erectile dysfunction

Erectile dysfunction

Erectile dysfunction also known as ED or impotence, is a common male sexual dysfunction when a man has trouble getting an erection or keeping an erection for long enough to have satisfactory sex 1. An erection occurs when blood flows into the corpora cavernosa (spongelike cylinders inside your penis) and gets trapped there (see Figures 1 to 3 below). If the blood has problems getting to or staying in the corpora cavernosa (spongelike cylinders inside your penis), you may have erectile dysfunction. Sometimes you might also have low sex drive (loss of libido). Depending on the cause of your erectile dysfunction, you may still be able to get an erection at other times, such as when you wake up.

Erectile dysfunction (male impotence) can occur at any age, but it is more common in men older than 75 years of age. But it’s not a natural part of aging 2. Having erection trouble from time to time isn’t necessarily a cause for concern. If erectile dysfunction is an ongoing issue, however, it can cause stress, affect your self-confidence and contribute to relationship problems between you and your partner 3, 4, 5, 6.

If you have ED, you should tell your doctor. Because problems getting or keeping an erection can also be a warning sign of underlying health problems that needs treatment and a risk factor for heart disease. ED may mean your blood vessels are clogged (i.e., blocked coronary artery and blocked peripheral arteries), as erectile dysfunction increases your risk of future cardiovascular events such as heart attack (myocardial infarction), stroke, and all-cause mortality, with a trend towards an increased risk of dying from cardiovascular diseases 7. In fact, ED can precede coronary artery disease in almost 70 percent of cases. When you have heart disease, or coronary artery disease (blocked blood vessels), it will affect the tiny arteries in your penis sooner. Many times, your doctor will refer you to a cardiologist (heart specialist) to determine if you have cardiovascular disease that is causing your ED.

Erectile dysfunction may also mean you have nerve damage from diabetes. And if you don’t see your doctor, these problems will go untreated.

If you’re concerned about erectile dysfunction, talk to your doctor, even if you’re embarrassed. Sometimes, treating an underlying condition is enough to reverse erectile dysfunction. In other cases, medications or other direct treatments might be needed. For many men, the answer is as simple as taking a pill. Getting more exercise, losing weight to achieve a body mass index (BMI) of less than 30 kg/m2, and stopping smoking may also help.

When to see a doctor

Your family doctor is a good place to start when you have erectile dysfunction. See your doctor if:

  • You have concerns about your erections or you’re experiencing other sexual problems such as premature or delayed ejaculation
  • You have diabetes, heart disease or another known health condition that might be linked to erectile dysfunction
  • You have other symptoms along with erectile dysfunction

What is the penis?

Men’s penis is used for urination and sexual intercourse. The penis is made up of two erectile or spongelike cylinders called corpora cavernosa, that enlarge with blood during erection. During sexual arousal, nerve impulses increase blood flow to both of these cylinders (corpora cavernosa). This sudden influx of blood causes an erection by expanding, straightening and stiffening the penis. A tough fibrous, partially elastic outer casing surrounds the cavernosa. The corpus spongiosum surrounds the urethra (urinary tube), a tube that runs from the bladder to the end of the penis. The urethra carries urine and semen out of the body.

Figure 1. Male reproductive system
male reproductive system
Figure 2. Flaccid and erect penis

Flaccid and erect penis

Figure 3. Penis (cross section)

penis anatomy
penis cross-section

Footnote: The penis contains two cylindrical, spongelike structures (corpora cavernosa). During sexual arousal, nerve impulses increase blood flow to both of these cylinders. This sudden influx of blood causes an erection by expanding, straightening and stiffening the penis.

Cause of erectile dysfunction

Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels 8. Therefore, erectile dysfunction or ED is commonly classified into three groups based on the underlying cause: organic, psychogenic and mixed ED (a combination of physical and psychological issues), with most men having mixed ED (a combination of physical and psychological issues) 9. Moreover, most men occasionally fail to get an erection or keep an erection. This is usually caused by stress, performance anxiety (anxiety about maintaining an erection and the resulting anxiety can lead to or worsen erectile dysfunction), tiredness or drinking too much alcohol, and it has nothing to worry about. It can also be a side effect of some medicines.

