Diseases

Mechanical vacuum devices cause an erection by creating a vacuum around the penis that draws blood into the penis, engorging it, and expanding it. The devices have three components:

1. A plastic cylinder, in which the penis is placed
2. A pump, which draws air out of the cylinder
3. An elastic band, which is placed around the base of the penis, to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body (see figure 2).
4. The vacuum device may be operated by hand or be battery operated.

Picture of a penis pump for erectile dysfunction (ED); SOURCE: NIHHow does the vacuum device work?The vacuum device basically creates a vacuum to pull blood into the penis. Unlike a normal erection, the inflow of blood does not continue once the vacuum device is removed. The rubber band placed at the base of the penis constricts the penis to prevent the blood from leaving the penis. As there is no inflow or outflow of blood when the rubber band is in place, it is not uncommon for the tip of the penis (the glans) to appear a little blue and the penis to be cooler. Once intercourse is completed, the rubber band is removed and the blood drains out of the penis.Is the vacuum device effective?Yes, the vacuum device is effective. In fact, with use of the vacuum device, 88% of men will have an erection that is satisfactory for completion of sexual activity. The vacuum device may be the only therapy that is effective after the removal of a penile prosthesis. It is also used as part of penile rehabilitation after radical prostatectomy to help preserve the tissue of the penis and prevent scarring within the penis and loss of penile length. Its use, however, may be limited by the mechanical nature of it and the time taken to pump the device and apply the band. Sex partners may complain of the penis being cool to touch.What are the risks of the vacuum device?The rubber band must be removed immediately after completing intercourse. Leaving the band on too long can harm the penis. Rarely, bruising of the penis or blood in the ejaculate/urine may occur.

The U.S. FDA (Food and Drug Administration) has a list of 29 OTC products that claim to treat erectile dysfunction. These are recommended to be avoided because many contain harmful ingredients. Other natural or herbal remedies such as DHEA, L-arginine, ginseng, and yohimbe are supplements that have been used but have not been proven to be safe and effective according to some researchers. Before using such compounds, individuals should consult their doctor. Acupuncture, according to some experts, has not been definitively shown to effectively treat erectile dysfunction. Other home remedies for reducing ED symptoms include diet changes such as eating blueberries and citrus fruits and drinking red wine.

Erectile dysfunction (ED, impotence) varies in severity; some cannot have an erection at all, whereas other men sometimes have troubles getting a hard erection, and others get a hard erection but it only lasts for a short period of time. Approximately 50% of men over the age of 40 have troubles with erectile dysfunction.While erectile dysfunction can occur at any age, the risk of developing erectile dysfunction increases with age. According to the Massachusetts Male Aging Study, the prevalence of erectile dysfunction was 52% in men 40-70 years of age. The prevalence of complete erectile dysfunction increases from 5% at 40 years of age to 15% among men 70 years of age and older.

Patient health historyA diagnosis of erectile dysfunction is made in men who complain of troubles having a hard enough erection or a hard erection that does not last long enough. It is important as you talk with your doctor that you be candid in terms of when your troubles started, how bothersome your erectile dysfunction is, how severe it is, and discuss all your medical conditions along with all prescribed and nonprescribed medications that you are taking. Your doctor will ask several questions to determine if your symptoms are suggestive of erectile dysfunction and to assess its severity and possible causes. Your doctor will try to get information to answer the following questions:

1. Is the patient suffering from erectile dysfunction or from loss of libido or a disorder of ejaculation (for example, premature ejaculation) or orgasm, or problems with penile curvature (Peyronie's disease)?
2. Is your erectile dysfunction due to psychological (stress, relationship problems, etc.) or physical factors? Your doctor may ask if you note erections at night or in the early morning. Men have involuntary erections in the early morning and during REM sleep (a stage in the sleep cycle with rapid eye movements). Men with psychogenic erectile dysfunction (erectile dysfunction due to psychological factors such as stress and anxiety rather than physical factors) usually maintain these involuntary erections. Men with physical causes of erectile dysfunction (for example, atherosclerosis, smoking, and diabetes) usually do not have these involuntary erections. Men with psychogenic erectile dysfunction may relate the onset of problems to a "stressor," such as failed relationship. Your doctor may suggest a test to determine if you have erections during sleep, which may suggest that there may be a psychological cause of the erectile dysfunction.
3. Are there physical causes of erectile dysfunction? A prior history of cigarette smoking, heart attacks, strokes, and poor circulation in the extremities (for example, intermittent claudication or cramping in your leg[s] when you walk) suggest atherosclerosis as the cause of the erectile dysfunction. Loss of sexual desire and drive, lack of sexual fantasies, gynecomastia (enlargement of breasts), and diminished facial hair suggest low testosterone levels. A prior history of pelvic surgery or radiation and trauma to the penis/pelvis/perineum can cause problems with the nerves and blood vessels. Symptoms of intermittent claudication of the lower extremities with exercise may suggest a vascular problem as a cause of the erectile dysfunction.
4. Is the patient taking medications that can contribute to erectile dysfunction (see causes above), including prescribed, over-the-counter, or recreational drugs? It is important to discuss medications that you are prescribed, as well as over-the-counter medications and drugs of abuse such as opiates, alcohol, etc.

Physical examinationThe physical examination can reveal clues for physical causes of erectile dysfunction. A genital examination is part of the evaluation of erectile dysfunction. The examination will focus on the penis and testes. The doctor will ask you about penile curvature and will examine the penis to see if there are any plaques (hard areas) palpable. The doctor will examine the testes to make sure they are in the proper location in the scrotum and are normal in size. Small testicles, lack of facial hair, and enlarged breasts (gynecomastia) can point to hormonal problems such as hypogonadism with low testosterone levels. Pulses in your groin and feet may be checked to determine if there is a suggestion of hardening of the arteries that could also affect the arteries to the penis.Laboratory testsThe lab testing obtained for the evaluation of erectile dysfunction may vary with the information obtained on the health history, physical examination, and recent lab testing. A testosterone level is not necessary in all men; however, if other signs and symptoms of hypogonadism (low testosterone) are present then it should be obtained.The following are laboratory tests that may be obtained in the evaluation of erectile dysfunction:

• Complete blood counts
• Urinalysis: A high level of sugar (glucose) in the urine may be a sign of diabetes mellitus, and high protein in the urine may suggest kidney damage, which can cause erectile troubles.
• Lipid profile: High levels of LDL cholesterol (bad cholesterol) in the blood can cause atherosclerosis.
• Blood glucose levels: Abnormally high blood glucose (sugar) levels may be a sign of diabetes mellitus.
• Blood hemoglobin A1C: Abnormally high levels of blood hemoglobin A1C in patients with diabetes mellitus indicate that there is poor control of blood glucose levels.
• Serum creatinine: An abnormal serum creatinine, a chemical that reflects kidney function, may be the result of kidney damage.
• Liver enzymes and liver function tests: Liver disease (cirrhosis) can cause low testosterone. Thus, testing for liver disease may be needed in some men.
• Total testosterone levels: Blood samples for total testosterone levels should be obtained in the early morning (before 8 a.m.) because the testosterone levels go up and down throughout the day. If you have a low testosterone level, it should be checked again to confirm that it is truly low. In some men, a specialized test measuring the active form of testosterone may be recommended.
• Other hormone levels: Measurement of other hormones beside testosterone (luteinizing hormone [LH], prolactin level, and cortisol level) may provide clues to other underlying causes of testosterone deficiency and erectile problems, such as pituitary disease or adrenal gland abnormalities. Thyroid levels may be checked in some individuals as both hypothyroidism (low thyroid function) and hyperthyroidism (overactive thyroid function) can contribute to erectile dysfunction.
• PSA levels: PSA (prostate specific antigen) blood levels and prostate examination to exclude prostate cancer is important before starting testosterone treatment since testosterone can aggravate prostate cancer.
• Other blood tests: Evaluation for hemochromatosis, lupus, scleroderma, zinc deficiency, sickle cell anemia, and cancers (leukemia, colon cancer) are some of the other potential tests that may be performed based on each individual's health history and symptoms.

