"We think that if you have an active sex life it's probably an indicator of a healthy lifestyle, especially in the oldest quartile—those 70 to 80 years old," Andersson said. "From the perspective of a doctor, if a patient asks about erectile dysfunction drugs after a heart attack and has no contraindications for PDE5 inhibitors, based on these results you can feel safe about prescribing it."
Impotence, also known as erectile dysfunction or ED, is a very common problem, affecting up to half of 40-70 year old men in Australia.Treatment techniques for impotence 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 options for impotenceTreatment choices for erectile dysfunction include:medicines;self-injection therapy;devices such as vacuum pumps;penile implant surgery;hormone therapy; andcounselling.If you have erectile dysfunction, the treatment your doctor recommends will depend on the severity of symptoms and the underlying cause of your impotence.Your doctor will want to check that any conditions that could be contributing to or causing erectile dysfunction are being treated.Your doctor may also suggest that you make some lifestyle adjustments, such as:increasing the amount of physical activity you get;losing weight if you are overweight;reducing the amount of alcohol you drink;quitting smoking; andnot taking illicit drugs.These lifestyle recommendations can help improve impotence related to several causes and improve your health in general.Medicines for erectile dysfunctionThe first tablet available for erectile dysfunction, sildenafil (brand name Viagra), has been largely responsible for helping to bring the topic of erectile dysfunction out into the open. Similar medications — tadalafil (Cialis) and vardenafil ( Levitra) — are also available. These medicines all work in a similar way, although there is some difference in how long their effect lasts. Sildenafil, tadalafil and vardenafil belong to a group of medicines called phosphodiesterase type 5 (PDE5) inhibitors because they block the PDE5 enzyme.How do oral medicines help treat erectile dysfunction?PDE5 inhibitors help in the process of getting and keeping an erection by working on chemicals in the body that are involved in erections. These medicines 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 into the penis to cause an erection. When PDE5 is temporarily blocked by these medicines, it can’t break down the erection producing cGMP, so an erection can be achieved and maintained. PDE5 inhibitors can be used in the treatment of erectile dysfunction that is due to physical or psychological causes.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 PDE5 inhibitorsSide effects of these medicines can include headaches, flushes, blocked nose, indigestion and dizziness.In rare situations, sildenafil and vardenafil can cause a distortion of vision or change in colour vision.Tadalafil has been associated with back pain.Who can take medicines for impotence?PDE5 inhibitors cannot be taken by all men, so your doctor will need to evaluate your suitability before prescribing either of these medications.Men taking nitrates (often used to treat angina) should never take phosphodiesterase type 5 (PDE5) inhibitors. PDE5 inhibitors should also not be taken with some medicines used to treat high blood pressure.PDE5 inhibitors may also not be suitable for men with certain heart conditions or low blood pressure. Check with your doctor to find out if this type of medication may be suitable for you.Self-injection therapySelf-injection therapy delivers a medicine called alprostadil (brand name Caverject), 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.Self-injection therapy is usually recommended if PDE5 inhibitor medicines are not suitable or have not been effective in the treatment of erectile dysfunction.How to use self-injection therapyAlprostadil 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. Your doctor or urologist (specialist in problems with male reproductive organs and the urinary tract) will give you instructions on how to do this.Alprostadil should produce an erection in 5 to 20 minutes and, generally, the erection will last for 30 to 60 minutes.You should not use alprostadil 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 alprostadil, as your erection may last longer than is medically safe.Who can use self-injection therapy?You should ask your doctor if alprostadil is suitable for you. Your doctor will also be able to tell you how much alprostadil to use, depending on your condition and whether or not you are taking any other medications, and also how to use alprostadil properly.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 alprostadil.Men for whom sexual activity is not advised should not use alprostadil.Side effects of injection therapyThe most common side effects of alprostadil include pain in the penis or bruising in the penis at the site of injection. Fibrosis (the development of fibrous tissue) can also develop following injections into the penis.The most serious side effect is priapism (a persistent erection), which is a medical emergency. Your doctor will inform you of what to do if you have an erection that persists for 2 hours or more. It is very important that you follow your doctor’s instructions and inform them that you have experienced this side effect.Vacuum erection devicesVacuum 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.Penile implant surgery for impotencePenile 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.Vascular surgery for erectile dysfunctionIn cases where a man’s anatomy prevents blood flow into or out of the penis, vascular surgery may be an option. This treatment option is rarely recommended, and is usually only successful in younger men.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.Hormone treatments for impotenceIn a small number of men, blood tests may show abnormally low levels of testosterone, the male sex hormone. In such cases your doctor might prescribe a course of testosterone injections or a testosterone implant. The supplements can help boost sex drive as well as increasing the ability to have erections. Testosterone gel or patches, applied daily to the skin, are another option.Complementary medicines for erectile dysfunctionThere is a lack of scientific evidence supporting the effectiveness of complementary therapies for the treatment of impotence.Always check with your doctor before taking any herbal medicines or supplements for impotence. These formulations may contain ingredients that can interact with other medicines or cause dangerous side effects.Counselling for men with impotenceErectile dysfunction often has physical causes, but sometimes there is a psychological basis for erection problems. Often this is a form of performance anxiety. A man may have had an episode of erectile dysfunction due to some passing cause like fatigue, stress, relationship difficulty or intoxication. This may have led to embarrassment or a feeling of failure. Even if the physical cause does not remain, future attempts to have sex may trigger memories of this embarrassment and acute anxiety that it will happen again. This anxiety itself is capable of causing erectile dysfunction, and so a man 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, depression and low self-esteem, in fact, 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 skilled 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: 12 December 2016
Crossref | PubMed | Scopus (53) | Google ScholarSee all References This study found that, although hypertensive patients had more coronary artery disease, no direct evidence supported an association between hypertension and arteriogenic impotence, as measured by the PBI, peak systolic velocity, and resistive index, in patients with mild to moderate hypertension.
If your doctor says it's OK, you may be able to stop taking blood pressure medications temporarily to see if your sex life improves. To make sure your blood pressure remains within a safe range, you may need frequent blood pressure readings while you're not taking the blood pressure lowering medication that may be causing your sexual difficulties. This can be done with a home blood pressure monitoring device for convenience.
If your physician advises you that the risks of taking an erectile dysfunction medication are too high, he or she can advise you of other treatment options that can enable you to resume sexual activity without risks of complications. These might also include screening to try to determine if your erectile dysfunction has a physiological basis in need of medical intervention, can be corrected through lifestyle changes or if it may have psychological roots. After all, a heart attack or diagnosis of heart disease can lead to depression, which can also affect libido. Talk with your doctor to establish a safe, effective plan for resuming intimacy after your heart disease diagnosis.
There’s one more thing to remember: A visit to a physician can be helpful even if a man doesn’t want to go near Viagra or try one of the alternatives. In some cases, a treatable medical condition such as low testosterone or depression could explain a case of ED. “Sexual health should not be viewed as a luxury, but rather as an essential component to wellness,” said urologist Ryan P. Terlecki, MD, of Wake Forest Baptist Health in North Carolina.
The common associations between cardiovascular disease and ED have led some researchers to explore whether onset of ED can be an effective predictor of the presence of cardiovascular disease. A study of 40 patients with cardiac disease found an association between sexual dysfunction and the presence of cardiovascular disease, as well as a correlation between the severity of ED and the number of coronary arteries with extensive atherosclerosis.16x16Greenstein, A, Chen, J, Miller, H, Matzkin, H, Villa, Y, and Braf, Z. Does severity of ischemic coronary disease correlate with erectile function?. Int J Impot Res. 1997; 9: 123–126
Chronic heart failure often develops after other cardiac problems have damaged or weakened the heart, leaving it too weak or too stiff to fill and pump efficiently. Many underlying heart conditions can lead to heart failure. It can develop quickly after damage caused by a heart attack, or it can develop gradually after years of high blood pressure or coronary artery disease.

