Erections are initiated and maintained via integration of afferent inputs in the supra sacral regions of the central nervous system. Regions of the brain cited to have key roles in the integration of signals include the medial amygdala, MPOA, periaqueductal gray matter, paraventricular nucleus (PVN), and ventral tegmentum among others (16). Studies in animal models, particularly in rats, have been paramount in identifying these key areas of signal integration and control. Electrostimulation of the MPOA, PVN and hippocampus lead to erection and lesions in these areas may prevent erection (17). Marson et al. injected labeled pseudorabies virus into rat corpora cavernosa and traced them to neurons in the spinal cord, brain stem and hypothalamus (18). Stimulation of the rat dorsal nerve led to increased firing in the MPOA not found elsewhere (19). Axonal tracing in animals have shows direct projections from the hypothalamus to the lumbosacral autonomic erection centers. Oxytocin and vasopressin have been identified as central neurotransmitters within the hypothalamic nuclei and may have a role in penile erection (17). These signaling studies identifying key areas of erectile response integration may explain how ED is associated with cerebrovascular accident (CVA), Parkinson’s, epilepsy and MS.
Impotence is a common problem among men and is characterized by the consistent inability to sustain an erection sufficient for sexual intercourse or the inability to achieve ejaculation, or both. Erectile dysfunction can vary. It can involve a total inability to achieve an erection or ejaculation, an inconsistent ability to do so, or a tendency to sustain only very brief erections.

ICI Alprostadil may be used as a mixture with two other drugs to treat ED. This combination therapy called "bimix or trimix" is stronger than alprostadil alone and has become standard treatment for ED. Only the Alprostadil ingredient is FDA approved for ED. The amount of each drug used can be changed based on the severity of your ED, by an experienced health professional. You will be trained by your health professional on how to inject, how much to inject and how to safely raise the drug's dosage if necessary.
Achieving an erection is a complicated process, requiring transmission of sensations from the genital area to the nervous system and the return of nervous impulses to the muscles and blood vessels of the penis. Anything that interferes with this interchange, such as disease or injury of the blood vessels, muscles, or nerves, can make achieving and maintaining an erection difficult. Psychological factors, such as anxiety and depression, can also interfere with erectile function. Anxiety and depression may also develop as a consequence of impotence.
Certain feelings can interfere with normal sexual function, including feeling nervous about or self-conscious about sex, feeling stressed either at home or at work, or feeling troubled in your current sexual relationship. In these cases, treatment incorporating psychological counseling with you and your sexual partner may be successful. One episode of failure, regardless of cause, may propagate further psychological distress, leading to further erectile failure.
Some men should not take PDE5 inhibitors. They can cause hypotension (abnormally low blood pressure that can lead to fainting and even shock) when given to patients who are taking nitrates (medications taken for heart disease). Therefore, patients taking nitrates daily should not take any of the PDE5 inhibitors. Nitrates relieve angina (chest pain due to insufficient blood supply to the heart muscle because of narrowing of the coronary arteries); these include nitroglycerine tablets, patches, ointments, sprays, and pastes, as well as isosorbide dinitrate and isosorbide mononitrate. Other nitrates such as amyl nitrate and butyl nitrate also are in some recreational drugs called "poppers."
Impotence, also known as erectile dysfunction or ED, is a very common problem, affecting up to half of 40-70 year old men in Australia.Treatment techniques for impotence have varied through the years, from external steel mechanical attachments, to static electricity attached to the penis and testicles, to simple aphrodisiacs such as oysters. Until as recently as 1970, erectile failure was almost always seen as being due to psychological causes and was usually treated with psychotherapy.Since then, the medical causes contributing to impotence have been recognised and the treatment of impotence has been revolutionised, providing a range of options which are far more acceptable and very much more successful.Treatment options for impotenceTreatment choices for erectile dysfunction include:medicines;self-injection therapy;devices such as vacuum pumps;penile implant surgery;hormone therapy; andcounselling.If you have erectile dysfunction, the treatment your doctor recommends will depend on the severity of symptoms and the underlying cause of your impotence.Your doctor will want to check that any conditions that could be contributing to or causing erectile dysfunction are being treated.Your doctor may also suggest that you make some lifestyle adjustments, such as:increasing the amount of physical activity you get;losing weight if you are overweight;reducing the amount of alcohol you drink;quitting smoking; andnot taking illicit drugs.These lifestyle recommendations can help improve impotence related to several causes and improve your health in general.Medicines for erectile dysfunctionThe first tablet available for erectile dysfunction, sildenafil (brand name Viagra), has been largely responsible for helping to bring the topic of erectile dysfunction out into the open. Similar medications — tadalafil (Cialis) and vardenafil ( Levitra) — are also available. These medicines all work in a similar way, although there is some difference in how long their effect lasts. Sildenafil, tadalafil and vardenafil belong to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors because they block the PDE5 enzyme.How do oral medicines help treat erectile dysfunction?PDE5 inhibitors help in the process of getting and keeping an erection by working on chemicals in the body that are involved in erections. These medicines work by stopping PDE5 from breaking down an erection-producing chemical called cyclic guanosine monophosphate (cGMP). cGMP helps to relax the smooth muscle cells in the penis's erectile tissue, allowing more blood to flow into the penis to cause an erection. When PDE5 is temporarily blocked by these medicines, it can’t break down the erection producing cGMP, so an erection can be achieved and maintained. PDE5 inhibitors can be used in the treatment of erectile dysfunction that is due to physical or psychological causes.Medications such as Viagra, Cialis and Levitra will work only if you are sexually