When seeing a urologist for erectile dysfunction (ED), many men ask about oral medications (pills that can be taken by mouth).
These drugs have been a major force in erectile dysfunction treatment for over two decades. Sildenafil (brand name Viagra®) was the first to be approved by the U.S. Food and Drug Administration (FDA) in 1998. Tadalafil (Cialis®) and vardenafil (Levitra®) followed; both drugs were approved in 2003. The FDA approved the fourth ED drug, avanafil (Stendra®) in 2012.
All of the drugs are classified as phosphodiesterase type 5 (PDE5) inhibitors, and they work in similar ways. Many men find them effective and convenient.
Still, they’re not right for every man, and there are differences among them that men should be aware of.
How do oral ED drugs work?
There are differences among oral medications for ED that men should be aware of.
For a man to get an erection, muscles in the penis need to relax so that blood can flow in during sexual stimulation. As the penis fills with blood, it becomes firm and erect. A chemical called nitric oxide, which is naturally produced by the body, helps this process along.
The four oral ED drugs help nitric oxide do its job so that the penis muscles can relax and let the blood in.
ED drugs do not create an erection automatically, however. A man still needs sexual stimulation to achieve an erection.
How are oral ED drugs similar?
Oral ED drugs share these similarities:
In the United States, they are available by prescription only.
ED drugs are not sold over the counter, and men need a doctor’s prescription to obtain them.
It’s important for men to see a doctor when they start having trouble with erections. ED can be a sign of health conditions like diabetes and heart disease. If these conditions are found, they can be treated along with the ED.
ED can be a sign of health conditions like diabetes and heart disease.
ED drugs don’t increase sexual desire.
ED drugs allow blood to flow into the penis more easily to create an erection, but they do not affect sexual desire. Men need to have the drive for sexual activity as well as sexual stimulation for the drugs to work.
ED drugs don’t prevent pregnancy or lower risk for sexually transmitted infections.
Couples still need to use contraceptives and follow safe sex practices, like using condoms and dental dams.
ED drugs have some side effects in common.
The 4 ED drugs do share some mild side effects, such as headache and flushing.
They also have some more serious side effects in common. If any of these symptoms occur, patients should seek emergency medical care:
An erection lasting longer than 4 hours
Sudden loss of vision
Sudden loss of hearing
Ringing in the ears
Dizziness
Swelling of the face, mouth, throat, hands, feet, or legs
However, other side effects may be different for each drug:
Avanafil
Mild side effect:
Back pain
Side effects that need emergency care:
Rash
Itching
Sildenafil
Mild side effects:
Heartburn
Diarrhea
Nausea
Nosebleeds
Numbness or tingling in the limbs, hands, or feet
Pain in muscles, back, or limbs
Changes in color vision, such as a blue tinge or trouble seeing the difference between blue and green
Sensitivity to light
Nasal congestion
Side effects that need emergency care:
Blurred vision
Fainting
Chest pain
Shortness of breath
Rash, itching or hives
Difficulty breathing or swallowing
Tadalafil
Mild side effects:
Heartburn
Nausea
Diarrhea
Pain in the muscles, back, arms, legs, or stomach
Coughing
Side effects that need emergency care:
Blurry vision
Changes in color vision, such as a blue tinge or trouble seeing the difference between blue and green
Chest pain
Hives, rash, blisters, or peeling skin
Difficulty breathing or swallowing
Vardenafil
Mild side effects:
Nausea
Heartburn
Stuffy or runny nose
Flu-like symptoms
Side effects that need emergency care:
Blurry vision
Changes in color vision, such as a blue tinge or trouble seeing the difference between blue and green
Hoarseness
Difficulty breathing or swallowing
Fainting
Hives or rash
Patients should note that some side effects are more common with specific drugs. For example, men who take sildenafil may be more likely to experience a blue/green tinge to their vision than men who take tadalafil. And men who take tadalafil may be more likely to have muscle pain (myalgia) than men who take sildenafil.
A man’s doctor can best advise on the likelihood of certain side effects and how they might affect a man’s personal situation.
ED drugs are not safe for all men.
Men who take drugs containing nitrates should not take ED medications. This combination can cause a dangerous drop in blood pressure. Some examples of nitrates are nitroglycerin, isosorbide mononitrate, and isosorbide dinitrate. Nitrates are prescribed to prevent or treat chest pain related to heart disease.
ED drugs are also not appropriate for men with low blood pressure, uncontrolled high blood pressure, and severe liver disease. Men who are on dialysis for kidney disease should also not take ED drugs.
Men who take alpha blockers for enlarged prostate symptoms may need to space out their doses of these drugs and ED drugs to avoid an interaction.
Men should always tell their doctor about any other medications, street drugs, herbs, or supplements they use. These products may interact with ED drugs.