Imaging testsImaging tests are not routinely obtained in the evaluation of erectile dysfunction.Ultrasound with Doppler imaging (ultrasound plus evaluation of blood flow in the arteries and veins) can provide additional information about blood flow of the penis and may be used in the evaluation of patients prior to surgical intervention. This study is typically performed after the injection of a chemical that causes the arteries to open up, a vasodilator (prostaglandin E1), into the corpora cavernosa in order to cause dilation of blood vessels and promote blood flow into the penis. The rate of blood flow into the penis can be measured along with an evaluation of problems with compression of the veins.Rarely, an angiogram (injecting a dye into the arteries that supply the penis and taking X-rays to look for areas of narrowing of the arteries) may be performed in cases in which possible vascular surgery could be beneficial.Other health testsMonitoring erections that occur during sleep (nocturnal penile tumescence) can help you and your doctor to understand if the erectile dysfunction is due to psychological or physical causes. A band is wrapped around the penis and worn for two to three successive nights. The band is able to monitor when the penis expands during an erection at night during sleep and how long the erection lasts. The presence of nocturnal erections does not, however, indicate that an individual does not have erectile dysfunction, as the ability to penetrate and duration of rigidity for completion of sexual activity cannot be assessed by this test.Psychosocial examinationIf there seems to be a psychological cause contributing to your erectile dysfunction, you may be asked questions to help determine stressor, events and relationship issues that may be causing your erectile troubles. It may be helpful to have your sexual partner involved in this assessment.

Erections are neurovascular events, meaning that nerves and blood vessels (arteries and veins) are involved in the process of an erection and all must work properly to get a hard erection that lasts long enough. Erection begins with sexual stimulation. Sexual stimulation can be tactile (for example, by a partner touching the penis or by masturbation) or mental (for example, by having sexual fantasies, viewing porn). Sexual stimulation or sexual arousal causes the nerves going to the penis to release a chemical, nitric oxide. Nitric oxide increases the production of another chemical, cyclic GMP (cGMP), in the muscle of the corpora cavernosa. The cGMP causes the muscles of the corpora cavernosa to relax, and this allows more blood to flow into the penis. The incoming blood fills the corpora cavernosa, making the penis expand.

As blood flows into the penis, the corpora cavernosa swell, and this swelling compresses the veins (blood vessels that drain the blood out of the penis) against the tunica albuginea. By compressing the veins, blood is prevented from leaving the penis. This creates a hard erection. When the amount of cGMP decreases by the action of a chemical called phosphodiesterase type 5 (PDE5), the muscles in the penis tighten, and the blood flow into the penis decreases. With less blood coming into the penis, the veins will not be compressed and will drain blood out of the penis, and the erection goes down.

Prevention of some of the causes that contribute to the development of erectile dysfunction can decrease the chances of developing the problem. For example, if a person decreases their chances of developing diabetes, heart disease, and hypertension, they will decrease their chances of developing erectile dysfunction. Other things like stopping smoking, eating a healthy diet (heart healthy with adequate vitamin intake), and exercising daily may also reduce a person's risk.

Experts often treat psychologically based impotence using techniques that decrease anxiety associated with intercourse. The patient's partner can help apply the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when physical impotence is being treated. If these simple behavioral methods at home are ineffective, referral to a sex counselor may be advised.

The common risk factors for ED include the following:

• Advanced age
• Cardiovascular disease
• Hypertension
• Diabetes mellitus
• High cholesterol
• Cigarette smoking
• Recreational drug use
• Depression or other psychiatric disorders
• Pelvic surgery, including radical prostatectomy and colorectal surgery
• Pelvic radiation, such as for prostate cancer and some colorectal cancers
• Trauma to the pelvis (pelvic fracture), penis (penile fracture), and perineum

Signs and symptoms of erectile dysfunction may include the following:

• Penile erection occurs, but the penis does not remain hard enough for completion of sex.
• Penile erections are not hard enough for penetration.
• There is an inability to obtain a penile erection.
• One can still achieve an orgasm and ejaculate with erectile dysfunction.

