Erectile Dysfunction: Evaluation and Treatment

There is no sure cure for ED. However, most cases can be resolved by combining lifestyle adjustments, stress management, counseling and medical treatment.

Step One: Consult a Doctor
Medical conditions contribute to a substantial proportion of ED cases. Start with a check-up. Bring your doctor a list of all the medications you take: over-the-counter, prescription and recreational. Be honest about your use of alcohol and recreational drugs.

• Your doctor should:
• Ask about the problem. When did it start? How? What else was happening in your life? Can you get an erection by masturbation? Do you wake with morning erections?
• Review your medical history. Relevant items include your age, weight, cholesterol level, blood pressure, smoking, drinking, medication use, recent illnesses and any history of depression, anxiety, heart disease, stroke, diabetes, prostate surgery, pelvic injury and hormonal or neurological problems.
• Review your psychological history. Relevant items include any symptoms of anxiety or depression, your satisfaction with your relationship and how the problem has affected your relationship.
• Take your blood pressure and order tests, including cholesterol, testosterone, blood sugar, thyroid and possibly others.

The Ladder of Treatment
Don't simply ask for Viagra. You might not need it. Think of ED treatment as a ladder to be climbed one rung at a time, with Viagra on a high rung. Other approaches may help -- and most of them are good for you anyway.

Healthy Lifestyle

If you smoke, quit. Get regular exercise. Eat a healthy diet. Control your weight. Limit alcohol and recreational stimulants and depressants. Sleep at least seven hours a night.

Manage Stress

Do you have relationship problems? Family trouble? Money woes? Job dissatisfaction? Chronic stress can hit below the belt. Exercise helps manage stress. So does professional counseling.

Reach Out

When faced with ED, many men withdraw into a cocoon of silence. Big mistake. ED treatment is a team effort. Talk to your lover about your situation. If you have relationship or sexual issues, work on them, perhaps with professional help.

Have sex

You don't need an erection to please a woman. Fewer than half of women have orgasms during vaginal intercourse. Most need direct clitoral stimulation, and you don't need an erection for that. Use your fingers, tongue or a sex toy. Sensual lovemaking can help, and your lover probably needs reassurance that you still want to make love with her.

Focus on sensuality

Enjoy mutual whole-body massage. Try sensual enhancements: showering together, music, candlelight, sex toys, a romantic getaway. When your erections return, continue to emphasize sensuality in sex. Your penis needs sensuality for erection.

Try new fantasies

Sex fantasies can get stale. Try some hot new ones.

Ask for the stimulation you need

Erection is automatic for many young men, but with age, direct stimulation becomes more important. If you like your penis caressed in a particular way, say so. Take turns giving and receiving pleasure. When it's your turn to receive, lie back and enjoy it.

Try sex therapy

Sex therapy for ED typically involves:
• Reducing sexual anxieties
• Correcting sexual misinformation
• Managing stress
• Resolving relationship issues
• Helping you both ask for what you want
• Encouraging more sensual lovemaking

Sex therapy may quickly produce dramatic relief from ED. Australian sex therapists worked with thirty-two men suffering moderate to severe ED. After just ten sessions, half regained their erections. To find a sex therapist near you, contact The American Association of Sex Educators, Counselors and Therapists (AASECT) at www.aasect.org, or the Society for the Scientific Study of Sexuality (SSSS), at www.sexscience.org

How Sex Toys Can Help
Sex toys help in general by making sex more playful and sensual. Explore vibrators, massage toys, fantasy toys -- anything that appeals to you. But beyond sensuality, some toys actually help treat or compensate for ED:

• Penis pumps
• Pumps include a plastic tube that fits over the penis and a bulb hand pump. Squeezing the bulb creates suction, drawing blood into the penis and raising a temporary erection. The key to success is a good vacuum from a tube that seals tightly around the base of the penis. If sex-toy pumps don't provide a tight enough seal, a urologist can prescribe a custom pump (vacuum constriction device, or VCD). Most studies of custom VCDs report 70 percent effectiveness. Penis pumps are safe and endorsed by the American Urological Association.
• Once you're erect, you may be able to increase firmness by using an erection ring. This compresses the veins that drain blood from the penis and helps maintain the erection. Some rings are adjustable. Just make sure it's not too tight or it might bruise.
• Extenders
• Extenders are penis-shaped dildos with a hollow base into which an erect or semi-erect penis can be inserted, creating extra size. Extenders are usually used by those who enjoy playing with penis size, but men with erection balkiness may also find them helpful.
• Prosthetic Penis Attachments (PPAs)
• Similar to extenders, PPAs fit over a flaccid penis and attach to the user with straps.
• Strap-ons
• In porn, only women use strap-ons. But men can also enjoy them, particularly men with ED. A strap-on includes a harness worn around the waist that holds a special dildo with a flared base. The dildo's base rests against the wearer's pubic bone or against the front piece, allowing the wearer to enjoy the realism of pushing with hip movements.