stimulated. They are not aphrodisiacs and won’t increase your sex drive.Side effects of PDE5 inhibitorsSide effects of these medicines can include headaches, flushes, blocked nose, indigestion and dizziness.In rare situations, sildenafil and vardenafil can cause a distortion of vision or change in colour vision.Tadalafil has been associated with back pain.Who can take medicines for impotence?PDE5 inhibitors cannot be taken by all men, so your doctor will need to evaluate your suitability before prescribing either of these medications.Men taking nitrates (often used to treat angina) should never take phosphodiesterase type 5 (PDE5) inhibitors. PDE5 inhibitors should also not be taken with some medicines used to treat high blood pressure.PDE5 inhibitors may also not be suitable for men with certain heart conditions or low blood pressure. Check with your doctor to find out if this type of medication may be suitable for you.Self-injection therapySelf-injection therapy delivers a medicine called alprostadil (brand name Caverject), also known as prostaglandin E-1, to the erectile tissue of the penis. Prostaglandin E-1 occurs naturally in the body and helps increase the blood flow to the penis to cause an erection. Unlike the PDE5 inhibitors, alprostadil will cause an erection whether the penis is stimulated or not.Self-injection therapy is usually recommended if PDE5 inhibitor medicines are not suitable or have not been effective in the treatment of erectile dysfunction.How to use self-injection therapyAlprostadil is injected into either of the 2 cigar-shaped chambers of the penis known as the corpora cavernosa, which run along the length of the penis, one on either side. Your doctor or urologist (specialist in problems with male reproductive organs and the urinary tract) will give you instructions on how to do this.Alprostadil should produce an erection in 5 to 20 minutes and, generally, the erection will last for 30 to 60 minutes.You should not use alprostadil more than once in a 24-hour period, and you should use it no more than 3 times a week.Don’t try to use more than the recommended dose of alprostadil, as your erection may last longer than is medically safe.Who can use self-injection therapy?You should ask your doctor if alprostadil is suitable for you. Your doctor will also be able to tell you how much alprostadil to use, depending on your condition and whether or not you are taking any other medications, and also how to use alprostadil properly.People with certain illnesses, such as leukaemia and sickle cell anaemia, or who have a penile implant or Peyronie’s disease, where the penis may be scarred and produces erections that are not straight, should not use alprostadil.Men for whom sexual activity is not advised should not use alprostadil.Side effects of injection therapyThe most common side effects of alprostadil include pain in the penis or bruising in the penis at the site of injection. Fibrosis (the development of fibrous tissue) can also develop following injections into the penis.The most serious side effect is priapism (a persistent erection), which is a medical emergency. Your doctor will inform you of what to do if you have an erection that persists for 2 hours or more. It is very important that you follow your doctor’s instructions and inform them that you have experienced this side effect.Vacuum erection devicesVacuum erection devices work by creating a vacuum, which increases blood flow to the penis, producing an erection.The penis is lubricated and placed inside a hollow plastic chamber. Air is pumped out of the chamber, either manually or by a battery powered pump. This creates a vacuum which pulls blood into the penis to cause an erection. This takes about 5 minutes.Once the penis is erect, the man fits a rubber ring around the base of his penis to keep the blood trapped inside the penis when the cylinder is removed. After intercourse, the ring can be removed to return the penis to a limp state.Vacuum erection devices avoid surgery and can be used as often as required. However, they may be difficult to use, and many men and their partners feel they take much of the pleasure and spontaneity away from sexual activities. Vacuum pumps are not suitable for men who have problems with blood clotting, or blood disorders such as leukaemia.Penile implant surgery for impotencePenile implant surgery is not a common procedure but in some cases it may be the most appropriate treatment for erectile dysfunction.The procedure involves placing an implant inside the penis, along its length, so that it can become erect. The implant may be a pair of semi-rigid rods or a pair of inflatable cylinders.The inflatable implants allow the penis to look and feel limp (flaccid) or erect, depending on how much the cylinders are inflated. The cylinders in an inflatable implant are hollow, and the man gets an erection by squeezing a pump located in his scrotum to fill the cylinders with salt water (saline) stored in a reservoir implanted in his lower abdomen. A release valve drains the saline out of the cylinders and back into the reservoir.With the semi-rigid, malleable rod type of implant, the rods run along the length of the penis and can be bent upwards to produce an erect penis, or downwards when an erect penis is not required.Like all surgery, there are some risks, such as infection or bleeding. If you have had surgery and have severe pain, fever, swelling or excessive bleeding, you should contact your doctor as soon as possible.Vascular surgery for erectile dysfunctionIn cases where a man’s anatomy prevents blood flow into or out of the penis, vascular surgery may be an option. This treatment option is rarely recommended, and is usually only successful in younger men.If there is a blockage that prevents blood from flowing into the penis, a doctor may recommend an operation that bypasses the blocked blood vessels, using a length of vein or manufactured tubing, to allow more blood to flow into the penis and help produce an erection.If the problem is that blood leaks back out of the penis, this can be corrected by tying off the major veins that drain the penis, a procedure known as venous ligation.Hormone treatments for impotenceIn a small number of men, blood tests may show abnormally low levels of testosterone, the male sex hormone. In such cases your doctor might prescribe a course of testosterone injections or a testosterone implant. The supplements can help boost sex drive as well as increasing the ability to have erections. Testosterone gel or patches, applied daily to the skin, are another option.Complementary medicines for erectile dysfunctionThere is a lack of scientific evidence supporting the effectiveness of complementary therapies for the treatment of impotence.Always check with your doctor before taking any herbal medicines or supplements for