According to the Boston University School of Medicine, erectile dysfunction affects 5-10% of men below age 40, 22% of men at age 40 and 49% of men by age 70 (1). I suspect the numbers are even higher, depending on how you define erectile dysfunction. The medical community typically defines erectile dysfunction or “ED” as the inability to achieve or maintain an erection satisfactory for intercourse. This is a perfectly acceptable definition for a medical textbook but, to me, it is far too narrow of a definition. I define erectile dysfunction for my patients as not being satisfied with the firmness of your erections. There are many men who are able to have intercourse but their erections just aren’t as full and firm as they used to be. There are two main reasons why I like my definition better. The first reason is that even if able to have intercourse, fuller and firmer erections can give men a confidence boost and make them (and their partners) more satisfied with their sexual performance and sexual health. The other reason is that if you wait until you are unable to achieve an erection, the disease processes that lead to erectile dysfunction are more severe. In other words, earlier treatment is easier and more successful than later treatment.
Complications of Erectile Dysfunction
Erectile dysfunction can affect many areas of a man’s life.
- Low self-esteem can cross over into other aspects of life leading to poor performance at work.
- An unsatisfactory sex life can lead to relationship issues
- Physical intimacy often leads to emotional intimacy
- ED can lead to chronic anxiety
How does an erection occur?
During sexual arousal, chemicals (such as nitric oxide) are released that relax blood vessels and increase blood flow to the penis. Blood flows into two erection chambers called the corpora cavernosa (think balloons with spongy blood vessels inside). As the penis fills with blood, it becomes firm and enlarges. After an orgasm, nerves signals change, allowing the blood to leave the penis and return to the rest of the body.
Causes and Contributing Factors
Erectile dysfunction has many contributors, but nerve function and blood flow are usually at the core of the physical causes. Below is a list of physical factors that can contribute or cause ED.
- Heart disease
- High cholesterol
- High blood pressure
- Low Testosterone
- Prostate Surgery
- Nerve or Spinal cord injury
The brain plays a large role in erections as well. Feelings of attraction and sexual desire start in the brain. Many other psychological factors can worsen or cause ED. Often mildly diminished erectile function can lead to anxiety about performance, which greatly compounds the issue,
- Excessive or prolonged stress
- Relationship problems
There are many actions that you can take (or avoid) to help improve or maintain erectile function. Luckily, many of these actions are not just good for erectile function but support better overall health.
- Exercise regularly – exercise has been shown to improve erectile function
- Stop Smoking- smoking leads to blood vessel damage, which increases the risk of heart disease, stroke, and erectile dysfunction
- Regular doctor appointments – identifying and treating health conditions early on is almost always easier than when they are more progressed
- Stress reduction
- Relationship strength
While ED is a very common medical problem, many men are too embarrassed to discuss this issue with their doctor and many doctors are not educated and skilled at the numerous treatments available. A large part of my practice is specifically men’s health, focusing on optimal sexual health for men. This is why I continuously research new (and some old) treatments for erectile function. Below is a brief description of most treatment options for erectile dysfunction.
Stem Cell Treatment/Caverstem
Caverstem is the only FDA-approved method to use stem cells to treat erectile dysfunction (2). This procedure starts by removing concentrated stem cells from the bone marrow in your hip. The stem cells are then injected to repair damaged tissues and stimulate the growth of new blood vessels. The study of this treatment showed over 80% of men who did not respond to medications saw improvement in erectile function without any serious adverse effects (5). This is amazing because the study only included men who did not respond to medications such as Viagra or Cialis. This means that even in the more difficult cases, the vast majority of the men saw a significant improvement. I am very proud to say that (as of March 2020) I am one of only about 10 physicians in the United States who are trained to perform this procedure. This procedure takes 60-90 minutes and is performed in the office without the need for sedation. There is no required downtime following this procedure.
