Is your erectile dysfunction due to psychological (stress, relationship problems, etc.) or physical factors? Your doctor may ask if you note erections at night or in the early morning. Men have involuntary erections in the early morning and during REM sleep (a stage in the sleep cycle with rapid eye movements). Men with psychogenic erectile dysfunction (erectile dysfunction due to psychological factors such as stress and anxiety rather than physical factors) usually maintain these involuntary erections. Men with physical causes of erectile dysfunction (for example, atherosclerosis, smoking, and diabetes) usually do not have these involuntary erections. Men with psychogenic erectile dysfunction may relate the onset of problems to a "stressor," such as failed relationship. Your doctor may suggest a test to determine if you have erections during sleep, which may suggest that there may be a psychological cause of the erectile dysfunction.
3. Are there physical causes of erectile dysfunction? Erectile dysfunction may be a symptom of underlying medical conditions, which if not detected may cause further medical problems. A prior history of cigarette smoking, heart attacks, strokes, and poor circulation in the extremities (for example, intermittent claudication or cramping in your leg[s] when you walk) suggest atherosclerosis as the cause of the erectile dysfunction. Loss of sexual desire and drive, lack of sexual fantasies, gynecomastia (enlargement of breasts), and diminished facial hair suggest low testosterone levels. A prior history of pelvic surgery or radiation and trauma to the penis/pelvis/perineum can cause problems with the nerves and blood vessels. Symptoms of intermittent claudication of the lower extremities with exercise may suggest a vascular problem as a cause of the erectile dysfunction.
#2 Physically exhausted. If you’ve been cranking it at the gym, haven’t been sleeping well, or you’ve been working your ass off at your job, getting tangled up with your lover for even more physically demanding activities may not sound ideal. Physical exhaustion has a direct effect on your ability to get aroused. The only fix for this one is to get some rest.
If you're regularly having trouble getting or maintaining erection and it's not situation specific (for instance, this happens whether you're with a partner or alone or watching porn or whatever), it could be a tip-off to a physiological problem. Diabetes, high cholesterol, high blood pressure, and cardiovascular issues can all present with erectile problems, says Paduch. That's because basically anything affecting your nerves or blood flow can impact your boners.
My boyfriend has a hard time getting and staying hard. It's obviously a difficult situation to talk about, but he says he feels pressure when he's with me (versus previous random hookups he wasn't invested in), so he psyches himself out. When we do have sex, I'm almost always really satisfied and I care a lot about him, both things I express in and outside of the bedroom. But the situation seems to be only getting worse. We've stopped having sex during the week because our busy lives mean we don't have an hour or more to devote to sex (which is sometimes what it takes), or we can't have sex at all because of what he's experiencing. I'm afraid this is going to continue to get worse, not only sexually but emotionally in our relationship. How can I help him fix this, and reassure him in the meantime that I care about him and want to support him?
Surgery: If neither drugs nor the vacuum pump works, your doctor may suggest surgery. With surgery, the doctor can place a device in your penis that will cause enough hardness for intercourse. In a few cases, infections may develop after the operation, and the doctor may have to remove the device. Another operation that may help you is rebuilding the blood vessels in the penis to increase blood flow into the penis or decrease blood flow out of the penis. These procedures can help you to get and maintain an erection.

Impotence: A common problem among men characterized by the consistent inability to sustain an erection sufficient for sexual intercourse or the inability to achieve ejaculation, or both. Impotence can vary. It can involve a total inability to achieve an erection or ejaculation, an inconsistent ability to do so, or a tendency to sustain only very brief erections.

What to do: Close your eyes and relax. If you're overly nervous, you may have triggered your sympathetic nervous system, the so-called "fight or flight" reaction your body has in intense situations. This can prevent you from having an erection for between five and 15 minutes. So go back to the foreplay stage. Kiss passionately. Caress. Perform oral sex. Don't rush things. Let your instinct take over. Remember; she's a person, just like you. 


