Treating Erectile Dysfunction

by J. François Eid, MD

Most men will, at some point in their sexual lives, have difficulty getting it up. But for approximately thirty million men in the United States, erectile dysfunction, or male impotence, is a chronic problem.

Men are often embarrassed by erectile dysfunction, and only one in twenty sufferers seeks treatment, even though there are treatments that can address each of the causes of erectile dysfunction. Below, some of the most effective treatments are described.


In 1998, Viagra was approved by the FDA, becoming a milestone in the field of treatment for erectile dysfunction. It works by increasing blood flow to the penis, as well as causing penile muscles to relax. It does not, however, initiate an erection, and this is a common misperception that has led to widespread disappointment. Viagra works by storing penile blood flow in an already-stimulated penis. So, for Viagra to be effective, one must be able to initiate a partial erection in response to sexual stimulation. In the absence of this partial erection, or without sexual, tactile stimulation, Viagra will not work.

Optimal performance
Viagra works best when taken at a dosage of 100mg, one to one and a half hours before sex on an empty stomach. Studies show that it may take six to eight tries before it works optimally, as it may require time to overcome performance anxiety.

Side effects
Side effects of Viagra include headaches, redness of the face, nasal stuffiness, and heartburn. Three percent of men may experience visual disturbance in the form of an increased sensitivity to light or seeing a bluish tint to everything. All side effects are very mild, well-tolerated, transient, and actually very few patients discontinue use because of them.

Viagra should not be taken by men taking medications that contain nitrates of any form or schedule.

Internal Penile Pump ®

Today, 250,000 men are the secret keepers of what is called the Internal Penile Pump-a manual device surgically implanted in the penis and scrotal sac, used to create erections. The IPP, one example of a penile implant or prosthesis, is a soft saline-filled device that can expand and contract without losing its elasticity. It consists of three small components: very thin tubes, a pump, and a reservoir. The reservoir contains the saline, which is transferred into the penis by a gentle squeeze of the scrotal sac where the pump is housed, causing the tubes in the penis to fill and become rigid.

The IPP has some excellent advantages over oral and injectable medications and its surgical predecessors. First, there are no drug side effects. Second, the entire IPP can be placed through a 2 to 3 centimeter opening in the scrotal skin in under an hour, unlike previous surgeries that required much larger openings and far more painful recoveries. Third, the IPP is entirely invisible in both the flaccid and hard penis. And last, but certainly not least, the IPP does not interfere with normal sensation or ejaculation. And a man is able to have a full erection at any time -- without planning ahead, as is necessary with other treatments.

Good candidates
The Internal Penile Pump is an excellent alternative for men who do not respond to Viagra. For most men, it represents a cure. Excellent candidates are men between the ages of 50 and 90 years old and are sexually motivated and active; men who have had prostate, bladder, or colon cancer treatment, and who have penile deformity and/or atrophy (shrinkage).

Injection treatments
Prior to the FDA approval of Viagra, injection therapy was the most effective medical treatment available. Injection therapy works by injecting a medication through a very small hypodermic needle at the base of the penis, five minutes before intercourse. The medication injected dilates the blood vessels to produce an erection.

Prostaglandin E-1 (Alprostadil) (Caverject or Edex) has been the drug used for injections since 1995. Alprostadil is a naturally occurring substance in the penile tissue. It can be self-injected safely at home with few side effects. This is currently the only FDA approved medication for penile injection.

In addition to prostaglandin E-1, off-label use of a combination medication called Trimix (which contains Papaverine, Phentolamine, and Alprostadil) is very successful and safe, and is currently the preferred penile injection method.

Side effects
A dull penile ache is experienced by 40 percent of patients using prostaglandin E-1. This is transient and well-tolerated in the majority of patients.

Tests show that scarring from prostaglandin E-1 injections is minimal (occurring in only 5 percent of cases) and the satisfaction rate is high. The instance of long-term use, however, is poor; more than 50 percent of men stop using the injection method after two months and less than 30 percent use this technique for more than two years.

External Penile Pumps

This vacuum device doesn't involve medications or surgery. A tube is placed over the end of the penis and the device is activated, creating a vacuum that encourages blood to flow into the penis to create an erection. A rubber ring is then snapped over the base of the penis to help maintain the erection, and a semi-hard erection is obtained.

While the initial success rate is high with vacuum devices, less than one-third of the men who buy them end up using the vacuum pump long-term. Many of the men who no longer use the external penile pumps say that they are too cumbersome and the erection that results can be somewhat painful and not quite normal. This is definitely not the preferred treatment option for couples who enjoy spontaneous, normal, and frequent sexual activity.

Psychological Treatment

If the dysfunction has a psychological cause, then you will be referred to a certified sex therapist. If the problem turns out to be an issue of communication with your partner, a therapist could help you resolve it.

When the dysfunction involves more deeply ingrained issues-for example, inhibition or performance anxiety related to upbringing, religion, and social background-it tends to be more difficult and time consuming to treat.

The bottom line is that ED is debilitating for most men, and I believe that for many couples, a supportive partner is the most important factor in regaining a full, healthy sex life.

Dr. Francois Eid is the Director of Advanced Urological Care, and Clinical Associate Professor of Urology at Weill/Cornell Medical College in New York City.

Copyright © Francois Eid. Permission to republish granted to, LLC.