ED is defined as the inability to achieve a full erection or the inability to maintain an erection adequate for sexual intimacy. Other types of sexual dysfunction such as premature ejaculation and low libido may occur; however, the most common and disruptive problem in men is ED. Although most men will experience periodic episodes of ED, these episodes tend to become more frequent with advancing age.


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The most important organic causes of impotence are cardiovascular disease and diabetes, neurological problems (for example, trauma from prostatectomy surgery), hormonal insufficiencies (hypogonadism) and drug side effects. Psychological impotence is where erection or penetration fails due to thoughts or feelings (psychological reasons) rather than physical impossibility; this is somewhat less frequent but can often be helped. In psychological impotence, there is a strong response to placebo treatment.
Achieving an erection is a complicated process, requiring transmission of sensations from the genital area to the nervous system and the return of nervous impulses to the muscles and blood vessels of the penis. Anything that interferes with this interchange, such as disease or injury of the blood vessels, muscles, or nerves, can make achieving and maintaining an erection difficult. Psychological factors, such as anxiety and depression, can also interfere with erectile function. Anxiety and depression may also develop as a consequence of impotence.

In order to establish whether normal erections are occurring overnight (nocturnal erections), the doctor may organise nocturnal penile tumescence (NPT) testing. This involves wearing a monitor overnight in your own home. The data from this monitor is then assessed to analyse how often erections occurred, how long they lasted, and how rigid and large the penis was during the erections. If NPT testing is normal, the cause of erectile dysfunction is usually psychological. If not, further testing of the blood flow in the genital area may be required to see if there is blockage or leakage. The doctor may also organise a blood test of levels of hormones such as testosterone, prolactin and thyroid stimulating hormone to see if these are contributing to the erectile dysfunction.


Pills such as Viagra® are the most common ED treatment, but they don’t work for everyone. Some guys find they cause bothersome headaches or persistent stomach troubles. Some have serious side effects such as chest pain and vision or hearing changes. Others don’t respond to the medication at all. And still others don’t like having to wait for the pill to take effect.
Another common problem for men who have trouble in the bedroom is substance use or abuse. In some cases, a man suffering from erectile dysfunction may be diagnosed with depression and be prescribed selective serotonin reuptake inhibitors, or SSRIs. These medications may be able to assist in alleviating the symptoms of depression, but they can also lead to erectile dysfunction.
Taking one of these tablets will not automatically produce an erection. Sexual stimulation is needed first to cause the release of nitric oxide from your penile nerves. These medications amplify that signal, allowing some men to function normally. Oral erectile dysfunction medications are not aphrodisiacs, will not cause excitement and are not needed in men who get normal erections.
Many men gain potency by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marked as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, sometimes can enhance erection when rubbed on the surface of the penis.
Other hormone levels: Measurement of other hormones beside testosterone (luteinizing hormone [LH], prolactin level, and cortisol level) may provide clues to other underlying causes of testosterone deficiency and erectile problems, such as pituitary disease or adrenal gland abnormalities. Doctors may check thyroid levels in some individuals as both hypothyroidism (low thyroid function) and hyperthyroidism (overactive thyroid function) can contribute to erectile dysfunction.
For some patients with an established diagnosis of testicular failure (hypogonadism), androgen replacement therapy may sometimes be effective in improving erectile function. A trial of androgen replacement may be worthwhile in men with low serum testosterone levels if there are no other contraindications. In contrast, for men who have normal testosterone levels, androgen therapy is inappropriate and may carry significant health risks, especially in the situation of unrecognized prostate cancer. If androgen therapy is indicated, it should be given in the form of intramuscular injections of testosterone enanthate or cypionate. Oral androgens, as currently available, are not indicated. For men with hyperprolactinemia, bromocriptine therapy often is effective in normalizing the prolactin level and improving sexual function. A wide variety of other substances taken either orally or topically have been suggested to be effective in treating erectile dysfunction. Most of these have not been subjected to rigorous clinical studies and are not approved for this use by the Food and Drug Administration (FDA). Their use should therefore be discouraged until further evidence in support of their efficacy and indicative of their safety is available.

