Treatment of Erectile Dysfunction

Can erectile dysfunction be treated?

Yes. Almost every man with ED can be helped. Treatment is usually given step by step, starting with the simplest options and moving on only if needed. Most men find a solution without any operation.

Step 1 – Treating the cause and your general health

Before, or alongside, any erection treatment:

• Stopping smoking – smoking damages the small blood vessels in the penis

• Regular exercise – around 150 minutes of brisk activity a week has been shown to improve erections

• Losing excess weight – especially around the waist

• Cutting down alcohol and avoiding recreational drugs

• Good control of diabetes, blood pressure and cholesterol

• Reviewing your medicines – sometimes a tablet can be switched to one that does not affect erections

• Treating low testosterone, if this is confirmed on repeat blood tests

For mild ED, these changes alone can make a real difference. For everyone, they help other treatments work better.

Step 2 – Tablets (PDE5 inhibitors)

These are the first-line treatment for most men and work in around two-thirds of cases.

How do they work?

They increase blood flow into the penis when you are sexually aroused. They do not cause an erection on their own and do not increase sex drive – you still need arousal and stimulation.

The main tablets:

• Sildenafil (Viagra) – take 30–60 minutes before sex; works for about 4–6 hours. Works more slowly after a heavy or fatty meal

• Tadalafil (Cialis) – works for up to 36 hours, giving more spontaneity. It can also be taken as a low daily dose, which means you do not need to plan ahead. The daily dose can also help urinary symptoms from an enlarged prostate

• Vardenafil (Levitra) – similar to sildenafil

• Avanafil (Spedra) – starts working more quickly, in around 15–30 minutes

Getting the most out of tablets

Many men who say "tablets don't work for me" have not been taking them in the best way. Before deciding a tablet has failed:

• Try it on at least 6–8 separate occasions

• Make sure you are on the right dose – many men start too low

• Allow enough time before sex, and take sildenafil on an empty stomach

• Remember that sexual stimulation is still needed

• Make sure your testosterone level is normal

• Use genuine medicines – tablets bought from unregulated websites may contain the wrong dose or other substances

Possible side-effects:

• Headache

• Flushing of the face

• Blocked nose

• Indigestion

• Muscle or back ache (mainly with tadalafil)

• Temporary blue tinge to vision (sildenafil, uncommon)

These are usually mild and often settle with continued use.

Important safety warning

• Never take these tablets with nitrate medicines (such as GTN spray or isosorbide mononitrate for angina) or with nicorandil or riociguat – the combination can cause a dangerous drop in blood pressure

• Take care if you are on prostate or blood pressure tablets called alpha-blockers

• If you have a heart condition, your doctor will check you are fit enough for sexual activity

Step 3 – Second-line treatments (when tablets are not enough)

If tablets do not work, cannot be taken, or cause side effects, there are several very effective options. These are explained in more detail in our separate guide, "MUSE, Vitaros and Caverject: ED Treatments When Tablets Don't Work".

MUSE (urethral pellet)

• A tiny soft pellet of a medicine called alprostadil is placed into the opening at the tip of the penis with a small applicator

• An erection usually develops in 5–10 minutes

• No needles involved

Vitaros (cream)

• The same medicine, alprostadil, as a cream applied to the tip of the penis

• Simple and needle-free; works best in mild to moderate ED

Penile injections (Caverject, Invicorp)

• A tiny injection into the side of the penis with a very fine needle

• Works in around 7 to 8 out of 10 men, including many for whom tablets have failed

• Produces a natural-looking erection within 5–15 minutes

• Your first dose is given and taught in clinic so you are confident doing it at home

Vacuum erection device

• A plastic cylinder placed over the penis; a pump creates a vacuum that draws blood in

• A soft ring is then placed at the base of the penis to hold the erection (for no more than 30 minutes)

• No medicines involved, so it can be used by almost everyone, including men on nitrates

• Reusable and cost-effective once purchased

Step 4 – Low-intensity shockwave therapy (Li-ESWT)

Gentle sound waves are applied to the penis over several short sessions to try to encourage new blood vessel growth. It is mainly of interest to men with mild ED caused by reduced blood flow, and may help some men respond better to tablets. The evidence is still developing and results vary. See our separate honest guide to shockwave therapy for ED.

Step 5 – Psychosexual therapy

Talking therapy with a specialist psychosexual therapist can be very effective, particularly when anxiety, stress or relationship issues are part of the picture. It works well alongside medical treatment, and partners can be involved.

Step 6 – Surgery (penile implant)

For the small number of men in whom all of the above options fail or are unsuitable, a penile prosthesis (implant) can be considered.

• An inflatable device is placed inside the penis during an operation, with a small pump hidden in the scrotum

• Squeezing the pump produces a firm erection whenever you want it

• Satisfaction rates among men and their partners are very high

• However, it is a permanent step – once an implant is placed, other treatments will no longer work – and, like any operation, it carries risks such as infection

Mr Keskin will discuss whether an implant is right for you and, if so, arrange referral to a specialist implant surgeon.

Which treatment is best for you?

There is no single "best" treatment. The right choice depends on:

• The cause and severity of your ED

• Your general health and other medicines

• How spontaneous you would like sex to be

• Whether you are comfortable with needles

• Your own priorities and those of your partner

Many men use a combination – for example, tablets plus lifestyle change, or a daily low-dose tablet with an injection for special occasions. The best plan is the one you agree together with your urologist after a proper assessment.