For patients who have ED related to hypertonic cavernous smooth muscle and excessive sympathetic discharge, we recommend a trial of a low-dose alpha adrenergic blocker, such as terazosin 1 mg PO at bedtime nightly. We typically increase the dosage as needed every 2–3 weeks for 3–5 months until the patient experiences improvement of the erection or we determine that treatment is ineffective. We explain the potential side effects of orthostasis, dizziness, and retrograde ejaculation in detail. We also take great care and time in explaining to the patient, and his family/partner if present, the pathophysiologic mechanism of their erectile dysfunction and the biological basis of the treatment plan. This detailed discussion helps to engage the patient in the treatment plan and provides encouragement regarding the potential for response to treatment and recovery. During these encounters, we utilize teaching tools, such as diagrams, drawings, printed handouts, and other visual aids to ensure that the discussion is patient-focused and patient-friendly. Patient education is critical to exploring treatment options and developing confidence in our ability to treat the ED, and their own ability to overcome and eventually resolve the problem of ED.

One hundred male subjects, consecutively admitted to the Deaddiction Centre of the National Institute of Mental Health And NeuroSciences (NIMHANS), Bangalore, India, with a diagnosis of Alcohol Dependence Syndrome With Simple Withdrawal Symptoms (F10.30, ICD-10 criteria) [WHO][13] were recruited for the study. All subjects gave informed consent for taking part in the study. Subjects were initially assessed on the schedules for clinical assessment in neuropsychiatry (SCAN)[14] by a trained psychiatrist (VB). All patients were subjected to detailed clinical and biochemical examinations including blood glucose and liver enzymes. Patients with significantly high levels of liver enzymes or physical findings suggestive of hepatic cirrhosis were referred for ultrasound assessment of the abdomen.
Men with a rare heart condition known as long QT syndrome should not take vardenafil since this may lead to abnormal heart rhythms. The QT interval is the time it takes for the heart's muscle to recover after it has contracted. An electrocardiogram (EKG) measures the QT interval. Some people have longer than normal QT intervals, and they may develop potentially life-threatening abnormal heart rhythms, especially when given certain medications. Men with a family history of long QT syndrome should not take vardenafil, as it is possible to inherit long QT syndrome. Furthermore, vardenafil is not recommended for men who are taking medications that can affect the QT interval such as quinidine (Quinaglute, Quinidex), procainamide (Pronestyl, Procan-SR, Procanbid), amiodarone (Cordarone), and sotalol (Betapace).

Yes, the vacuum device is effective. In fact, with use of the vacuum device, 88% of men will have an erection that is satisfactory for completion of sexual activity. The vacuum device may be the only therapy that is effective after the removal of a penile prosthesis. Patients also use vacuum devices as part of penile rehabilitation after radical prostatectomy to help preserve the tissue of the penis and prevent scarring within the penis and loss of penile length. Its use, however, is limited by the mechanical nature of it and the time taken to pump the device and apply the band. Sex partners may complain of the penis being cool to touch.