ED is often the result of atherosclerosis, and as a result, men with ED frequently have cardiovascular disease. Sexual activity is associated with increased physical exertion, which in some men may increase the risk of having a heart attack (myocardial infarction or MI). Thus, if you have ED and cardiovascular disease (for example, angina or prior heart attack), you should discuss whether or not treatment of ED and sexual activity are appropriate for you.

Medications can be injected directly into the corpora cavernosa to help attain and maintain erections. Medications such as papaverine hydrochloride, phentolamine, and prostaglandin E1 (alprostadil) can be used alone or in combinations to attain erections. All of these medications are vasodilators and work by increasing blood flow into the penis. Prostaglandin E1 (Caverject, Edex) is easier to obtain; however, it is associated with penile pain in some individuals. The use of combinations of two or three of these medications can decrease the risk of having penile pain.Risks associated with injection therapy including bleeding, pain with injection, penile pain, priapism, and corporal fibrosis (scarring inside of the corpora cavernosa). There is also concern that repetitive injections in the same area could cause scar tissue to build up in the tunica albuginea that could create penile curvature. Thus, it is recommended that one alternate sides with injection and perform injections no more frequent than every other day.If you are on a blood thinner, you must be careful. After injection, pressure should be applied to the site to minimize bleeding.It is recommended that one start with a low dose and increase in small doses until the dose that results in a rigid enough erection for completion of sexual activity is achieved. If one injects and there is an inadequate response, one should not reinject another dose of the medication at that time, due to the risk of priapism.

Prostaglandin E1 (intraurethral alprostadil or MUSE) can be inserted in a pellet (suppository) form into the urethra to attain erections. It is available in four dosage strengths: 125 mcg, 250 mcg, 500 mcg, and 1,000 mcg. Most individuals need 500 mcg to 1,000 mcg for a satisfactory response.How does intraurethral prostaglandin E1 work?The prostaglandin E1 is contained in a small suppository located at the tip of an applicator. You should urinate first as this lubricates the urethra and makes it easier to insert the applicator into the tip of the urethra (urethral meatus, the opening at the tip of the penis that urine passes through). By gently wiggling the applicator and pressing the button at the end, the suppository is released into urethra. Rubbing the penis allows the suppository to dissolve, and the prostaglandin is absorbed through the tissue of the urethra into the penis. It takes 15 to 30 minutes for this occur. Once into the penis, the prostaglandin causes increased blood flow into the penis. The prostaglandin can be present in the ejaculate and thus it is recommended that a condom be used when used by men having intercourse with a pregnant partner. A condom may also be needed if vaginal irritation occurs in female partner.It is recommend that the first trial of intraurethral prostaglandin be performed in the doctor's office due to the risk of hypotension with this medication.Who should not use intraurethral prostaglandin E1?Use of intraurethral prostaglandin E1 is not recommended in men with a known hypersensitivity to alprostadil.Alprostadil should not be used in men with urethral stricture (scarring and narrowing of the tube that urine and the ejaculate pass through), balanitis (inflammation/infection of the glans [tip] of the penis, severe hypospadias (a condition where the opening of the urethra is not at the tip of the penis, rather on the underside of the penis), penile curvature (abnormal bend to the penis), and urethritis (inflammation/infection of the urethra).Alprostadil should not be used in men at higher risk for priapism (erection lasting longer than six hours) including men with sickle cell anemia, thrombocytopenia (low platelet count), polycythemia (increased red blood cell count), multiple myeloma (a cancer of the white blood cells), and is contraindicated in men prone to venous thrombosis (blood clots in the veins) or hyperviscosity syndrome who are at increased risk for priapism.How effective is alprostadil?Success rates up to 65% have been reported with intraurethral alprostadil.What are side effects of intraurethral alprostadil?Side effects of intraurethral alprostadil include pain in the penis and sometimes in the testicles, mild urethral bleeding, dizziness, and vaginal itching in the sex partner. Syncopal (fainting) episodes are rarely reported with initial use, and thus the first trial of this medication should be performed in the physician's office.

