Erectile dysfunction is trouble getting or keeping an erection firm enough for sex. It's common, it becomes more common with age, and it's very treatable. It can also be an early sign of heart or blood vessel disease, so it's worth a proper evaluation.

Common causes

• Blood vessel problems from high blood pressure, high cholesterol, diabetes, or smoking

• Nerve damage from prostate, bladder, or rectal surgery, radiation, diabetes, or spinal problems

• Low testosterone, sleep apnea, and some medications

• Peyronie's disease

• Stress, anxiety, and relationship factors, often on top of a physical cause

How I evaluate it

A history and exam, a short questionnaire (the SHIM), and blood work that usually includes a morning testosterone, blood sugar, and cholesterol. Some men need a penile Doppler ultrasound, done in the office, to look at blood flow.

Treatment

Treatment steps up only as far as you need:

• Pills such as sildenafil or tadalafil, adjusted to dose and timing

• Penile injections (Trimix or alprostadil), which often work when pills don't

• A vacuum device, a drug-free option

• A penile implant, if none of these work for you or you'd rather not use them

Taking ED pills the right way

Pills such as sildenafil and tadalafil help blood flow, but they still need sexual stimulation to work. Many men who think the pills failed were taking them in a way that blunts the effect.

• Sildenafil (Viagra): take it 30 to 60 minutes before sex on an empty stomach or after a light meal. A heavy, fatty meal delays it. It lasts about 4 to 6 hours.

• Tadalafil (Cialis): take it 30 minutes to 2 hours before sex, with or without food. It can last up to 36 hours, and a low daily dose is another option.

• Give it a fair trial: several attempts at the right dose before deciding it doesn’t work. Let me know before giving up, because the dose or timing can often be adjusted.

Precautions

• Never with nitrates: nitroglycerin, isosorbide, or “poppers” can cause a dangerous drop in blood pressure. If you have chest pain after taking a pill, tell the emergency team which pill you took and when.

• Blood pressure and prostate pills: alpha-blockers such as tamsulosin or doxazosin can add to lightheadedness. Tell me what you take so we can time the doses.

• Common side effects: headache, flushing, a stuffy nose, indigestion, and back aches with tadalafil. These usually fade.

• Get care right away for an erection lasting four hours, or sudden loss of vision or hearing.

• Skip online sellers without a prescription. The contents and doses are unreliable.

If pills don’t work well enough or you can’t take them, the next steps are Trimix injections or a penile implant.

Will an implant change sensation or orgasm?

An implant sits inside the erectile chambers and doesn't affect the nerves that carry sensation. Feeling, orgasm, and ejaculation, if you had it before, stay the same. It's fully internal, so nothing is visible from the outside.

Related

Medications and non-surgical care · Trimix injections · Inflatable penile implant · Testosterone results explained

Manufacturer information: Coloplast Men’s Health