According to the Alternative Medicine Review, as many as 30 million men are affected by erectile dysfunction.
You are not alone.
If you are having trouble getting or maintaining an erection, there are many benefits to seeking treatment. Not only is erectile dysfunction highly treatable, it is also sometimes the first symptom of cardiovascular disease or heart attack risk. Treatment for erectile dysfunction can often address these serious conditions, leading to a better sex life, better quality of life, and healthier life overall…
The National Institutes of Health defines erectile dysfunction as a condition “where a man has trouble getting or keeping an erection.” A variety of physical, psychological, and relational causes contribute to erectile dysfunction. Still, older men are more likely to suffer from ED (erectile dysfunction) than younger men. According to the Postgraduate Medical Journal, erectile dysfunction affects roughly 50% of men by age 50, 60% of men at age 60, and 70% of men at age 70. The British Journal of Clinical Pharmacology notes that as many as 30% to 50% of all men may have difficulty maintaining or getting an erection.
What causes erectile dysfunction?
Sexual health is complex and involves a range of psychological and physical factors. Erection takes place when the penis fills with blood, but a range of complex, automatic processes must also take place for this to happen. Nerves release nitric oxide into the penis, which causes the smooth muscle in the arteries of the penis to relax. As the smooth muscle in these arteries relax, the penis fills with blood. As the penis fills with blood, the veins that drain blood are compressed and the erection is maintained.
Let’s start by offering a quick overview of the common causes of erectile dysfunction. They include:
- Cardiovascular conditions, including hypertension
- Prostate gland enlargement
- Urinary tract issues
- Surgical treatments for cancer, particularly prostate cancer
- Nerve damage due to injury or other causes
- Certain types of medications
- Endocrine issues, including low testosterone
- Psychological factors
Certain types of medications, surgeries, or treatment for diseases can cause erectile dysfunction. Medical conditions including hypertension and cardiovascular disease can lead to the development of erectile dysfunction, and in some cases, erectile dysfunction can be an indicator that a patient might be suffering from a “silent” cardiovascular condition.
According to the Postgraduate Medical Journal, doctors are advised to evaluate men with erectile dysfunction for silent cardiovascular disease. The arteries in the penis are very sensitive and erectile dysfunction could be an early warning sign for cardiovascular conditions and for the risk of heart attack. In fact, patients with cardiovascular conditions first developed symptoms of erectile dysfunction, on average, three years before experiencing cardiac symptoms.
Not all men seek help for erectile dysfunction (according to the Alternative Medicine Review). Only 10 percent of men seek treatment for erectile dysfunction, or ED) and not all men talk to their doctors about the condition. Given that ED can be an early warning sign of heart attack and cardiovascular issues, it might be a good idea to talk to your doctor as soon as possible if you are experiencing erectile dysfunction. Hardening of the arteries and narrowing of the arteries associated with cardiovascular conditions can lead to reduced blood flow, which is required for an erection to occur.
Cardiovascular disease is not the only physical cause of erectile dysfunction. Diabetes can affect blood vessels and nerves in the penis. Obesity can lead to reduced sex drive and erectile dysfunction. According to Nature Reviews Disease Primers, prostate gland enlargement and urinary tract issues have also been implicated in erectile dysfunction. Certain types of medications can also cause erectile dysfunction. The Postgraduate Medical Journal notes that these medications include beta blockers, hydrochlorothiazides, SSRIs, depression medications, treatments for prostate cancer, hormone therapy, radiation therapy, and surgical treatments for prostate cancer.
In addition to physical causes, erectile dysfunction can stem from psychological causes. Performance anxiety, traumatic experiences, relationship problems, anxiety, depression, and stress can also cause erectile dysfunction. Hormonal imbalances, low testosterone, and androgen deficiency can also lead to erectile dysfunction. Sometimes erectile dysfunction needs to be approached from the perspective of the couple. Menopause in women can impact sexual desire and have an impact on a couple’s sexual dynamic. Erectile dysfunction can cause problems in a man’s relationships, mood, and quality of life. When treating a patient for erectile dysfunction, a doctor will usually take a full medical assessment. Nature Reviews Disease Primers notes that younger men suffering from erectile dysfunction are more likely to have the condition due to psychological factors, but that physical factors need to be taken into account.
