A Difficult Issue

Erectile dysfunction and current treatment

/ Author:  / Reviewed by: Joseph V. Madia, MD

The scourge of late night television and advertisements for erectile dysfunction are now unavoidable, showing up in your magazines, in your email and in your AARP newsletter. What is erectile dysfunction, and what exactly do these drugs do?


Public perception of erectile dysfunction (ED) has very little to do with the issue as a medical problem - that is, it's not a masculine failing. While some erectile dysfunction can be attributed to psychological causes, including depression or dependency on alcohol or substance abuse, the majority of erectile dysfunction cases are medical issues with real underlying problems.

Medication side effects

Out of the top 12 drugs prescribed in the United States, eight list erectile dysfunction as a side effect. The medical treatment of depression frequently causes erectile dysfunction, and it is important that alternative medical therapies are explored for patients who experience erectile dysfunction as a side effect of medication.

Antidepressants, spironolactone, clonidine, thiazide diuretics, ketoconazole, and cimetidine are all medications for common conditions like acid reflux and high blood pressure that have been linked to disrupting normal male sexual function.

Always discuss unusual side effects from your medication with your doctor and pharmacist.

Disease-related dysfunction

While there is some association with declining function related to the aging process, the true culprits behind a sizeable percentage of erectile dysfunction are high blood pressure, the build up of cholesterol in the arteries and diabetes, which can cause a similar build up of simple sugars in arteries and nerves.

Notably, while function may decline, libido does not significantly decrease in men due to the aging process alone. 

Getting help

In the United States, a third of adult men will experience the symptoms of erectile dysfunction at some point in their lives.

The majority of men with erectile dysfunction surveyed found that they had never discussed their condition with their doctor, despite feeling a significant drop in their quality of life.

Not just an awkward conversation with your doctor, erectile dysfunction may be an early sign of serious cardiovascular problems, and should always be brought up during your next medical visit.

Patients with cardiovascular erectile dysfunction are encouraged to start an exercise program, improve nutrition and attempt weight loss in order to reverse their symptoms.

Diagnosing erectile dysfunction

Patients who report problems with erectile function were historically encouraged to try the postage stamp test. While no longer recommended due to the rapidly increasing cost of postage stamps, after fastening a ring of stamps around the penis before going to sleep, patients learned whether the automatic nocturnal erections during REM sleep had occurred or if the problem was of a more serious nature.

Modern day devices such as the Rigi-Scan monitor can help to rule out impotence in the comfort of the patient’s own home. Some doctors may use specialized ultrasound machines to detect vascular disease in the arteries surrounding the penis as part of the evaluation.

Medications to treat erectile dysfunction

Widely hailed as a series of miracle drugs, starting with Viagra, the phosphodiesterase inhibitor class of drugs include Viagra (sildenafil), Levitra (vardenafil), and Cialis (tadafil).

Originally developed as a means to treat high blood pressure, the side effects became the main feature. This class of drug is effective in treating anywhere from 50 to 70 percent of the cases of erectile dysfunction in men.

These drugs were also ruled safe to use in patients with heart disease, as long as nitroglycerine is not also being used. In cases were both nitroglycerine and ED medications are taken, blood pressure may drop to dangerously low levels. 

In contrast to Viagra and Levitra, which last about four hours, Cialis reportedly lasts up to 12 hours and does not need to be taken on an empty stomach.

In one study of 215 men who were randomized on each drug in succession, 66 percent expressed a preference for Cialis, and 33 percent preferred Viagra.

Side notes

Notable side effects from taking this class of medications include the original effect of low blood pressure, altered blue-green vision, with the most common symptoms being headache, dizziness and flushing. Some men develop flu like symptoms or back pain.

Blue vision occurs in approximately three percent of the men who take Viagra, and disappears spontaneously after a few hours.Long term effects on vision are unknown.

In addition to nitrates, the consumption of alcohol should be avoided when taking ED medications  in order to avoid dangerously low blood pressure levels.

Levitra may be linked to causing problems in men already taking medication for heart arrhythmias and should be avoided in those cases.

Rarely, sudden hearing loss may occur in administration of this class of drug. While only 29 cases have been reported out of all known trials, the FDA placed hearing loss as a known risk of the phosphodiesterase class of medications.

As you have no doubt heard in the advertisements, a medical emergency stemming from the use of these drugs is priapism, an erection lasting more than six hours. Most priapism can be reversed non-surgically, but after 48 hours, irreversible fibrosis occurs and surgery is required.

Some health professionals worry that the Viagra class of drugs is used as a cure-all panacea for the wide array of medical and psychological issues that can contribute to erectile dysfunction. 


Formerly the only permanent option, surgical treatment of erectile dysfunction is now reserved for men who cannot use pharmaceutical options due to cardiac problems, or men who do not respond to pharmaceutical options.

Patients with structural abnormalities of the penis, such as internal scarring associated with Peyronie’s disease, may need a surgical device to function normally.

Implantation devices that cause a permanent erection, but mobile state were developed several decades ago, and despite the obvious drawbacks, reliability is excellent, with few complications occurring.

Inflatable prosthesis more accurately mimic the properties of the normal penis. Patients reportedly prefer the inflatable prosthesis over other surgical alternatives. Surgical options may be covered by insurance and range from $2,000-$10,000.

Some of the oldest therapies include drugs injected directly into the spongy tissue of the penis, vacuum devices and drugs applied directly to the urethra. While effective, the most commonly reported side effect was severe localized pain. Fortunately, these methodologies are rarely used today.

Herbs and supplements

While a healthy diet and natural foods can help with sexual health, herbal medications and supplements should not be used as a direct treatment for erectile dysfunction. Unknown amounts and mixtures of drugs such as yohimbine can result in dangerous side effects if used unmonitored, and the patient runs the risk of ignoring an important underlying diagnosis.

Get it checked out

Erectile dysfunction should always be evaluated by a doctor in order to rule out underlying issues first, including medical problems such as low testosterone, side effects from other drugs, diabetes, atherosclerosis, blood pressure, depression, anxiety and psychological issues.

So if you or your partner suffers from ongoing erectile dysfunction, don't ignore it hoping it will go away. Talk to your doctor.

Review Date: 
March 9, 2012