However, if your erectile dysfunction happens often, it may be caused by a condition such as:

  • Vascular conditions:
  • Diabetes. Half of men with diabetes will experience ED within 10 years of their diagnosis. High blood sugar levels can damage the nerves that control sexual stimulation. They can also damage the blood vessels needed to provide adequate blood flow to the penis in order to have and maintain an erection.
  • Depression or anxiety
  • Trauma:
    • Spinal cord injury
    • Pelvis injury
  • Neurologic disease:
  • Radiation to the pelvis for cancer
  • Endocrine or hormone problems:
  • Pelvis surgery:
    • Radical prostatectomy (a surgical procedure for the partial or complete removal of the prostate)
    • Surgeries for rectal cancer or bladder cancer
  • Medication side effects:
    • Antidepressants
    • Antihypertensives (high blood pressure medicine)
    • Antiandrogens (testosterone blockers)
    • Antiarrhythmics (heart rhythm medicine)
  • Alcohol
  • Cocaine and marijuana
  • Cigarette smoking or using “e-cigs,” “vapes,” “e-hookahs,” “vape pens,” and “electronic nicotine delivery systems” 10, 11

Likewise, stress and mental health concerns can cause or worsen erectile dysfunction.

Sedentary lifestyle, a significant risk factor for cardiovascular disease, may also be a modifiable risk factor for erectile dysfunction 12. Obesity nearly doubles your risk of erectile dysfunction 13; one study determined that one third of men who were obese improved their erectile dysfunction with moderate weight loss and an increase in the amount and duration of regular exercise 14. The risk of moderate or total erectile dysfunction is almost double in men who smoke compared with nonsmokers 15.

Physical causes of erectile dysfunction

In many cases, erectile dysfunction is caused by something physical. Common causes include:

If you can’t keep your blood sugar or your blood pressure under control, you can get erectile dysfunction. It’s important that you take your medicines for these problems just the way your doctor tells you.

Sometimes your hormones get out of balance, and this causes erectile dysfunction. Your doctor will decide if you need blood tests to check your hormones. Some medicines can cause erectile dysfunction. If this is true for you, your doctor may take you off that medicine or give you a different one. Drinking too much alcohol, smoking too much, and abusing drugs can also cause erectile dysfunction.

Table 1. Medications and Substances that may cause or contribute to erectile dysfunction (ED)

Medication class or substanceExamples
AnticholinergicsTricyclic antidepressants
AnticonvulsantsPhenytoin (Dilantin), phenobarbital
AntidepressantsLithium, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants
AntihistaminesDimenhydrinate, diphenhydramine (Benadryl), hydroxyzine (Vistaril), meclizine (Antivert), promethazine (Phenergan)
AntihypertensivesAlpha blockers, beta blockers, calcium channel blockers, clonidine (Catapres), methyldopa, reserpine
Anti-Parkinson agentsBromocriptine (Parlodel), levodopa, trihexyphenidyl
Cardiovascular agentsDigoxin, disopyramide (Norpace), gemfibrozil (Lopid)
Cytotoxic agentsMethotrexate
DiureticsSpironolactone (Aldactone), thiazides
Hormones5-alpha reductase inhibitors, corticosteroids, estrogens, luteinizing hormone-releasing hormone agonists, progesterone
Illicit drugs, alcohol, and nicotineAmphetamines, barbiturates, cocaine, heroin, marijuana
TranquilizersBenzodiazepines, butyrophenones, phenothiazines
[Source 16 ]

Psychological causes of erectile dysfunction

The brain plays a key role in triggering the series of physical events that cause an erection, starting with feelings of sexual excitement. A number of things can interfere with sexual feelings and cause or worsen erectile dysfunction. These include:

  • Depression, anxiety or other mental health conditions
  • Stress
  • Relationship problems due to stress, poor communication or other concerns. Problems in your relationship with your sexual partner can also cause erectile dysfunction. Improving your relationship may help your sex life. If you decide to seek therapy, it will probably be most effective if your sex partner is included.

Couples can learn new ways to please one another and to show affection. This can reduce anxiety about having erections.