In addition, men should let their doctor know if they typically eat grapefruit or drink grapefruit juice, as this combination may cause an interaction as well.
How are oral ED drugs different?
Dosing may be different.
Sildenafil, avanafil, and vardenafil are taken on an as-needed basis, meaning a man takes them before he wishes to have an erection. Tadalafil may also be taken this way, but some prescriptions call for it to be taken every day. Men should be sure to take their medicine as directed.
The time between taking the drug and getting an erection may vary.
ED drugs do not produce an erection immediately. It takes some time for the drug to work, and these time frames vary by medication. For example, men usually get an erection about 30 to 60 minutes after taking sildenafil or vardenafil. Men who take tadalafil as needed (not daily) may need to wait 30 to 45 minutes. For those who take avanafil, the wait may be 15 to 30 minutes.
They last for different durations.
ED medications also vary in how long they are effective. For example, once sildenafil or vardenafil take effect, a man might be able to get an erection for four to five hours. For avanafil users, the time frame is about six to twelve hours. Tadalafil has the longest effective time—usually 24 to 36 hours for as- needed users. Men who take tadalafil daily should be able to get an erection at any time.
Which ED drug should a man choose?
When prescribing ED drugs, doctors take many factors into account. They consider a man’s overall health and the drugs and supplements he currently takes.
Sometimes, it takes time to find the most effective ED drug. These medications have been shown to be quite effective, but results vary from man to man. If a particular drug doesn’t work as well or has bothersome side effects, a man’s doctor may prescribe a different drug or suggest a different ED treatment.
It’s important to remember that in the United States, ED drugs are available only by prescription. Men may see online advertisements for non-prescription products that claim to improve erectile function. But these claims are often misleading, and taking such products could be dangerous. (Learn more about sexual enhancement supplements here.)
Erectile Dysfunction: Coping Before and During Treatment
Erectile dysfunction (ED) – difficulty with erections – is quite common. In fact, an estimated 30 million men in the United States have ED to some extent. Some men are unable to get an erection at all. Others may get an erection, but it’s not firm enough for sex.
No matter what causes it or how it develops, ED can affect a man’s well-being and his ability to enjoy sex. Men may question their masculinity and their ability to satisfy a sexual partner. They may become anxious about sex and worry about their performance. And they may feel sad about changes to a once-active sex life.
There is good news, however. Over the years, scientists have developed several effective treatment approaches, including lifestyle changes, pills, injections, vacuum devices, suppositories, and penile implant procedures.
Still, it can take a little time to find the right treatment. And with lifestyle changes and surgery, it takes time for the situation to improve. What can men do in the meantime? How can they cope with ED in the here and now?
Read on to find out.
Learn about ED
Over the years, scientists have developed several effective treatment approaches
Learning as much as possible about ED is a useful starting point. A man’s doctor can recommend reliable websites, brochures, podcasts, videos, books, and magazines for learning more. Asking questions while seeing the doctor is another opportunity. Some men write out their questions before their appointment so they don’t forget them.
For example, men might ask:
What’s causing my ED? What can I do about it?
What treatment options are available to me?
Are treatments covered by insurance?
Do you think sex therapy would help me?
Once men have some background knowledge, they can come up with a treatment plan with their doctor.
Communicate with partners
Some people shy away from talking about sex. But being open and honest about ED is an important part of coping – for both partners.
Such discussions allow couples to better understand each other’s point of view. One partner may not be aware of how the other is feeling.
For example, if the man with ED starts avoiding sex, his partner might worry that they are not attractive or fulfilling his needs. And that might not be the case at all.
Having these conversations allow partners to comfort, reassure, and encourage each other. Couples who need help with their communication skills might consider counseling.
Redefine intimacy
There is more to intimacy than penetrative intercourse, and couples can maintain their intimate bond in other ways. Doing so can be as simple as holding hands at the mall, cuddling on the couch during a movie, or giving each other a massage at the end of a long day. In the bedroom, it can be having oral sex or role playing a favorite fantasy.
This is a time to experiment, relax, and have fun. Couples may discover new activities they enjoy – activities that they continue after erections improve. Some see a sex therapist for new ideas, perspectives, and communication tips.
Stay healthy
Eat nutritious foods. Exercise regularly. Quit smoking. Get enough sleep. Practice self-care. These suggestions often top lists of recommended healthy habits. They help with erections, too.
For example, healthy habits lower the risk of health conditions like diabetes and heart disease, which can lead to ED. Research suggests that following a Mediterranean diet could be good for erections, too.
Staying fit and maintaining a healthy weight boosts confidence and body image. It may also improve depression or anxiety that often accompany ED. Read more about lifestyle changes and ED here.
