A significant number of men develop impotence from psychological causes that can be overcome. When a physiological cause is treated, subsequent self-esteem problems may continue to impair normal function and performance. Qualified therapists (e.g., sex counselors, psychotherapists) work with couples to reduce tension, improve sexual communication, and create realistic expectations for sex, all of which can improve erectile function.
Psychological therapy may be effective in conjunction with medical or surgical treatment. Sex therapists emphasize the need for men and their partners to be motivated and willing to adapt to psychological and behavioral modifications, including those that result from medical or surgical treatment.
Oral medications used to treat erectile dysfunction include selective enzyme inhibitors (e.g., sildenafil [Viagra©], vardenafil HCl [Levitra ©], tadalafil [Cialis ©) and yohimbine (Yohimbine©, Yocon©).
Selective enzyme inhibitors are available by prescription and may be taken up to once a day to treat ED. They improve partial erections by inhibiting the enzyme that facilitates their reduction and increase levels of cyclic guanosine monophosphate (cGMP, a chemical factor in metabolism), which causes the smooth muscles of the penis to relax, enabling blood to flow into the corpora cavernosa.
Patients taking nitrate drugs (used to treat chest pain) and those taking alpha-blockers (used to treat high blood pressure and benign prostatic hyperplasia) should not take selective enzyme inhibitors.
Men who have had a heart attack or stroke within the past 6 months and those with certain medical conditions (e.g., uncontrolled high blood pressure, severe low blood pressure or liver disease, unstable angina) that make sexual activity inadvisable should not take Cialis®. Dosages of the drug should be limited in patients with kidney or liver disorders.
Viagra® is absorbed and processed rapidly by the body and is usually taken 30 minutes to 1 hour before intercourse. Results vary depending on the cause of erectile dysfunction, but studies have shown that Viagra is effective in 75% of cases. It helps men with erectile dysfunction associated with diabetes mellitus (57%), spinal cord injuries (83%), and radical prostatectomy (43%).
In clinical studies, Levitra™ has been shown to work quickly, provide consistent results, and improve sexual function in most men the first time they take the drug. It also has shown to be effective in men of all ages, in patients with diabetes mellitus, and in men who have undergone radical prostatectomy.
Cialis™ has been shown in clinical trials to stay in the body longer than the other selective enzyme inhibitors. It promotes erection within 30 minutes and enhances the ability to achieve erection for up to 36 hours.
Common side effects of selective enzyme inhibitors include headache, reddening of the face and neck (flushing), indigestion, and nasal congestion. Cialis™ may cause muscle aches and back pain, which usually resolve on their own within 48 hours.
Yohimbine improves erections for a small percentage of men. It stimulates the parasympathetic nervous system, which is linked to erection, and may increase libido. It is necessary to take the medication for 6 to 8 weeks before determining whether it will work or not.
Yohimbine has a stimulatory effect and side effects include elevated heart rate and blood pressure, mild dizziness, nervousness, and irritability. Yohimbine’s effects have not been studied thoroughly, but some studies suggest that 10% to 20% of men respond to treatment with the drug.
Ease of administration makes oral medication advantageous. Some drugs, however, are suitable for only a relatively small group of men, and in many cases, oral medications may by less effective than other treatments.
Self-injection involves using a short needle to inject medication through the side of the penis directly into the corpus cavernosum, which produces an erection that lasts from 30 minutes to several hours. Prostaglandin (alprostadil, Caverject, Edex), and phentolamine (Regitine) produce results similar to Viagra but are localized in the penis after injection. They cause vascular dilation and a relaxation of smooth muscle. Prostaglandin is the only substance currently approved for erectile dysfunction treatment. Phentolamine is a heart medication with similar effects used by some physicians to treat impotence.
These drugs have been shown to produce erections in 80% of men who inject them. Some men claim that they produce erections that feel natural and improve sex. The injections are relatively painless and create an erection that begins about 5 to 15 minutes after the injection. It is recommended that self-injection be performed no more than once every 4 to 7 days. Side effects include infection, bleeding, and bruising at the injection site, dizziness, heart palpitations, and flushing. There is a small risk for priapism (an erection that lasts for more than 6 hours and requires medical relief). Repeated injection may cause scarring of erectile tissue, which can further impair erection.
Urethral suppositories containing prostaglandin (aprostadil), like Muse (Medicated Urethral System for Erections), may be an alternative to injection. Using a hand-held delivery device, a man inserts a prostaglandin pellet through the meatus (penis opening) into the urethra. Prostaglandin is absorbed through the urethral mucosa and into the surrounding erectile tissue. It is available with a prescription, is well tolerated, and may improve erections in 60% of men who use it.
In addition to the side effects associated with injecting aprostadil, pain in the penis and perineum (area between scrotum and rectum) may occur with suppository use.
Vacuum devices work by manually creating an erection. The penis is inserted into a plastic tube, which is pressed against the body to form a seal. A hand pump attached to the tube is used to create a vacuum that draws blood into the penis, causing the penis to become engorged. After 1 to 3 minutes in the vacuum, an adequate erection is created. The penis is removed from the tube and a soft rubber O-ring is placed around the base of the penis to trap blood and maintain the erection until removed. The ring can be left in place for 25 to 30 minutes.
Vacuum devices work best in men who are able to achieve partial erections on their own. They are easy to use at home, require no other procedure, and typically improve erections regardless of the cause of impotence. Some men experience a numbing feeling after placing the O-ring. Since the penis is flaccid between the ring and the body, the erection may be somewhat floppy.
American Urological Association
Revision date: June 11, 2011
Last revised: by Jorge P. Ribeiro, MD