Most men don’t call their doctor’s office the day after an ugly night. They wait.
It was the wine, the work, maybe things will be fine on the weekend
Sometimes they are, but if the pattern persists, this avoidance can start to warp what happens with sex. Dates are planned around the terror of losing it, the girlfriend assumes the magic has leached out for good, and the subject in question might quietly order whatever “performance booster” comes up top on a search engine the next time he feels blue.
That’s a shame, because erectile dysfunction is regularly treatable; it’s just that working out what treatment might be useful can be the more challenging part.
Erectile dysfunction is a syndrome, not a diagnosis
An erection involves multiple pathways in the body, and a disruption at any point can impair the ability to achieve or maintain one – the brain has to register arousal, the nervous system has to respond, blood vessels have to dilate and the penis has to hold its fill.
Conditions like diabetes can damage nerves and circulation, so can smoking and cholesterol, drugs like some antidepressants can dampen libido or climax, and low testosterone can reduce sex drive – but it’s less often the sole culprit than some men are led to believe. Anxiety too, can lead to an overfocus on the problem that makes a man unaware of being stimulated at all, while the body is acutely sensitive to stress.
Erectile dysfunction symptoms that persist or which include the absence of morning erections or have appeared suddenly are worth investigating with a medical professional, looking at morning erections, blood pressure, glucose levels, cholesterol, medication and risks to the cardiovascular system.
Viagra and its ilk are standard starting points for most men
The first line treatment for most men is a PDE5 inhibitor, of which the best known are sildenafil, tadalafil, vardenafil and avanafil.
Sildenafil, the active ingredient in Viagra, is usually taken an hour before sex and works for several hours, but can be affected by a big or fatty meal, leading to the drug taking longer to start working.
Tadalafil, more commonly known as Cialis, has a longer window of effectiveness, potentially up to 36 hours, and also has a lower daily maintenance dose for some men who take it. Both drugs allow for spontaneous sex, but some men may feel that taking sildenafil only when needed is preferable to a daily dose.
Neither of these medications causes an erection on their own, sexual stimulation is still required, the drugs simply assist the body in its physical response.
Men considering either medication can refer to our comparison of Cialis and Viagra for more information.
Common side effects include headaches, warmth, indigestion, a stuffy nose and dizziness, with sildenafil potentially impacting colour vision, and tadalafil causing discomfort in the muscles and back. Nitrate heart medications and the recreational drug “poppers” should never be mixed with either drug, due to a dangerous drop in blood pressure that can occur, alongside other medications including alpha-blockers, antifungals, antibiotics and HIV treatments.
What if the pill doesn’t work?
Don’t judge sildenafil by the night it was swallowed after a cheeseburger and three whiskeys.
Incorrect dosing, timing, heavy meals or alcohol, a lack of stimulation and unrealistic expectations can lead to a fair number of disappointments. Some men may also take the drug at the start of sex and be let down when it takes longer to start working, or simply give up after one bad experience when they were highly anxious.
A prescriber may ask for several attempts, spaced out appropriately, before moving on to alternative treatment, although the dose may be adjusted for subsequent tries, rather than increased. Taking Viagra and Cialis together is not an advisable way of boosting efficacy.
If a PDE5 inhibitor fails repeatedly, an underlying issue such as uncontrolled diabetes, severe vascular disease, nerve damage, hormone imbalance or psychological factors that medication alone cannot address may need to be investigated.
A vacuum device may not be glamorous, but it is often effective
A vacuum erection device consists of a cylinder, a pump and a tension ring. The penis is placed in the cylinder and the pump is used to create suction, drawing blood into the penis and causing an erection, before the tension ring is placed at the base to maintain it. It is mechanical, which puts some couples off, but it is often effective.
It may feel cooler than usual, and bruising or numbness can occur, but the ring should generally be removed after 30 minutes. A proper device with a built in pressure limiter is preferable to a cheap novelty device.