Celebrate successes
Even if ED is frustrating, treatment offers many reasons to celebrate:
Making a first appointment with a urologist
Talking about sex with a partner
Trying a new way of intimacy
Trying a new treatment
Seeing a counselor or sex therapist
Eating healthier meals for a week
Sticking to a workout routine
Making a plan to quit smoking.
Getting a firmer erection than last time
No matter how small an achievement may seem, celebrating progress can boost motivation, confidence, and hope for the future. How men celebrate is up to them. Having date night with their partner, playing a round of golf, or seeing a favorite band can all work.
Stay in touch with a doctor
As noted above, ED treatment can take time. What works well for one man might not be so effective for another. That’s why it’s important for men to stay in touch with their doctor throughout the process. If one approach doesn’t seem to work, there are others to try. Keeping the doctor informed can help them tailor treatment.
A penile implant (also called a penile prosthesis) is a surgically placed, mechanical device that helps a man get an erection—and keep it—for as long as he likes. It’s one of several treatment options for men with erectile dysfunction (ED). And it has high satisfaction rates.
Still, men need to weigh some important pros and cons before getting an implant. Read on to learn more about the different types of implants, the surgery involved, and what men can expect afterward.
Why do men choose penile implants?
Erectile dysfunction—the inability to get an erection firm enough for sex—is a common problem. While there are several treatments available, such as pills, self-injections, and vacuum devices, they’re not suitable for all men. For example, men who take nitrates for heart conditions cannot use ED medications because of a dangerous drug interaction.
Success with ED treatments can vary, too. What works for one man may not work for another. Generally, men try other ED treatment options before deciding on an implant.
Men with Peyronie’s disease may also get penile implants. This condition causes the penis to bend, sometimes to a point where intercourse becomes quite difficult. An implant can straighten the penis and help with any erection problems.
Transgender men may get penile implants as they undergo gender affirmation surgeries. During these procedures, surgeons create a penis and may implant a prosthesis to aid sexual activity.
Types of penile implants
In general, there are two different types of implants:
Inflatable implants
The most common type of implant is a 3-piece inflatable implant. The three parts are connected by tubes. They include:
A pair of inflatable cylinders that are inserted into the shaft of the penis
A fluid-filled reservoir placed in the abdomen
A pump placed in the scrotum
When a man wishes to have an erection, he simply activates the pump in his scrotum. Saline fluid from the reservoir then moves into the cylinders and inflates them, creating the erection. When the man is done with sexual activity, he presses on the pump again. The cylinders deflate and the fluid moves back to the reservoir.
A 2-piece inflatable implant is also available, but it’s less common. This type works in a similar way, but the reservoir and the pump are in the same piece.
Malleable (semirigid) implants
These implants are flexible silicone rods that are inserted into the penis. When a man wants an erection, he can simply lift his penis up into position, then move it back down when he is finished with sexual activity. Malleable implants are not common nowadays, but they might be suitable for men who may have trouble activating a pump in the scrotum.
Advantages of penile implants
The man has full control. A man can get an erection and keep its firmness for as long as he likes. He can also have as many erections in a day as he wishes.
They have high satisfaction rates. Studies have shown that the satisfaction rate among men with 3-piece implants is 90% or higher.
Sex can be more spontaneous. A man does not have to worry about timing the dose of a pill or stopping sexual activity to give himself an injection or use a vacuum device. Instead, he can create an erection in the moment.
Implants last for years. Some men get 15 to 20 years of use from the same implant before it needs replacing.
They’re discreet. The penis looks natural. People usually can’t tell if a man has an implant by looking at his penis. (Malleable implants may be an exception, as the penis is always somewhat firm.) During intercourse, partners usually cannot tell that a man has an implant.
They don’t affect sexual desire or performance. For most men, sexual sensations, ejaculation, and orgasms feel the same as they did before the implant.
They may boost a man’s sexual confidence. Men may feel less anxious about intimacy knowing that they can get a firm erection every time they have intercourse.
A man can get an erection and keep its firmness for as long as he likes.
Disadvantages of penile implants
A surgical procedure is involved. Like any surgery, penile implant surgery has risks, such as infection, bleeding, and injury to surrounding areas. However, surgeons take special precautions to lower the risk of complications. Infection rates are estimated to be 1% to 2%. If there is an infection, the device is usually replaced.
Implants can malfunction. There are times when a penile implant can malfunction, although this is rare.
They are permanent. Because of the nature of implant surgery, a man can no longer have natural erections once he has an implant. Other ED treatments, such as pills or injections, will no longer be options.
What happens during penile implant surgery?
Before surgery, a man’s doctor will tell him how to prepare. The man may receive special instructions for taking medications or supplements, eating and drinking, and bathing beforehand.
