Nonsurgical Treatment of Erectile Dysfunction

Exploring Your Treatment Options

Virtually any man who wishes to have an erection can obtain it, regardless of the underlying cause of his problem.

Many reasonable nonsurgical treatment options exist for erectile dysfunction (also called male impotence), including external vacuum devices, medications (oral and topical), hormonal therapy, penile injection therapy, and intraurethral pellet therapy. Sex counseling is another option and is discussed in Living With Erectile Dysfunction.

In selected cases and under the supervision of an experienced urologist who treats erectile dysfunction, therapy combining several of these methods can be used. If none of these therapies is satisfactory, surgical treatment, such as a penile prosthesis, can be considered.

External Vacuum Devices

Specially designed vacuum devices to produce erections have been used successfully for many years. Vacuum devices are safe, relatively inexpensive, and reliable. Vacuum devices do not require surgery.

The typical vacuum device consists of a plastic cylinder that is placed over the penis, tension rings of various sizes, and a small hand pump. Air is pumped out, causing a partial vacuum, which draws blood into the penis and creates the erection.

Once an erection is obtained, a tension ring, which acts like a tourniquet to keep the blood in the penis and to maintain an erection, is placed around the base of the penis.

Using the correct size of tension ring is critical in obtaining the best possible result from this type of treatment. If the ring is too tight, it can be uncomfortable. If too large a ring is used, the erection may not last. The tension ring should not be left in place longer than 30 minutes.

Although these devices are generally safe, bruising can occur and the erect penis may lack some support. Other possible side effects include:

Pain
Lower penile temperature
Numbness
No or painful ejaculation
Pulling of scrotal tissue into the cylinder

Many of these side effects can be helped by proper selection of the tension rings and cylinder size, use of adequate lubrication, adequate practice with the device, and proper technique.

Vacuum devices are effective in a majority of men. About half of the men who use a vacuum device obtain good or excellent erections with them, but only half of these men consistently use the device over long periods of time.

The most common cause of failure is improper use of or unfamiliarity with the device. Other drawbacks to the use of vacuum devices include the need to assemble the equipment and the difficulty in transporting it. Many men also lose interest in the device because of:

Necessary preparations (may need to interrupt foreplay)
Inability to hide the tension ring
Relative lack of spontaneity

Although vacuum devices can be operated and used quickly with experience, they still are perceived by many to be less "romantic" than other nonsurgical treatment options.

Medications

Medications can be used to treat erectile dysfunction, some of which are discussed below. For a more complete discussion, see Erectile Dysfunction Medications.

Viagra, Levitra, Cialis, and Stendra

Since the introduction of Viagra (sildenafil citrate) in March 1998, no other therapy for erectile dysfunction has achieved such wide public recognition.

Viagra is the first oral medicine (a pill you take by mouth) available that has been proven to improve erections in men who have difficulty achieving or maintaining erections sufficient for sexual intercourse due to erectile dysfunction. Viagra does not improve erections in healthy men. It is not an aphrodisiac and will not increase sexual desire.

Since its introduction, the Food and Drug Administration (FDA) has approved two additional drugs in the same class as Viagra:

Levitra (vardenafil), Cialis (tadalafil), and Stendra (avanafil) have essentially the same activity as Viagra. Cialis has a longer duration of increased sensitivity to develop an erection (up to 24-36 hours) compared with Viagra and Levitra (up to 4-16 hours). Stendra can work as rapidly as 15-30 minutes and can be taken with alcohol.

Viagra, Levitra, Stendra, and Cialis work by blocking an enzyme found mainly in the penis that breaks down a chemical created during stimulation that increases blood flow in the erectile bodies of the penis, which then produces erections. Viagra, Levitra, and Cialis allow this chemical of arousal to survive longer and greatly improve erectile function. Viagra, Levitra, and Cialis will not have any effect without sexual stimulation.