Feelings that can lead to erectile dysfunction include:

  • Feeling nervous about sex, perhaps because of a bad experience or because of a previous episode of impotence.
  • Feeling stressed, including stress from work or family situations.
  • Being troubled by problems in your relationship with your sex partner.
  • Feeling depressed.
  • Feeling so self-conscious that you can’t enjoy sex.
  • Thinking that your partner is reacting negatively to you.

Risk factors for erectile dysfunction

As you get older, erections might take longer to develop and might not be as firm. You might need more direct touch to your penis to get and keep an erection.

Various risk factors can contribute to erectile dysfunction, including:

Erectile dysfunction prevention

The best way to prevent erectile dysfunction is to make healthy lifestyle choices and to manage any existing health conditions. For example:

  • Work with your doctor to manage diabetes, heart disease or other chronic health conditions.
  • See your doctor for regular checkups and medical screening tests.
  • Stop smoking, limit or avoid alcohol, and don’t use illegal drugs.
  • Exercise regularly. Exercise can help with underlying conditions that play a part in erectile dysfunction in a number of ways, including reducing stress, helping you lose weight and increasing blood flow. Just 30 minutes of walking a day was linked with a 41% drop in risk for ED, according to one Harvard study, while a separate trial reported that moderate exercise can help restore sexual performance in obese, middle-aged men with ED 17.
  • Lose excess weight. Being overweight can cause — or worsen — erectile dysfunction. Obesity raises risks for vascular disease and diabetes, two major causes of ED. And excess fat tinkers with several hormones that may feed into the problem, too. The smaller your waist, the better—a man with a 42-inch waist is 50% more likely to have ED than one with a 32-inch waist.
  • Take steps to reduce stress.
  • Get help for anxiety, depression or other mental health concerns.
  • Work through relationship issues. Consider couples counseling if you’re having trouble improving communication with your partner or working through problems on your own.

Whether you’ll be able to prevent erectile dysfunction depends on what is causing your ED. Here are some things you can do that may help prevent erectile dysfunction.

  • Avoid drinking too much alcohol, smoking, or abusing drugs. If you smoke, quit. If you have trouble quitting, get help. Try nicotine replacement, such as over-the-counter gum or lozenges, or ask your doctor about a prescription medication that can help you quit. Get treatment for your alcohol or drug problems.
  • Before starting a new medicine, ask your doctor if erectile dysfunction is a possible side effect. If it is, you could discuss possible alterative medicines.
  • Keep your blood sugar and blood pressure under control.
  • Try to avoid feeling stressed.
  • See your dentist. A 2018 systematic review in American Journal of Men’s Health found an association between gum disease and risk for ED 18. Gum disease causes chronic inflammation, which is believed to damage the endothelial cells that line blood vessels, including those in your penis 19, 20.

Erectile dysfunction symptoms

The primary symptom of erectile dysfunction is not being able to get or keep an erection in order to have sex.

Erectile dysfunction (male impotence) symptoms might include persistent:

  • Trouble getting an erection
  • Trouble keeping an erection
  • Reduced sexual desire (low libido)

Erectile dysfunction complications

Complications resulting from erectile dysfunction can include:

  • An unsatisfactory sex life
  • Stress or anxiety
  • Embarrassment or low self-esteem
  • Relationship problems
  • The inability to get your partner pregnant

Erectile dysfunction diagnosis

Erectile dysfunction is usually easy to diagnose. Even if you are tempted to self-diagnose, you should still talk to your doctor. Your doctor will want to make sure that your erectile dysfunction is not a sign of other health problems.

Your doctor will probably start by asking you some questions (medical history) and doing a physical exam. If you have chronic health conditions or your doctor suspects that an underlying condition might be involved, you might need further tests or a consultation with a specialist.

Tests for underlying conditions might include:

  • Physical exam. This might include careful examination of your penis and testicles and checking your nerves for sensation.
  • Blood tests. A sample of your blood might be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels and other health conditions.
  • Urine tests (urinalysis). Like blood tests, urine tests are used to look for signs of diabetes and other underlying health conditions.
  • Dynamic duplex ultrasound. This test is usually performed by a specialist in an office. It involves using a wandlike device (transducer) held over the blood vessels that supply the penis. It creates a video image to let your doctor see if you have blood flow problems. This test is sometimes done in combination with an injection of medications into the penis to stimulate blood flow and produce an erection.
  • Psychological exam. Your doctor might ask questions to screen for depression and other possible psychological causes of erectile dysfunction.