The surgery itself is performed under general anesthesia and takes about one to two hours. It may be done as an outpatient procedure, and many men can go home the same day. However, some men may need to spend a night in the hospital.
To implant the device, the surgeon makes a small incision in the genital area. The inflatable cylinders (or bendable rods, if a malleable implant) are inserted into the shaft of the penis. If it is a 3-piece inflatable device, small incisions are made so that the reservoir can be placed in the abdomen and the pump can be placed in the scrotum. The pieces are then connected and the incisions are closed. The man may have a temporary surgical drain.
Men having implant surgery will need to have someone drive them home. They should also have someone stay with them for the first day or two.
Note: Not all men are good candidates for implant surgery. Men who are at higher risk for complications and those who have heart disease or poorly managed diabetes may not be able to have surgery.
Recovering from penile implant surgery
Back at home, men recovering from implant surgery may experience swelling, pain, or discomfort for the first week. These symptoms may be managed with medicines and ice packs. If there is a drain, it will be removed in the first few days after the procedure.
Men will need to avoid heavy lifting and vigorous activity, including exercise, for up to four weeks. If they work a desk job, they can return to work after a week or so. Men with more physical jobs may need to wait up to four weeks before returning to work.
Sex—both intercourse and masturbation—will need to wait four to six weeks while the body heals. At this time, the man’s doctor will teach him how to use the implant.
Men who have the following symptoms during recovery should call their doctor right away:
Heavy bleeding
Fever
Worsening pain
Infection
Adjusting to a penile implant
It may take time to adjust to sex with a penile implant. However, many men find that their sex life improves, knowing that they can now count on having a firm erection. Men who have problems with their device or have further questions should talk to their doctor.
Resources
Cleveland Clinic
“Penile Implants” (Last reviewed: November 11, 2022) https://my.clevelandclinic.org/health/treatments/10054-surgical-penile-implants
EAU Patient Information (European Association of Urology)
“What to Know about Penile Implants with Dr. Melissa Mendez” (Urology Care Podcast. 2021) https://www.urologyhealth.org/healthy-living/urology-care-podcast/sexual-health-podcasts/what-to-know-about-penile-implants-with-dr-melissa-mendez
Mediterranean Diet: Can It Improve Erections?
“You are what you eat” has been a popular phrase in English for decades. And it makes sense. Much of a person’s overall health is linked to their eating habits. A balanced, nutritious diet can lower risk for a variety of health conditions, like heart disease and diabetes. And a diet full of fast food and TV dinners could have the opposite effect.
Scientists have studied the way a man’s eating habits may affect his ability to get erections. Not surprisingly, men with healthier diets often fare better.
This notion applies to sexual health, too. For example, scientists have studied the way a man’s eating habits may affect his ability to get erections. Not surprisingly, men with healthier diets often fare better.
So what should men eat? While choosing healthy foods is wise, researchers have found that the Mediterranean diet could be an easy, effective path to better erections in the future.
For example, a 2020 JAMA Network Open study investigated the link between diet and erections in over 21,000 men aged 40 to 75 living in the United States. The researchers discovered that men who followed a Mediterranean or similar diet were less likely to have erectile dysfunction (ED) compared to those who didn’t.
And in 2021, researchers presented preliminary results on this topic at the European Society of Cardiology’s annual meeting. After reviewing data from 250 men with high blood pressure and ED, they reported that the Mediterranean diet could be linked to better erectile function.
What is a Mediterranean Diet?
A Mediterranean diet is widely eaten in countries around the Mediterranean Sea, such as Spain, Italy, and Greece.
A Mediterranean diet is widely eaten in countries around the Mediterranean Sea, such as Spain, Italy, and Greece. Because it encompasses a variety of cultures, there’s no one “official” Mediterranean diet. But diets in this geographic area have some similarities:
More plant-based foods. Fruits, vegetables, whole grains, nuts, and legumes (like beans and chickpeas) are staples of a Mediterranean diet.
Limited red meat, eggs, and dairy. Red meat is seldom eaten on a Mediterranean diet. Eggs and butter are used sparingly.
Moderate amounts of lean meats. Mediterranean diet followers eat poultry, like chicken and turkey, every once in a while.
More seafood. Fish and shellfish—such as salmon, tuna, and clams—might be eaten several times a week.
Healthy fats. Monounsaturated fats, like olive oil and avocados, are favored over saturated fats and trans fats, which are found in items like red meat, cakes, cookies, and processed foods.
Fewer desserts. Sweets and traditional desserts are eaten in moderation. Fruit is a frequent dessert substitute.
Alcohol. Alcoholic beverages, such as red wine, are included in a Mediterranean diet, but only if safe to do so. People should avoid alcohol if they are pregnant, tend to misuse alcohol, or have a health condition that worsens with alcohol use.