How can you tell if your erectile dysfunction is due to psychological causes or physical causes? A doctor can provide the best assessment, but according to Nature Reviews Disease Primers, psychological erectile dysfunction happens suddenly and is situational (a patient can maintain an erection in some situations and not in others). Physical erectile dysfunction gets progressively worse over time, involves consistent inability to get or maintain an erection, and the erection may be better when the patient is standing up.
Physical factors most commonly contribute to erectile dysfunction in older men. Men with physical causes for their erectile dysfunction can be divided into those suffering from endocrine disorders and cases that are non-endocrine-related. The most common non-endocrine-related cause of erectile dysfunction involves blood-flow issues. If you suffer from erectile dysfunction, your treatment options will depend on the cause of your erectile dysfunction. The first line treatment for erectile dysfunction is to treat the underlying condition and prescribe lifestyle changes that can often lead to improved erections. Men suffering from erectile dysfunction may be advised to seek counseling because ED stemming from physical causes can still have a psychological impact. Let’s explore the various treatment options for erectile dysfunction available, starting with the first-line treatments, and then moving on to second-line therapies, which are often prescribed for patients when first-line therapies don’t work.
Lifestyle Changes & Treating Underlying Conditions of Erectile Dysfunction
Because erectile dysfunction is often a symptom of another medical condition, first-line treatments will involve addressing the causes of your erectile dysfunction and treating these conditions. For example, if you are suffering from erectile dysfunction due to cardiovascular issues, your doctor will likely prescribe medication and changes to your diet that may be able to improve your condition. Lowering your weight if you are obese can also improve your sex life because obesity is linked to sexual dysfunction and erectile dysfunction. If prescription drugs like depression medications are impacting your ability to maintain or get an erection, your doctor may be able to help you find alternative medications that may have less of an impact on your sex life. If your doctor believes that psychological factors or relational factors may be contributing to your ED, you may be referred to a counselor. Couples who attend counseling together are more likely to see positive results than those who seek counseling individually, when erectile dysfunction is the issue.
Sometimes simple changes to lifestyle can improve your ability to maintain and get an erection. According to Nature Reviews Disease Primers, 30-minutes of moderate intensity exercise every day, most days of the week, coupled with switching to a Mediterranean diet high in whole grains, legumes, vegetables, fruits, and a diet low in red meat, full-fat dairy products, and sugar is associated with lower levels of erectile dysfunction. The more active you are, the less likely you are to suffer from erectile dysfunction.
Reducing your alcohol intake and quitting smoking can also improve your ability to get and maintain an erection. While mild alcohol use can help with performance anxiety, chronic alcohol abuse or overuse can lead to erectile dysfunction. Drugs like marijuana and other illicit substances can also impact your ability to get or maintain an erection.
Certain medications can also impact a man’s ability to get or maintain an erection. What are some medications associated with erectile dysfunction? According to Nature Reviews Disease Primers, medications that can affect your erection include:
- “Thiazide diuretics, β-blockers and spironolactone used to treat hypertension.”
- “Digoxin used to treat atrial fibrillation.”
- “5α-reductase inhibitors used to treat benign prostatic hyperplasia.”
- “Anti-androgens used to treat prostate cancer.”
- “Luteinizing hormone-releasing agonists and antagonists used to treat prostate cancer.”
- “Tricyclic antidepressants, selective serotonin reuptake inhibitors, benzodiazepines, antipsychotics and phenytoin used to treat depression and other psychiatric conditions.”:
- “H2 blockers used to treat ulcers.”
- “Opiates used to treat pain.”
Changing medications, changing your habits, and changing your diet may be able to naturally improve your ability to get and maintain an erection. Because diet can be a big factor in sexual health, some men choose to take natural and herbal remedies for erectile dysfunction. What are some natural and herbal options for men experiencing erectile dysfunction? Let’s explore.
Herbal & Natural Remedies for Erectile Dysfunction
When it comes to choosing an herbal remedy for erectile dysfunction, it is important to have realistic expectations about what an herbal or natural remedy can offer. While some supplements have been studied and have been found to have some health benefits when it comes to erectile dysfunction treatment, there is no single supplement that can offer the exact same benefits as a medication like Viagra. Many men might try herbal remedies before trying medications, but because erectile dysfunction can sometimes be an early indication of other serious medical conditions, men should always talk to their doctor before trying any remedy.