Low Intensity Extracorporeal Shock Wave Therapy (Li-ESWT) is a technology that is used for several treatments. It has been used to treat erectile dysfunction in Europe for 10-20 years. Thee sound waves help to break up plaque within the blood vessels, lead to better blood vessel dilation, and can even stimulate the growth of new blood vessels. Each treatment is painless, takes 20-30 minutes and there are no activity restrictions. We recommend a series of 6-12 treatments at weekly intervals to improve erectile function.
The P Shot or Priapus Shot is a patented procedure using your own growth factors from your platelets to improve erectile function. Growth factors from your own blood (Platelet Rich Plasma or PRP) are activated to stimulate the growth of new blood vessels and nerves of the penis. Platelet Rich Plasma or PRP, is a concentrated form of your own platelets. Professional athletes have been using PRP for decades to recover from injuries more quickly and to help avoid surgery for certain injuries. Suppose you fall and scrape your knee, your platelets begin to initiate the blood clotting process but that is only part of their function. In response to their activation, the platelets release over thirty growth factors from their granules. One of these growth factors can stimulate your stem cells to grow new blood vessels in the corpus cavernosa of the penis. This treatment takes 30-60 minutes and does not require any down time.
There are countless over-the-counter supplements and treatments aimed at improving erectile function. Many of these are unsafe and not effective. Many are also made overseas and merely contain unknown amounts of the above drugs such as sildenafil or tadalafil. This is illegal and unsafe as the amounts of active ingredients and impurities are not regulated properly. The FDA has issued a warning regarding these “supplements” finding that over 300 different supplements have been found to contain potentially dangerous ingredients (4).
The only supplements that I recommend for ED are arginine and citrulline supplements. Arginine is an amino acid that the body uses to produce nitric oxide, which helps blood vessels dilate within the penis. Having the necessary amino acids to make nitric oxide can be helpful to maintain healthy erections and is perfectly safe. I carry and recommend L-Arginine from Douglas Laboratories and Nitric Oxide Boost from Pure Encapsulations. Bottom line: don’t buy supplements from Walmart, Amazon, etc. expecting a safe, effective treatment for ED.
There are several oral medications available to improve erectile function. Viagra (sildenafil), Cialis (Tadalafil), and Levitra (vardenafil) are the most well known brands. These medications all function to delay the breakdown of nitric oxide in the penis, which allows the blood vessels to stay open longer. These medications do provide symptom relief to millions of men with ED. However, they do nothing to help the cause of ED and often carry side effects such as nausea, diarrhea, congestion, headache, flushing, dizziness and more. To be fair, I do prescribe these medications, but prefer to use small doses as part of a more comprehensive treatment plan.
Vacuum pumps or “penis pumps” can be used to improve erectile function. These devices are often sold as novelty items and the quality may be lacking. They can be an effective treatment when used correctly but if excessive pressures or erroneously used, these devices can actually damage the penis. The most convincing research regarding these devices is following prostate surgery for cancer (6). I do often advocate the use of these devices but I give my patients specific criteria of time and pressure ranges to help maintain safety.
There are medications such as alprostadil or “Trimix” which is a combination of alpprostadil/phentolamine/papaverine. These medications are injected into the penis to dilate blood vessels and cause an erection. These medications are effective for many men with ED but have significant limitations and risks. The medications must be refrigerated and usually have short expiration time periods. The patient must inject these medications into the penis prior to intercourse, which can be painful. These medications can also cause priapism which is a prolonged and painful erection that will not go down. While rare, priapism can lead to long-term damage to the penis.
There are two main surgical options. One is placement of a bendable implant that can allow enough firmness for intercourse. The second is an inflatable type implant that is placed in the penis with the inflating device usually placed in the scrotum between the testicles. This treatment is definitely a viable option but does carry significant risks. I support these surgical options only as a last resort for severe ED usually found in severe medical conditions.
My patients commonly ask if insurance covers these treatments. Unfortunately, the answer is usually no. Some insurance companies will partially cover the cost of the oral medications or surgery under certain circumstances but many do not even cover the medications. Caverstem, Gainswave, and P shot are not covered by insurance companies at this time.