Fewer processed foods. Following a Mediterranean diet often means preparing meals from fresh, basic ingredients rather than relying on processed foods.
Mediterranean Diet and ED: What’s The Connection?
How might a Mediterranean diet help with a man’s erections?
It’s good for the cardiovascular system
This system includes the heart and the roughly 60,000 miles of blood vessels throughout the body. Some of these blood vessels are in the penis. Because a firm erection depends on blood flow, these blood vessels need to be clear.
Research suggests that the Mediterranean diet keeps the lining of blood vessels healthy and reduces the risk of atherosclerosis (hardening of the arteries), which can interfere with blood flow. With the path open, blood can flow to the penis—and form an erection—more easily.
It helps with the production of nitric oxide
This chemical plays an important role in erections. Before blood can flow into the penis for an erection, the arteries need to relax and dilate. Nitric oxide is essential for this process.
It lowers a man’s risk for diabetes
Men with diabetes are at higher risk for ED than men without diabetes. They also tend to get ED several years earlier.
High blood sugar can damage blood vessels and nerves. As noted above, blood vessel damage can limit blood flow into the penis. And nerve damage can interfere with signals from the brain that “tell” the penis to start an erection when a man is sexually aroused.
It helps with weight management
The heavier a man is, the higher his risk for ED. A healthy diet, combined with physical activity, can be a good way to manage weight. That said, people still need watch their calories, even with a Mediterranean diet.
Putting it All Together
So can eating a Mediterranean diet prevent ED altogether? Could it cure ED?
Scientists aren’t sure yet, but they’re interested in finding out. For now, research suggests that men who follow a healthier diet could be less likely to develop ED later. But researchers don’t know yet whether diet can prevent ED altogether or whether changing dietary habits can improve ED in men who already have trouble with erections.
The good news, however, is that a healthy diet benefits the body from head to toe. And many people find that taking care of the whole body improves their sexual health as well as their overall wellbeing.
Jimenez-Torres, Jose, et al. “Mediterranean Diet Reduces Atherosclerosis Progression in Coronary Heart Disease: An Analysis of the CORDIOPREV Randomized Controlled Trial” (Originally published: August 10, 2021) https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.120.033214
Erectile Dysfunction
Erectile dysfunction (ED) – you know the term. It’s when a man can’t get – or keep – an erection hard enough for satisfying sex. Your father or grandfather might have called it impotence, if they talked about it at all.
If you can’t get an erection at all, no matter what, that’s ED. But a partial erection – one that’s not as firm as you’d like it to be – is ED too. Maybe it only happens once in a while. Or maybe it only happens in certain situations – like when you’re with someone but not when you masturbate. It’s all ED.
Understandably, men are typically concerned about ED. Your sex life is likely to suffer – or at least change quite a bit. Your sense of masculinity may be bruised. You may be worried about satisfying your partner. And what about your overall physical health?
Don’t panic! ED is actually quite common. Most men experience it at some point in their lives. And often, it’s very treatable.
The American Urological Association estimates that 30 million men have erectile dysfunction
How common is ED?
It’s the most common sex problem men discuss with their doctors. The American Urological Association (AUA) estimates that 30 million men have ED.
ED is more common if you’re older, but younger men get it, too. If you’re not as healthy as you could be, the odds you’ll be dealing with ED go up. If you have diabetes, heart disease, or kidney disease, you’re at higher risk. Psychological issues, like depression and anxiety, can play a role as well.
Why can’t I get (or keep) a strong erection?
Ideally, here’s what happens to your penis when you get aroused: smooth muscle tissue relaxes and arteries widen. Additional blood starts to flow in. This extra blood makes your erection firm. Veins temporarily close, keeping the blood inside the penis until you ejaculate or the stimulation stops. Then the veins open up again and the blood flows back into your body.
ED is often a blood flow problem. The smooth muscle tissue might not relax or the arteries don’t open enough. Or, arteries might be blocked by plaques, as is the case the atherosclerosis (hardening of the arteries), making it more difficult for blood to flow in. In some cases, veins don’t constrict enough, so blood can’t stay in the penis.
What causes ED?
There are a number of possibilities here:
Vascular disease
Vascular disease involves damage to your circulatory system – the arteries and veins which carry blood throughout your body. Remember, “hard” arteries are “clogged” with plaques that form on your artery walls. Vascular disease makes it harder for blood to flow through your blood vessels. Less blood flow typically means a softer erection.
This is a common way for vascular disease to lead to ED. Your risk for vascular disease increases as you get older. An estimated 50 to 60 percent of men over 60 have ED due to vascular disease.