Erectile dysfunction treatment

Erectile dysfunction treatment depends on what is causing it. If it is caused by uncontrolled blood sugar and high blood pressure, take your medicine and follow your doctor’s instructions.

After your doctor checks you for medical problems and medicines that might cause your erectile dysfunction, he or she may recommend a medicine to help with your ED. Phosphodiesterase type 5 (PDE5) inhibitors are the most effective oral drugs in the treatment of erectile dysfunction 21 and should be considered first-line therapy. Your doctor may prescribe Sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). These medicines are taken by mouth to help you maintain an erection. Approximately one third of men with erectile dysfunction do not respond to therapy with PDE5 inhibitors. These agents are not effective for improving libido 22.

However, not everyone can use these medicines. Your doctor may talk to you about alprostadil if oral medicines aren’t an option for you. Alprostadil is a synthetic version of prostaglandin E. It can be injected into your penis or inserted as a tiny suppository into the urethra (the hole at the end of the penis). Your doctor will help you decide which treatment is best for you.

Follow your doctor’s instructions when taking ED medicine. Usually, a man takes 1 tablet 30 minutes to 1 hour before he plans to have sex. Sildenafil (Viagra) works for 4-8 hours; vardenafil (Levitra) works for up to 8 hours; and tadalafil (Cialis) works for up to 36 hours.

You should not take more than 1 dose in 24 hours. Tadalafil (Cialis) and vardenafil (Levitra) come in tablets of 2.5 mg, 5 mg, 10 mg and 20 mg. Sildenafil (Viagra) comes in tablets of 25 mg, 50 mg and 100 mg.

Even if you take the ED medicine, you still need physical and mental stimulation and desire to have an erection. If your first dose doesn’t help, call your doctor. Your doctor may want to change your tablet strength.

The side effects of ED medicine are mostly the same. Sildenafil (Viagra) and vardenafil (Levitra) can cause:

  • Headache
  • Flushing (face and upper body turning red and warm)
  • Upset stomach
  • Runny nose
  • Vision changes (things look blue)

Tadalafil (Cialis) has the same side effects, except for the flushing and possible changes in vision. Tadalafil (Cialis) can also cause back pain and muscle aches. For each of the ED medicines, headache is the most common side effect. Vision changes are the least common. See your doctor if you have any side effect that bothers you.

Call your doctor right away if you take one of these medications and have a prolonged erection that lasts 4 hours or longer (also known as priapism). This condition may cause permanent impotence if not treated.

The prevalence of hypogonadism (defined as a morning serum total testosterone level less than 300 ng per dL [10.41 nmol per L]) in men with erectile dysfunction is estimated to be 5 to 10 percent 23. In men with hypogonadism, testosterone supplementation is superior to placebo in improving erections and sexual function. Response rates are higher in primary versus secondary testicular failure, and with transdermal versus oral or intramuscular testosterone 24. Supplementation is also associated with improved satisfaction with erectile function and sexual desire.29 Men with hypogonadism who failed a trial of sildenafil were found to have significant improvement in erectile function with the addition of testosterone supplementation 25. Testosterone supplementation may result in erythrocytosis, elevated serum trans-aminase levels, exacerbation of untreated sleep apnea, benign prostatic hyperplasia, and an increased risk of adenocarcinoma of the prostate. Men receiving testosterone supplementation require more frequent monitoring of hemoglobin, serum transaminase, and prostate-specific antigen levels, and prostate examinations 26.

ED medications

Sildenafil (Viagra), vardenafil (Levitra, Staxyn), tadalafil (Cialis) and avanafil (Stendra) are oral medications that reverse erectile dysfunction by enhancing the effects of nitric oxide, a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation.

Although they work in similar ways, each oral medication has a slightly different chemical makeup. These minor differences affect the way each medication works, such as how quickly it takes effect and wears off, and the potential side effects. Your doctor will consider these factors as well as any health problems you have and possible interactions with other medications you take.

