonadism.
If you are approved for treatment, testosterone is administered by injection or a topical gel. Gel is applied daily to the shoulders, thighs, or upper arms. Be sure to let it absorb fully before skin contact (usually a few hours), since the gel can have adverse effects on women and children.
Injections are usually given every two weeks into the buttock muscles. While this is an efficient way to administer testosterone, it can also have a “high and crash” effect when treatment begins. After a few weeks many men report a reduction in this side effect.
Testosterone therapy can be an effective treatment method for men with low testosterone levels. Ask your doctor to run some tests if you suspect that you are not producing enough testosterone.
Doctors and researchers are always looking for new ways to combat ED. One such drug, alprostadil, has been approved for use in the US via injection or MUSE therapy and is currently available for use in a cream application in Europe and Canada. Melanocortin activators seem to be effective for men who experience ED for mental reasons and are administered as a nasal spray. Gene therapy is in the early stages of animal testing but could be effective in humans in the future.
Men who cannot tolerate or do not prefer other treatment methods have the option of using certain devices to help achieve or maintain an erection. Penile bands are flexible rings which fit around the base of the erect penis and prevent blood from leaving the penis due to venous leakage. For men who have trouble achieving erections, a vacuum device may be helpful. These can be manual or battery-operated and are highly effective. The device is placed around the penis and the air is pumped out, creating a vacuum effect and increasing blood flow to the penis. Once erection is achieved, a band is placed around the base of the penis to maintain the erection. While effective, this treatment is not recommended for men who have blood disorders.
This is a treatment recommended only for men who meet certain criteria and is not generally very effective. One such surgery involves tying off the blood vessels that leak blood during an erection. For men with blood vessels that are blocked, another type of surgery is done to bypass those vessels and allow better blood flow to the penis.
Surgical options should be considered only after all other options have been exhausted. Penile implants used to consist of a doctor inserting a rib bone into the penis. Thankfully, this process has changed in the past several decades. Men today have two main options when it comes to penile implants.
Inflatable implants consist of either two or three parts. A three-piece implant will have a fluid reservoir in the abdomen, a pump with release valve in the scrotum, and two inflatable tubes in the shaft of the penis. When the pump in the scrotum is pressed, fluid is released into the inflatable cylinders to produce an erection. When the release valve is squeezed, the fluid drains from the penis and back into the reservoir. With a two-piece implant, the reservoir and pump are both located in the scrotum. To relax the erection, simply bend the penis slightly to return the fluid to the reservoir. These are the most popular types of implant due to their natural feel and appearance. Complications could include accidental inflation, leaking of the reservoir, or an implant breaking through the skin.
Semi-rigid, or malleable, implants are flexible rods implanted into the penile shaft and can be bent upward for intercourse and downward for a normal appearance under clothing. Malleable implants are not as popular as inflatables because they can be more difficult to conceal under clothing, but their ease of use and simpler surgical insertion makes them a better option for some men.
Penile implants in general have a very high success rate. Men with implants and their partners report high levels of satisfaction and low instances of mechanical failure. However, any surgery should be considered carefully, since complications or infections, while rare, are still a possibility.
Dr Fox supplies ED treatment on prescription. Answer a quick medical questionnaire, select which treatment you would like to receive, and you can have the medicine sent confidentially to your address.