Similar to heart-disease-related to atherosclerosis (plaque formation within the blood vessels), the concept of bypassing or angiographically dilating and stenting penile arteries has been entertained recently with improvements in microvascular surgery and interventional radiology. However, the main drawback with most erectile dysfunction is the failure of vascular relaxation within the corpora cavernosa rather than the one feeding penile artery. Stenting or surgical grafting to bypass a blockage would be ideal for a single obstruction site along a penile artery. Because most erectile dysfunction pathology resides within the sponge-like vascular plexus of the penis, the ability of diffusely dilating and expanding the many vascular chambers of the penis is difficult to impossible. As such, unless the situation is that the penile artery was injured during a pelvic trauma, and the potential to bypass another vessel into the single penile artery, the concept of vascular reconstruction or angio-radiology stenting has very low yield.
When aroused, stimulated nerves supplying the penis release chemicals that cause the muscle that surrounds blood vessels in the penis to relax. As the blood vessels relax, there is an increase in blood coming into the penis. This blood fills the spaces in the corpora cavernosa, allowing each of the corpora to expand. As the corpora expand, the veins that drain blood out of the penis are compressed against the tunica albuginea. Compression of the veins prevents blood from leaving the penis and results in a fully rigid penis. When the stimulation/arousal subsides, there is a decrease in the chemicals from the nerves, the muscle around the arteries tightens, decreasing inflow of blood, resulting in a lack of compression of the veins and the drainage of blood out of the penis.
Sildenafil is available as oral tablets at doses of 25 mg, 50 mg, and 100 mg. Patients should take sildenafil approximately one hour before sexual activity. In some men, the onset of action of the drug may be as early as 11-20 minutes. It's best for men to take sildenafil on an empty stomach for best results since absorption and effectiveness of sildenafil can be diminished if it is taken shortly after a meal, particularly a meal that is high in fat. Sildenafil and the other PDE5 inhibitors don't cause an immediate erection. Sexual stimulation is necessary for these medications to work.
Psychological factors — Psychological issues such as depression, anxiety, guilt or fear can sometimes cause sexual problems. At one time, these factors were thought to be the major cause of impotence. Doctors now know that physical factors cause impotence in most men with the problem. However, embarrassment or "performance anxiety" can make a physical problem worse.
It is common for a healthy older man to still want sex and be able to have sex within appropriate limitations. Understanding what is normal in older age is important to avoid frustration and concern. Older men and their partners often value being able to continue sexual activity and there is no age where the man is ‘too old’ to think about getting help with his erection or other sexual problems.
This book will explore alternative and much healthier methods to deal with the sensitive issue of erectile dysfunction. It’s time for men to realize that there is life beyond the pharmacy counter, beyond what our contemporary culture tells us is acceptable, and it’s time to delve into centuries-old remedies that build up, not tear down our system.
Nerve or spinal cord damage: Damage to the spinal cord and nerves in the pelvis can cause erectile dysfunction. Nerve damage can be due to disease, trauma, or surgical procedures. Examples include injury to the spinal cord from automobile accidents, injury to the pelvic nerves from prostate surgery for cancer (prostatectomy), and some surgeries for colorectal cancer, radiation to the prostate, surgery for benign prostatic enlargement, multiple sclerosis (a neurological disease with the potential to cause widespread damage to nerves), and long-term diabetes mellitus.
Poor sleep patterns can be a contributing factor for erectile dysfunction, Mucher says. One review published in the journal Brain Research emphasized the intricate relationship between the level of sex hormones like testosterone, sexual function, and sleep, noting that testosterone levels increase with improved sleep, and lower levels are associated with sexual dysfunction. Hormone secretion is controlled by the body’s internal clock, and sleep patterns likely help the body determine when to release certain hormones. 
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.
In some cases, nocturnal penile tumescence testing is performed to find out whether the man has erections while asleep. Healthy men usually have about four or five erections throughout the night. The man applies a device to the penis called a Rigiscan before going to bed at night, and the device can determine whether he has had erections. (If a man is able to have normal erections at night, this suggests a psychological cause for his impotence.)
For many men, stopping smoking is an erectile dysfunction remedy, particularly when ED is the result of vascular disease, which occurs when blood supply to the penis becomes restricted because of blockage or narrowing of the arteries. Smoking and even smokeless tobacco can also cause the narrowing of important blood vessels and have the same negative impact. 
Sildenafil has been previously suggested as a treatment option for ED in men with epilepsy (77,78). However, Matos et al. warned that PDE5i are potentially pro-convulsant and should be used with great caution in men with epilepsy (79). Animal studies in rat and mice overwhelmingly suggest PDE5i can reduce seizure threshold. In human trials, seizures were rare but reported. PDE5i exerted their proconvulsive effect by lower seizure threshold possibly by worsening sleep or obstructive sleep apnea, causing cardiovascular changes, or leading to EEG changes specifically with tadalafil use.

As with most other organ system in the human body, changes and loss of function is normal consequence of the ageing process. This is also true of the endocrine system, specifically the levels of testosterone production from the Leydig cells of the testicle. Accompanying the decrease in testosterone is a decrease in erections which also has a component in decrease in the blood supply to the penis making erection not as frequent and not as rigid compared with a young man’s erectile function. Although these changes are in itself not life threatening, they can impact a man’s relationship with his partner, and also ED may be a harbinger of other undiagnosed conditions such as coronary artery disease (CAD), hypercholesterolaemia or diabetes mellitus.6
The most common treatment for erectile dysfunction is drugs known as phosphodiesterase-5 (PDE-5) inhibitors. These include tadalafil (Cialis), vardenafil (Levitra), and sildenafil citrate (Viagra). These are effective for about 75% of men with erectile dysfunction. They are tablets that are taken around an hour before sex, and last between 4 and 36 hours. Sexual stimulation is required before an erection will occur. The PDE-5 inhibitors cause dilation of blood vessels in the penis to allow erection to occur, and help it to stay rigid. Men using nitrate medication (e.g. GTN spray or sublingual tablets for angina) should not use PDE-5 inhibitors.
Psychosocial problems are important and may cause erectile dysfunction by themselves or together with other causes of erectile dysfunction, such as diabetes and heart disease. Relationships are complicated and many factors cause tensions, which can affect sexual relations. For some men, these problems can become ongoing and it can help to talk through the issue with a skilled counsellor. It is important to know that the longer erectile dysfunction is left untreated, the greater the effect on relationships. This is another reason why early treatment of erectile dysfunction is important.
Lifestyle choices that impair blood circulation can contribute to ED. Smoking, excessive drinking, and drug abuse may damage the blood vessels and reduce blood flow to the penis. Smoking makes men with atherosclerosis particularly vulnerable to ED. Being overweight and getting too little exercise also contribute to ED.  Studies indicate that men who exercise regularly have a lower risk of ED.
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