impotence. These formulations may contain ingredients that can interact with other medicines or cause dangerous side effects.Counselling for men with impotenceErectile dysfunction often has physical causes, but sometimes there is a psychological basis for erection problems. Often this is a form of performance anxiety. A man may have had an episode of erectile dysfunction due to some passing cause like fatigue, stress, relationship difficulty or intoxication. This may have led to embarrassment or a feeling of failure. Even if the physical cause does not remain, future attempts to have sex may trigger memories of this embarrassment and acute anxiety that it will happen again. This anxiety itself is capable of causing erectile dysfunction, and so a man may get trapped in a self-reinforcing cycle of anxiety and erectile dysfunction. In these instances, seeing a GP, counsellor or psychologist can be very helpful.Stress, anxiety, depression and low self-esteem, in fact, almost all significant emotional problems, can have a major effect on sexuality. So do many chronic physical illnesses, even if they don't directly affect genital function. Counsellors and psychologists can assist with these and a wide range of other sexual and relationship problems and can also help female partners suffering from sexual problems. They are particularly skilled in helping patients to overcome guilt or anxiety relating to sexual abuse, and in helping couples to sort out relationship difficulties. Simple problems can be dealt with in a few visits, but more complex problems may require several months or even years of therapy.Your doctor may be able to recommend a psychologist or counsellor who specialises in sexual and relationship problems. Last Reviewed: 12 December 2016
Several medications can interfere with the chemical processing of PDE5i medications by the liver. These can include ketoconazole (an antifungal medication known by the brand name Nizoral), erythromycin (an antibiotic), and cimetidine (also known as Tagamet, for reducing stomach acid). A lower dose of PDE5i medications should be used if one is taking any of these medications.
Suppositories “were developed so men wouldn’t have to use needles,” Bivalacqua says. They contain the drug alprostadil (also known as prostaglandin E1) and are sold under the brand name Muse. If they are going to work, it takes about five to 10 minutes. However, Muse produces erections in only 30 to 40 percent of patients, usually those with mild ED, because some of the drug is absorbed systemically and diverted from its function of opening penile arteries to allow more blood to flow in. The out-of-pocket cost is around $20 to $30 per suppository.
Somatomotor penile innervation originates in Onuf’s nucleus in the S2-4 spinal segments. These nerves travel to the ischiocavernosus and bulbocavernosus muscles when activated lead to contraction necessary for the rigid-erection phase. Several animal studies show that stimulation of the somatomotor pathways may also be under sympathetic control, and adrenergic stimulation may lead to contraction of these muscles during ejaculation (13,14). Somatomotor spinal reflexes may also be initiated by genital stimulation. For instance, the well-known bulbocavernosus reflex is evidence this reflex exists; however the clinical significance of its absence in the neurological assessment of ED has not been substantiated (15).
An analysis of 14 studies involving more than 90,000 patients with ED confirmed the relation between ED and an increased risk of cardiovascular events and mortality. [56] Compared with patients without ED, those with ED had a 44% increased risk of cardiovascular events, a 25% increased risk of all-cause mortality, a 62% increased risk of MI, and a 39% increased risk of cerebrovascular events. Treatment of ED, either through lifestyle interventions or by pharmacologic means, may improve prognosis and reduce risk.
Total testosterone levels: Health care professionals should obtain a patient's blood samples for total testosterone levels in the early morning (before 8 a.m.) because the testosterone levels go up and down throughout the day. If you have a low testosterone level, a health care professional should check it again to confirm that it is truly low. In some men, a specialized test measuring the active form of testosterone (free or bioavailable testosterone) may be recommended.

SD in MS can be classified into three categories. Primary SD is due directly due to MS-related neurological deficits, secondary SD is related to physical impairments and symptoms or drugs used for MS treatment, and tertiary SD is due to the psychological, social and cultural problems attributed to MS (38). These classifications are important, and underscore the importance of addressing all the issues leading to SD not just the neurologic impairment.
There have been rare reports of priapism (prolonged and painful erections lasting six or more hours) with the use of PDE5 inhibitors. Patients with blood cell diseases such as sickle cell anemia, leukemia, and multiple myeloma have higher than normal risks of developing priapism. Untreated priapism can cause injury to the penis and lead to permanent impotence. Therefore, if your erection lasts four hours, you should seek emergency care.

As is true in so many medical conditions, lifestyle modifications, considered first-line therapy, can have a salutary effect in ED management, and men should be encouraged to make the necessary changes to the benefit of their sexual function and to their overall health as well. Despite the benefits of behaviour modification, men presenting with ED want the physician to help with measures that can have an immediate impact.

Penile prostheses are very effective, and most patients who have a prosthesis placed are satisfied with the prosthesis. However, placement of a prosthesis causes scarring of the tissue within the corpora cavernosa, and if the prosthesis requires removal, other forms of therapy, except for the vacuum device, are often not effective. Thus, most physicians reserve placement of a prosthesis for men who have tried and failed or have contraindications to other therapies.


Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, Association of Women Surgeons, New York Academy of Sciences, Society of Government Service Urologists, Society of University Urologists, Society of Urology Chairpersons and Program Directors, and Society of Women in Urology
Once implanted, the pumps become “part of their body,” Montague explains. “No out-of-pocket cost per use. Predictable response. Works every time.” Pills, even when they work, might be less effective if you’ve had more than a couple drinks or are out of sorts for other reasons. Injections are slightly more reliable than pills but, Montague says, are still subject to variability.