When choosing to use herbal remedies for erectile dysfunction, it is important to do your research. The U.S. Food & Drug Administration notes that some supplements labeled to treat erectile dysfunction have been found to contain medication or have been flagged for having labels that don’t match the ingredients in the bottle; the FDA website contains a list of supplements to avoid.
Yet, some herbal remedies have been studied and show promise for treating erectile dysfunction. What are some herbal remedies that may work? L-Arginine, ginseng, Tribulus Terrestris, L-carnitine, yohimbe, and ginkgo biloba have each been found to have potential benefits in improving erections, sexual satisfaction, and ability for men to maintain an erection. Of course, not all men respond the same to herbal remedies (in the same way that all men don’t respond the same to medications). And, men should consult with their doctors before beginning a course of treatment in herbal medicine, because some of these medications can interact with prescribed drugs or have potential side-effects, or other health risks. That said, let’s take a look at the herbs known to help with erectile dysfunction:
- L-Arginine: There aren’t many studies showing that L-arginine alone can improve erections, but a study in the Journal of Sex & Marital Therapy found that L-arginine, when taken along with pycnogenol (which is found in the bark of pine trees and witch hazel trees), led to improved sexual functioning in patients. Alternative Medicine Review also noted that L-arginine appears most effective when used in conjunction with other treatments.
- Ginseng: For more than 5,000 years, ginseng has been used as an herbal medicine in ancient Chinese herbal practice. For thousands of years, ginseng has been used as an aphrodisiac, and to treat erectile dysfunction. Ginseng was one of the 365 medicinal herbs written about in the classic Chinese text, the Shen Nung Benchau Jing, and it is also mentioned in ancient Vedic texts. According to the Indian Journal of Urology, ginseng contains phytoestrogens, chemicals which play a role in libido and sexual desire. However, ginseng can also have serious side effects and serious drug interactions (including headache, sleep dysfunction, gastrointestinal issues and more serious drug interactions), so patients should consult with their doctor before taking ginseng to treat erectile dysfunction. According to the Asian Journal of Andrology, patients who took 1000 mg of Korean red ginseng three times daily saw improvement in erectile dysfunction symptoms. Another study published in the International Journal of Impotence Research found that 60% of men who took Korean red ginseng saw improvement in their ability to maintain an erection. The longer men took Korean red ginseng, the stronger the improvement, but individuals should take these results with a grain of salt, because taking ginseng didn’t result in complete remission, and the results were modest. In a systematic review of various studies on the effectiveness of ginseng in treating erectile dysfunction, the writers for the British Journal of Clinical Pharmacology noted that Korean red ginseng appeared to be effective in improving erectile dysfunction in patients treated. However, the researchers noted that there are different types of ginseng (three types: fresh ginseng, white ginseng, and Korean red ginseng), and Korean red ginseng was found to be the most effective. It isn’t really clear why Korean ginseng works, but some researchers believe that it may have hormonal effects similar to testosterone or that it may aid in relaxing the smooth muscle of the penis, required for an erection to occur and be maintained.
- Tribulus Terrestris: The effectiveness of Tribulus Terrestris in treating erectile dysfunction has sometimes been supported and sometimes been disputed depending on the study you’re looking at, but it appears that Tribulus Terrestris can have some impact on sexual desire and libido. Tribulus Terrestris has been used historically as an aphrodisiac and to treat male infertility in traditional medicine. According to a paper written in the 6th Biennial Asian-Pacific Meeting on Impotence in Kuala Lumpur, protodioscin is a chemical found in Tribulus Terrestris that is known to treat male infertility. In particular, men with diabetes who suffer from erectile dysfunction may have lowered levels of DHEA-S. Tribulus Terrestris may be able to increase DHEA-S levels, leading to increased instances of successful intercourse. Another paper in the Journal of Ethnopharmacology found that Tribulus Terrestris can have a positive effect on male erection, though the reasons why this is so are unclear.
- L-Carnitine: Research suggests that L-carnitine, when taken in conjunction with other medications or herbs could improve the results of patients suffering from erectile dysfunction. According to research published in the journal Andrologia, 40% of patients saw improvements in their erections when they took a formulation that included L-carnitine, L-arginine, and niacin. Another study published in Current Medical Research and Opinion found that L-carnitine, when taken together with medications like Viagra, could lead to greater effectiveness of both drugs when treating erectile dysfunction patients with diabetes.