Intraurethral alprostadil (Muse) provides a less invasive alternative to intrapenile injection. It is a pellet that is inserted 5–10 min before intercourse, and its effects last for 1 h. The response rate is ∼50–60%. It can be used twice daily but is not recommended for use with pregnant partners. Complications of priapism and penile fibrosis are less common than after alprostadil given by penile injection. The cost is ∼$18–24 per treatment.
CONDITIONS OF USE: The information in this database is intended to supplement, not substitute for, the expertise and judgment of healthcare professionals. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects, nor should it be construed to indicate that use of a particular drug is sage, appropriate or effective for you or anyone else. A healthcare professional should be consulted before taking any drug, changing any diet or commencing or discontinuing any course of treatment.
If the patient reports intermittent ability to obtain and maintain an erection, evaluation with combined injection and stimulation test (CIS) will give you additional diagnostic and potentially therapeutic answers. It will determine if he has adequate inflow to obtain erection and if he has adequate venous occlusive function to maintain erection. It may also provide reassurance to the patient that his anatomy is functional. However, it is well documented that due to increased sympathetic tone these young men will often require additional injection or a separate visit in order to respond appropriately with complete smooth muscle relaxation (7,20,21).
Men with a rare heart condition known as long QT syndrome should not take vardenafil since this may lead to abnormal heart rhythms. The QT interval is the time it takes for the heart's muscle to recover after it has contracted. An electrocardiogram (EKG) measures the QT interval. Some people have longer than normal QT intervals, and they may develop potentially life-threatening abnormal heart rhythms, especially when given certain medications. Men with a family history of long QT syndrome should not take vardenafil, as it is possible to inherit long QT syndrome. Furthermore, vardenafil is not recommended for men who are taking medications that can affect the QT interval such as quinidine (Quinaglute, Quinidex), procainamide (Pronestyl, Procan-SR, Procanbid), amiodarone (Cordarone), and sotalol (Betapace).
Tadalafil should not be used with alpha-blockers (except Flomax), medicines used to treat high blood pressure, and benign prostate hypertrophy (BPH) because the combination of tadalafil and an alpha-blocker may lower the blood pressure greatly and lead to dizziness and fainting. Examples of alpha-blockers include tamsulosin (Flomax), terazosin (Hytrin), doxazosin (Cardura), alfuzosin (Uroxatral), and prazosin (Minipress). Tamsulosin (Flomax) is the only alpha-blocker that patients can use safely with tadalafil. When tadalafil (20 mg) was given to healthy men taking 0.4 mg of Flomax daily, there was no significant decrease in blood pressure and so patients on this dose of tamsulosin (Flomax) can be prescribed tadalafil. The only alpha-blocker not tested with tadalafil is alfuzosin (Uroxatral), and no recommendations can be made regarding the interaction between the two.
This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.
Cigarette smoking is a risk factor for ED, according to the 2014 Report of the U.S. Surgeon General. Excess weight can also contribute to erectile dysfunction. A 2004 Italian study found that one-third of their 110 obese study subjects were able to eliminate their erectile dysfunction problems by losing fifteen percent of their weight through diet and exercise.
Erectile dysfunction related to medical/physical causes is often treatable but less commonly curable. In some cases of medication-induced erectile dysfunction, changes in medication may improve erections. Similarly, in men with a history of arterial trauma, surgical intervention can restore erectile dysfunction. In most cases of ED associated with a medical condition, treatment allows one to have an erection "on demand" or with the aid of medications/device (but not spontaneous).

In patients with low testosterone, testosterone treatment can improve libido and erectile dysfunction, but many men still may need additional oral medications such as sildenafil, vardenafil, or tadalafil. Some studies suggest that men with ED and low testosterone may respond better to PDE5 inhibitors when given testosterone therapy; however, this is controversial.
At the same time, people with diabetes are susceptible to a type of blood vessel damage known as endothelial dysfunction. A recent study found that men with ED are at a greater risk of heart disease, which is also associated with endothelial dysfunction. If blood vessels aren't in good working order, the penis may not get enough blood for an erection.

Many younger men are concerned that this will create a dependency on the medication.  However, you cannot become dependent because there is no tachyphylaxis to these medications.  This means, that unlike some other drugs (opiates, benzodiazepines) your body does not get used to these medications over time, so you won’t need to up the dosage over time to get the same effect.  In fact, we have found the opposite to be true.  Over time, many of our younger patients need less medication and need it less frequently.


The two main physical treatments are vacuum pumps and constriction rings. A vacuum pump is a cylinder which is placed over the penis. The air is then pumped out of it, gently ‘forcing’ the penis to become erect. Constriction rings are used to maintain an erection. A ring is placed around the base of the penis, trapping blood and keeping it hard for longer.
ED is often the result of atherosclerosis, and as a result, men with ED frequently have cardiovascular disease. Sexual activity is associated with increased physical exertion, which in some men may increase the risk of having a heart attack (myocardial infarction or MI). The major risk factors associated with cardiovascular disease are age, hypertension, diabetes mellitus, obesity, smoking, abnormal lipid/cholesterol levels in the blood, and lack of exercise. Individuals with three or more of these risk factors are at increased risk for a heart attack during sexual activity. The Princeton Consensus Panel developed guidelines for treating ED in men with cardiovascular disease. Thus, if you have ED and cardiovascular disease (for example, angina or prior heart attack), you should discuss whether or not treatment of ED and sexual activity are appropriate for you.

