Tulane Urology

Erectile dysfunction

Many men experience occasional difficulties with erections, but some face a condition known as erectile dysfunction (ED). ED makes it challenging to achieve or maintain an erection firm enough for sexual activity.

What Causes Erectile Dysfunction?

ED becomes more prevalent with age, but aging itself is not the root cause. It may signal underlying health issues, such as heart disease, high blood pressure, and diabetes, or the effects of smoking and substance abuse.

How is erectile dysfunction diagnosed?

Diagnosing the cause of ED is crucial for determining the most effective treatment. Healthcare providers typically inquire about health history, conduct a physical exam, and order lab tests:

    • Health & ED History: Providers review medical history, medications, and lifestyle factors to identify potential contributors to ED. Adjusting or discontinuing certain medications may improve symptoms.
    • ​Physical Exam: A physical exam assesses overall health and includes an examination of the penis, offering insights into the potential causes of ED.
    • Lab Tests: Blood tests and urine samples may be ordered to identify diseases associated with ED.
    • Stress & Emotional Health: Providers may ask about depression, stress, or relationship difficulties, as these emotional factors can impact ED.

How is Erectile Dysfunction treated?

The encouraging news is that ED can be safely treated, and effective treatments are available. Treating ED involves addressing underlying causes. Healthcare providers may recommend quitting smoking, reducing substance abuse, managing emotional factors like stress or depression, or adjusting medications. If testosterone levels are low, testosterone replacement therapy may help.

Other options include:

  • Oral Medications
  • Vacuum Erection Devices
  • Self-Injections
  • Surgical Implants

It is crucial not to discontinue medications without consulting a healthcare provider. Dietary supplements, often labeled as “herbal remedies,” are popular but may not be safe or effective. Consulting with a healthcare provider before trying any supplements for ED is highly recommended.

Treatment Options for Erectile Dysfunction

Explore treatment options below by toggling each section for detailed information on managing erectile dysfunction.

Oral Medications

Pills for ED have been in use for nearly 30 years. These medications, known as PDE5 (phosphodiesterase type 5) inhibitors, work by improving blood flow to the penis, allowing for stronger and more sustained erections.

Common PDE5 inhibitors include:

  • Sildenafil (Viagra®)
  • Tadalafil (Cialis®)
  • Vardenafil (Levitra®)
  • Avanafil (Stendra®)

How They Work

These medications block the enzyme PDE5, allowing blood vessels in the penis to relax and expand. This increased blood flow supports the ability to achieve and maintain an erection.

Dosage and Timing

Your urologist will prescribe the appropriate dosage. Always follow your provider’s instructions carefully to ensure safety and effectiveness.

Side Effects

Common side effects include:

  • Headache
  • Indigestion
  • Flushing
  • Nasal congestion

Warning

If you are taking nitrates for a heart condition, consult your cardiologist before using any PDE5 inhibitor, as the combination can be dangerous.

Summary

While these medications are not a cure for ED, they can significantly improve erectile function and help restore confidence and sexual satisfaction.

Vacuum Erection Devices

Vacuum erection devices (VEDs) are non-invasive tools that help induce an erection by creating negative pressure around the penis. This draws blood into the shaft, resulting in an erection. A constriction ring placed at the base of the penis helps maintain the erection once the device is removed.

How They Work

Vacuum erection devices may be either manually operated or battery powered. These devices work by creating a vacuum that draws blood into the penis, producing an erection. Once the erection is achieved, a constriction ring is placed at the base of the penis to help maintain it during sexual activity. VEDs are particularly effective for men whose ED is caused by medical or physical conditions.

Caution

If you are taking blood-thinning medications, be cautious when using a VED, as it may increase the risk of bruising or bleeding.

Summary

For patients seeking a drug-free and non-invasive option, VEDs are a safe and effective solution. While they are not ideal for everyone, they can be a valuable part of an ED treatment plan.

Self Injections

Self-injection therapy involves using a tiny needle to inject medication directly into the base or side of the penis. This method has been used successfully for many years and is particularly helpful for men who do not respond to oral medications.

Common injectable medicines include:

  • Alprostadil

  • Papaverine

  • Phentolamine

These drugs are often used in combination (known as Trimix).

How It Works

The medication is injected into the erectile tissue of the penis (the corpora cavernosa) using a very fine needle. The injection typically causes an erection within 5 to 15 minutes and lasts 30 to 60 minutes. This method does not require sexual stimulation, and it should not be used more than once in a 24-hour period or more than 2–3 times per week, as directed by your urologist.

Dosing and Technique

Your urologist will prescribe the appropriate dose and teach you the proper injection technique during an office visit. It is important to follow instructions carefully to avoid side effects or injury.

Side Effects

Possible side effects include:

  • Mild pain or burning at the injection site
  • Bruising or bleeding at the injection site
  • Prolonged erection (priapism), which requires immediate medical attention if lasting longer than 4 hours
  • Scar tissue formation (fibrosis) with frequent use over time

If you are taking blood-thinning medications, your urologist will review the risks and advise whether this method is safe for you.

Summary

Self-injection therapy is a reliable and effective treatment for ED, especially when oral medications are ineffective or not recommended. While it does require proper technique and preparation, many men find it to be a discreet and satisfactory solution.

Penile Implants (Prostheses)

Penile implants offer a long-term surgical solution for men with persistent ED who have not found success with other treatments. These devices allow for both the initiation and maintenance of an erection.

Typically considered a last-resort treatment, penile implants are highly effective and can significantly improve sexual satisfaction.

Types of Penile Implants

  • Inflatable Implants consist of three parts: a pump (in the scrotum), cylinders (in the penis), and a fluid reservoir (usually in the lower abdomen behind the abdominal muscles). Pumping the fluid from the reservoir into the cylinders creates an erection and pressing the deflate valve returns the penis to a flaccid state.
  • Semi-Rigid Implants are flexible rods implanted into the penis that can be manually positioned as needed for an erection or flaccid state.

Surgical Technique

Penile implant surgery is performed under general anesthesia. Incisions are made in the penis and scrotum (if needed) to insert the components. The procedure is usually performed on an outpatient basis.

Benefits

Penile implants are durable and reliable, with a high rate of patient and partner satisfaction.

Risks and Side Effects

  • Infection (especially in men with diabetes)
  • Device failure or mechanical issues
  • Potential need for revision surgery
  • Local discomfort

Summary

Penile implants are best suited for men with persistent ED who are emotionally and physically prepared for a surgical solution. Ideal candidates are in overall good health and do not have other urologic issues such as significant prostate enlargement or urethral stricture disease.