Erectile Dysfunction



Erectile dysfunction is the inability of a man to obtain an erection satisfactory for sexual function. It is different from ejaculatory dysfunction and issues with libido (extra) that can often times occur in concert with these. It is a very common condition within incidence very similar to enhance age (example about 40% of men age 40 years old will have ED and roughly 70% of men age to 7 years old will have ED). A smaller number of man will have severe erectile dysfunction as defined by an inability to obtain any erection whatsoever.


Information on penile anatomy can be found here. In general, the average length of an erect penis is about 5.5 inches.




There are many different causes. It can be associated with cardiovascular disease and othe

There are multiple different potential causes for erectile dysfunction. These include:


  1. Cardiovascular disease
  2. Medications
  3. Neurological problems
  4. Postsurgical changes
  5. Psychological issues


Quite often, there are multiple contributing causes.


Diagnosis & Evaulation

Your urologist will take a thorough history. Before coming for your visit, it is important to think about the following issues:

  1. What aspect of erectile function are you concerned about? Obtaning an erection, the duration of the erection, the hardness of your erection or a combination?
  2. When did the problems first start? Are they progressive? Often times, the onset is gradual, so you don't have to give a precise date.
  3. Do your problems with erections vary based on the situation? That is, are they worse with one partner than another or with mastubation vs. intercourse?
  4. What sort of treatments have you already tried? e.g. Viagra, Cialis, Levitra
  5. Are there any 'structural' problems with your penis - that is, any curvature or firm plaques?
  6. How is your sex drive (libido)?

Taking the time to complete a questionnaire on erectile function can be very helpful in assessing your problem and tracking response to therapy.


Physical examination involves assessing the cardiovascular system since erectile dysfunction is often associated with cardiovascular disease. Examining the genitals can provide clues to the diagnosis as well.


If your family doctor has not already done this, blood tests to check for low testosterone, diabetes and cholesterol problems will be ordered. If appropriate, a PSA to screen for prostate cancer will also be arranged.


Most men do not require further testing and will simply have a trial of oral medication. For those who have refractory or complex types of erectile dysfunction, the following tests may be ordered.


Duplex ultrasound and intracavernosal injection ('Duplex ICI'): During this test, a prostaglandin is injected into the penis using a very small needed. The blood flow to the penis is then checked with an ultrasound machine. This can give important information on if there are problems with blood supply to the penis (arterial insufficiency) or if the penis is not holding the blood in properly (venous leak).




Options for Treating Erectile Dysfunction  

General Measures

Oral Medications

Intracavernosal Injections

Vacuum Constriction Device

Penile Prosthesis


General Measures


Some of the most important things that men can do to prevent further decreases in erectile dysfunction have to do with looking after their general health. Erectile dysfunction is often a sign of cardiovascular disease and as such, shares similar risk factors. Things which can prevent or reduce progression of erectile dysfunction include:


  1. Maintaining a healthy level of cholesterol - avoid fatty foods, treat dyslipidemia/high cholesterol if it is present
  2. Exercise, weight loss and stress reduction
  3. Optimize control of diabetes
  4. Quit smoking
  5. Develop your relationship so that your partner is supporting and understanding of your problem. 'Performance anxiety' always has a negative impact on erections.


While changing your behavior may not reverse erectile dysfunction which has occurred from many years of habits, it can prevent or slow progression.


Oral Medications


The mainstay of medical treatment for erectile dysfunction is the use of phosphodiesterase 5 inhibitors (PDE5I). This includes medications such as Viagra (sildenafil), Cialis (tadalafil) and Levitra (vardenafil). This class of medications helps prevent the breakdown of nitric oxide (NO) in the penis. Nitric oxide as a key substance which is released into the penis when stimulated (by visual, tactile or imagination stimuli) and facilitates inflow of blood to obtain an erection. These medications do not and of themselves produced erections and do require some form of stimulation to be affected. In effect, and they enhance what you already have.


All 3 of the medications in his class work by similar mechanism and had similar side effects. some of the differences and tips for optimizing these are listed below.


Medication Tips for Using

Common side-effects: stuffiness, facial flushing, reflux


CIALIS (Tadalafil): max dosage is 20 mg daily; window of opportunity 24-36 hours; can rarely cause back pain. There is a low-dose daily formulation - 5 mg per day - which can be useful in men who want to maximize spontaniety.  Cialis Website.


LEVITRA (Vardenafil): max dosage is 20 mg daily; window of opportunity 6-10 hours; may have slightly quicker onset of action compared with other medications. Levitra Website.


STAXYN: one dose 10 mg. Basically a quick absorption form of Levitra. Placed under the tongue rather than swollowed


STENDRA (Avanafil): max dose 200 mg (range 50-200 mg). Slightly faster onset than other medications. Stendra Website.


VIAGRA (Sildalafil): max dosage is 100 mg daily; window of opportunity 6-10 hours; can occasionally cause blue-tinted vision. Viagra Website.



  1. Take about 1 hour before you plan on engaging 
  2. Avoid a fatty meal or high alcohol intake
  3. You need stimulation for them to work
  4. Taking the medication every 1-2 days tends to result in a general increase in response which plateaus after about 5 doses
  5. Take the lowest dose that does the job - this may mean taking as little as 1/4 to 1/2 of a full pill


You can find additional information on the website for each medication


It is not uncommon for patients to enquire about visual side effects of these medications. Information on PDE5I and non-arteritic anterior ischemic optic neuropathy (NAION) can be found here.


Intraurethral Medications


There are 2 options. 