You’re more likely to face vascular disease if you have:
Diabetes
High blood pressure (hypertension)
High cholesterol
A history of smoking
Diabetes
When your blood sugar is too high, it can damage nerves and blood vessels throughout your body, including those needed for a firm erection. Your penis might not “get the message” from your brain to start an erection. And if an erection does get triggered, you might not have sufficient blood flow to keep it going. Diabetes is a huge ED risk factor. About 60 percent of men with diabetes have trouble with erections.
Drugs
Lots of medications men take have sexual side effects, which can include ED. If you take blood pressure drugs, heart medications, antidepressants, tranquilizers, or sedatives, you might see some changes in your erections. Over-the-counter meds that you buy at the pharmacy can have similar effects.
If you drink alcohol or use illicit drugs, you should watch your intake. These can cause ED, too.
Kidney and liver disease can affect your hormones and your sex life
Hormone imbalances
Most men know testosterone affects sexuality. It may surprise you though that it’s pretty rare for low testosterone to cause ED or low sex drive. Still, it does happen. Check with your doctor.
Prolactin is another hormone to watch. Men with pituitary gland tumors may have too much prolactin, which in turn reduces testosterone levels.
Kidney and liver disease can also affect your hormones and your sex life.
Obesity
We all know obesity is a growing problem in the United States. Maybe you’re struggling with your weight. You’re not alone. In 2017-2018, the Centers for Disease Control and Prevention (CDC) reported that 42% of Americans were obese – in other words, they had a body mass index (BMI) of over 30. Carrying extra weight puts a lot of stress on your body. The result can be heart disease, diabetes, and yes, ED.
Neurologic conditions
Some neurologic conditions, like paraplegia and stroke, interrupt nerve impulses from the brain to the penis. In other words, the penis won’t “know” that there’s a reason to become erect. Other neurologic conditions, such as multiple sclerosis (MS), Parkinson’s disease, and Alzheimer’s disease can lead to ED, too.
Pelvic trauma, surgery, radiation therapy
If you’ve had pelvic surgery, radiation treatment for cancer, or trauma to the pelvic region or spinal cord, you might experience ED.
For example, if you have prostate cancer, you might have your prostate removed surgically. Unfortunately, the prostate is surrounded by nerves needed for erections. Surgeons do their best to keep as many nerves intact as they can (a technique called nerve-sparing). But many men still have some degree of ED afterward. The situation usually improves, but it takes time – sometimes up to 18 months.
The situation is similar if you have a radical cystectomy for bladder cancer.
Peyronie’s disease
Men with Peyronie’s disease have a noticeable curve to their erect penis due to areas of hardened scar tissue (plaques) that form just beneath the skin’s surface. Some men with Peyronie’s develop painful erections or ED.
Venous leak
Good blood flow into the penis is critical for a firm erection. But that’s only half of the story. The blood needs to stay in place to keep a strong erection. Sometimes, there’s a problem with the veins, and they can’t keep the blood in. So it leaks back into your body. The result? A softer erection, or no erection at all.
Psychological and emotional issues
Stress and anxiety can have a huge impact on our health, including our sex lives. If you’re worried about your relationship, your kids, your job, or just life in general, that might transfer to the bedroom.
Add in anxiety about ED and things can go downhill quickly. If you’re in bed with your partner and worried about your performance, it’s going to be tough to relax – and that’s a recipe for ED.
Diagnosing ED
We know. It’s tough for many men to talk with a doctor about the possibility of ED. But your doctor has heard it all. And talking with your doctor is the first step in doing something about the issue.
Your doctor will ask the usual questions about your medical history and your lifestyle. Do you smoke? How much exercise do you get? What’s your diet like? Your doctor will also need some details about your erections. How often do you have trouble getting or staying firm? Can you get an erection in some situations (like when you masturbate), but not others? How has your sex drive been? Do you have any pain?
Again, your doctor has heard it all. Men are treated for ED every day. You want your treatment to be as effective as possible, so answer the questions with as much honesty and detail as you can muster.
Lab tests will probably be part of this too. You’ll likely have blood and urine tests. They’ll want to check how your liver, kidneys, and thyroid are working. You might even have an ultrasound to check your blood flow.
How Is ED Treated?
We’ve all seen the ads for ED drugs. But pills are only one way to treat ED. Treatments can even be combined. Work with your doctor to find the best approach. Again, the more information you provide and the more questions you ask, the more effective your treatment is likely to be.
Lifestyle changes and natural treatments
Sometimes, ED can be managed by simple lifestyle changes. For example, if you have diabetes, then controlling your blood sugar may improve your erections. Or, if you’re taking a medication with sexual side effects, tweaking your prescription might help. (Never make medication changes on your own. Always check with your doctor.)
These basic changes are the first treatment options for many men:
Quit smoking. Your doctor can help tailor a smoking cessation plan that is right for you. You’ll feel better. You’ll look better. Your wallet will thank you.