Apart from their beneficial effect in erectile dysfunction and their safe profile in antihypertensive medication, PDE-5 inhibitors have even more advantages to demonstrate. Several lines of evidence has proven that patients receiving PDE-5 inhibitors are more likely to initiate an antihypertensive regime and more willing to add a new agent to their existing treatment, a fact that raises significantly patient’s adherence and as a matter of fact control of high blood pressure and quality of life[63,64]. Moreover, a handful of clinical data has demonstrated the considerable vasodilating and anti-proliferative properties of PDE-5 inhibitors in the pulmonary vasculature, establishing them as a first-line treatment in patients with pulmonary arterial hypertension[65,66]. The same properties have been considered as potentially responsible for improving microcirculation in patients with secondary Raynaud phenomenon and ameliorating cardiopulmonary exercise performance in patients with heart failure[67,68]. In addition, the therapeutic implementation of PDE-5 inhibitors has expanded in the field of benign prostate hyperplasia-lower urinary tract symptoms (BPH-LUTS). The common pathophysiologic substrate between erectile dysfunction and BPH-LUTS has rendered PDE-5 inhibitors an effective treatment which significantly improves measures of both conditions while at the same time exhibits high efficacy and safety. The beneficial effect is much more pronounced when taking into consideration the fact that a-blockers, the mainstay of therapy for benign prostate hyperplasia frequently provoke sexual side effects, erectile dysfunction included[69].