Everything You Need to Know About Viagra
Viagra works by relaxing the muscle tissue surrounding the arteries that carry blood into the penis. As this muscle tissue relaxes, the arteries open up and more blood flows into the penis, producing erection.

• Viagra Advantages:
• It works. Most studies show it effective in 75 percent of cases, with greater effectiveness among men with mild or occasional problems.
• It's a pill and very easy to take.
• It works best taken two to four hour before sex, so the woman need not know you're using it.
• It helps men with ED caused by both physical illness and anxiety.
• It only raises erection with sexual stimulation. No walking around with an embarrassing bulge in your pants.
• It's safe for most men. Side effects include: headache (16 percent of users), flushing (10 percent), upset stomach (7 percent) and nasal congestion (4 percent).
• It's affordable. Few health insurers cover it, but the dose most men take, 50 mg, costs about $10. Some men can take half a pill; some need two.

• Viagra Disadvantages:
• It doesn't work in about 25 percent of cases.
• Its effectiveness decreases with more severe cases.
• Even in mild situations, Viagra may not work if you feel particularly stressed.
• Viagra slightly increases risk of heart attack and stroke. At-risk users should consult their doctors first.

IMPORTANT WARNING: Some men should never use Viagra -- those taking nitrate medication for heart disease (notably nitroglycerine for angina) or the party drug amyl nitrate (poppers). If you take nitrate medication, don't take Viagra, as the combination can cause death.

Viagra comes in 50 mg pills. The typical dose is one or two pills, though side effects are more likely with the higher dose. Men with erection dissatisfaction who are interested in "erection insurance" can often take half a pill.

Everything You Need to Know About Levitra (Verdenafil Hydrochl)
Levitra works by assisting with the increase of blood flow to the penis. Similar to Viagra, Levitra works specifically by relaxing the muscle tissue surrounding the arteries that carry blood into the penis. As this muscle tissue relaxes, the arteries open up and more blood flows into the penis, producing erection. It is recommended that this medication should be taken one hour prior to sexual activity but some studies show that this drug can take effect much sooner (see below). Direct sexual stimulation to the penis is necessary to produce an erection. Once a man has completed sexual activity, blood flow to his penis should decrease and his erection should go away.Levitra is a newer drug on the market and thus less data are available in terms of its effectiveness but initial studies are promising for the treatment of ED.

• Levitra Advantages:
• It works. In clinical trials, Levitra provided first time success and reliable improvement in erection quality for many men. Levitra consistently improved rates of penetration, intercourse success, and hardness with sexual experience in a broad population of men with ED.
• It works quickly. According to the results of a new study, some men with erectile dysfunction (ED) can now achieve an erection in as few as 10 minutes with Levitra. These findings were presented at the 7th Congress of the European Federation of Sexology (EFS) in May, 2004. In a separate retrospective analysis of two studies, Levitra was shown to provide a favorable window of opportunity of up to 12 hours. Other research has indicated that it can take up to 20 minutes to take effect.
• Varying dosages offered. Levitra is available in 2.5 mg, 5 mg, 10 mg, and 20 mg tablets to help meet an individual’s needs, so the woman need not know you're using it.
• It works in the long run. Studies show that, compared to placebo, Levitra provides good reliability in terms of first-time success and subsequent success rates for vaginal penetration, successful completion of intercourse, and overall patient satisfaction with the sexual experience. In addition, a separate study found that the efficacy of Levitra was maintained in ED patients over a two-year period.
• It works in difficult cases. Clinically shown to improve erectile function even in men who had other health factors, like diabetes or prostate surgery.
• It's easy on the stomach. Can take with or without food because there are few food interactions.

• Levitra Disadvantages:
• Common side effects: headache (13%), flushing (12%), stuffy or runny nose (9%), indigestion or upset stomach (3%).
• Does not work for everyone.
• Must plan in advance for sexual activity.

IMPORTANT WARNING: LEVITRA can cause your blood pressure to drop suddenly to an unsafe level if it is taken with certain other medicines. With a sudden drop in blood pressure, you could get dizzy, faint, or have a heart attack or stroke.