If you use recreational drugs, stop. Your doctor can help you here, too.
Do you drink a lot? Does someone else in your life think you should cut back? Give it a try. Or stop completely. Again, your doctor can help you.
Exercise! It’s the closest thing there is to a wonder drug. Start exercising (or increase your current effort even modestly) and you’ll almost immediately lower your risk for health problems. Chances are you’ll feel better too. You might lose a few pounds. Maybe your pants will fit a little better. Exercise doesn’t have to be a grind to be effective. Play some basketball. Go for a bike ride. Walking is excellent exercise.
Change your diet. Think salads, fruits, and veggies. Whole grain breads and pastas. Soy, beans, seeds, nuts, olive oil, and cold-water fish (like salmon, tuna, sardines, halibut, and mackerel). Avoid fast food, processed foods, caffeine, and sugar.You don’t have to make drastic changes all at once. Try a salad for lunch twice a week instead of drive through. Have an apple or a peach for dessert instead of that chocolate-chip cookie. Pour yourself a glass of flavored seltzer water instead of soda or fruit punch. Get a cookbook full of healthy recipes and experiment with foods you’ve never tried before. (This can be especially fun with your partner or friends.)
Sex therapy and counseling
If anxiety, depression, or another mental health issue is triggering your ED, your doctor might suggest counseling or sex therapy. Therapy can give you a chance to talk things over with a professional and learn some coping strategies. If you have a partner, you might bring them with you. Together, you can work on your communication and your relationship.
Pills
Yes, you’ve seen and heard commercials for ED drugs. In the United States, there are four oral medications used to treat ED: sildenafil (Viagra), vardenafil (Levitra), tadalafil (Levitra), and avanafil (Stendra).
They’re called phosphodiesterase type 5 inhibitors – PDE5s inhibitors for short. And while they are all used a little differently, they work in similar ways, by relaxing smooth muscle tissue in your penis. Then, enough blood can flow in for a firmer erection.
Usually, men take PDE5 inhibitors about an hour or two before sex, but you should always follow your doctor’s instructions.
PDE5 inhibitors are effective for about 70% of men, but they’re not safe for everyone. Men who take nitrates for heart conditions should never take PDE5 inhibitors. Combining PDE5 inhibitors with nitrates can cause a dangerous drop in blood pressure. If you take nitrates, you will need to use a different ED treatment.
Pay attention to side effects of your ED medication
Are there side effects? Yes, there can be. Some men get headaches or muscle aches when they take these drugs. Others get a stuffy nose, a flushed face, or indigestion. For most men, these effects are mild.
Men who take Viagra might notice temporary vision changes, where things look like they’re in a blue-green filter. If your visual acuity (how well you see) changes, you must stop taking the medication and inform your doctor immediately. Cialis users sometimes experience back pain.
If any side effects give you trouble, reach out to your doctor and ask whether another ED treatment is right for you.
Self-injections
The medical term for this approach is intracavernosal injection (ICI). The success rate for this method is about 85%, according to the American Urological Association (AUA). As with all medications, however, the response will depend on many different factors, including the severity of the condition and the medication dose.
If you take this route, you’ll use a tiny needle to inject a medication called alprostadil into the side of your penis. Sometimes, other medications are mixed with alprostadil, so you might hear terms like bimix or trimix, depending on what is used. Ask your physician about the differences between these medications and how they work.
After the injection, an erection usually starts within 15 minutes and can last up to two hours. Don’t be alarmed if your erection lasts a while after you ejaculate. That can happen.
However, if you have a rigid erection that lasts longer than 4 hours, head to your local emergency department. This condition is called priapism and you’ll want medical attention ASAP.
If you use ICI, make sure you space each injection at least 24 hours apart. Up to 3 injections a week should be safe but ask your doctor about the right plan for you. Using ICI too often can scar the penis, which can make erections more difficult later on.
The idea of giving yourself an injection in the penis might make you queasy, but lots of men manage their ED this way. Your doctor will teach you how to do it safely for effective results and minimal pain. Your partner can also be taught how to do it.
Urethral Suppositories (MUSE)
The drug alprostadil (also used in injections) can come in suppository form, too. With the MUSE intraurethral method, you place a pellet into your urethra – the tube that allows urine and semen to leave your body. An erection usually starts within 10 minutes, when the drug gets absorbed and moves from the urethra into the erection chambers, the corpora cavernosa. Typically, the erection lasts for 30 to 60 minutes.
As with self-injections, your doctor will show you how to use MUSE safely and effectively. Side effects may include pain in the penis, testicles, legs, and the area between the scrotum and rectum. Some men feel warmth or burning sensations in the urethra, and the penis might redden. There could be some minor bleeding, too, if you don’t place the pellet correctly.