Lemonaid Health services are provided by one of our three medical groups. All three medical groups do business as 'Lemonaid Health'. In all states other than Texas and Kansas, Lemonaid services are provided by LMND Medical Group, Inc., A Professional Corporation, doing business as Lemonaid Health. In Texas, Lemonaid services are provided by LMND Medical Group, A Professional Association, with registered office 1999 Bryan Street, Suite 900, Dallas, TX 75201. In Kansas, Lemonaid services are provided by LMND Medical Group, A Professional Association, with registered office 112 SW 7TH Street, Suite 3C, Topeka, KS 66603. Our team is based at 150 Spear Street, Suite 350, San Francisco, California 94105, USA. You can call us on +1 415 926 5818.
Erectile dysfunction (ED), also known as impotence, is the inability to achieve or sustain a hard enough erection for satisfactory completion of sexual activity. Erectile dysfunction is different from other health conditions that interfere with male sexual function, such as lack of sexual desire (decreased libido) and problems with ejaculation release of the fluid from the penis (ejaculatory dysfunction) and orgasm/climax (orgasmic dysfunction), and penile curvature (Peyronie's disease), although these problems may also be present. ED affects about 50% of men age 40 and over. This article focuses on the evaluation and treatment of erectile dysfunction.
Erectile dysfunction can be effectively treated with a variety of methods. Many patients and health care providers are unaware of these treatments, and the dysfunction thus often remains untreated, compounded by its psychological impact. Concurrent with the increase in the availability of effective treatment methods has been increased availability of new diagnostic procedures that may help in the selection of an effective, cause-specific treatment. This conference was designed to explore these issues and to define the state of the art.
Sexual dysfunction is highly prevalent in men and women. In the MMAS, 52% of the respondents reported some degree of erectile difficulty. Complete ED, defined as (1) the total inability to obtain or maintain an erection during sexual stimulation and (2) the absence of nocturnal erections, occurred in 10% of the respondents. Mild and moderate ED occurred in 17% and 25% of responders, respectively. [15]
Psychosexual counselling, or sex therapy, is an appropriate recommendation especially for men who are experiencing discord with their partner especially if the conflict is related to the man’s ED. Counselling usually consists of 5–20 sessions with counsellor. It is our recommendation that referral doctors treating men with ED make a referral to a psychotherapist or sex therapist who is certified by AASECT (American Association of Sexuality Educators, Counselors and Therapists) of certified sexuality educator.43
A lot of the time, the issue is a combination of both. For instance, cortisol – which is an important steroid hormone in the body – is released in greater amounts when we're stressed. It's supposed to briefly shut down non-essential functions like reproduction and fighting off illnesses whilst you deal with the danger at hand. However, the chronic and ongoing stress of modern life increases our background cortisol levels, activating the sympathetic system and stopping an erection.
Endocrine problems, though uncommon, should be considered in patients presenting with impotence. As a rule, impotence due to hypogonadism will be partial and accompanied by decreased libido. Hypothalmic–pituitary problems, which include tumors, are the most common endocrine disorders causing impotence, followed by primary gonadal failure from one of many causes. Poorly controlled diabetes with polyuria and polydypsia is an important reversible cause of impotence, as is hyperthyroidism. Certain drugs, alcohol included, can lead to impotence as a result of endocrine disturbances.

