How is erectile dysfunction treated?


For most men, erectile dysfunction cannot be cured; for some there may be a reversible underlying cause. For this reason, it is important to assess all men with erectile problems to see if there is a treatable cause.


Erectile difficulties might happen when there has been a sudden psychological problem that is short-term and can be overcome. Sometimes if erectile dysfunction happens straight after starting a new medicine, then stopping the medicine, under medical supervision, may improve the situation. When erectile dysfunction in younger men is caused by a pelvic injury, surgery can sometimes fix the problem. Drug and alcohol abuse can be treated and this may restore erectile function. Men with low testosterone levels may be helped with testosterone treatment.


Usually there will not be a specific treatment that will lead to the improvement of erectile dysfunction. However, there are treatments that will allow erections to happen and can be used to allow sexual activity to take place.


Why is treating other health problems sometimes important?


Erectile dysfunction is often caused by other more serious life-threatening health problems such as heart disease, diabetes, hypertension, high cholesterol, obesity and depression. Treating the erectile difficulties alone will not fix the underlying health problem, which if left untreated can have serious health consequences.


It is important that any underlying problems are identified and also treated as a priority. This is why men with erectile dysfunction need to see their local doctor and be correctly assessed.


Is counseling important for treating erectile dysfunction?


Psychosocial problems are important and may cause erectile dysfunction by themselves or together with other causes of erectile dysfunction, such as diabetes and heart disease. Relationships are complicated and many factors cause tensions, which can affect sexual relations. For some men, these problems can become ongoing and it can help to talk through the issue with a skilled counselor. It is important to know that the longer erectile dysfunction is left untreated, the greater the effect on relationships. This is another reason why early treatment of erectile dysfunction is important.


Erectile problems are common after a long-term relationship has ended, either through the death of a partner or relationship breakdown. Some psychological support may be needed if the man wants to establish sexual relations with a new partner. Many doctors have the necessary skills to discuss erectile problems in detail and to give support through this difficult phase. Counselors and psychologists who are trained in psychosexual counseling may also be called upon for further support if needed. Seeing a person a number of times over a few months may be needed to help re-establish normal erectile function. Sometimes when there is possible psychiatric illness, such as depression or psychosis, seeing a psychiatrist can be helpful.


Should I seek help for performance anxiety? Young, healthy men may at times worry about their sexual performance, such as when starting a new relationship or seeing advertisements for sexual performance-enhancing drugs. They may seek treatment in the belief that they can improve their sex life, even when they don’t have erection problems. If you are feeling concerned, you should seek counseling for your anxiety, and if medication for erectile dysfunction is used it should be in conjunction with counseling. Taking medicines for erectile dysfunction when not needed, and combining these treatments with other substances of abuse, may have dangerous and unexpected outcomes.


What are the main forms of treatment for erectile dysfunction?


There are three main types of treatments. The doctor will usually talk about all the types of treatment so that a man (and/or couple) knows about the options available.


Most doctors suggest starting with ED medicine. These tablets don’t always work straight away. It can take up to four or six tries to have a good erection. A full course of treatment should be tried before looking at other options.


If the tablets don’t work, injectable treatments may be tried. Doctors prescribing these injections should be correctly trained to manage any problems, such as priapism (prolonged erections).


Referral to a specialist, such as a urologist, may be made if the treatment by tablets or injections are not suitable or do not work well. Surgical treatments are an option for men who have not been able to get a good erection with non-invasive or injectable treatments.


Except for a small group of veterans, the Pharmaceutical Benefits Scheme (PBS) in Australia does not currently cover any of the treatments for erectile dysfunction. Some private health insurance schemes may include packages with rebates for private prescriptions.


What are the tablet medicines?


Tablet medicines for erectile dysfunction are called phosphodiesterase-5 (PDE5) inhibitors, which refers to the chemical mechanism of these treatments. There are three PDE5 inhibitors currently available in Australia.


How do PDE5 inhibitors work?


