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Trying counselling if a psychological cause is suspected.

Trying medicines that are injected or inserted into the penis.

Erection Problems: Should I Try Injection Treatments?

If you are taking nitrate-containing medicines, such as nitroglycerin, you cannot use sildenafil (for example, Viagra), tadalafil (for example, Cialis), or vardenafil (for example, Levitra). You also should not take certain alpha-blockers—used to lower blood pressure and to treat an enlarged prostate gland —with these medicines.

There is a risk of a dangerous drop in blood pressure. Check with your doctor to see whether you can take PDE-5 inhibitors with your alpha-blocker. Oral medicines are commonly tried first before other medicine or surgery.

It is important to involve your partner in your decision, regardless of the treatment you choose.

Many men overestimate how important being able to have erections is to their relationships. Some men find that when they are able to have erections again, the hassle of using the treatment isn't worth the effort. Other men may find that being able to have erections doesn't change their relationship as much as they or their partners had expected.

You may be able to avoid erection problems related to anxiety and stress by taking a more relaxed approach to sex. Talk to your partner about your problems and concerns.

If you and your partner talk about sex, it will help reduce your stress and anxiety.

Erections may gradually become more difficult to get and keep as you get older. But foreplay—erotic stimulation before intercourse—and the right environment can help increase your ability to have an erection, regardless of your age. Here are some other things you can do that may reduce your risk for erection problems: Quit smoking. Even small amounts of alcohol can cause erection problems.

Keep your cholesterol level low to reduce the risk of hardening of the arteries (atherosclerosis). Keep your blood sugar in your target range if you have diabetes.

In some cases, occasional episodes of erection problems can be treated at home, without a doctor's help.

And don't be embarrassed about seeking professional help if erection problems are consistent and troublesome. You may be able to help yourself by: Some men may try methods available in health food stores or through magazine ads.

Most of these methods have never been medically proved to work.

Making lifestyle changes such as quitting smoking and drinking less alcohol can also help make erection problems less likely.

Medicines that can help produce an erection may be used to treat erection problems that are caused by blood vessel (vascular), hormonal, nervous system, or psychological problems. They also may be used along with counselling to treat erection problems that have psychological causes. Commonly used oral medicines include: PDE-5 inhibitors such as sildenafil (for example, Viagra), tadalafil (for example, Cialis), and vardenafil (for example, Levitra).

Other medicines that may be used include: Injected medicines.

Hormones and other medicines may be prescribed for men who have low testosterone or high prolactin levels.

Erection Problems: Should I Try Injection Treatments? Although oral medicines for erection problems can be purchased over the Internet, you need to talk with your doctor before using this medicine. This is especially important if you have a heart problem. PDE-5 inhibitors should never be used if you may need to take a nitrate-containing medicine, such as nitroglycerin.

Taking nitroglycerin and a PDE-5 inhibitor within 24 hours of each other may greatly lower your blood pressure.

This could lead to a heart attack, stroke , or death.

Talk with your doctor about whether medicines for erection problems are safe for you if you: Have heart disease. If you are taking a PDE-5 inhibitor and are going to have a test for heart disease, make sure that your doctor knows you are taking it.

You should not take sildenafil (for example, Viagra) or vardenafil (for example, Levitra) for 24 hours before the test. Do not take tadalafil (for example, Cialis) for at least 48 hours before the test.

Then if you have a problem during the test, it will be safe to use nitrate-containing medicines such as nitroglycerin. If you are using a combination of drugs for high blood pressure, PDE-5 inhibitors could cause low blood pressure (hypotension).

Also for this reason, you should not take alpha blockers—used to lower blood pressure and to treat an enlarged prostate—with these medicines without talking to your doctor.

The combination could cause a dangerous drop in blood pressure.

If you have a heart condition and have not been sexually active for a while, talk with your doctor to make sure you can engage in sexual activity safely.

In a few cases, surgery may be an option to treat erection problems. Surgery will rarely be recommended before non-surgical treatment and counselling have been tried. Think carefully about non-surgical options and about the possible risks of surgery.

