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How to Treat Erectile Dysfunction:
What Are Your Options?

a happy mature coupleBefore we begin the discussion of how to treat ED, let’s quickly discuss how erectile dysfunction is evaluated.

How do we evaluate Erectile Dysfunction?

Nowadays, evaluating ED is relatively straight forward. Thirty to forty years ago, ninety percent of ED, known then as only impotence was thought to be a psychological problem and men often underwent extensive psychological and personality testing.

We also used to commonly do tests to measure the presence and strength of night time erections to decide if the cause was physical or psychological. Those tests are now rarely needed.

Of course the first thing you should do is have a thorough review of your health history and a physical exam by your primary doctor or urologist. If they have not been done recently, you should have lab tests performed to check your blood sugar, cholesterol and other lipids. Depending on your history and exam, you may need to have your testosterone levels checked. Occasionally men need to have another hormone called “prolactin” checked as well.

How to treat Erectile Dysfunction

Up until 1983 there were only two treatments for ED: behavioral therapy that was popularized by Masters and Johnson, and surgical implantation of a penile prosthesis. The first option didn’t work very well since contrary to the prevailing wisdom of the time, most ED is due to physical not psychological reasons. The second choice, a penile prosthesis, was more treatment than most men wanted or would accept.

Then in 1983 Herbert Brendler amazed a group of urologists gathered for a formal dinner with his personal demonstration of an erection from an injection of the drug Papaverine into his penis. This was the beginning of the modern era of research into the physiology of erection and the development of treatment for ED, eventually leading to the development of effective oral medications.

Medications to treat ED

There are 3 drugs which are very good at treating erectile dysfunction: Viagra (sildenifil), Levitra (vardenifil) and Cialis (tadalafil). They all work by inhibiting an enzyme called phosphodiesterase type 5 (PDE-5). This causes blood flow to the penis to increase. All three drugs have similar success rates and similar side effects.

These medications don’t automatically give you an erection—they help you get a better erection with stimulation, just like normal sex. The erection will go away after orgasm just like normal.

blue pill (viagra)Viagra takes about thirty minutes to get absorbed so you have to give it that long to start to work. It will stay in you system for about 4 hours. It is not absorbed well after a fatty meal. The usual dose is 50-100mg.

round yellow pill (levitra)Levitra also takes about 30 minutes to get absorbed and will stay in your system for about 4 hours, but it is still absorbed well after a big meal. The usual dose is 10 to 20 mg.

egg-shaped beige pill (cialis)Cialis takes 30 minutes to get absorbed but it stays around for 36 hours. Some men find this a plus—they can take it one day and if things don’t work out that night, there is always tomorrow to look forward to. The usual dose is 10-20mg. Because of its long half-life, Cilais can either be taken on an as needed basis, just like Viagra and Levitra, or once a day. Taking it every day means not having to wait 30 minutes for it to take effect.

Side effects of medication

The side effects from these three medications are very common, but are rarely severe. Although at least a third of men have some side effects, only 2% have side effects that are bad enough that they decide not to take the medication. And the side effects usually go away within a couple of hours.

The most common side effect is a headache … if this happens; you can avoid it by taking Tylenol or Advil at the same time you take the medicine. Other common side effects include a flush feeling in the face, stuffy nose and heartburn. A few people get a blue tint to their vision, which is harmless unless you are an airplane pilot.

Unlike the other two drugs, Cialis sometimes leads to back pain the next day. For the men who take Cialis once a day, the side effects usually go away after a few days, a process pharmacologists call tachyphylaxis.

Which medication should you choose?

There is a lot of debate as to how appropriate it is for pharmaceutical companies to supply doctors’ offices with free drug samples. Samples may unjustifiably persuade some doctors and their patients to choose a more expensive medication than they really need.

For the PDE-5 drugs like Viagra, Cialis and Levitra however, samples are an excellent way to start. If you can, get samples of all 3 drugs. Try them all and see which drug works best for your circumstances and see which drug has the least side effects. An advantage of a smaller dose is that you will be less likely to have side effects. Another advantage of a smaller dose is that when you do end up purchasing the pills, you can buy a bigger dose and save money by cutting it in half.

After you have tried the samples and know what you want, you can call your doctor and let him know which medicine and which dose you want.

illustration and diagram of penile injection therapyPenile Injection Therapy

For men who do not respond to oral medications like Viagra, or who have prohibitive side effects from the pills, penile injection therapy (PIT) will usually be successful. It can be used up to once a day, but no more than 6-8 times a month.

Many men are reluctant to try the injections. They cannot imagine putting a needle, however small into their own penis. But after trying it the first time, we have never had a man quit the injections because of pain or fear of the needle again. They may well quit because they or their wife lose interest in sex, but not because of the needle.

One case illustrates this perfectly. A man with ED was not responding to Viagra came to us and told us that, although he was very afraid of needles, his wife was not happy with his ED and he wanted to learn how to do penile injection therapy. He became so anxious with the needle approaching his penis that he pushed me across the room. I told him this was not for him. He then came back 6-months later, his marriage now in trouble and he had a renewed motivation. This time, with some trepidation, he did the injection himself…it worked well and he said, “”oh that was easy, I don’t know what I was so scared of.” He still uses PIT to this day.