ED may occur with or without other sexual dysfunction, including decreased libido (decreased interest in sexual activity), orgasmic dysfunction (troubles achieving an orgasm/climax), and ejaculatory dysfunction (problems with the fluid released during sex, including lack of ejaculation [anejaculation], small volume ejaculate, ejaculation that occurs too quickly [premature ejaculation], ejaculate that goes backward into the bladder [retrograde ejaculation] and pain with ejaculation).
Centrally active compounds such as apomorphine have been used in men with ED whose cardiovascular comorbidity may prohibit PDE5i use, or in men who have concurrent apomorphine use for its anti-parkinsonian properties. Unfortunately, its side effect profile and poor effectiveness compared to other ED treatments have impaired its mainstream utilization (118). It is suspected that the side effects of apomorphine relate to its D2 receptor affinity. D4 receptor agonists, such as ABT-724 and azulenylmethylpiperazines, may not have the same associated side effects and show potent pro-erectile effects in animal models compared to apomorphine (32,119).
The truth is medication or psychosexual counselling are the first treatments a doctor will suggest because they’ve been proven to work. If a doctor has approved a medication for you then it’s safe. If you would still like to see if herbal supplements work for you, then there is a list below of supplements thought to work for erectile dysfunction. Just before you invest your money in them, remember they aren’t proven to work:
Individuals at higher risk for priapism (painful erection lasting longer than six hours), including men with sickle cell anemia, thrombocytopenia (low platelet count), polycythemia (increased red blood cell count), multiple myeloma (a cancer of the white blood cells), and history of blood clots (for example, deep venous thrombosis [DVT]) or hyperviscosity (thick blood) syndrome are at increased risk for priapism with MUSE.
Alprostadil injections, which produce an erection in five to 20 minutes that lasts for about an hour. Patients use a fine needle to inject alprostadil (commonly known by the brand names Caverject Impulse and Edex) into the base or side of the penis. Side effects can include bleeding or fibrous tissue formation at the injection site as well as prolonged erection, according to the Mayo Clinic.
A physical cause can be identified in about 80% of cases.[2] These include cardiovascular disease, diabetes mellitus, neurological problems such as following prostatectomy, hypogonadism, and drug side effects. Psychological impotence is where erection or penetration fails due to thoughts or feelings; this is somewhat less frequent, in the order of about 10% of cases.[2] In psychological impotence, there is a strong response to placebo treatment.

As is true in so many medical conditions, lifestyle modifications, considered first-line therapy, can have a salutary effect in ED management, and men should be encouraged to make the necessary changes to the benefit of their sexual function and to their overall health as well. Despite the benefits of behaviour modification, men presenting with ED want the physician to help with measures that can have an immediate impact.
If you have symptoms of ED, it’s important to check with your doctor before trying any treatments on your own. This is because ED can be a sign of other health problems. For instance, heart disease or high cholesterol could cause ED symptoms. With a diagnosis, your doctor could recommend a number of steps that would likely improve both your heart health and your ED. These steps include lowering your cholesterol, reducing your weight, or taking medications to unclog your blood vessels.
Treatment depends on the underlying cause. In general, exercise, particularly of the aerobic type, is effective for preventing ED during midlife. Exercise as a treatment is under investigation.[22]:6, 18–19 For tobacco smokers, cessation often results in a significant improvement.[23] Oral pharmacotherapy and vacuum erection devices are first-line treatments,[22]:20, 24 followed by injections of drugs into the penis, as well as penile implants.[22]:25–26 Vascular reconstructive surgeries are beneficial in certain groups.[24]
The sympathetic pathway originates from the 11th thoracic to the 2nd lumbar spinal segments and goes via the white rami to enter the sympathetic chain ganglia. Subsequently nerves travel through the lumbar splanchnic to inferior mesenteric and superior hypogastric nerves to the pelvic plexus. The T10 through T12 segments are most often the origin of sympathetic fibers, and the sympathetic chain ganglia that innervate the penis are located in the sacral and caudal ganglia (3).

Physicians make a diagnosis of erectile dysfunction in men who complain of troubles having a hard enough erection or a hard erection that does not last long enough. It is important as you talk with your doctor that you be candid in terms of when your troubles started, how bothersome your erectile dysfunction is, how severe it is, and discuss all your medical conditions along with all prescribed and nonprescribed medications that you are taking. Your doctor will ask several questions to determine if your symptoms are suggestive of erectile dysfunction and to assess its severity and possible causes. Your doctor will try to get information to answer the following questions:
Aging, liver and kidney problems, and concurrent use of certain medications (such as erythromycin [an antibiotic] and protease inhibitors for HIV) slows the metabolism (breakdown) of sildenafil. Slowed breakdown allows sildenafil to accumulate in the body and potentially may increase the risk of side effects. Therefore, in men over 65 years of age, in men with significant kidney and liver disease, and in men who also are taking medications called protease inhibitors, the doctor will initiate sildenafil at a lower dose (25 mg) to avoid accumulation of sildenafil in the body. A protease inhibitor ritonavir (Norvir) is especially potent in increasing the accumulation of sildenafil, thus men who are taking Norvir should not take sildenafil doses higher than 25 mg and at a frequency of no greater than once in 48 hours. Other medications that may affect the level of sildenafil include erythromycin and ketoconazole.