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The ability to achieve and sustain erections requires the following:

1. A healthy nervous system that conducts nerve impulses in the brain, spinal column, and penis
2. Healthy arteries in and near the corpora cavernosa that when stimulated can bring increased blood flow into the penis
3. Healthy muscles and fibrous tissues within the corpora cavernosa, which can distend to allow the penis to fill with blood
4. Adequate levels of nitric oxide in the penis
5. Normal-functioning tunica albuginea that allows for compression of the veins
6. Appropriate psychosocial interactions

Erectile dysfunction can occur if one or more of these requirements are not met. The following are causes of erectile dysfunction, and many men have more than one potential cause:

• Aging: There are two reasons why older men are more likely to experience erectile dysfunction than younger men. First, older men are more likely to develop diseases (such as heart attacks, angina, cardiovascular disease, strokes, diabetes mellitus, and high blood pressure) that are associated with erectile dysfunction. Second, the aging process alone can cause erectile dysfunction in some men by causing changes in the muscle and tissue within the penis.
• Diabetes mellitus: Erectile dysfunction tends to develop 10 to 15 years earlier in diabetic men than among nondiabetic men. The increased risk of erectile dysfunction among men with diabetes mellitus may be due to the earlier onset and greater severity of atherosclerosis (hardening of the arteries) that narrows the arteries and thereby reduces the delivery of blood to the penis. Atherosclerosis can affect the arteries in the penis. Diabetes mellitus also causes erectile dysfunction by damaging nerves that go to the penis, much like the effect of diabetes on nerves in other areas of the body (diabetic neuropathy). Diabetes can also affect the muscles in the penis, leading to troubles with erections. Smoking cigarettes, obesity, poor control of blood glucose levels, and having diabetes mellitus for a long time further increase the risk of erectile dysfunction in people with diabetes.
• Hypertension (high blood pressure): Men with high blood pressure have an increased risk of developing erectile dysfunction. Hypertension can cause troubles with erections related to atherosclerosis or from low levels of nitric oxide being made from the arteries in the penis.
• Cardiovascular diseases: The most common cause of cardiovascular diseases in the United States is atherosclerosis, the narrowing and hardening of arteries that reduces blood flow. Atherosclerosis (a type of vascular disease) typically affects arteries throughout the body and is aggravated by hypertension, high blood cholesterol levels, cigarette smoking, and diabetes mellitus. Hardening of the arteries to the penis and pelvic organs, atherosclerosis, causes insufficient blood flow into the penis. There is a close correlation between the severity of atherosclerosis in the coronary arteries and erectile dysfunction. For example, men with more severe coronary artery atherosclerosis (hardening of the arteries in the heart) also tend to have more erectile dysfunction than men with mild or no coronary artery atherosclerosis. Some doctors suggest that men with new onset erectile dysfunction should be evaluated for silent coronary artery diseases (advanced coronary artery atherosclerosis that has not yet caused angina or heart attacks).
• Cigarette smoking: Cigarette smoking aggravates atherosclerosis and can cause vasospasm (spasms of the arteries) and thereby increases the risk for erectile dysfunction.
• Nerve or spinal cord damage: Damage to the spinal cord and nerves in the pelvis can cause erectile dysfunction. Nerve damage can be due to disease, trauma, or surgical procedures. Examples include injury to the spinal cord from automobile accidents, injury to the pelvic nerves from prostate surgery for cancer (prostatectomy), and some surgeries for colorectal cancer, radiation to the prostate, surgery for benign prostatic enlargement, multiple sclerosis (a neurological disease with the potential to cause widespread damage to nerves), and long-term diabetes mellitus.
• Substance abuse: Marijuana, heroin, cocaine, methamphetamines, crystal meth, and narcotic and alcohol abuse contribute to erectile dysfunction. Alcoholism, in addition to causing nerve damage, can lead to atrophy (shrinking) of the testicles and lower testosterone levels.
• Low testosterone levels: Testosterone (the primary sex hormone in men) is not only necessary for sex drive (libido) but also is necessary to maintain nitric oxide levels in the penis. Therefore, men with hypogonadism (low testosterone with symptoms) can have low sex drive and erectile dysfunction.
• Medications: Many common medicines produce erectile dysfunction as a side effect. Medicines that can cause erectile dysfunction include many used to treat high blood pressure, antihistamines, antidepressants, tranquilizers, and appetite suppressants. Examples of common medicines that can cause erectile dysfunction include propranolol (Inderal) or other beta-blockers, hydrochlorothiazide, digoxin (Lanoxin), amitriptyline (Elavil), famotidine (Pepcid), cimetidine (Tagamet), metoclopramide (Reglan), indomethacin (Indocin), lithium (Eskalith, Lithobid), verapamil (Calan, Verelan, Isoptin), phenytoin (Dilantin), gemfibrozil (Lopid), amphetamine/dextroamphetamine (Adderall), and phentermine.
• Depression and anxiety: Psychological factors may be responsible for erectile dysfunction. These factors include stress, anxiety, guilt, depression, widower syndrome, low self-esteem, posttraumatic stress disorder, and fear of sexual failure (performance anxiety). It is also worth noting that many medications used for treatment of depression and other psychiatric disorders may cause erectile dysfunction or ejaculatory problems.