In the early years of my cardiology practice, I was surprised by the number of men with heart disease who also suffered from impotence. In fact, being incapable of having an erection was the norm rather than the exception after heart attack. In those days, impotence was widely attributed to the psychological depression that often followed heart attack.

Testosterone therapy (TTh) should be reserved for patients who (i) are symptomatic (ED or reduced libido) of testosterone deficiency45 and (ii) they have biochemical evidence of low testosterone (TT <8 nmol/L or 2.3 ng/mL). In men with borderline TT (8–12 nmol/L or 2.3–3.5 ng/mL), a TTh trial (for 3–6 months and continuation if effective) may be envisaged. While adding a PDE5 inhibitor can be considered in men who have not improved with TTh, the usual clinical scenario is to add TTh in patients who have not responded to PDE5 inhibitors. Improvement is dependent on the testosterone levels with better results being obtained at lower levels of TT.45 Despite evidence of benefit in patients with pre-existing cardiovascular conditions (angina or heart failure), it should be emphasized that TTh is not a medication with cardiovascular indications.
Yohimbine is an indole alkaloid derived from the bark of the African yohimbe tree (33). Yohimbine has been noted to treat fatigue, depression, diabetes, and sexual dysfunction. A meta-analysis of seven placebo-controlled trials (34) deemed yohimbine superior to placebo for the treatment of ED with rare adverse events. The proposed mechanism of action (35) is via the inhibition of central alpha-2-adrenergic receptors, decreasing central inhibition of arousal, and increasing penile nerve stimulation resulting in increased NO. Common side effects include headache, sweating, agitation, hypertension and insomnia. Contraindications include patients on tricyclic antidepressants, anti-hypertensives and central nervous system stimulants.
Abstract | Full Text | Full Text PDF | PubMed | Scopus (95) | Google ScholarSee all References Since then, several other oral PDE-5 inhibitors have been developed, including vardenafil and tadalafil, which generated considerable interest in both the scientific and lay communities. There was also much concern about their safety, especially in men with cardiovascular disease. Compared with the 2 newer PDE-5 inhibitors vardenafil and tadalafil, sildenafil has been available for a much longer time; therefore, the vast majority of published cardiovascular safety studies have been performed on this medication. Recommended starting and maximum doses of oral PDE-5 inhibitors are shown in Table 1.
Erectile dysfunction is frequent in patients with established CAD with prevalence rates ranging between 47 and 75% in studies.2,4,14 The AssoCiatiOn Between eRectile dysfunction and coronary Artery disease (COBRA) trial tested the hypothesis that the ED rate differs in CAD patients according to the clinical presentation (acute vs. chronic coronary syndromes) and the extent of vessel involvement (one vs. two to three vessel disease)15 (Figure 3). The overall ED prevalence in CAD patients was 47%, whereas in the normal coronary angiography group the ED rate was 24%. When separately considered, the ED rate was 22% in patients with acute coronary syndromes (ACS) and one-vessel disease and 55 and 65% in patients with ACS and multi-vessel disease and with chronic coronary syndrome, respectively. The study also showed that both severity (IIEF <10) and duration (>24 months) of ED were predictive of severe coronary involvement at angiography. This study offers pathophysiological and mechanistic explanations related to the clinical setting. In patients with multi-vessel disease, regardless of the clinical presentation, the advanced coronary and systemic atherosclerosis is the reason for the high rate of ED. However, in the setting of acute myocardial infarction with one-vessel disease, ED is far less frequent because the atherosclerotic burden is modest (i.e. abrupt occlusion of a single non-obstructing plaque in the absence of extensive atherosclerosis) in both the coronary and penile circulations.15,16