Impotence, also known as erectile dysfunction or ED, is a very common problem, affecting up to half of 40-70 year old men in Australia.Treatment techniques for impotence have varied through the years, from external steel mechanical attachments, to static electricity attached to the penis and testicles, to simple aphrodisiacs such as oysters. Until as recently as 1970, erectile failure was almost always seen as being due to psychological causes and was usually treated with psychotherapy.Since then, the medical causes contributing to impotence have been recognised and the treatment of impotence has been revolutionised, providing a range of options which are far more acceptable and very much more successful.Treatment options for impotenceTreatment choices for erectile dysfunction include:medicines;self-injection therapy;devices such as vacuum pumps;penile implant surgery;hormone therapy; andcounselling.If you have erectile dysfunction, the treatment your doctor recommends will depend on the severity of symptoms and the underlying cause of your impotence.Your doctor will want to check that any conditions that could be contributing to or causing erectile dysfunction are being treated.Your doctor may also suggest that you make some lifestyle adjustments, such as:increasing the amount of physical activity you get;losing weight if you are overweight;reducing the amount of alcohol you drink;quitting smoking; andnot taking illicit drugs.These lifestyle recommendations can help improve impotence related to several causes and improve your health in general.Medicines for erectile dysfunctionThe first tablet available for erectile dysfunction, sildenafil (brand name Viagra), has been largely responsible for helping to bring the topic of erectile dysfunction out into the open. Similar medications — tadalafil (Cialis) and vardenafil ( Levitra) — are also available. These medicines all work in a similar way, although there is some difference in how long their effect lasts. Sildenafil, tadalafil and vardenafil belong to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors because they block the PDE5 enzyme.How do oral medicines help treat erectile dysfunction?PDE5 inhibitors help in the process of getting and keeping an erection by working on chemicals in the body that are involved in erections. These medicines work by stopping PDE5 from breaking down an erection-producing chemical called cyclic guanosine monophosphate (cGMP). cGMP helps to relax the smooth muscle cells in the penis's erectile tissue, allowing more blood to flow into the penis to cause an erection. When PDE5 is temporarily blocked by these medicines, it can’t break down the erection producing cGMP, so an erection can be achieved and maintained. PDE5 inhibitors can be used in the treatment of erectile dysfunction that is due to physical or psychological causes.Medications such as Viagra, Cialis and Levitra will work only if you are sexually stimulated. They are not aphrodisiacs and won’t increase your sex drive.Side effects of PDE5 inhibitorsSide effects of these medicines can include headaches, flushes, blocked nose, indigestion and dizziness.In rare situations, sildenafil and vardenafil can cause a distortion of vision or change in colour vision.Tadalafil has been associated with back pain.Who can take medicines for impotence?PDE5 inhibitors cannot be taken by all men, so your doctor will need to evaluate your suitability before prescribing either of these medications.Men taking nitrates (often used to treat angina) should never take phosphodiesterase type 5 (PDE5) inhibitors. PDE5 inhibitors should also not be taken with some medicines used to treat high blood pressure.PDE5 inhibitors may also not be suitable for men with certain heart conditions or low blood pressure. Check with your doctor to find out if this type of medication may be suitable for you.Self-injection therapySelf-injection therapy delivers a medicine called alprostadil (brand name Caverject), also known as prostaglandin E-1, to the erectile tissue of the penis. Prostaglandin E-1 occurs naturally in the body and helps increase the blood flow to the penis to cause an erection. Unlike the PDE5 inhibitors, alprostadil will cause an erection whether the penis is stimulated or not.Self-injection therapy is usually recommended if PDE5 inhibitor medicines are not suitable or have not been effective in the treatment of erectile dysfunction.How to use self-injection therapyAlprostadil is injected into either of the 2 cigar-shaped chambers of the penis known as the corpora cavernosa, which run along the length of the penis, one on either side. Your doctor or urologist (specialist in problems with male reproductive organs and the urinary tract) will give you instructions on how to do this.Alprostadil should produce an erection in 5 to 20 minutes and, generally, the erection will last for 30 to 60 minutes.You should not use alprostadil more than once in a 24-hour period, and you should use it no more than 3 times a week.Don’t try to use more than the recommended dose of alprostadil, as your erection may last longer than is medically safe.Who can use self-injection therapy?You should ask your doctor if alprostadil is suitable for you. Your doctor will also be able to tell you how much alprostadil to use, depending on your condition and whether or not you are taking any other medications, and also how to use alprostadil properly.People with certain illnesses, such as leukaemia and sickle cell anaemia, or who have a penile implant or Peyronie’s disease, where the penis may be scarred and produces erections that are not straight, should not use alprostadil.Men for whom sexual activity is not advised should not use alprostadil.Side effects of injection therapyThe most common side effects of alprostadil include pain in the penis or bruising in the penis at the site of injection. Fibrosis (the development of fibrous tissue) can also develop following injections into the penis.The most serious side effect is priapism (a persistent erection), which is a medical emergency. Your doctor will inform you of what to do if you have an erection that persists for 2 hours or more. It is very important that you follow your doctor’s instructions and inform them that you have experienced this side effect.Vacuum erection devicesVacuum erection devices work by creating a vacuum, which increases blood flow to the penis, producing an erection.The penis is lubricated and placed inside a hollow plastic chamber. Air is pumped out of the chamber, either manually or by a battery powered pump. This creates a vacuum which pulls blood into the penis to cause an erection. This takes about 5 minutes.Once the penis is erect, the man fits a rubber ring around the base of his penis to keep the blood trapped inside the penis when the cylinder is removed. After