Research is mixed on the effectiveness of acupuncture as an erectile dysfunction cure, but one study published in November 2013 in the Journal of Alternative and Complementary Medicine found that acupuncture can be beneficial for men experiencing erectile dysfunction as a side effect of antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs).
The most common inflatable prosthesis is the three-piece penile prosthesis. It is composed of paired cylinders, which doctors surgically insert inside the penis. Patients can expand the cylinders using pressurized fluid (see figure 3). Tubes connect the cylinders to a fluid reservoir and pump, which doctors also surgically implant. The reservoir is usually in the pelvis. A doctor places the pump in the scrotum. By pressing on the pump, sterile fluid transfers from the reservoir into the cylinders in the penis. An erection is produced primarily by expansion of the width of the penis, however, one model can increase in length a small amount also. Lock-out valves in the tubing prevent the fluid from leaving the cylinder until a release valve is pressed. By pressing the relief valve and gently squeezing the penis, the fluid within the cylinders transfers back into the reservoir.
Similar to the general population (58), in subjects consulting for sexual dysfunction, T deficiency is progressively more prevalent as a function of age (50). In a series of 4,890 subjects consulting our Sexual Medicine and Andrology Unit for sexual dysfunction, one in five (19.6%) and one in three (29.4%) patients have total T below 10.4 and 12 nmol/L, respectively (60). Clinical correlates of T deficiency show different figures according to patient’s age. In fact, we previously demonstrated that in the youngest quartile (17–42 years old), but not in the oldest one (62–88 years old), severity of reported ED and penile blood flow impairment (dynamic peak systolic velocity) were not associated to decreasing testosterone levels (50). It is possible to speculate that, in young individuals, intercourse-related penile erection is such a complex phenomenon that other determinants (i.e., intrapsychic or relational) might mask its androgen regulation and that T deficiency produces greater sexual disturbances in subjects with greater frailty, such as older individuals. However, reported frequency of spontaneous erection and sexual thoughts were significantly decreased as a function of T decline even in younger subjects (50). Moreover, in young individuals low T was associated with a worse metabolic profile, including hypertriglyceridemia and increased waist circumference (50). Accordingly, the prevalence of MetS in the youngest quartile was clearly associated with T deficiency, as it was in the older quartiles (50). Therefore, T deficiency must be accurately verified in all subjects consulting for sexual dysfunction, even in the youngest ones.
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.

Since the decrease in T levels is often a consequence of obesity or weight gain (51), the milestone of treating testosterone deficiency in obese men is encouraging substantial lifestyle changes, including physical activity and weight loss. In fact, it is universally recognized that a low calorie diet or bariatric surgery can induce a significant increase in T plasma levels, reaching 10 nmol/L with the most invasive surgical procedures (62). Weight loss-induced T rise is more evident in young individuals (62), and, therefore, it must be strongly recommended in this age band.
What has been excluded entirely from all recent discussions of ED in young men is a concept presented many years ago—the concept of increased sympathetic tone as an organic etiology of “psychogenic” erectile dysfunction in young men (5). Previous studies have shown that elevated central sympathetic tone may be one cause of impotence (6,7). This article focuses on the presentation, work-up, and treatment of young men (age: 16–35 years old) with complaints of ED, and we will attempt to present a new method of approaching these patients. It is important to identify the precise etiology of ED in these men before proceeding with potentially unnecessary evaluation and treatment as the process can be anxiety-provoking, invasive, and costly and may provide an unreliable diagnosis which produces further psychological distress in these psychologically fragile young men.
Condom troubles. Can the simple act of putting on a condom cause so much stress that it actually leads to erectile dysfunction? Sure it can — in fact, one recent survey of 234 young men conducted by the Children's Memorial Hospital in Chicago found that 25 percent had lost an erection while putting on a condom. “Putting on a condom requires a break from stimulation, and when it is on, it can reduce sensation,” says Dr. Montague.

Erosion of the prosthesis, whereby it presses through the corporal tissue into the urethra, may occur. Symptoms and signs may include pain, blood in the urine, discharge, abnormal urine stream, and malfunction. If the prosthesis erodes into the urethra, a physician must remove it. If the other cylinder remains intact, it can be left in place. A physician leaves a catheter in place to allow the urethra to heal.


There are a number of reasons a man may not achieve the desired result from an oral erectile dysfunction drug. In some cases, a man may experience drug side effects severe enough to outweigh any potential benefit of taking the drug. Possible side effects of these drugs include headache, facial flushing, nasal congestion, and transient abnormal vision. (In October 2007, the FDA added a warning about sudden hearing loss to the package labels of oral erectile dysfunction drugs. While it’s not absolutely clear that the drugs can cause sudden hearing loss, a number of cases have been reported in men within hours or days of taking one of the drugs.)
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