Treatment depends on the cause. Testosterone supplements may be used for cases due to hormonal deficiency. However, the cause is more usually lack of adequate penile blood supply as a result of damage to inner walls of blood vessels. This damage is more frequent in older men, and often associated with disease, in particular diabetes.
Treatments (with the exception of testosterone supplementation, where effective) work on a temporary basis: they enable an erection to be attained and maintained long enough for intercourse, but do not permanently improve the underlying condition.
Deciding which treatment is best depends on a number of factors, including:
Whether the cause of a patient’s ED is physical, psychological or both
The presence of other medical conditions
The possibility of interaction with other medications
Which option is most likely to be effective for a particular patient
The preferences of the man and his partner
Physical issues that may cause varying degrees of sexual dysfunction include: injury or surgery; underlying medical conditions, such as diabetes and/or cardiovascular disease; lifestyle issues, such as smoking and the use of alcohol or other substances; and side effects of medications used to treat other conditions. Psychological issues that can lead to ED include performance anxiety, stress or secondary sexual dysfunctions (premature, delayed and/or retrograde ejaculation).
While the first step of good medical practice is to alter controllable risk factors (such as smoking, obesity, and alcohol abuse; stress, fatigue, depression; the adjustment of prescription medications etc.), most patients with male impotence will need an additional form of treatment. Therapies currently available include: sexual counseling and education, oral medications, injection therapy, vacuum devices and surgical treatments.
Male impotence can in many cases be treated by drugs taken orally, injected, or as penile suppositories. These drugs increase the efficacy of NO, which dilates the blood vessels of corpora cavernosa. When oral drugs or suppositories fail, injections (e.g. of apomorphine) into the erectile tissue of the penile shaft may work.
When pharmacological methods fail, a purpose-designed external vacuum pump can be used to attain erection, with a separate compression ring fitted to the penis to maintain it. These pumps should be distinguished from other “penis pumps” (supplied without compression rings) which, rather than being used for temporary treatment of impotence, are claimed to increase penis length if used frequently, or vibrate as an aid to masturbation.
More drastically, inflatable or rigid penile implants may be fitted surgically. Implants are irreversible and costly.
All these mechanical methods are based on simple principles of hydraulics and mechanics and are quite reliable, but have their disadvantages.
In a few cases there is a vascular problem which can be treated surgically.
Treatment options have varied with the following possibilities. Each varies from one person to the other on overall effectiveness.
The prescription PDE5 inhibitors sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) are prescription drugs which are taken orally. They work by blocking the action of PDE5, which causes cGMP to degrade. cGMP causes the smooth muscle of the arteries in the penis to relax, allowing the corpus cavernosum to fill with blood.
An external vacuum pump will produce an engorged penis with success approaching 90%; a penis ring will maintain this state, although it should be removed after not more than 30 minutes.
The erection is not as rigid or hard as a natural erection; drugs or injections, when they work, may be preferable. Various studies show the degree of satisfaction of users and their partners to be vary variable, even when drugs and injections do not work; in one study, about 20% of men who tried a (high-priced) pump decided to proceed to purchase one.
Other studies show higher percentages of satisfied users. In some cases frequent use of a vacuum pump can eventually improve the degree of erection attainable without use of the pump. Claims of cheap “penis pumps” to permanently increase maximum penis size should be viewed with caution, however. Some vacuum pumps, such as Osbon ErecAid, are sold at a higher price with 100% refund within 90 days to dissatisfied users, with a somewhat lower price with 50% refund guarantee.This pump is supported by medical insurance schemes, including the UK’s NHS and US Medicare and private insurers.
The better-known pumps sell for prices of around 200 GBP/400 USD (2006). There is at least one vacuum pump with rings which sells for around one-fifth of this price.
Surgical treatment of certain cases
The experimental drug Bremelanotide (formerly PT-141) does not act on the vascular system like the former compounds but increases sexual desire and drive in male as well as female. It is applied as a nasal spray. Bremelanotide works by activating melanocortin receptors in the brain. It is currently in Phase IIb trials.
hMaxi-K is a form of gene therapy using a plasmid vector that expresses the hSlo gene, that encodes the alpha-subunit of the Maxi-K channel. It has undergone phase I safety trials.
A double-blind study appears to show evidence that ginseng is better than placebo: see the ginseng article for links and more details.
Herbal and other alternative treatments
These are generally may be useful and highly-praised. Often expensive pharmaceutical treatment can be costly in comparison.