PDE5 inhibitors help the body to have a natural response to sexual stimulation. To work correctly, the medicines need to be in the body’s system at least 30 minutes or more before sex. This gives the medicines enough time to get into the muscle cells in the penis to block the enzyme PDE5. This allows the build-up of cGMP (cyclic guanosine monophosphate) which allows the erection to be maintained longer.


How are PDE5 inhibitors used?


These tablets are usually used ‘on demand’, when sexual activity is desired and planned. The medicine is taken with a view that sexual activity will happen within the following few hours.


More recently low-dose ED medicines have become available for regular daily use, allowing sexual activity to happen independent of when tablets are taken, which for some men allows a more spontaneous approach to sexual activity.


All of the PDE5 inhibitors currently available can be used daily, but the increased cost usually means that only couples having more frequent intercourse will use the medicines this way.


How well do PDE5 inhibitors work?


PDE5 inhibitors work well and are safe for treating most men with erectile dysfunction, allowing intercourse in about 70% of users. However, they don’t work so well in men with diabetes and those who have had some type of prostate surgery, or in men who present with severe erectile dysfunction. It is likely that there will be some individual differences in response so that some men who do not respond to one of the PDE5 inhibitors may find one of the other PDE5 inhibitors works better.


How long does the effect of PDE5 inhibitors last?


The helpful effects of ED medicine are best within four hours, and in many men these PDE5 inhibitors continue to work for up to 12 hours. ED medicine stays in the body for a much longer time. Many men can still have erections 24 hours or longer after taking ED medicine.


What are the side-effects of PDE5 inhibitors ? The most common side-effects of PDE5 inhibitors are facial flushing and a blocked nose. Indigestion and headaches can happen but these problems generally become less frequent with ongoing use of the medicines. Muscle aches, like those caused by influenza can also happen. ED medicine can cause backache. Sometimes with ED medicine, men notice a brighter or a blue tinge to their vision.


These side-effects are not usually troublesome and overall not many men stop taking these PDE5 inhibitors because of them. Most side-effects will only last an hour or two. The side-effects are no different when used daily.


What factors may affect how PDE5 inhibitors work?


There are a number of factors that may affect how well the PDE5 inhibitors work. These include:


  • trying sexual intercourse too soon after taking the medicine


  • no sexual stimulation


  • eating a fatty meal when taking ED medicine


  • drinking alcohol, as it can lessen the sexual response


  • a high degree of anxiety (which can happen when trying any new medicine).


When is it not safe to take PDE5 inhibitors? There are some medical situations where tablet treatments for erectile dysfunction should not be prescribed:


When taking ‘nitrate’ medicines Treatments in the nitrate families that are sometimes used to treat heart disease may interact badly with all PDE5 inhibitors. Nitrates and PDE5 inhibitors should NOT be taken together, as both treatments dilate the blood vessels that can result in a dangerous drop in blood pressure and collapse.


Nitrates come in a variety of forms • short-acting nitrate tablets or sprays used if chest pain arises


  • long-acting nitrate tablets or nitrate patches used daily to prevent chest pain


Unstable heart disease


For some men with heart disease, sexual activity may be too great a physical strain for the heart.


Men who have chest pain or shortness of breath when they exercise and those receiving treatment for a new cardiac problem should avoid taking PDE5 inhibitors. The safety of taking the treatments with an unstable heart disease needs to be checked on an individual basis and should be talked about with your doctor or cardiologist. On the other hand a history of previous heart attack or heart surgery does not rule out the use of PDE5 inhibitors.


Are there other ED medicines for erectile dysfunction?


Other ED medicines have been released in different countries, but have not worked well enough for widespread distribution. Claims are made for many natural products and other compounded medicines to help erectile problems. Some clinics sell ‘home made’ mixtures of medicines that can be very expensive and for which there is no good information on their safety or how well they work.


Men must be aware that if buying tablet medicines on the Internet, they could be buying useless and dangerous versions of the medicines. There are global spam merchants, who sell counterfeit drugs on the Internet at discounted prices, but there is no guarantee that they work and their safety is not known.


There are reported instances of death and hospitalization of men purchasing contaminated erectile dysfunction medicines over the Internet.


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