  • Sildenafil (Viagra). This medication is most effective when taken on an empty stomach one hour before sex. It’s effective for up to six hours.
  • Vardenafil (Levitra, Staxyn). This medication also is most effective when taken one hour before sex and can be taken with or without food. It’s effective for up to seven hours.
  • Tadalafil (Cialis). This medication is taken with or without food about one to two hours before sex. It’s effective for 36 hours. It can be taken in a small dose daily or in a larger dose as needed.
  • Avanafil (Stendra). This medication is taken with or without food 15 to 30 minutes before sex, depending on the dose. It lasts up to six hours.

Before taking any medication for erectile dysfunction, get your doctor’s OK.

Medications for erectile dysfunction might not work or might be dangerous if you:

  • Take nitrate drugs — commonly prescribed for chest pain (angina) — such as nitroglycerin (Minitran, Nitro-Dur, Nitrostat, others), isosorbide mononitrate (Monoket) and isosorbide dinitrate (Dilatrate-SR, Isordil)
  • Have very low blood pressure (hypotension) or uncontrolled high blood pressure (hypertension)
  • Have severe liver disease
  • Have kidney disease that requires dialysis

While oral ED medications are a common first step for therapy, they only tend to work in about 50 percent of men with diabetes. Diabetic men are more likely to move on to other treatment options, such as the pump, penile injection therapy, and penile implants.

Most men who take oral erectile dysfunction medications aren’t bothered by side effects. When side effects do occur, they can include:

  • Flushing
  • Stuffy or runny nose
  • Headache
  • Visual changes, such as color tinge to vision, sensitivity to light or blurred vision
  • Indigestion
  • Dizziness and fainting

Rarely, more-serious side effects can occur, including:

  • Hearing loss or vision loss. Some men have had sudden loss of hearing or loss of vision after taking one of these medications. However, it isn’t clear whether vision or hearing loss was directly caused by taking the medication or by a pre-existing condition. If you’re taking an oral erectile dysfunction medication and have sudden loss of hearing or vision, seek prompt medical attention.
  • An erection that doesn’t go away on its own. Called priapism, this rare condition can be painful and requires medical treatment to avoid damage to your penis. If you have an erection that lasts more than four hours, seek immediate medical attention.

Treatments for erectile dysfunction are big business, and online scams abound.

If you do buy medications over the internet:

  • Check to see if an online pharmacy is legitimate. Never order medications from an online pharmacy if there’s no way to contact the pharmacy by phone, if prices seem too good to be true or if you’re told no prescription is necessary. Some illegal businesses sell counterfeit versions of legitimate medications, which can be ineffective or dangerous. In the U.S., the National Association of Boards of Pharmacy can tell you whether an online pharmacy is licensed and in good standing.
  • Make sure you get the right prescription and dose. When you order medications — and when you receive them in the mail — make sure they’re the exact dose and type prescribed by your doctor.
  • Don’t be fooled into buying ‘herbal viagra.’ Never take any medications that claim to be the “herbal” or nonprescription equivalent of an oral medication for erectile dysfunction. These aren’t an effective alternative, and some contain harmful substances.

How should you take erectile dysfunction medications?

Follow your doctor’s instructions. Usually, a man takes 1 tablet 30 minutes to 1 hour before he plans to have sex. Sildenafil works for 4-8 hours; vardenafil works for up to 8 hours; and tadalafil works for up to 36 hours.

You should not take more than 1 dose in 24 hours. Tadalfil and vardenafil come in tablets of 2.5 mg, 5 mg, 10 mg and 20 mg. Sildenafil comes in tablets of 25 mg, 50 mg and 100 mg.

Even if you take the medications, you still need physical and mental stimulation and desire to have an erection. If your first dose doesn’t help, call your doctor. Your doctor may want to change your tablet strength.

What are the side effects of ED medications?

The side effects of impotent medications are mostly the same. Sildenafil and vardenafil can cause these side effects:

  • headache
  • flushing (face and upper body turning red and warm)
  • stomach upset
  • runny nose (sniffles)
  • vision changes (things look blue).

Tadalfil has the same side effects, except for the flushing and possible changes in vision. Instead, it can also cause back pain and muscle aches. For each of the medications, headache is the most common side effect. Vision changes are the least common. Talk to your doctor if you have any side effect that bothers you.

Call your doctor right away if you take one of these medications and have a prolonged erection that lasts 4 hours or longer. This condition may cause permanent impotence if not treated.

