Impotence, also known as erectile dysfunction or ED, is a very common problem, affecting more than 100 million men worldwide. Treatment techniques 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 choices now include tablets, self-injection therapy, surgery, devices such as vacuum pumps, hormone therapy, and counselling.
The first tablet available for erectile dysfunction, Viagra (sildenafil), has been largely responsible for helping to bring the topic of erectile dysfunction out into the open. Similar medications — Cialis (tadalafil) and Levitra (vardenafil) — are now also available, and have a similar mechanism of action to Viagra, though there is some difference in their duration of action.
These treatments help in the process of gaining and maintaining an erection by working on the biochemical mechanism of an erection. They belong to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors. These treatments 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 in to the penis to cause an erection.
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 these medications can include headaches, flushes, indigestion and, in rare situations, a distortion of vision or change in colour vision.
PDE5 inhibitors cannot be taken by all men, so your doctor will need to evaluate your suitability before prescribing either of these medications. Men with certain heart problems or those taking nitrates for angina, for example, should never take Viagra, Cialis or Levitra. Check with your doctor to find out if this type of medication may be suitable for you.
Caverject is a self-injection therapy that delivers alprostadil, 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.
Caverject 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. Caverject should produce an erection in 5 to 20 minutes and, generally, the erection will last for 30 to 60 minutes.
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 Caverject. Men for whom sexual activity is not advised should not use Caverject.
You should ask your doctor if Caverject is suitable for you. Your doctor will also be able to tell you how much Caverject to use, depending on your condition and whether or not you are taking any other medications, and also how to administer Caverject properly.
You should not use Caverject 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 Caverject, as your erection may last longer than is medically safe. If your erection lasts for more than 4 hours, contact your doctor.
The most common side effects of Caverject include pain in the penis or bruising in the penis at the site of injection.
Penile 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.
In cases where a man’s anatomy prevents blood flow into or out of the penis, vascular surgery may be recommended.
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.
Vacuum 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.
In a small number of men, blood tests may show abnormally low levels of testosterone, the male sex hormone. In such cases a doctor might prescribe a course of testosterone injections or a testosterone implant. The supplements should help boost sex drive as well as increasing the ability to have erections. Traditionally, testosterone injections had to be delivered every 2 or 3 weeks, though a formulation is now available permitting 2 to 3-month dosing. Testosterone implants last for 4 to 6 months. Testosterone gel or patches, applied daily to the skin, are another option.
Erectile dysfunction often has physical causes, but in some cases there is a psychological basis for erection problems. Most commonly this is a form of performance anxiety. A man may have had an episode of erectile dysfunction due to some transient cause like fatigue, stress, relationship difficulty or intoxication. This may have led to embarrassment or a feeling of failure. While the physical cause does not persist, future attempts at intercourse may be accompanied by memories of this embarrassment and acute anxiety that it will recur. This anxiety itself is capable of causing erectile dysfunction, and so he 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, and low self-esteem, indeed 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 adept 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: 29 July 2009