intercourse, the ring can be removed to return the penis to a limp state.Vacuum erection devices avoid surgery and can be used as often as required. However, they may be difficult to use, and many men and their partners feel they take much of the pleasure and spontaneity away from sexual activities. Vacuum pumps are not suitable for men who have problems with blood clotting, or blood disorders such as leukaemia.Penile implant surgery for impotencePenile implant surgery is not a common procedure but in some cases it may be the most appropriate treatment for erectile dysfunction.The procedure involves placing an implant inside the penis, along its length, so that it can become erect. The implant may be a pair of semi-rigid rods or a pair of inflatable cylinders.The inflatable implants allow the penis to look and feel limp (flaccid) or erect, depending on how much the cylinders are inflated. The cylinders in an inflatable implant are hollow, and the man gets an erection by squeezing a pump located in his scrotum to fill the cylinders with salt water (saline) stored in a reservoir implanted in his lower abdomen. A release valve drains the saline out of the cylinders and back into the reservoir.With the semi-rigid, malleable rod type of implant, the rods run along the length of the penis and can be bent upwards to produce an erect penis, or downwards when an erect penis is not required.Like all surgery, there are some risks, such as infection or bleeding. If you have had surgery and have severe pain, fever, swelling or excessive bleeding, you should contact your doctor as soon as possible.Vascular surgery for erectile dysfunctionIn cases where a man’s anatomy prevents blood flow into or out of the penis, vascular surgery may be an option. This treatment option is rarely recommended, and is usually only successful in younger men.If there is a blockage that prevents blood from flowing into the penis, a doctor may recommend an operation that bypasses the blocked blood vessels, using a length of vein or manufactured tubing, to allow more blood to flow into the penis and help produce an erection.If the problem is that blood leaks back out of the penis, this can be corrected by tying off the major veins that drain the penis, a procedure known as venous ligation.Hormone treatments for impotenceIn a small number of men, blood tests may show abnormally low levels of testosterone, the male sex hormone. In such cases your doctor might prescribe a course of testosterone injections or a testosterone implant. The supplements can help boost sex drive as well as increasing the ability to have erections. Testosterone gel or patches, applied daily to the skin, are another option.Complementary medicines for erectile dysfunctionThere is a lack of scientific evidence supporting the effectiveness of complementary therapies for the treatment of impotence.Always check with your doctor before taking any herbal medicines or supplements for impotence. These formulations may contain ingredients that can interact with other medicines or cause dangerous side effects.Counselling for men with impotenceErectile dysfunction often has physical causes, but sometimes there is a psychological basis for erection problems. Often this is a form of performance anxiety. A man may have had an episode of erectile dysfunction due to some passing cause like fatigue, stress, relationship difficulty or intoxication. This may have led to embarrassment or a feeling of failure. Even if the physical cause does not remain, future attempts to have sex may trigger memories of this embarrassment and acute anxiety that it will happen again. This anxiety itself is capable of causing erectile dysfunction, and so a man may get trapped in a self-reinforcing cycle of anxiety and erectile dysfunction. In these instances, seeing a GP, counsellor or psychologist can be very helpful.Stress, anxiety, depression and low self-esteem, in fact, almost all significant emotional problems, can have a major effect on sexuality. So do many chronic physical illnesses, even if they don't directly affect genital function. Counsellors and psychologists can assist with these and a wide range of other sexual and relationship problems and can also help female partners suffering from sexual problems. They are particularly skilled in helping patients to overcome guilt or anxiety relating to sexual abuse, and in helping couples to sort out relationship difficulties. Simple problems can be dealt with in a few visits, but more complex problems may require several months or even years of therapy.Your doctor may be able to recommend a psychologist or counsellor who specialises in sexual and relationship problems. Last Reviewed: 12 December 2016
Adverse effects related to PDE5i use with mild-moderate and transient (58). Furthermore, side effects usually attenuate if use is not discontinued. Autonomic dysreflexia, a life-threatening phenomenon characterized by bradycardia, hypertension, facial flushing and headaches associated with SCI lesions above T6, has not been reported with use. However, hypotension leading to dizziness in individuals treated with sildenafil has been noted with high thoracic and cervical levels of injury (72). No adverse events were noted within the study; however, the dizziness was reported by use of sildenafil 50 mg in the cervical LOI and 100 mg in the thoracic LOI patients. Headache is the most reported side effect of all PDE5i, followed by dyspepsia and flushing. Priapism, and death have not been reported after use of PDE5i by SCI patients.
There have been rare reports of priapism (prolonged and painful erections lasting six or more hours) with the use of PDE5 inhibitors. Patients with blood cell diseases such as sickle cell anemia, leukemia, and multiple myeloma have higher than normal risks of developing priapism. Untreated priapism can cause injury to the penis and lead to permanent impotence. Therefore, if your erection lasts four hours, you should seek emergency care.
Adverse effects related to PDE5i use with mild-moderate and transient (58). Furthermore, side effects usually attenuate if use is not discontinued. Autonomic dysreflexia, a life-threatening phenomenon characterized by bradycardia, hypertension, facial flushing and headaches associated with SCI lesions above T6, has not been reported with use. However, hypotension leading to dizziness in individuals treated with sildenafil has been noted with high thoracic and cervical levels of injury (72). No adverse events were noted within the study; however, the dizziness was reported by use of sildenafil 50 mg in the cervical LOI and 100 mg in the thoracic LOI patients. Headache is the most reported side effect of all PDE5i, followed by dyspepsia and flushing. Priapism, and death have not been reported after use of PDE5i by SCI patients.