  1. MUSE: this is a prostaglandin pellet
  2. Vitaros: this is a prostaglandin gel


Intracavernosal Injections


Injection of medications directly to the penis is another option for treatment. There are different composition is a medication which can be injected into the erectile bodies of the penis to stimulate an erection, even without other forms of sexual stimulation.


These medications are very effective, especially following prostate surgery. A major issue for men taking these medications is 'needle phobia'. Most men are very surprised at the very small size of the needle and how quick and easy these injections are. If your interested in obtaining an erection but are not responsive to PDE 5 inhibitors, please ask your urologist and we can arrange for an in office test injection to check technique and show you have easy this is.



Potential side effects:

  1. Priapism: this is a condition where a prolonged erection occurs. If conservative methods do not result in detumescence then medical attention and should be sought (see below).
  2. Penile pain. This is more common in increasing doses, especially with prostaglandin.
  3. Penile bruising is not uncommon and can be controlled by applying pressure to the injection site for 5 minutes.
  4. Penile scarring.

To start using intracavernosal injections, you will need:

  1. Medication: Trimix or PGE1
  2. Injection syringes: single use, 29-31 guage, 1 cc/mL syringes (these are the same ones used for insulin injections)
  3. Needle disposal container
  4. Alcohol swabs
  5. Sudafed 30 mg tablets


Important Points
  • Always keep the mixture refrigerated.
  • Avoid using medication which is more than 6 months old. Medication which has been frozen may be good for over 6 months.
  • Injection can be performed within 5-20 minutes of desire intercourse.
  • Increase the dose of the medication until the desired effect is achieved or the maximum dose is reached. Your urologist will have let you know the maximum dose.
  • Do not increase the dose above the maximum prescribed dose without speaking to your doctor.
  • Do not do more than 1 injection in 24 hours
  • Do not do more than 3 injections per week
  • Do not reuse a needle
  • Do not let anything touch the tip of the needle except when withdrawing the medication from the bottle or injecting into the penis (ensure that both of these have been cleaned with alcohol before putting the needle in).
  • Do not take any other medication for erectile dysfunction without speaking to you doctor first.


Injection Technique
  • Getting things ready
    • Wash hands.
    • CAP AND COCK: Alcohol swab to clean the top of the medication bottle and the base of the penis.
    • Remove the needle cover.
      • Pull the plunger back until the end of the plunger (the end closest to the needle) is at the dose you were told to inject. 
      • Put the needle into the center of the rubber at the end of the medication bottle.
      • Invert the bottle and needle so that the needle is pointed up
      • Inject the air from the syringe into the bottle then withdraw the same amount of medication. Don't worry about tiny air bubbles.
  • Inject the medication
    • Pull the penis out on a stretch by grasping under the head of the penis. If there is a foreskin, pull the foreskin back and pull directly under the head of the penis.
    • AVOID the topside and underside (this is where the nerves and urethra are).
    • Do not inject into the head of the penis.
    • Inject near the base (close to the body and on the side
    • Slide the needle into the penis: at a RIGHT angle to the surface, ALL the way to the hilt
    • Depress the plunger quickly.
    • Pull the needle straight out of the penis and safely dispose.
    • Apply pressure to the injection site for 2-3 minutes (5 mintues if you are taking a blood thinner or aspirin).
    • Massage the penis to distribute the medication.
    • Alternate sides if possible.



These medications are 'compounded' at each pharmacy. This means that batches of the medication need to be made periodically. In pharmacies which do this infrequently and fill relatively few prescriptions, the medication may not be as 'fresh' or mixed to the correct proportions. Please ask your pharmacist if they have experience in compounding your prescription and if the medication has recently been made.


If you have any concerns, Laur

el Pharmacy in Vancouver has a long history of providing good quality mixtures and good patient instructions. Laurel Prescription's price list can be downloaded here.


Priapism Is An Erection That Lasts Too Long


If you develop an erection that lasts over 2 hours (i.e. priapism) and does not respond to conservative methods, you should take steps to bring the erection down. Failure to treat priapism promptly can result in permanent loss of erectile function bu causing damage to the tissues responsible for erections. 


Treatment of priapism:

  1. Cold shower
  2. Exercise such as walking
  3. Pseudoephedrine HCl (Sudafed or similar). Take 4 (30 mg) tablets. Take the short-acting tablets but AVOID the extended-release or long-acting tablets.
    1. Intracavernosal injection of vasoconstrictor by MD: Phentolamine 125-250 mcg q5 minutesSurgery: T-shunt


Vacuum Constriction Device


Osbon ErecAid Vacuum Therapy System: Patient information including instructional video and user manual | Your local medical supply store may have the device available; if not, you can obtain the device at Laurel Prescriptions in Vancouver or Davies Medical Supplies Ltd. in North Vancouvertend to do best with the three-piece devices, but the choice of device is individualized.


Penile Prosthesis

A penile prosthesis is mechanical device that is surgically implanted into the penis to help reduce erections satisfactory for intercourse. This is generally a last resort after all conservative methods have failed.


There are 2 basic types, semirigid and inflatable (these are all "three-piece"). In general, men 

There are some important considerations to be aware of before having the sort of surgery. These include:

  1. Some loss of length compared to what was present prior to surgery with native erections occurs in all men, usually 2-3 cm.
  2. Increase in girth usually does not occur with a penile prosthesis
  3. Revision for mechanical failure or infection is sometimes necessary. About 1 in 10 men need revision over 10 years.


AMS Inflatable Penile Prosthesis


On the Web

CUA Brochure on Treatment Options in Erectile Dysfunction


Topical lidocaine spray for premature ejaculation.