They generally don’t rely on medication, which can be helpful for men who cannot take ED drugs, and are used for men after prostate surgery, sometimes as part of a penile rehabilitation program.
Injections can be an option when pills are ineffective
Penile injections are less scary than they sound, a fine needle is used to inject a medication such as alprostadil into the side of the penis, which can cause an erection without the same neural pathways being used by an oral medication. They can be effective for men after prostate surgery or with severe diabetes.
Some clinicians may utilise compounded medications such as Bimix or Trimix, which are mixed to a patient’s individual requirements, but proper training is required to administer them, and the first dose is often given in a medical setting to avoid complications.
The aim is to reach a suitable dose of medication, without it being excessive and refusing to subside. Pain, bruising, bleeding and fibrosis are potential risks, but priapism – an erection that lasts for longer than four hours – requires emergency treatment.
Alprostadil is also available in pellet form, inserted into the urethra, but it can cause penile burning and is often less reliable than an injection.
Sometimes the right treatment is less pressure
Consider a man who wakes with normal erections and has no problems during masturbation, but loses his erection every time sex becomes “serious”. His circulation may be fine, it is his attention that has been hijacked.
Sex therapy can be useful for performance anxiety, relationship problems, fears around past failures and the impact of depression or trauma on sex drive, without diminishing the very real physiological effects of anxiety. A partner might be invited to some sessions, and often removing the pressure for penetration can allow both people to reconnect and relearn arousal. Medication and therapy can also be used together, there is no prize for treating ED with just one method.
Lifestyle advice is a valuable addition, but it shouldn’t be a lecture
“Stop eating junk food and get off the couch!” may be a good mantra for life, but as a solo presentation on erectile dysfunction, it could be alienating.
Improved cardiovascular fitness does support erections, but results are generally seen over time, not by Saturday night, and medication review may uncover an unexpected contributor to ED. Things like antidepressants, opioids, some blood-pressure or prostate treatments can play a role, without stopping cold turkey or changing doses on your own. In some cases, the dose may be reduced or a different drug prescribed.
Testosterone treatment is ineffective for men with normal hormone levels
Testosterone treatment is pitched as a cure-all for male sexuality, but biology is not so obliging. Men with genuinely low testosterone may see improvements in desire, spontaneous erections, fatigue and muscle mass if their levels are low and consistent with their symptoms, but it would do little for a man with healthy testosterone to address a circulation problem.
It can also suppress sperm production, so it is not generally recommended for men attempting to conceive.
Low sex drive and ED often occur together, but they are not the same problem.
A penile implant is a permanent solution for men with severe ED
For men whose ED has not responded to other treatments, a penile implant can be a reliable source of erections, although it is a surgical procedure. An inflatable implant consists of cylinders placed in the penis and a pump in the scrotum, which the man can use to initiate or end an erection.
Satisfaction can be high, due to the predictable results, but infection, mechanical failure and surgery are all risks, and the erectile tissue is permanently altered, so it is normally considered when other options have been exhausted or refused.
What about shockwaves, PRP, and supplements?
This is where marketers can greatly outshine medical professionals. Low intensity shockwaves may help some men with vascular ED, but studies use different devices and regimens and are not FDA approved specifically for ED in the US.
PRP and stem cell procedures are still investigational, and expensive clinics can promise “rejuvenation” with little back up from research. Over the counter sexual supplements present another issue, as the FDA has found sildenafil and similar drugs masked as male enhancement pills, which can be dangerous if the user is also taking nitrates.
Established erectile dysfunction treatments may not sound as exciting as a miracle honey packet or rejuvenation shot, but they have proven dosages, known risks, and significantly more evidence behind them.
For one man, sildenafil used correctly may be the answer, another man may find daily tadalafil more effective, someone recovering from prostate surgery might require injections or a vacuum device, while a man caught in a cycle of performance anxiety may find therapy most helpful.
The more useful question is, not “what is the strongest ED treatment”, but “what is interfering with this erection, and which treatment actually addresses it”.