Doctors who specialize in conditions of the urinary tract (urologists) do most penile implants.

Specially trained urologic surgeons usually do blood vessel repair surgery. Vacuum devices are useful for all types of erection problems—physical, psychological, or both.

You pump the device to create a vacuum that leads to an erection.

Counselling (psychotherapy) is recommended for men whose erection problems are caused, at least in part, by psychological factors.

It focuses on ways to improve attitudes toward sex.

Evidence shows that group therapy helps with erection problems in some men. Adding group therapy to treatment with sildenafil (for example, Viagra) helped more than sildenafil alone.

Men who were taking part in group therapy also were more likely to keep taking their medicine. Counselling also may be used with medicine treatment or vacuum devices for erection problems that have psychological and physical causes. Medicines are usually the main treatment for erection problems.

If you don't want to use medicine, or if medicine doesn't work for you, you may want to talk with your doctor about some of the following options. Most of these treatments need more research before doctors can know if they work for sure.

It has been shown to work for some men who have erection problems.

But because it is sold as a dietary supplement, it is hard to know if you are getting the right amount.

Some men take this dietary supplement to try to treat erection problems.

The amino acid increases the amount of nitric oxide in the blood, which relaxes blood vessels. Some men who have low zinc levels in their body have had success using zinc supplements to treat erection problems.

Male Genital Problems and Injuries Reducing Medication Costs Healthy Aging Dealing With Medicine Side Effects and Interactions Premature Ejaculation Tests for Erection Problems Low Testosterone. Psychosocial interventions for erectile dysfunction.

In AJ Wein et al., eds., Campbell-Walsh Urology , 10th ed., vol. American Urological Association (2005, reviewed and confirmed 2011).

Also available online: http://www.auanet.org/content/clinical-practice-guidelines/clinical-guidelines.cfm?sub=ed.

Use of sildenafil (Viagra) in patients with cardiovascular disease.

Effect of lifestyle changes on erectile dysfunction in obese men.

In AJ Wein et al., eds., Campbell-Walsh Urology, 10th ed., vol.

Gregory Thompson, MD - Internal Medicine Brian O'Brien, MD, FRCPC - Internal Medicine Adam Husney, MD -

Family

Often, an organic problem can be complicated by psychological factors. The cause can usually be found by history and examination, but testosterone, luteinising hormone and prolactin should be measured. Non-drug treatments are suitable for some patients, while prostaglandin E1 is the most appropriate drug for intracavernosal injection. Introduction Erectile dysfunction (impotence) is the inability to obtain and sustain an erection adequate for sexual intercourse.

This is a common problem and the prevalence increases with age. It is important to distinguish erectile dysfunction from ejaculatory disorders including premature ejaculation and ejaculatory failure.

Many men are reluctant to seek help from their doctors as evidenced by the proliferation of franchised, entrepreneurial clinics advertising in the popular press.

Basic clinical assessments should be undertaken for all men presenting with erectile dysfunction to identify. – men who have significant underlying medical disease.

– those for whom specific medical therapy may be beneficial.

– those with a psychogenic cause where psychotherapy as part of the medical management may be important. Extensive investigations are not usually justified. History A careful history, including a drug history, will usually differentiate organic from psychogenic impotence.

Drugs that are commonly associated with sexual dysfunction include antihypertensives (including diuretics), cimetidine, major tranquillisers and most antidepressants. Organic impotence generally has a gradual, insidious onset with progressive worsening until no erection is obtained. At first, there may be loss of

rigidity

Nocturnal erections are markedly diminished and this manifests as a loss of erections on waking. Psychogenic impotence is more likely to have an abrupt onset. This is often related to a distinct precipitating event (e.g. a online shopping viagra tablet psychologically traumatic episode of sexual failure). The impotence is often inconsistent, occurring only in certain situations. Nevertheless, organic impotence usually invokes a secondary psychological overlay which may complicate evaluation of the aetiology. This underlines the need for a careful, unhurried approach and empathy during history taking. Androgen deficiency causes more loss of libido than erectile dysfunction. It is unusual for men complaining of impotence to have androgen deficiency as a cause of their sexual dysfunction. This is in contrast to the low sexual activity of androgen-deficient men which often causes them little concern. Physical examination Evidence of possible causative factors (e.g.

diabetes, pituitary disease, lipid disorders, vascular or neuropathic disease, androgen deficiency) should be sought systematically.