Currently, the preferred treatment for erectile dysfunction includes sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis). However, numerous experts have raised concerns about the use of these drugs in patients with chronic heart failure who also take nitrates (or other medications that relax and widen blood vessels). This drug combination has been shown to be dangerous, because it can increase the risk for a life-threatening drop in blood pressure.
Because ED has several causes, sorting out exactly what is causing your problem may take some time. First, make sure your doctor knows about all the medicines you are using, including over-the-counter or herbal products. Drugs frequently used to treat high blood pressure, anxiety, depression, and peptic ulcers can all cause ED. But don’t stop taking any of your medications without first talking to your doctor.

Does drinking water improve erectile dysfunction? Erectile dysfunction or ED is a common concern for men. Everyday factors, such as hydration levels, may affect a person's ability to get or maintain an erection. Drinking water may, therefore, help some men with ED. In this article, learn about the link between hydration and ED, and other factors that can cause ED. Read now


Patients who use this therapy should be trained under the guidance of a urologist, and sterile technique must be used. The drugs must be injected into the shaft of the penis and into one of the penile erectile bodies (corpus cavernosum) 10–15 min before intercourse. Most patients do not complain of pain upon injection. Sexual stimulation is not required, and resulting erections may last for hours. Side effects include penile pain and priapism. The cost is about $12–20 per injection.
Crossref | PubMed | Scopus (24) | Google ScholarSee all References Almost every class of antihyper-tensive medication has been implicated in causing ED; however, most of these studies, published as case reports or patient surveys, have been relatively subjective and uncontrolled.4x4Feldman, HA, Goldstein, I, Hatzichristou, DG, Krane, RJ, and McKinlay, JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994; 151: 54–61

Cavallini, G., Modenini, F., Vitali, G., & Koverech, A. (2005, November). Acetyl-L-carnitine plus propionyl-L-carnitine improve efficacy of sildenafil in treatment of erectile dysfunction after bilateral nerve-sparing radical retropubic prostatectomy. Urology, 66(5), 1080-5. Retrieved from http://www.sciencedirect.com/science/article/pii/S0090429505006515


For oral erectile dysfunction medicines to work as desired, they must be used properly in the first place. This means taking the medicine 30–45 minutes before engaging in sexual intimacy; taking the drug on an empty stomach or at least avoiding a heavy or high-fat meal before taking the drug (this is especially important when using sildenafil); and engaging in adequate genital stimulation before attempting intercourse. Drinking small amounts of alcohol (one to two drinks) should not compromise the effectiveness of erectile dysfunction medicines, but larger amounts of alcohol can diminish a man’s ability to have an erection.
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