Viagra, Levitra, Stendra and Cialis work successfully in a majority of all men with erectile dysfunction. Of those men with diabetes or with spinal cord injury, a majority reported being successfully treated with these medications. In men who became impotent after radical prostate cancer surgery, almost half reported improved erections with Viagra, particularly if they had the "nerve-sparing" type of prostate surgery. These medications are most effective if there is some erectile function; if there is no erectile function, these medications are not usually beneficial.

Viagra is available in 3 strengths: 25 mg, 50 mg, and 100 mg. Viagra works best if taken on an empty stomach about 30-45 minutes before sexual activity. Optimal results may not be realized until the medication has been tried 6-8 times. Viagra may be used cautiously with alpha-blocker medications as long as sufficient time has passed between their dosing.

Levitra is available in 2 strengths: 10 mg and 20 mg. It is not necessary to take it on an empty stomach. Currently, Levitra cannot be used with any alpha-blocker medication because of potentially dangerous drops in blood pressure. Many people who fail Viagra therapy have found Levitra to be effective.

Cialis is available in 2 strengths: 10 mg and 20 mg. Cialis can work in 30 minutes, but peak results usually take longer. Cialis has the advantage of a much longer period (24-36 hours) during which sexual ability is increased. Cialis may be used with the alpha-blocker medication Flomax but not with other alpha-blocker medications.

Stendra is available in 3 strengths: 50mg, 100 mg, and 200 mg. Stendra can work as rapidly as 15-30 minutes and can be taken with food or alcohol.

Side effects of Viagra, Levitra, Stendra and Cialis can occur but are generally mild. They include:

Headache
Hypotension (a drop in blood pressure)
Transient dizziness
Facial flushing
Indigestion
Nasal congestion
Lower back pain (unique to Cialis)
Visual disturbance (eg, blurred vision, increased light sensitivity, persistence of a bluish tinge, temporary loss of the ability to distinguish between blue and green)

Your physician will determine which of these medications is most appropriate for you and the optimal dosage. Never give any of these medications to anyone else as they can cause serious problems due to drug interactions if not monitored by a physician.

Medications, such as ketoconazole (an antifungal medication known as Nizoral), erythromycin (an antibiotic), and cimetidine (a drug to reduce stomach acid known as Tagamet), can interfere with the chemical processing of medications like Viagra by the liver.

Alpha-blocker type medications (eg, Hytrin, Cardura, Uroxatral, Flomax, Rapaflo) may have potentially dangerous interactions with Viagra, Levitra, Stendra and Cialis. If you are taking any of these medications, check with your physician or pharmacist about potential drug interactions.

Certain street drugs (eg, ecstasy) can also cause serious problems if taken with Viagra, Levitra, Stendra or Cialis.

Viagra, Levitra, Stendra and Cialis should absolutely not to be taken by:

Men with heart conditions who are taking nitrates, such as nitroglycerine (Combining Viagra, Levitra, Stendra or Cialis with nitrate-based medications can cause a severe and dramatic drop in blood pressure with potentially very dangerous consequences.)
Men with serious heart disease or exertional angina (chest pain)
Men who are taking multiple drugs for high blood pressure

Yohimbine

Yohimbine, an herbal product, comes from the bark of a West African tree. Its use in treating erectile dysfunction is questionable, and, in studies, yohimbine is only slightly better than placebo (no drug at all).

Nonetheless, yohimbine is considered safe with few known side effects. The usual daily dose is a 5.4-mg tablet taken 3 times a day.

Hormonal Therapy

Men with low sex drive and erectile dysfunction may have low levels of testosterone (the male hormone). As a general guideline, a testosterone level of 300 ng/dL or less is considered low, but this varies depending on the laboratory that does the testing and the time of day the sample is taken.

Hormone replacement may be beneficial, especially when used in combination with other therapies for erectile dysfunction; however, testosterone supplementation alone is not particularly effective in treating erectile dysfunction.