- Yohimbe: While yohimbe has been used as an aphrodisiac and is available with a prescription, research indicates that individuals should take this medicine with great caution. Alternative Medicine Review found that yohimbe may not be more beneficial in treating erectile dysfunction than a placebo when studied in a clinical setting. The side effects of yohimbe have also not been robustly studied for their potential toxicological or cancer effects. The National Institutes of Health notes that yohimbe is an evergreen tree native to western Africa which has been used as an aphrodisiac and as a dietary supplement to treat impotence. Few studies have been done on its benefits, according to NIH, but we have documented instances where yohimbe can pose a heart attack and seizure risk, as well as increase the risk of stomach problems and high blood pressure.
- Ginkgo: According to the Alternative Medicine Review, research indicates that gingko may be able to reduce sexual dysfunction caused by SSRIs and antidepressant medications. Ginkgo may be able to increase levels of serotonin responsible for erections. Research indicates that ginkgo may be as much as 76% effective in reducing symptoms of erectile dysfunction when 40-60 mg capsules of gingko were taken daily. Another study published in the Journal of Sex Education and Therapy found that 19 patients out of 30 were able to maintain erections after taking 240 mg of gingko over a nine-month period. Yet, other studies dispute these results, so more research needs to be done.
- ArginMax: In a small study performed at the University of Hawai’i, researchers found that ArginMax, a blend of herbs that includes L-arginine, American ginseng, Korean ginseng, and gingko, was able to improve patients’ ability to maintain an erection in 88.9% of cases in those suffering from mild to moderate erectile dysfunction. If you recall from our earlier discussion of how an erection takes place, nitric oxide is a key factor in relaxing the muscles in the arteries of the penis, which then results in increased blood flow and erection. L-arginine is needed to make nitric oxide, which could help improve erections. The Los Angeles Times reported on ArginMax and noted that “the company website provides links to actual scientific studies published in real medical journals, a rarity in the world of libido remedies.” Beverly Whipple, a professor at Rutgers University noted that ArginMax is one of the few supplements on the market supported by placebo-controlled clinical trials.
Patients may want to speak to their doctor before taking herbal remedies and making any major dietary changes because many of the active ingredients in these herbal remedies can interact with other drugs. And, when lifestyle changes or herbal remedies don’t work, many patients try medications as their next line of treatment. What medications are available and how do they work? Let’s take a closer look.
Medications for Erectile Dysfunction
Medications known as PDE5 inhibitors are used to treat erectile dysfunction. These include some of the most popular erectile dysfunction drugs on the market, including Viagra, Levitra, Cialis, and Stendra. PDE5 inhibitors work by enhancing the effects of nitric oxide, the chemical that lets the muscles in the arteries of the penis relax and fill with blood. According to the Mayo Clinic, there are four main types of medications for erectile dysfunction: sildenafil, vardenafil, tadalafil, and avanafil. While each of these types of medications are PDE5 inhibitors, they each have a distinct chemical composition and work differently.
- Sildenafil (for example, Viagra) must be taken one hour before sex without food, and is effective for four to five hours.
- Vardenafil (for example, Levitra) must be taken one hour before sex without food and is effective for four to five hours.
- Tadalfil (for example, Cialis) must be taken one to two hours before sex and is effective for 36 hours, and can be taken with food.
- Avanafil (for example, Stendra) must be taken 30 minutes before sex and is effective for 6 hours, and can be taken with food.
Each patient will respond differently to these drugs, so choosing which one is best will depend on your individual needs and a conversation with your doctor. According to Harvard Health Publishing, avanafil and tadalfil are seen as allowing for more “spontaneous” sex, while sildenafil and vardenafil require more planning. Patients taking these medications should also be aware that they can’t just pop a pill and expect results. Foreplay and stimulation are required. When these medications don’t work, second-line treatments include urethral suppositories and erectile dysfunction injections. According to the Cleveland Clinic, urethral suppositories are inserted into the urethra directly and dosages are patient-dependent. Erectile dysfunction injections require the patient to inject medication themselves into the penis, according to Healthline. Erection follows in five to fifteen minutes after the injection is administered, and erectile injections are among one of the most reliable ways to induce erection with medications. Yet, because of the risks (not to mention pain) involved with injecting yourself in the penis, injections are considered second-line therapy, used only when oral medications or suppositories don’t work.