Medications for erectile dysfunction include the following:

• Oral phosphodiesterase type 5 (PDE5) inhibitors (sildenafil [Viagra], vardenafil [Levitra], tadalafil [Cialis]), and avanafil [Stendra])
• Intracavernosal injections (papaverine, phentolamine, and PGE1 [Trimix], Bimix, and alprostadil injection [Caverject, Edex])
• Intraurethral suppositories (MUSE)
• Testosterone in individuals with ED and other signs/symptoms of hypogonadism and an unequivocally low serum testosterone

A doctor can help decide what medication(s) may be the best for the patient. This is an important step to do so the doctor can help choose the best and safest drug(s) and other treatments so that men with other medical problems can get individualized care appropriate for their medical conditions.

Erectile dysfunction (ED), also known as impotence, is the inability to achieve or sustain a hard enough erection for satisfactory completion of sexual activity. Erectile dysfunction is different from other health conditions that interfere with male sexual function, such as lack of sexual desire (decreased libido) and problems with ejaculation release of the fluid from the penis (ejaculatory dysfunction) and orgasm/climax (orgasmic dysfunction), and penile curvature (Peyronie's disease), although these problems may also be present. ED affects about 50% of men age 40 and over. This article focuses on the evaluation and treatment of erectile dysfunction.

The penis contains two cylinders, called the corpora cavernosa, which are on the top of the penis (see figure 1 below). These two cylinders are involved in erections. The urethra, the tube that the urine and ejaculate passes through, runs along the underside of the penis and is surrounded by tissue known as the corpus spongiosum. The corpora cavernosa are made up of spongy tissue that has muscles, fibrous tissues, veins, and arteries within it. The inside of the corpora cavernosa is like a sponge, with potential spaces that can fill with blood and distend. A layer of tissue that is like Saran Wrap, called the tunica albuginea, surrounds the corpora. Veins located just under the tunica albuginea drain blood out of the penis.

Currently, there are no therapies that cure erectile dysfunction. However, a number of effective therapies are available that allow an individual to have an erection when desired. Depending on the cause of the erectile dysfunction, certain therapies may be more effective than others. Although there is limited data on lifestyle modification, intuitively, decreasing risk factors for erectile dysfunction may help prevent progression of disease.