Certain types of blood pressure medications, antiulcer drugs, antihistamines, tranquilizers (especially before intercourse), antifungals (hetoconazole), antipsychotics, antianxiety drugs, and antidepressants, known as selective serotonin reuptake inhibitors (SSRIs, including Prozac and Paxil), can interfere with erectile function. Smoking, excessive alcohol consumption, and illicit drug use may also contribute. In rare cases, low levels of the male hormone testosterone may contribute to erectile failure. Finally, psychological factors, such as stress, guilt, or anxiety, may also play a role, even when the impotence is primarily due to organic causes.
A vacuum erection device helps draw blood into the penis by applying negative pressure. This type of device is sometimes referred to as penis pump and may be used just prior to sexual intercourse. Several types of FDA approved vacuum therapy devices are available under prescription. When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the base of the penis to maintain it. These pumps should be distinguished from other penis pumps (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to masturbation. More drastically, inflatable or rigid penile implants may be fitted surgically.
Cosgrove et al reported a higher rate of sexual dysfunction in veterans with posttraumatic stress disorder (PTSD) than in veterans who did not develop this problem. [42] The domains on the International Index of Erectile Function (IIEF) questionnaire that demonstrated the most change included overall sexual satisfaction and erectile function. [43, 44] Men with PTSD should be evaluated and treated if they have sexual dysfunction.
3. Testosterone replacement. Before oral medications like Viagra, testosterone was routinely used to treat erectile dysfunction as it is central in the male sexual response, including the desire for sex and the process of getting an erection. Testosterone can be administered in a number of ways, for example orally, by means of an injection, skin patch, or subcutaneous (under the skin) pellet. 
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There are treatments available to help you to get and maintain an erection. In addition, making healthy changes to your lifestyle could help with impotence. Switching to a healthier balanced diet, taking more exercise and cutting down on or giving up alcohol and cigarettes could help you to see an improvement in sexual function. If you think that the problem may be related to stress or anxiety, counselling can also help.
The penis is composed of three cylinders, two on the top and one on the underside of the penis. The top two cylinders are involved in the erectile process. The urethra, the tube that urine and semen pass through, is on the underside of the penis. The top two penile cylinders, the corpora cavernosa, are composed of tissue that is analogous to a sponge, containing spaces that can fill with blood and expand. These two cylinders are surrounding by a strong layer of tissue, like Saran wrap, the tunica albuginea. For an erection to occur, there must be properly functioning nerves, arteries, veins, and normal penile tissues.

Stanley A Brosman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Advancement of Science, American Association for Cancer Research, American College of Surgeons, American Medical Association, American Urological Association, Society for Basic Urologic Research, Society of Surgical Oncology, Society of Urologic Oncology, Western Section of the American Urological Association, Association of Clinical Research Professionals, American Society of Clinical Oncology, International Society of Urology, International Society of Urological Pathology


For many of the 30 million Americans affected by erectile dysfunction, Viagra, Levitra, and Cialis are the first line of ED treatment — and they’re successful for about 80 percent of men. These drugs, called phosphodiesterase-5 inhibitors, are approved by the U.S. Food and Drug Administration (FDA) and work by increasing blood flow to an erection. Common side effects include nasal congestion and headache. Note: If you take nitroglycerin pills for heart disease, you won’t be able to take ED pills, as they can cause a dangerous drop in blood pressure.
All studies demonstrate a strong association with age, even when data are adjusted for the confounding effects of other risk factors. The independent association with aging suggests that vascular changes in the arteries and sinusoids of the corpora cavernosa, similar to those found elsewhere in the body, are contributing factors. Other risk factors associated with aging include depression, sleep apnea, and low HDL levels.
Self-injection of these agents has been of enormous benefit because they represent the most effective way to achieve erections in a wide variety of men who otherwise would be unable to achieve adequate rigid erections. The need for intact nerve pathways to the penile tissue is not needed. The locally injected medication directly relaxes the arteriole vessels and penile cavernosal tissue. Thus, this therapy is not dependent on sexual stimulation.
Under normal circumstances, when a man is sexually stimulated, his brain sends a message down the spinal cord and into the nerves of the penis. The nerve endings in the penis release chemical messengers, called neurotransmitters, that signal the corpora cavernosa (the two spongy rods of tissue that span the length of the penis) to relax and fill with blood. As they expand, the corpora cavernosa close off other veins that would normally drain blood from the penis. As the penis becomes engorged with blood, it enlarges and stiffens, causing an erection. Problems with blood vessels, nerves, or tissues of the penis can interfere with an erection.
The causes of erectile dysfunction include aging, high blood pressure, diabetes mellitus, cigarette smoking, atherosclerosis (hardening of the arteries), depression, nerve or spinal cord damage, medication side effects, alcoholism or other substance (drug) abuse, pelvic surgery including radical prostatectomy, pelvic radiation, penile/perineal/pelvic trauma such as pelvic fracture, Peyronie's disease (a disorder that causes curvature of the penis and sometimes painful erections), and low testosterone levels.
A variety of lifestyle choices can affect the ability to achieve and maintain an erection, so preventing ED is possible in some cases. Men are encouraged to manage chronic health problems with their doctors and to exercise regularly. They also should avoid smoking and excess alcohol and get help for anxiety or depression, according to the Mayo Clinic.