There are hundreds of medications that have the side effect of ED and/or decreased libido. Examples of drugs implicated as a cause of ED include hydrochlorothiazides and beta-blocking agents. Medications used to treat depression, particularly the SSRIs such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Prozac Weekly, Sarafem), fluvoxamine (Luvox, Luvox CR), paroxetine (Paxil, Paxil CR, Pexeva) and sertraline (Zoloft), may also contribute to ED.9 Bupropion (Wellbutrin) which has a predominant effect on blocking the reuptake of dopamine is an antidepressant with lower incidence of ED.10 The side effects of 5ARIs occurring in fewer than 5% of patients can include gynaecomastia, ED, loss of libido and ejaculatory dysfunction.11
Penile implants: This treatment involves permanent implantation of flexible rods or similar devices into the penis. Simple versions have the disadvantage of giving the user a permanent erection. The latest (and most expensive) device consists of inflatable rods activated by a tiny pump and switch in the scrotum. Squeezing the scrotum stiffens the penis, whether the person is aroused or not. The penis itself remains flaccid, however, so the diameter and length are usually less than a natural erection, and hardness is lacking, although it's sufficient for intercourse.
Now, there are lots of ways that you can reduce stress and anxiety in your life. One of those things you can do is exercising daily. Now, it doesn’t mean getting into a gym all the time, but it can just be doing sit-ups at home, long walks at the grocery store, bicycling, and if you can afford the gym, getting there maybe two to three days a week. But don’t forget, a healthy body equals a healthy mind. Meditation, yoga, breathing exercises– now, here’s where you can take a few moments to be centered and communicate with your inner self, peace. Healthy eating– now, taking control of the intake of what goes into your body makes you to start feeling better and looking better. That wellness is the opposite of anxiety. And treating issues and tackling things that are weighing you down, taking that very first step is liberating.
The National Institutes of Health Consensus Development Conference on Impotence was convened to address (1) the prevalence and clinical, psychological, and social impact of erectile dysfunction; (2) the risk factors for erectile dysfunction and how they might be used in preventing its development; (3) the need for and appropriate diagnostic assessment and evaluation of patients with erectile dysfunction; (4) the efficacies and risks of behavioral, pharmacological, surgical, and other treatments for erectile dysfunction; (5) strategies for improving public and professional awareness and knowledge of erectile dysfunction; and (6) future directions for research in prevention, diagnosis, and management of erectile dysfunction. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement.

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Some may use alcohol as a way to get into the mood and overcome some of the nerves associated with having sex, but too much of a good thing can actually backfire. In fact, having a long history of alcohol abuse may lead to long-term erectile dysfunction. As many as 70 percent of men with chronic erectile dysfunction also have a history of alcohol abuse.
Remember what I said before about how it's not you? Okay, sometimes it is you. But it's not that you're not sexy — it's that for men, as well as women, relationship problems (like fighting all the time, or having clashing expectations about where things are going) can severely mess up your sex drive and ability to become aroused. Which makes sense — if you're spending 90 percent of your time together fighting about whether you're going to move in, switching gears to make 10 percent of your time together into a sexy sex party is pretty damned difficult.
Three days after Michael was found to have a dangerously blocked coronary artery, surgeons inserted a stent to prop the artery open. Now he is keen to get more men going to their doctor to be checked up. "When it comes to sex, people keep things to themselves. But this is an easy way to catch heart problems at an early stage and treat them before the worst happens."
In patients who either fail to respond to first or second-line therapy, or are not interested in the conservative therapies, penile prosthesis implantation is available. Malleable and rigid implants were available for many years, but in 1973 the world of penile prosthetics took a giant leap forward with the advent of the inflatable penile implant. Most implants done nowadays are of the inflatable variety. Adverse events including malfunction and infection are rare, and patient satisfaction is very high.45

Conditions associated with reduced nerve and endothelium function (eg, aging, hypertension, smoking, hypercholesterolemia, and diabetes) alter the balance between contraction and relaxation factors (see Pathophysiology). These conditions cause circulatory and structural changes in penile tissues, resulting in arterial insufficiency and defective smooth muscle relaxation. In some patients, sexual dysfunction may be the presenting symptom of these disorders.
There have been some studies to suggest that a placebo effect that improves ED may work for some men. One study found that men taking an oral placebo pill showed as much improvement in ED symptoms as men who took actual medication to improve ED. Conversely, men who were given therapeutic suggestions to improve ED did not see signs of symptom improvement.
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early 15c., "physical weakness," also "poverty," from Middle French impotence "weakness," from Latin impotentia "lack of control or power," from impotentem (nominative impotens); see impotent. In reference to a want of (male) sexual potency, from c.1500. The figurative senses of the word in Latin were "violence, fury, unbridled passion." Related: Impotency.