Testosterone therapy
If your testosterone levels are lower than normal (below 300 ng/dL), your doctor might suggest testosterone replacement therapy (TRT).
Testosterone is an important hormone for men. It drives male-typical characteristics like a lower voice and body hair distribution. It also drives your libido.
But in some cases, men’s bodies don’t produce enough testosterone. Also, men’s testosterone levels naturally drop as they get older. It’s a normal part of aging.
Your doctor might start you on TRT if you have other symptoms of testosterone deficiency, like low sex drive, depressed mood, or fatigue. You’ll follow up with your doctor periodically to see how well it’s going.
Don’t get duped! You might find over-the-counter products that claim to contain testosterone to improve sexual performance. Lots of men think about trying these on their own, without seeing a doctor. But it’s essential for your doctor to measure your testosterone levels and monitor them over time. Your doctor may also want to conduct other important blood tests.
Testosterone should always be taken by prescription. Think about it. Do you really want to trust your sexual health to the convenience store on the corner or a shady website?
Vacuum erection devices (VEDs)
If you don’t do well with medications – or can’t take them – you might try a VED, a simple mechanical tool. As the name suggests, a VED triggers an erection by using a vacuum to bring blood to your penis.
The basic components of a VED are a plastic tube, a small hand pump, and a rubber O-ring. Here’s how they work together:
When you’re ready to have an erection, you place your penis into the plastic tube, and hold it close to your body.
Next, run the hand pump for about one to three minutes.
Once your penis is fully erect, you place the O-ring around the base of your penis to keep the blood inside.
From there, you can remove the tube and have intercourse.
When you’re done, remove the O-ring.
VEDs have their pros and cons. On the pro side, they can be used at any VEDs have their pros and cons. On the pro side, they can be used at any time, so you can always be ready for sex. You don’t need to take any medication, and there’s no surgery involved. And if used properly, about 75% of men have success, according to the AUA. Your doctor will show you how to use it. Again, for any individual patient, the response depends on the severity of the condition and many other factors that your doctor can discuss with you.
On the con side, VEDs can be a little cumbersome. They take about 5 to 10 minutes to set up, which means you and your partner will have to take a short break during lovemaking so you can get an erection started. Some couples find this interruption less than romantic, and it might take away some of the excitement and spontaneity.
Other drawbacks to the VED: Your erection might look a bit floppy because there’s no erection/additional blood stored between the O-ring and your body. Some men find that their ejaculation feels different. You could feel some coldness or numbness in your penis, too.
Note: Sometimes, a man’s body shape makes it difficult to use a VED. Also, men who have problems with blood clotting and those who use blood thinners shouldn’t use VEDs.
Revascularization surgery
Younger men with ED caused by pelvic trauma may benefit from revascularization surgery. This process involves using an artery from the abdomen to create a “bypass” in the penis.
Revascularization is a very uncommon and specialized surgery that is ideal for young men, often trauma patients, who do not have general vascular disease since the “new” connection needs to be “atherosclerosis free” to be able to bring blood to the penis.
Penile implants (prostheses)
What, exactly, is an implant? It’s a device that’s surgically implanted into your penis and helps you create an erection on demand.
Implants come in two types:
Malleable implants are semi-rigid bendable rods, usually made from silicone. When you want an erection, you simply move your penis into an upward position. When you’re finished with sex, you can move it back down.
Inflatable implants are cylinders that fill with fluid to create an erection. You control the timing by using a special pump that is also surgically implanted, usually in your scrotum. You can start an erection with just the press of a button. After sex, you can push the same button to deflate the cylinders.
Getting an implant is a big decision. Once you have one, there’s no going back. That’s because the rods or cylinders replace two chambers in the penis called the corpora cavernosa. These are the chambers that normally fill with blood during an erection. During implant surgery, the corpora cavernosa are removed completely.
Implant surgery is fairly straightforward. Chances are, you’ll spend a night in the hospital, although you might go home the same day. You’ll probably have some pain, bruising, and swelling for a few weeks. Your doctor will give you special instructions about lifting things and exercising. You’ll need to wait about 8 weeks before having sex again.
Like any surgery, implants have risks. You might develop an infection. There’s also a slim chance that the device will malfunction, and you might need surgery again to fix the problem. However, most men with implants have successful, satisfying sex lives for many years after surgery.
Implants do have high satisfaction rates among men and their partners. In fact, some partners might not even know you have an implant. And orgasm should feel the same.
How about supplements?
Some men find it helpful to take supplements and herbs, but your mileage may vary. No matter what, always check in with your doctor before taking any product. Supplements aren’t regulated by the FDA the way drugs are, and you might not know how a product will interact with other health conditions or medications.