Gonadal status (secondary sexual characteristics, testis size) and visual field defects suggesting pituitary tumour should be assessed. Altered peripheral pulses and neurological reflexes in the legs can be evidence of vascular or neurological disorders. Investigation Few investigations of erectile dysfunction lead to specific interventions, so extensive testing cannot be justified in routine practice.

Specific correctable underlying causes such as androgen deficiency or pituitary tumour should be sought, even though they are rare. Their treatment may be gratifying and has implications for general health (e.g.

general energy and well-being, risk of osteoporosis).

Serum prolactin, testosterone and luteinising hormone (LH) should be measured and repeated if any is abnormal. If consistently abnormal, further investigations are required. Although treatment of diabetes or hyperlipidaemia may not improve erectile function, they should not be overlooked. Apart from measurement of penile blood pressure which may exclude or confirm a vasculogenic basis, other complex investigations are not usually justified. Surgically correctable vascular lesions are rarely found and, even then, surgical outcomes are functionally very disappointing. Sleep studies with or without determination of nocturnal penile tumescence are not usually justified clinically.

They add information which usually does not influence management.

Management The success of most commonly-used therapies will depend on co-operation of the partner.

It is important to determine the partner's attitudes to the problem and involve them in discussions of treatment options.

Men who do not have a regular or supportive partner rarely do well with therapies which necessitate treatment at the time of intended intercourse. Psychotherapy A psychological reaction to persistent erectile failure is almost inevitable and universal.

This complicates the identification of primarily psychogenic impotence so it is essential to have an insightful and empathetic manner to manage erectile dysfunction effectively.

Even when erectile dysfunction is primarily organic, appropriate counselling provided by the patient's doctor can be reassuring if adequate time is made available.

Psychogenic impotence can be improved with the help of an experienced psychiatrist or psychologist.

This psychotherapy requires a supportive and understanding partner willing to participate in couple-oriented behavioural sessions.

In some men with psychogenic impotence, a limited trial of empirical intracavernosal therapy may break the self-reinforcing cycle of performance anxiety and failure.

This may restore their confidence in the ability to obtain an adequate erection. Mechanical devices Vacuum erection devices These external devices create a vacuum to induce an erection.

This is then maintained by a thick rubber band placed tightly at the root of the penis.

They have a modest role in the treatment of men in whom intracavernosal injection therapy is contraindicated (e.g.

These devices have modest efficacy and are suitable mainly for men with psychogenic or partial organic impotence.

Their efficacy and acceptability are limited in men with severe neurovascular impotence. Apart from occasional penile bruising, they are generally safe if the duration of each use is limited.

Compared with penile implants or long-term intracavernosal injections, their cost is low.

Implants Surgical penile implants are an expensive last resort when simpler measures (such as psychotherapy, vacuum

devices

As most cavernosal tissue is excised, the procedure is functionally irreversible.

It is justified only for men with complete organic impotence.

Devices vary in complexity from simple semi-rigid rods to fully inflatable with an implanted reservoir.

Satisfaction with the implants is variable, but depends on thorough pre-surgical counselling and close involvement of the partner.

Complications include infection, mechanical failure and erosion.

Hormonal treatment Treatment with testosterone should never be given without clear evidence of androgen deficiency. 1 Once testosterone starts, the endocrine investigations become confusing and it can take many months to clarify the patient's requirement for ongoing therapy.

Furthermore, testosterone therapy has a significant placebo effect in eugonadal men with psychogenic impotence.

Unlike genuine androgen deficiency, such men generally have an inconsistent and poorly maintained response to testosterone treatment.

This further confuses the diagnosis and leads to frustration and disappointment for the patient.