Can apple cider vinegar treat erectile dysfunction? Apple cider vinegar is thought to have many health benefits, but can it help treat erectile dysfunction (ED)? ED can result from cardiovascular problems, diabetes, and other factors. Apple cider vinegar may help improve symptoms of conditions related to ED. Find out how it may help, and how to use it safely. Read now
Radical prostatectomy for the treatment of prostate cancer poses a significant risk of ED. A number of factors are associated with the chance of preserving erectile function. If both nerves that course on the lateral edges of the prostate can be saved, the chance of maintaining erectile function is reasonable. The odds depend on the age of the patient. Men younger than 60 years have a 75-80% chance of preserving potency, but men older than 70 years have only a 10-15% chance.
Certain street drugs such as "poppers" also can cause serious problems if taken with PDE5i medications. These poppers are often types of nitrates and can cause severe drops in blood pressure. Ecstasy is another street drug that may increase sexual desire but interferes with performance. This has prompted some men to combine ecstasy with PDE5i medications. This mixture (a combination sometimes called "sextasy") can improve erection ability but also causes severe headache and priapism. (Priapism is an abnormally prolonged erection that becomes extremely painful and may result in permanent damage to the erection mechanism.) There are also potentially dangerous effects to your heart from mixing PDE5i medications with various other street drugs.

MalaCards based summary : Impotence, also known as erectile dysfunction, is related to vasculogenic impotence and hyperprolactinemia, and has symptoms including angina pectoris, pelvic pain and tremor. An important gene associated with Impotence is NOS1 (Nitric Oxide Synthase 1), and among its related pathways/superpathways are Response to elevated platelet cytosolic Ca2+ and Platelet homeostasis. The drugs Methyltestosterone and Testosterone have been mentioned in the context of this disorder. Affiliated tissues include prostate, spinal cord and endothelial, and related phenotypes are normal and reproductive system


Erectile dysfunction (ED), or impotence, is the inability to obtain or maintain an erection suitable for intimate activity. While most frequently seen in 50-65% of males aged 65 and older and nearly all men over the age of 70, erectile dysfunction affects up to 39% of 40-year-old men, too; more than 35 million men total in the United States. Left untreated, the physical frustrations of living with erectile dysfunction can quickly turn emotionally stressful as well, with men often reporting relationship and related issues. And that’s why NuMale Medical Center offers the most advanced and effective therapies to treat erectile dysfunction, so you and your partner can experience sex and intimacy both joyfully and confidently.
Patients receiving penile prostheses should be instructed in the operation of the prosthesis before surgery and again in the postoperative period. The prosthesis usually is not activated until approximately 6 weeks after surgery, so as to allow the edema and pain to subside. The prosthesis is checked in the office before the patient begins to use it.
3. An intact, anatomically correct penis; 25% of impotence may be psychologic or 'partner-specific', 25% has an organic component and 50% of impotence is organic in nature; in organic impotence, nocturnal penile tumescence is absent Management-surgical Microvascular surgery to bypass occluded vessels–most effective in younger ♂, penile prosthesis Management-medical Combined therapy with phentolamine and papaverine–self-injected by the Pt, wielding an erection of 1 hr's duration is useful for arterial, neurologic, psychogenic impotence; other therapies–zinc, bromocriptine–Parlodel, isoxsuprine-Vasodilan, Voxsuprine, nitroglycerine, yohimbine–Yocon, Yohimex Etiology Smoking, CAD, HTN, DM, medications–hypoglycemic agents, vasodilators, cardiac drugs, antihypertensives, anger and depression; it is inversely correlated to dehydroepiandrosterone, HDL-C, and an index of dominant personality Primary impotence Complete absence of successful sexual coupling Secondary impotence Priapism, penile plaques, Peyronie's disease; drugs linked to impotence: antihypertensives–eg, methyldopa, guanethidine, reserpine, clonidine, due to ↓ BP, antidepressants–eg, phenelzine, isocarboxazide, amitriptyline–causing altered moods and decreased libido, tranquilizers–eg, chlordiazepoxide and lorazepam, and the muscle-relaxing diazepam, cimetidine, which ↑ prolactin, and is associated with impotence and loss of libido. Cf Infertility, Orgasmic dysfunction.
Injection therapy involves injecting a substance into the penis to enhance blood flow and cause an erection. The Food and Drug Administration (FDA) approved a drug called alprostadil (Caverject) for this purpose in July of 1995. Alprostadil relaxes smooth muscle tissue to enhance blood flow into the penis. It must be injected shortly before intercourse. Another, similar drug that is sometimes used is papaverine—not yet been approved by the FDA for this use. Either drug may sometimes cause painful erections or priapism (uncomfortable, prolonged erections) that must be treated with a shot of epinephrine.
This technique is effective in 60%-90% of men. It is not recommended to leave the tension ring in place longer than 30 minutes. The vacuum device may be the only therapy that is effective after removal of a penile prosthesis. The vacuum device has become a commonly used therapy as part of penile rehabilitation after radical prostatectomy to preserve the tissue of the penis and prevent scarring within the penis and loss of penile length.
A meta-analysis of 36 744 men with ED in 12 prospective cohort studies found that the presence of ED significantly increased the risk of CVD, CAD, stroke and all-cause mortality, and the presence of ED was an independent risk factor for CVD. Ponholzer et al found that men with moderate to severe ED had a 65% increased relative risk for developing symptomatic CAD compared with men who did not have ED.26
Counselling or sex therapy (58% of people find this works for them) –mind-related causes of erectile dysfunction can affect anyone. They are more likely if you experience erectile dysfunction at a younger age. Talking to a counsellor or therapist can help some people overcome erectile dysfunction related to these problems, possibly for good. They can also help you if your erectile dysfunction is causing you stress, as this can make matters worse.
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