• Do Not Take Levitra If You:
• Take any medicines called "nitrates."
• Use recreational drugs called "poppers" like amyl nitrate and butyl nitrate.
• Take medicines called alpha-blockers.

Everything You Need to Know About Cialis (Tadalafil)
Working in the same fashion as Viagra and Levitra, Cialis helps increase blood flow in the penis when a man is physically sexually stimulated. Once a man has completed sexual activity, blood flow to his penis should decrease and his erection should go away. Cialis is a newer drug on the market and thus less data are available in terms of its effectiveness but initial studies are promising for the treatment of ED. It is different from Viagra and Levitra mostly because of its ability to be "in effect" for up to 36 hours!

• Cialis Advantages:
• Works for up to 36 hours so you can relax and take your time.
• Varying dosages available (5 mg, 10 mg, and 20 mg).
• Cialis works in as little as 30 minutes after taking the medication.
• No need to plan around meals because there are few food interactions.
• Works effectively, in mild, moderate or severe ED.
• Studies shown to be a good treatment choice for people with Diabetes.

• Cialis Disadvantages:
• Common side effects: headache (11%), flushing (4%) stuffy or runny nose (4%), indigestion or upset stomach (7%).
• Does not work for everyone.
• Must plan in advance for sexual activity.

• IMPORTANT WARNING: You should not take Cialis if you:
• Take any medicines called "nitrates."
• Take medicines called "alpha blockers", other than Flomax® 0.4 mg daily.
• You have been told by your healthcare provider to not have sexual activity because of health problems.
• Are allergic to Cialis or any of its ingredients.

• OTHER TREATMENTS

Yohimbine. For centuries, West African yohimbe tree bark was reputed to boost erection. In the 1980s, studies showed that a chemical in yohimbine increases blood flow into the penis. It's FDA-approved and available in three prescription drugs: Ahprodyne, Yocon and Yohimex. Possible side effects include increased heart rate and blood pressure, fluid retention, nervousness, irritability, headache, dizziness, tremor and flushing.

L-Arginine. L-Arginine is an amino acid and the chemical precursor of nitric oxide, a compound crucial to erection. Some studies show that this nutritional supplement helps treat ED.

Ginkgo. This over-the-counter medicinal herb increases blood flow to the penis. In one study, sixty men with ED were given ginkgo (60 mg/day). After one year, half regained their erections. It's safe for most men; however, ginkgo is an anticoagulant. If you take anticoagulant medication or use other anticoagulants frequently -- aspirin, garlic, ginseng, vitamin E -- you may experience bruising or bleeding problems. Consult your physician.

Ginseng. For centuries, Asians have considered ginseng a sex enhancer, and Korean researchers found that ginseng users experienced significant erection improvement. Ginseng is available over the counter and is safe for most men; however, ginseng is an anticoagulant (see ginkgo warning above).

ArginMax for Men. This over-the-counter supplement contains ginkgo, ginseng and L-arginine. University of Hawaii researchers found it to cause significant improvement with no significant side effects (except increased bruising because of the anticoagulants). ArginMax is available where supplements are sold.

Implants. If other treatments don't help, implants are your last resort. Implants don't interfere with urination, ejaculation or orgasm. But they involve surgery and the risk of surgical complications. Still, some men opt for implants.

Two types are available, flexible rods and hydraulic cylinders. Rods are the simpler option. The surgeon inserts a rod into the penile shaft, giving you a permanent erection. You bend the rod down to make it inconspicuous, and bend it up for sex. Complications are rare. However, the surgery may cause scarring, and a rod can be embarrassing if you wear tight clothing or undress in a locker room.

With hydraulic implants, the penis usually appears flaccid. They consist of nested cylinders inserted into the penile shaft, a reservoir of salt water implanted in the lower abdomen and a squeeze bulb inserted into the scrotum. For sex, you squeeze the bulb and fluid flows from the reservoir into the cylinders, which inflate and extend, producing erection. After ejaculation, you hit a release valve, and the erection subsides as fluid refills the reservoir. Hydraulic implants may malfunction, necessitating corrective surgery.

If you're interested in an implant, consult a urologist.

The Afterglow: What to Expect After Treatment
Couples returning to sex after ED should proceed slowly. If they have not been physically affectionate in a while, they often feel awkward with sex. Don't rush intercourse. Work up to it by having non-sexual fun together for a while. Go out on dates. Flirt with each other. Cuddle. Treat your relationship as new, because in some ways, it is. Even with a restored erection, you can't have good sex without feeling emotionally close and trusting. And if closeness eludes you, consider professional therapy. With time, everything should be in good working order, both physically and emotionally.