Sexual desire (libido) and an overall sense of well-being are likely to improve when serum testosterone levels (the level of the male hormone in the blood) are restored.

Replacement testosterone is available in the following forms:

Injections: Injections are a reliable way to restore testosterone levels, but this therapy requires periodic injections (usually every 2 weeks) to sustain an effective level. It also causes high hormone levels right after the injection and low hormone levels just before the next shot. This is thought to be slightly more risky than other methods that maintain a moderate hormone level throughout the treatment period.
Skin patches and gels: Skin patches and gels that are rubbed into the skin deliver a sustained dose and are generally well accepted. A strip that is placed in the mouth on the gums is also available. With the patches and the gels, skin rashes and irritation are the most common problems.
Injectable pellets (Testopel) are injected under the skin every 4-6 months. Testosterone levels are maintained at an effective level, but the injection can be uncomfortable and cause bruising. Oral therapy (pills): This is the least effective therapy. Pills are also associated with a small risk of liver problems. Testosterone pills are not recommended.

If your doctor prescribes long-term testosterone replacement therapy, you will have follow-up visits to assess your testosterone levels, to periodically monitor your blood counts, and to undergo regular prostate checks, including digital rectal examinations and prostate specific antigen (PSA) blood tests

Penile Injection Therapy

Although many substances are touted as male sexual boosters, the modern age of such drug therapies began in 1993.

At that time, papaverine, a drug that produces vasodilatation (widening of the blood vessels), was shown to produce erections when injected directly into the penis. Soon afterward, other vasodilators were demonstrated to be effective as a treatment of erectile dysfunction.

Alprostadil is currently the most commonly used drug for injections into the penis. Alprostadil works well in most men who try it. TriMix (a combination of alprostadil, phentolamine, and papaverine) has roughly twice the effectiveness of alprostadil alone. However, it is relatively expensive and usually not covered by insurance, whereas alprostadil is often covered by most insurance plans.

Self-injection of these drugs has been very beneficial. Penile injection therapy represents the most effective way to achieve erections in a wide variety of men who would otherwise be unable to obtain adequate rigid erections. In fact, if the vascular structure of the penis is healthy, the use of injectable drugs is almost always effective. Men on anticoagulant medications (blood thinners) cannot use this therapy. Your doctor will determine an appropriate dose. The dose is adjusted to achieve an erection with adequate rigidity for no more than 90 minutes. The injection cannot be done more than 3 times per week.

Side effects include:

Pain from the medication (not from the injection)
Priapism
Priapism is a persistent or abnormally prolonged erection that lasts 4 hours or more.
Priapism is a urologic emergency. If an erection lasts for 4 hours or more, you must either contact your urologist or go to an emergency department for immediate treatment.
Scarring or bleeding at the site of the injection

If you choose this therapy, your doctor will teach you how to perform the injections. Even though the injection itself is painless, many men are still uncomfortable with penile injection therapy.

Intraurethral Pellet Therapy

Intraurethral pellet therapy, also called the medicated urethral system for erections (MUSE), is a useful alternative for men who do not want to use self-injections or for men in whom oral medications have failed.

Intraurethral pellet therapy is effective in a majority of men.
Intraurethral pellet therapy may be effective in men with vascular disease or with diabetes and in those who have undergone prostate surgery.
Intraurethral pellet therapy has been successful when used together with Viagra; however, this type of combination treatment should only be done under the supervision of a urologist who is experienced in treating erectile dysfunction.

Alprostadil, a drug also discussed in Penile Injection Therapy, has been formulated into a small suppository. This suppository is inserted into the urethra (the canal through which urine and semen are excreted). Because of this, urinating immediately before use is important in order to moisten the passage.

A temporary tourniquet is often helpful in allowing the medication to stay in the erectile tissue a little longer and seems to give a somewhat better response.

Few side effects occur with intraurethral pellet therapy. The most common side effect is pain at the site where the pellet is deposited. A small amount of bleeding may also occur.