The most common drugs used for injection

Most men use a combination of three drugs:

  1. Papaverine
  2. Phentolamine
  3. Alprostadil

Usually we prescribe all 3 mixed together and we call this the Tri-mix. Alprostadil, sold under the brand names Caverject, Edex and Prostin, can be used alone but its cost approaches $30 a dose and about a third of men will have painful erections when it is used by itself. Mixing the 3 drugs together results in a more potent formula and this allows for smaller doses of each individual drug. One multidose vial of Tri-mix costs $100-200. Depending on the dose required this comes to $2 to $20 per erection.

The risks of penile injection therapy

A small number, about 1-3%, of users experience a prolonged erection, called priapism. If you have an erection last over 6 hours you should call immediately so we can inject you with a different medication to make the erection go down. Left untreated priapism would lead to permanent damage. The risk of priapism is dose related, so we usually start with a small dose and if it isn’t effective, gradually work up to a dose that does work.

Another risk is scarring inside the penis. This may be due to bleeding at the injection site and irritation from the medications themselves. The risk of scarring can be decreased by applying pressure to the injection site for several minutes and by limiting the frequency of injections to not more than 6 times a month.

Sometimes injections may be painful … this is common with Alprostadil, but uncommon with the Tri-mix. If it does occur with Tri-mix, we can delete alprostadil from the mixture.

Instructions for penile injection…coming soon.

vacuum erection deviceVacuum Erection Device (VED)

A vacuum erection device, or VED for short, consists of a plastic cylinder that goes over the penis. You pump the air out of the cylinder, creating an erection. Then you put a large rubber ring around the base of the penis, release the vacuum pump and take the cylinder off. The rubber ring can stay on safely for 30 minutes.

Some men like the device; others do not. It does require some practice and dexterity to learn how to use. It is very safe. Two companies’ devices require a prescription and so are considered “durable medical equipment” and may be covered by insurance. Others are available on the internet with out a prescription. See this company’s web site for more details:

If you are interested in a vacuum device, a representative from one of the companies will meet with you in our office to show you the device and instruct you in how to use it before you decide whether to purchase one. The devices come with video instructions, but they can be tricky to use and we find more men succeed with personal instruction.

diagram of MUSE in useMUSE

MUSE is a pellet of alprostadil, which is the same medicine as Caverject used in penile injections, and is inserted into the tip of the penis to create an erection. It comes in four doses. The advantage of MUSE over penile injection therapy is that it is easier to learn how to use and does not involve needles. It also has a lower risk of a prolonged erection.

There are however several disadvantages. It is expensive, about $30 a dose. It is less likely to work than an injection and only about 30-40% of men get a good erection with it. At least a third of men have pain with the erection from Muse

It should not be used at home until you have tried it in the doctor’s office under his supervision and instruction. Although it is relatively easy to use, there are a few nuances to the insertion necessary to get a good response. Also about 2% of men will become very lightheaded due to the drop in blood pressure within a few minutes. This could be dangerous were it to occur at home.


Penile Prostheses

Penile prostheses were developed in the 1970’s and were the first successful treatment for ED. The modern prostheses are much better than the first ones, but now they are usually only used if other treatments have failed. There are two main types of prosthesis: semi-rigid and inflatable. These devices are surgically implanted inside the body. No parts are visible externally.

The semi-rigid prosthesis consists of two silicone cylinders. The penis consists of three cylinders: the urethra which carries urine and two corpora cavernosa which engorge with blood and become rigid during erection. We implant one cylinder into each corpus cavernosum. With this type of prosthesis, the penis is always rigid but can be bent downward and out of the way. The operation is usually done as an outpatient and requires only a small incision.

The multi-component inflatable prosthesis consists of two soft, hollow cylinders connected by tubing to a pump and reservoir filled with 2-3onces of fluid. One cylinder goes into each corpus cavernosum. Tubing connects the cylinders to the pump which we place beside the right testicle and the reservoir which we place in the pelvis front of the bladder.
At rest, the cylinders remain nearly empty so the penis is flaccid. When you want to have sex you push on the pump several times, transferring fluid from the reservoir into the cylinders and thereby creating a firm erection. After sex you push a release valve on the pump and the fluid goes out of the cylinders and back into the reservoir, making the penis soft once again. This operation is also done through a small incision, usually with an overnight hospital stay.

Most men choose the inflatable type because of its superior cosmetic result, but both types work well. Complications are not common but can occur. As with any surgical implant there is a risk of infection. If that occurs, the implant has to be removed. With the inflatable type, there is a risk of mechanical failure, which is very uncommon in the first 10 years, but if it occurs a second operation would be perfumed to replace the device.
See this company’s website:


Although nerve sparing during radical prostatectomy improves the chances for potency postoperatively, it is uncommon for erections to return to normal right after surgery. They may take 6 months to 2 years. Improving blood flow to the penis may help to improve the reliability and rapidity of the return to normal erections. This is called, somewhat euphemistically, penile rehabilitation. Some men go with the whole program, some with part of it and some aren’t interested in any treatment.

Starting several weeks after surgery, we begin with prescribing a PDE-5 drug 3 nights a week. The medication may not produce an erection this soon after surgery but will increase blood flow to the penis at night during REM sleep. After a month or so, we prescribe a vacuum device to use daily. As with the medications, the idea isn’t necessarily to have sex, but to improve blood flow to the penis. The third step is to begin with penile injections, again to improve blood flow to the penis and, if desired, to have sex. The goal is, with time, to be able to get by with less treatment or no treatment.