Now that we have examined the basics of the physiology of male sexual activity, and have examined the various causes of erectile dysfunction, what are the most successful treatments for erectile dysfunction?  As with any physiologic problem, the first step to proper treatment is proper diagnosis. Of the causes of ED outlined in the second article, which ones may be contributing to the problem? Is it a simple case of a single cause, or are multiple factors at work?

When I am discussing erectile dysfunction with a patient, one of the first questions I usually ask is, “Do you ever have erections?” or “Do you have morning erections?”  If a man does get a good erection at least occasionally, then the chances of a serious neurologic or vascular cause is greatly decreased, and the problem is likely at least partly psychological.  If he can never get an erection, then it is much more likely that he does have a significant neurologic or vascular cause. Other important parts of the history are a personal or family history of other arterial disease (such as heart attack or stroke), a history of trauma to the groin or pelvis, a history of drug or alcohol use (including tobacco), and a list of medications.  

Once the likely causes of ED are determined, then we can seriously start to consider treatment.  The first thing to consider, as is the case for most medical issues, is lifestyle adjustment. If the patient is obese or sedentary then even moderate weight loss combined with an exercise program can help a great deal.  If he has strong risk factors for arterial disease, such as smoking, obesity, diabetes, or a family history of stroke or heart attack, then treatment of arterial disease, such as control of blood pressure and cholesterol, can help in the long term.  If there are medications contributing to the problem then it is worth considering if some of them could be changed. For example, beta-blockers are a type of blood pressure medicine which often causes problems and this might could be changed to a less problematic medication.  And, of course, alcohol use must be considered and either eliminated or restricted if it seems to be contributing to the problem.

If the dysfunction is at least in part psychological, then this should also be addressed.  Are the episodes of ED occurring only in certain situations? What might be causing him to be particularly tense or on guard in these situations?  Can this be changed? It is also important to consider any relationship issues with the man and his sexual partner (or partners, in the lifestyle!)  

We can then also consider the use of medications to assist in performance.  We are fortunate in the modern world to have the PDE-5 inhibitors such as sildenafil (Viagra) and tadalafil (Cialis).  To be honest, these medicines usually help no matter the underlying problem causing dysfunction. They work to amplify the signal from the brain through hormones in the bloodstream to cause the vascular changes leading to erections.  This means, importantly, that one does not have an erection the entire time that the medication is active, but only when he gets the appropriate stimulation.

I must admit that although the extensive history I discussed above would be best, in reality when men ask me about ED I usually just ask a few quick questions to make sure nothing more serious is going on, and then offer them a prescription for one of these medications with instructions that if it doesn’t help then they need to return for a more thorough workup.  While there are several others on the market, I primarily prescribe either Viagra or Cialis. The primary difference is in the length of action: Viagra lasts from about 30 minutes until 4 hours after taking the pill; Cialis lasts from 30 minutes until 72 hours. So Viagra must be taken just before sex, whereas one can take Cialis in anticipation of (for example) a romantic weekend.  There is also a daily version of Cialis which uses a lower dose, although this is more often used for prostate problems.

In my practice and personal life I generally prefer Cialis, as it requires less attention to timing.  Also, until recently the pills were similarly priced, so Cialis gave you more (ahem) bang for your buck.  However generic sildenafil is now available and is sometimes much cheaper. Tadalafil will hopefully be available as a generic later this year.

There are relatively few problems with these medications; the primary one is that the vasodilation they cause can be dangerous for people with certain kinds of heart disease.  They also interact with other vasodilators, but these are generally only given to patients with heart disease as well. Discuss it with your doctor if you are concerned about this.

Since we are discussing medications, I do want to touch on the use of testosterone.  As I alluded to in my second article, the treatment of “low T” is often touted as the cure for all kinds of problems including erectile dysfunction.  I have almost never found this to be the case in my practice; when people get benefit from testosterone replacement (only about 30%) it helps with overall energy, not specifically libido or ED.  If your testosterone is low and you want to try replacement then discuss it with your doctor, but don’t believe the hype.

I sincerely hope that these articles have been helpful for you.  If you have any questions, please post them in the discussion below!


Happy erections,

Dr. C