Can everyone use ED medications?

No. You shouldn’t use these medicines if you take nitroglycerin or any other nitrates for chest pain. If you have heart problems, tell your doctor before taking any ED medicines. These medicines can have serious side effects in people who have heart problems.

If you use sildenafil, tadalfil, or vardenafil and get chest pains, be sure to tell the paramedics, nurses or doctors at the hospital that you use it and when you used it last.

Other ED meds

Other medications for erectile dysfunction include:

  • Alprostadil self-injection. With this method, you use a fine needle to inject alprostadil (Caverject, Edex) into the base or side of your penis. In some cases, medications generally used for other conditions are used for penile injections on their own or in combination. Examples include alprostadil and phentolamine. Often these combination medications are known as bimix (if two medications are included) or trimix (if three are included). Each injection is dosed to create an erection lasting no longer than an hour. Because the needle used is very fine, pain from the injection site is usually minor. Side effects can include mild bleeding from the injection, prolonged erection (priapism) and, rarely, formation of fibrous tissue at the injection site.
  • Alprostadil urethral suppository. Alprostadil (Muse) intraurethral therapy involves placing a tiny alprostadil suppository inside your penis in the penile urethra. You use a special applicator to insert the suppository into your penile urethra. The erection usually starts within 10 minutes and, when effective, lasts between 30 and 60 minutes. Side effects can include a burning feeling in the penis, minor bleeding in the urethra and formation of fibrous tissue inside your penis.
  • Testosterone replacement. Some people have erectile dysfunction that might be complicated by low levels of the hormone testosterone. In this case, testosterone replacement therapy might be recommended as the first step or given in combination with other therapies.

Alprostadil (Caverject) is a viable second-line therapeutic option for the treatment of erectile dysfunction. It should initially be administered in your doctor’s office at the lowest dose and sequentially titrated to an adequate erectile response while monitoring for fainting (syncope). Your doctor should also teach you on self-administration. Intra-cavernosal alprostadil is more effective, better tolerated, and preferred by men over the intraurethral form 27. Common side effects of intraurethral alprostadil include local penile pain, urethral bleeding, dizziness, and dysuria. Common adverse effects of intracavernosal alprostadil include penile pain, edema and hematoma, palpable nodules or plaques, and priapism. Your doctor should inform you about the potential for occurrence of prolonged erections (priapism) and that you should seek emergency medical care for rigid erections lasting longer than 4 hours. Priapism is most commonly treated with suction of blood from the corpus cavernosum under local anesthetic. If this treatment is insufficient, then intra-cavernosal injections of phenylephrine should be performed with hemodynamic monitoring to watch for severe hypertension, tachycardia, or arrhythmia.


Recent studies have found that exercise, especially moderate to vigorous aerobic activity, can improve erectile dysfunction.

Even less strenuous, regular exercise might reduce the risk of erectile dysfunction. Increasing your level of activity might also further reduce your risk.

Psychological counseling

If your erectile dysfunction is caused by stress, anxiety or depression — or the condition is creating stress and relationship tension — your doctor might suggest that you, or you and your partner, visit a psychologist or counselor.

Dietary supplements for erectile dysfunction

You’ve likely seen advertisements for erectile dysfunction herbs or supplements to “increase your sexual performance.” Before using any supplement, check with your doctor to make sure it’s safe for you — especially if you have chronic health conditions. Some ED herbs or supplements that claim to work for erectile dysfunction can be dangerous.

Erectile dysfunction supplements and other natural remedies have long been used in Chinese, African and other cultures 28. But unlike prescription medications for erectile dysfunction, such as sildenafil (Viagra), vardenafil (Levitra, Staxyn), tadalafil (Cialis) and avanafil (Stendra), erectile dysfunction herbs and supplements haven’t been well-studied or tested. Some of these drugs can cause side effects or interact with other medications and cause dangerously low blood pressure. These products are especially dangerous for anyone who takes nitrates. And the amount of the active ingredient can vary greatly from product to product.