Jenna finds working with and helping people on a daily basis combines her two greatest passions - health care and helping others to make a difference in their lives. Prior to Lemonaid, she was a Certified Nursing Assistant caring for senior citizens, had advocated and provided resources for the mentally ill, and also had customer service experience in the field of behavioral health. Jenna graduated from the University of Arizona with a degree in Psychology.


Vascular: Anything that affects the flow of blood to the penis can result in erectile dysfunction. The main culprit tends to be atherosclerosis, the condition that narrows arteries and which can result in poor blood circulation, high blood pressure, heart disease and stroke. Atherosclerosis causes about half the cases of erectile dysfunction in men over 50. Also, the veins through which the blood leaves the penis may not be working properly, allowing the blood to leave too soon.
You may already know that lots of hard drugs — like cocaine, heroin, or Oxycontin — can cause sexual problems (though, quite frankly, if you're on cocaine, heroin, or Oxycontin, you have many more pressing concerns to deal with than getting dirrrty). But did you know that sometimes, even pot can inhibit erections? And you thought weed was just a harmless way to enjoy the musical stylings of Pink Floyd. Who knew it could actually mess with one's own pink floyd?
Half of all men between the ages of 40 and 70 will experience erectile dysfunction. While the problem doesn't cause heart disease, the two often occur together – study after study has shown that men with ED are dramatically more likely to develop heart disease and have a heart attack or stroke. One German study from 2010 found men with erectile dysfunction are twice as likely to die within the next two years as those without, prompting some experts to call the phenomenon "the canary in the trousers".
The mechanisms by which testosterone plays a role in erectile function are not completely understood. A study evaluating the effect of testosterone on erections in surgically castrated rabbits and control animals, in which the rabbits’ intracavernosal pressures were compared after cavernosal nerve stimulation, determined that castrated rabbits had much lower pressures after stimulation than control rabbits did. [21] Notably, the pressures increased when castrated rabbits received exogenous testosterone replacement.
Because impotence can be due to health problems that can affect the whole body, and because it can interfere with one’s quality of life, it is important to talk with your doctor if you have trouble attaining or maintaining an erection. With increasing discussion of impotence in the media, coupled with advances in treatment, men are now much more comfortable talking with their doctors about impotence. It is currently estimated that between 15 and 30 million men in the United States are affected by impotence (Source: NIDDK).

Vacuum constriction devices may be effective at generating and maintaining erections in many patients with erectile dysfunction and these appear to have a low incidence of side effects. As with intracavernosal injection therapy, there is a significant rate of patient dropout with these devices, and the reasons for this phenomenon are unclear. The devices are difficult for some patients to use, and this is especially so in those with impaired manual dexterity. Also, these devices may impair ejaculation, which can then cause some discomfort. Patients and their partners sometimes are bothered by the lack of spontaneity in sexual relations that may occur with this procedure. The patient is sometimes also bothered by the general discomfort that can occur while using these devices. Partner involvement in training with these devices may be important for successful outcome, especially in regard to establishing a mutually satisfying level of sexual activity.
Just as certain meds can make it difficult for men to have an orgasm, some can keep the flagpole from even getting raised in the first place. Anti-depressant medications like Prozac and Zoloft, anti-anxiety pills like Valium, high blood pressure medicine like Diuril, and even over-the-counter cold medicines like Sudafed and anti-heartburn pills like Zantac can inhibit erections.