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Dr Kenny du Toit is a urologist practicing in Rondebosch, Cape Town. He is also consultant at Tygerberg hospital, where he is a senior lecturer at Stellenbosch University. He is a member of the South African Urological Association, Colleges of Medicine South Africa and Société Internationale d’Urologie. Board registered with both the HPCSA (Health professions council of South Africa) and GMC (General medical council UK). He has a keen interest in oncology, kidney stones and erectile dysfunction.http://www.dutoiturology.co.za
Impotence, or erectile dysfunction, is the inability of a male to attain and keep an erection sufficiently firm to engage in or complete sexual intercourse. Although it is more common in older men, impotence can occur at any age. Impotence is not a normal consequence of aging. About 70% of erectile dysfunction is due to diseases such as diabetes and atherosclerosis, another 10% to 20% is due to psychological factors, and the remaining percentage is related to medications, lifestyle factors, and injury (Source: NIDDK).
Aging, liver and kidney problems, and concurrent use of certain medications (such as erythromycin [an antibiotic] and protease inhibitors for HIV) slows the metabolism (breakdown) of sildenafil. Slowed breakdown allows sildenafil to accumulate in the body and potentially may increase the risk of side effects. Therefore, in men over 65 years of age, in men with significant kidney and liver disease, and in men who also are taking medications called protease inhibitors, the doctor will initiate sildenafil at a lower dose (25 mg) to avoid accumulation of sildenafil in the body. A protease inhibitor ritonavir (Norvir) is especially potent in increasing the accumulation of sildenafil, thus men who are taking Norvir should not take sildenafil doses higher than 25 mg and at a frequency of no greater than once in 48 hours. Other medications that may affect the level of sildenafil include erythromycin and ketoconazole.
Stress is another factor that can be a cause or effect of ED. If you're stressed at work, at home, and in your relationships, it's going to take a toll on your sexual function. Your mind is elsewhere, and relaxing when you finally make it between the sheets is a long shot. Now you’re stressed because you can’t get it up (talk about the ultimate catch-22), so you're stuck in this sad, frustrating cycle. “ED really affects the psyche of a guy, regardless of the etiology, Gittens says. “If you have a problem getting an erection one night, you’re probably going to be anxious and worried your partner might see you as less of a man the next time you try to get an erection.” There's a pill that will help with this, and it's not promoted on television with middle-aged men in sports cars. It's a damn chill pill.
Effective treatment for erectile dysfunction is available, and for most men will allow the return to a fulfilling sex life. The side effects of the treatment for erectile dysfunction vary depending on the treatment that is used. Some may interrupt the spontaneity of sexual activity. For example, PDE-5 inhibitors typically need to be taken one hour before sex. Side effects may include headaches, indigestion, vasodilation, diarrhoea and blue tinge to vision. Other treatments such as penile injections may cause pain at the injection site, or an erection that will not go down. Treatment options need to be carefully discussed with your doctor to determine which one is best suited to you.
Years ago, the standard treatment for impotence was an implantable penile prosthesis or long-term psychotherapy. Although physical causes are now more readily diagnosed and treated, individual or marital counseling is still an effective treatment for impotence when emotional factors play a role. Fortunately, other approaches are now available to treat the physical causes of impotence.
Besides treating the underlying causes such as potassium deficiency or arsenic contamination of drinking water, the first line treatment of erectile dysfunction consists of a trial of PDE5 inhibitor (such as sildenafil). In some cases, treatment can involve prostaglandin tablets in the urethra, injections into the penis, a penile prosthesis, a penis pump or vascular reconstructive surgery.[1]
Having erection trouble from time to time isn't necessarily a cause for concern. If erectile dysfunction is an ongoing issue, however, it can cause stress, affect your self-confidence and contribute to relationship problems. Problems getting or keeping an erection can also be a sign of an underlying health condition that needs treatment and a risk factor for heart disease.
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