What About Testosterone Therapy for Erectile Dysfunction?
Before medications like Viagra entered the market, testosterone treatment was once the treatment of choice for erectile dysfunction, according to Harvard Health Publishing. Testosterone is the hormone responsible for male sexual response and desire, and is a critical hormone needed for getting and maintaining an erection. Generally, testosterone treatment is now only used when a patient has low testosterone levels. How do you know if you might be suffering from low testosterone levels? According to Healthline, 300 nanograms per deciliter is considered low testosterone. A blood test can reveal what your testosterone levels are. Symptoms of low testosterone include low sex drive, difficulty maintaining an erection, low mood, low semen volume, low energy, hair loss, fatigue, increased body mass with loss of muscle mass, mood changes, memory changes, smaller testicles, and even anemia.
Testosterone therapy in some patients can produce good results. The upside of testosterone therapy is that when it works, patients no longer need to take a pill right before sex, allowing for more spontaneous sexual encounters. Some patients who take testosterone therapy report better moods and improved energy as well. However, there are downsides to testosterone therapy, making testosterone therapy not right for most patients. According to Current Opinion in Urology, testosterone therapy may not help men suffering from severe erectile dysfunction. PDE5 inhibitors are often more reliable than testosterone therapy when it comes to helping men get and maintain an erection. Finally, according to the Postgraduate Medical Journal, testosterone therapy can potentially increase a patient’s risk of having a heart attack. Because erectile dysfunction patients may be at increased risk of heart attack due to the connection noted between cardiac conditions and erectile dysfunction, this risk needs to be taken seriously. Prostate cancer patients may also want to avoid testosterone therapy due to prostate cancer risks.
Other Erectile Dysfunction Treatments
Other erectile dysfunction treatments include the use of a penis pump or a penile implant. These treatments are usually used when medication doesn’t work or when patients can’t tolerate erectile dysfunction medication well. With a penis pump, a tube is placed over the penis, and the pump creates a vacuum effect, causing blood to fill the penis. Once the penis is erect, a ring is placed around the penis to maintain the erection. The effects of a penis pump last about 30 minutes and it isn’t advised for patients to use the device for longer. According to Healthline, use of a penis pump isn’t for everyone. Patients with blood disorders or those on blood thinners may not be good candidates, and those with a history of blood clots may also not want to use a penis pump. While you don’t need a prescription for a penis pump, if you are thinking of using one to treat erectile dysfunction, a prescription could help you find the right model for your needs and even allow you to have the pump covered by your insurance company.
Penile implants or penile prosthesis involve the surgical implantation of inflatable or flexible rods inside the penis. A pump, hidden in the scrotum, when pumped, causes the pump to inflate, resulting in an erection. Penile implants are used when all other methods of treating erectile dysfunction fail, and implants are not a solution for those suffering from erectile dysfunction due to a psychological condition, lack of sexual desire, urinary tract issues, or other issues with the penis or scrotum that may be reversed. There are several types of implants on the market, according to Healthline. The three-piece inflatable implant requires the most extensive surgery, but results in the most rigid erection. The two-piece inflatable implant requires less-extensive surgery, but doesn’t produce as rigid an erection. The semirigid implant stays firm at all times, and is less likely to malfunction, but is also more difficult to conceal because it is always erect. Penile implants have a 90-95% success rate. Patients who were able to orgasm before the implant, should still be able to orgasm after the implant has been surgically placed.
Key Takeaways for Erectile Dysfunction:
Many men suffer from erectile dysfunction, but only a small proportion of men seek treatment for the condition and others may try to self-treat. Fortunately, erectile dysfunction is a highly-treatable condition. Many men can see results by making lifestyle changes or changes to their diet, while other men may need medical interventions. Oral medications are often tried first, followed by injections, suppositories, penis pumps, and penile implants.
The most important thing to remember is that erectile dysfunction can be an early warning sign of a heart attack or cardiovascular condition. It should never be ignored. In many cases, your doctor may be able to address your underlying condition, and therefore treat your erectile dysfunction as well—and possibly save your life in the process.