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.
Nearly every primary care physician, internist and geriatrician now understand that many older men retain an interest in sexual activity as they age. Some primary care physicians think that sexual potency in older men is the norm, and that if it is lacking, it is ‘all in the head.’ This viewpoint has not been supported by current literature. The Massachusetts Male Aging Study (MMAS) found that 52% of men between 40 and 70 years old reported having some form of erectile dysfunction (ED).1 The reality is that ED is a natural part of ageing and that the prevalence increases with age. In the MMAS, they found that roughly 50% of men at 50 years old, 60% of men at 60 years old and 70% of men at 70 years old had ED. Thus, nearly all men who live long enough should develop ED. The myths that surround the problems of impotence or ED confound the attempts of patients to receive treatment and the attempts of physicians to help them.1
Penile erection is managed by two mechanisms: the reflex erection, which is achieved by directly touching the penile shaft, and the psychogenic erection, which is achieved by erotic or emotional stimuli. The former uses the peripheral nerves and the lower parts of the spinal cord, whereas the latter uses the limbic system of the brain. In both cases, an intact neural system is required for a successful and complete erection. Stimulation of the penile shaft by the nervous system leads to the secretion of nitric oxide (NO), which causes the relaxation of smooth muscles of corpora cavernosa (the main erectile tissue of penis), and subsequently penile erection. Additionally, adequate levels of testosterone (produced by the testes) and an intact pituitary gland are required for the development of a healthy erectile system. As can be understood from the mechanisms of a normal erection, impotence may develop due to hormonal deficiency, disorders of the neural system, lack of adequate penile blood supply or psychological problems.[17] Spinal cord injury causes sexual dysfunction including ED. Restriction of blood flow can arise from impaired endothelial function due to the usual causes associated with coronary artery disease, but can also be caused by prolonged exposure to bright light.
Dr. Liou says that some men come to him after getting a prescription from their primary care doctors, claiming that the drug doesn't work. Sometimes it's because they used it incorrectly. "The biggest misconception is that these drugs are an on/off switch for erections," Dr. Liou says. But the drugs don't work well without sexual stimulation. "During that time, you need to be with your partner and have foreplay," Dr. Liou says. "Don't take it, do the taxes or the dishes, and then meet at the bedroom thinking you'll be ready to go. It's not like that."
Little is known about the natural history of erectile dysfunction. This includes information on the age of onset, incidence rates stratified by age, progression of the condition, and frequency of spontaneous recovery. There also are very limited data on associated morbidity and functional impairment. To date, the data are predominantly available for whites, with other racial and ethnic populations represented only in smaller numbers that do not permit analysis of these issues as a function of race or ethnicity.
An erection might last indefinitely if it weren’t for chemicals in the body called phosphodiesterases. They work at reversing the process trying to return the penis to being soft (i.e., flaccid). Usually there is a balance between the chemicals that result in an erection lasting for as long as it is needed, which allows the phosphodiesterases to do their job when they should and no sooner. You wouldn’t want an erection forever so it is a good thing that phosphodiesterases exist.
It is important that all erectile dysfunction is reported to your doctor, as sometimes it can be an indicator of something physically wrong with you that has to be treated. Also, your doctor is in the best position to find the reason for your erectile dysfunction. Routine questions and tests will provide a guide to the cause and allow your doctor to decide what kind of treatment you might need to deal with it. This may involve referral to a specialist. Detailed information can be found at the website of the Impotence Association – www.sda.uk.net
In men, erectile dysfunction can be defined as being a persistent inability to get or keep an erection that is firm enough to attain sexual satisfaction. It should not be confused with the occasional incident when this occurs, which is an experience common to the vast majority of men for various reasons. These can include having had too much alcohol to drink, being overly-anxious about a new sexual partner, or being worried about current events in your life. The issue would only be classed as Erectile Dysfunction if it keeps happening again and again. Again, an erection once attained should be hard enough and last long enough to be satisfactory. Other conditions, like premature ejaculation, may interfere in this process but these are different problems, and would be treated differently.
Patients receiving penile prostheses should be instructed in the operation of the prosthesis before surgery and again in the postoperative period. The prosthesis usually is not activated until approximately 6 weeks after surgery, so as to allow the edema and pain to subside. The prosthesis is checked in the office before the patient begins to use it.