In patients with low testosterone, testosterone treatment can improve libido and erectile dysfunction, but many men still may need additional oral medications such as sildenafil, vardenafil, or tadalafil. Some studies suggest that men with ED and low testosterone may respond better to PDE5 inhibitors when given testosterone therapy; however, this is controversial.The use of testosterone therapy in men with ED without hypogonadism (a low testosterone level and symptoms related to this) is not recommended.Prior to starting testosterone therapy, it is important that you are evaluated thoroughly.Evaluation should include a breast examination, rectal examination of the prostate, and a PSA level (prostate specific antigen) blood test. Patients who have breast and prostate cancers or are suspected of having them should not use testosterone.Testosterone therapy should be continued only if there is improvement in the symptoms of hypogonadism and should be monitored regularly. You will need periodic blood tests for testosterone levels and blood tests to monitor your blood count and PSA. Testosterone therapy has health risks, and thus its use should be closely monitored. Testosterone therapy can worsen sleep apnea and congestive heart failure.A variety of testosterone therapies are available, including oral, topical (gel, spray, patch), intramuscular, and pellets. The advantages and disadvantages of each of these should be reviewed with your physician as well as the health risks and benefits of testosterone therapy.Certain medications can alter testicular function, including some diuretics (water pills), some seizure medications, long-acting oral opiate pain medications, antipsychotic medications, and oral steroids.

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The following are treatment options for erectile dysfunction:

1. Working with doctors to modify current medications to select medications that do not cause troubles with erectile function when possible
2. Making lifestyle improvements (for example, quitting smoking and exercising more) may help improve symptoms or prevent the erectile dysfunction from getting worse.
3. Taking oral therapies (drugs/medications) to treat ED, such as sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), or avanafil (Stendra)
4. Inserting medications into the urethra (intraurethral suppositories [MUSE])
5. Injecting medications into the corpora cavernosa (intracavernosal injections)
6. Vacuum constrictive devices for the penis
7. Penile prostheses
8. Rarely vascular surgery to improve blood flow to the penis
9. Psychotherapy

Adjusting medications that may cause or contribute to erectile dysfunctionMany common medications for treating hypertension, depression, and high blood lipids (high cholesterol) can contribute to erectile dysfunction (see above). Treatment of hypertension is an example. There are many different types (classes) of medications for high blood pressure; these include beta-blockers, calcium channel blockers, diuretics (medications that increase urine volume), angiotensin converting enzyme inhibitors (ACE inhibitors), and angiotensin receptor blockers (ARBs). These medications may be used alone or in combination to control blood pressure. Some of these medications can cause troubles with erections. For example, Inderal (a beta-blocker) and hydrochlorothiazide (a diuretic) are known to cause erectile dysfunction, while calcium channel blockers and ACE inhibitors do not seem to affect erectile function. On the other hand, other medications (such as angiotensin receptor blockers [ARB] including losartan [Cozaar] and valsartan [Diovan]) may actually help with erections. Therefore, if possible, you may benefit from changing your medications, but this requires approval by your prescribing health care provider.Lifestyle improvementsQuitting smoking, exercising regularly, losing excess weight, curtailing excessive alcohol consumption, controlling hypertension, and optimizing blood glucose levels in patients with diabetes are not only important for maintaining good health but also may improve or even prevent progression of erectile dysfunction. It is unclear if such lifestyle changes can reverse erectile dysfunction. Some studies suggest that men who have made lifestyle improvements experience increased rates of success with oral medications.

Combination therapy for the treatment of erectile dysfunction has been under investigation. Most of these studies have been small trials, and long-term data regarding their effectiveness and safety are lacking. However, with thorough evaluation and counseling, there may be a use for combination therapy for certain individuals with ED.Melanocortin receptor agonists are a new set of medications being developed in the field of erectile dysfunction. Their action is on the nervous system rather than the vascular system. PT-141 is a nasal preparation that appears to be effective alone or in combination with PDE5 inhibitors. The main side effects include flushing and nausea. These drugs are currently not approved for commercial use.Research in stem cell therapy and gene therapy for erectile dysfunction is also ongoing.