The Food and Drug Administration (FDA) has issued warnings about several types of “herbal viagra” because they contain potentially harmful drugs not listed on the label 29. The dosages might also be unknown, or they might have been contaminated during formulation. Some of these products contain unknown amounts of ingredients similar to those in prescription medications, which can cause dangerous side effects. Some actually contain the real drug, which should be given by prescription only. Although the Food and Drug Administration has banned many of these products, some potentially dangerous erectile dysfunction remedies remain on the market and on the internet.

Recently, a Cochrane review showed that ginseng may only have trivial effects on erectile function or satisfaction with intercourse compared to placebo when assessed using validated tools 30. Moreover, data suggested that daily administration of oral L-arginine, only when in combination with phosphodiesterase type 5 (PDE5) inhibitor use, improves sexual function 31.

Here’s a guide to erectile dysfunction herbs and supplements 32:

Table 2. Dietary supplements for erectile dysfunction (studied in humans and considered generally safe)

Herb or supplementDoes it work?Safety
DHEASome evidence shows that dehydroepiandrosterone (DHEA) increases libido in women and helps erectile dysfunction in men.DHEA appears to be safe at low doses. It can cause acne.
L-arginineSome evidence shows that taking high doses improves erectile dysfunction by stimulating blood vessels to open wider for improved blood flow.Side effects may include nausea, cramps and diarrhea. Don’t take L-arginine with Viagra.
GinsengOne study of Panax ginseng showed it improved sexual function in men with erectile dysfunction. A cream preparation is used for premature ejaculation.Panax ginseng contains many active ingredients. It appears to be safe used on a short-term basis. Insomnia is a common side effect.
Propionyl-L-carnitineStudies have shown that propionyl-L-carnitine combined with Viagra might improve erectile function better than sildenafil alone.Propionyl-L-carnitine is likely to be safe when used under medical supervision.
[Source 33 ]

Table 3. Dietary supplements for erectile dysfunction (studied in humans and considered risky)

Herb or supplementDoes it work?Safety
YohimbeA number of clinical trials have shown that the primary component of this bark from an African tree can improve sexual dysfunction associated with a drug used to treat depression.This herb has been linked to a number of side effects, including increased blood pressure, fast or irregular heartbeat, and anxiety. Yohimbe shouldn’t be used without a doctor’s supervision.

Table 4. Dietary supplements for erectile dysfunction (NOT studied in humans and considered risky or not effective)

Herb or supplementDoes it work?Safety
GinkgoGinkgo has the potential to increase blood flow to the penis. But there’s no evidence of benefit for erectile dysfunction.Ginkgo might increase the risk of bleeding.
Horny goat weed (epimedium)Substances in the leaves of this herb have been used to improve sexual performance, but the herb has not been studied in people.This herb might affect heart function.

Be cautious and talk to your doctor

Just because a product claims to be natural doesn’t mean it’s safe. Many herbal remedies and dietary supplements can cause side effects and dangerous interactions when taken with certain medications. Talk to your doctor before you try an alternative treatment for erectile dysfunction — especially if you’re taking medications or you have a chronic health problem such as heart disease or diabetes.

Living with erectile dysfunction

If the medicines aren’t right for you, you could also try using a penile implant, vacuum pump devices, or you could have surgery. Your doctor may send you to an urologist to talk about these options.

Vacuum penis pump devices for ED

Vacuum pump devices also called penis pumps are a noninvasive second-line option (Figure 4). Penis pumps are contraindicated in men with sickle cell anemia or blood dyscrasias (blood conditions), and in those taking anticoagulants. If used properly, adverse effects and potential risks are negligible, yet there may be a substantial learning curve. A penis pump (vacuum erection device) is a hollow tube with a hand-powered or battery-powered pump. The tube is placed over your penis, and then the pump is used to suck out the air inside the tube. This creates a vacuum that pulls blood into your penis. Once you get an erection, you slip a tension ring around the base of your penis to hold in the blood and keep it firm. You then remove the vacuum device.

The erection typically lasts long enough for a couple to have sex. You remove the tension ring after intercourse. Bruising of the penis is a possible side effect, and ejaculation will be restricted by the band. Your penis might feel cold to the touch.

If a penis pump is a good treatment choice for you, your doctor might recommend or prescribe a specific model. That way, you can be sure it suits your needs and that it’s made by a reputable manufacturer.