The association of CVD and ED was noted in 1997 as one analysed the results of the MMAS. In this landmark study, 1709 men aged 40–70 years were enrolled between 1987 and 1989. A follow-up some 10 years later revealed a striking relationship between ED and CVD. In this study, it became clear that the risk factors for ED were very similar to those of CVD, such as diabetes mellitus, smoking and dyslipidaemia.18
Erectile dysfunction can occur as a side effect of medication taken for another health condition. Common culprits are high blood pressure meds, antidepressants, some diuretics, beta-blockers, heart medication, cholesterol meds, antipsychotic drugs, hormone drugs, corticosteroids, chemotherapy, and medication for male pattern baldness, among others.
The circulatory system plays a central role in obtaining and sustaining erections. Augmentation of blood flow to the corporal bodies depends on the intravascular pressure in the penile artery. Vascular lesions—typically atherosclerotic, but occasionally fibrotic—and systemic hypotension will limit flow to the corpora. In certain patients, blood flow at rest may be sufficient to obtain an erection but not sufficient to maintain it during intercourse, when the pelvic musculature places greater demands on a compromised blood supply.

Male/Female Perceptions and Influences. The diagnosis of erectile dysfunction may be understood as the presence of a condition limiting choices for sexual interaction and possibly limiting opportunity for sexual satisfaction. The impact of this condition depends very much on the dynamics of the relationship of the individual and his sexual partner and their expectation of performance. When changes in sexual function are perceived by the individual and his partner as a natural consequence of the aging process, they may modify their sexual behavior to accommodate the condition and maintain sexual satisfaction. Increasingly, men do not perceive erectile dysfunction as a normal part of aging and seek to identify means by which they may return to their previous level and range of sexual activities. Such levels and expectations and desires for future sexual interactions are important aspects of the evaluation of patients presenting with a chief complaint of erectile dysfunction.
Under normal circumstances, when a man is sexually stimulated, his brain sends a message down the spinal cord and into the nerves of the penis. The nerve endings in the penis release chemical messengers, called neurotransmitters, that signal the corpora cavernosa (the two spongy rods of tissue that span the length of the penis) to relax and fill with blood. As they expand, the corpora cavernosa close off other veins that would normally drain blood from the penis. As the penis becomes engorged with blood, it enlarges and stiffens, causing an erection. Problems with blood vessels, nerves, or tissues of the penis can interfere with an erection.
Although women tend to become more around by psychological stimuli, such as fantasies or romance novels, men tend to be more visual creatures, meaning they need to be able to actually see the object of arousal. Obviously, no two people are alike, so this is not a blanket statement, but scientific study after study over the years has shown this to be the norm.
A lot of guys don’t want to admit it, but not being able to get or keep an erection happens more often than you’d think. Guys usually have trouble getting or keeping an erection when they’re nervous, scared or worried about something. They might be worried about how they’ll “perform,” or they could be feeling guilty about having sex. They might be afraid of getting a sexually transmitted disease (STD), or, if they are with a girl, getting their partner pregnant. Drugs (including some anti-depressants) and alcohol can also prevent you from getting and/or maintaining an erection.

Monitoring erections that occur during sleep (nocturnal penile tumescence) can help you and your doctor to understand if the erectile dysfunction is due to psychological or physical causes. The nocturnal penile tumescence test is a study to evaluate erections at night. Normally men have three to five erections per eight hours of sleep. The test can be performed at home or in a sleep lab. The most accurate way to perform the test involves a special device that is connected to two rings. The rings are placed around the penis, one at the tip of the penis and the other at the bottom (base) of the penis. The device records how many erections occur, how long they last, and how rigid they are. The test is limited in that it does not assess the ability to penetrate.

Cosgrove et al reported a higher rate of sexual dysfunction in veterans with posttraumatic stress disorder (PTSD) than in veterans who did not develop this problem. [42] The domains on the International Index of Erectile Function (IIEF) questionnaire that demonstrated the most change included overall sexual satisfaction and erectile function. [43, 44] Men with PTSD should be evaluated and treated if they have sexual dysfunction.


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]
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