Figure 4. Vacuum penis pump for men

Vacuum penis pump for men

Penile implants for erectile dysfunction

When first- and second-line therapies have failed, surgical implantation of an inflatable penile prosthesis can be considered in consultation with a urologist (Figure 5). Penile implant for erectile dysfunction involves surgically placing devices into both sides of your penis. These implants consist of either inflatable or malleable (bendable) rods. Inflatable devices allow you to control when and how long you have an erection. The malleable rods keep your penis firm but bendable.

Penile implants are usually not recommended until other methods have been tried first. Implants have a high degree of satisfaction among those who have tried and failed more-conservative therapies. As with any surgery, there’s a risk of complications, such as infection. Penile implant surgery is not recommended if you currently have a urinary tract infection.

The American Urological Association does not endorse penile venous reconstructive surgery or surgeries to limit venous outflow from the penis. Penile arterial reconstructive surgery is controversial and more rigorous trials are needed to prove short- and long-term effectiveness 15.

There are several different types of penile implants for erectile dysfunction. Your doctor will help you decide which implant is the best option for you. What is most important is that each person undergoes their own journey to choose the best penile implant that best meets their own individual goals and needs.

  1. One-Piece Implant. One-piece implants use flexible or semirigid cylinders. Some describe the flexibility like that of a goose-neck lamp. This implant is rigid enough for sex, but soft enough to be concealed easily in your clothing. Although one-piece implant may not inflate and deflate, it has been designed to be soft to the touch and strong in function. Due to its simpler design, surgery and recovery are faster after malleable penile implant placement compared to the inflatable penile implant.
    • Benefits: least expensive type of implant, fewer mechanical parts to fail
    • Downsides: least natural erection, no antibiotic coating; worst rigidity; worst flaccidity
    • Good for: men with poor hand function or men with buried penis who need a prosthetic to hold on a condom-style catheter. Best option for men who prefer a more straightforward device or have a history of complex abdominal surgery or kidney transplantation
  2. Two-Piece Implant. Two-piece cylinders are made of cylinders and a pump. The pump is hidden in your scrotum. Pumping fills the cylinders with fluid to give you an erection. Bending your penis allows the fluid to move out of the cylinders, so your penis can become flaccid (soft).
    • Benefits: excellent rigidity; no need to place any parts in the pelvis or abdomen
    • Downsides: no antibiotic coating; not as good flaccidity; not good for very thin men; not good for larger penises due to poor flaccidity
    • Good for: men who have extremely complex pelvic issues that make placement of a three-piece implant (see below) less desirable such as men who have had certain pelvic crush injuries or those with complex vascular reconstruction – very few men fall into this category.
  3. Three-Piece Implant. Three-piece implants are the most commonly used devices. They consist of a pair of cylinders in the penis, a pump placed inside your scrotum near your testicles, and a reservoir of saline. Squeezing the pump in your scrotum moves the saline into the cylinders, creating a rigid erection that feels natural. Implants remain inflated as long as you desire, even after climax. When you’re ready, you’ll hit a deflate button on the pump that returns the penis to a flaccid, soft state.
    • Benefits: excellent rigidity and flaccidity; total control over the erection; antibiotic coatings are available
    • Downsides: need for placement of reservoir in your pelvis/abdomen
    • Good for: most men with erectile problems, including those from prostate cancer, diabetes, vascular disease, spinal cord injury, pelvic trauma, transplant patients, and others

Most patients prefer to receive a 3-piece inflatable penile implant (AMS 700 or Coloplast Titan) since it is most naturally appearing and has the ability to become the most flaccid and most rigid. It is composed of a pump that is placed in the scrotum and a fluid reservoir hidden in your lower abdomen. There is sufficient space in the scrotum to accommodate the pump and the testicles do not need to be removed. The pump is hidden in the scrotal skin and is pressed it to fill the cylinders with fluid. This creates a confident erection that can be achieved whenever, wherever, and for as long as one desires. After sexual activity, the release button on the pump can be pressed routing the fluid back to the reservoir and returning penis to a non-erect position. The inflatable implant require a slightly longer surgery and recovery and higher risk for complications, but does result in higher rates of patient and partner satisfaction.

Figure 5. Inflatable penile prosthesis

Penile implants for erectile dysfunction
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