ED is a health disorder that is treatable and even curable. But, most people don't have the patience to control ongoing health issues or change their lifestyle. Do you?

When we think of Erectile Dysfunction (ED), the first drug that comes to mind is the big V=Viagra. Also known as “Vitamin V", "the Blue Pill", or "Blue Diamond”, Viagra has become a blockbluster drug, as well as Cialis, earning billions of dollars for big Pharma. But they are by no means the only money-making treatment in the market. Whether bought via prescription, over-the-counter, online, through bona fide drug suppliers or black marketers, ED is generating lots of bucks for manufacturers, wholesalers, retailers, advertisers and scammers.

The topic of ED was once taboo but with new developments in therapies, this disorder can now be treated like other medical conditions. Unfortunately, many of these so-called treatments are sold on the black market and many times they have turned out to be counterfeits and worthless, but even worse, toxic and dangerous.

In the Huffington Post, lecturer Sarah O'Leary refers to the advertising campaigns as “the marketing genius” of ED. The advertising experts of this world have transformed what was once an embarrassing and humiliating condition into an opportunity of regaining and even building up virility – without being perverse or obscene. In other words, ED has gotten a “make over” as a so-called “biobehavioral” disorder. Thus, at least in Western countries, getting ED treatment for men is now being perceived as “natural” as women getting silicone breast implants. It is simply an act of improving on nature.¹

Erectile dysfunction (ED), also known as impotence or male sexual dysfunction, is a condition where “a man has trouble getting or keeping an erection", thus preventing him from engaging in sexual intercourse. ED occurs when nerve impulses to the genitals or blood flow to the penis are restricted or blocked. ED may occur only intermittently or every time sexual intercourse is attempted. ED is not synonymous with poor libido or ejaculation problems.^2,3

There is still some resistance of openly discussing ED even with medical professionals, thus it remains under reported and under diagnosed. Only 1 out of 10 men suffering from ED seeks professional help. In some countries and in many cultures, ED remains taboo because its occurrence is taken to be synonymous to impotence, emasculation – and humiliation.

It appears that 9% of men aged 40 years will experience ED climbing to 54% by age 65, although ED incidence varies depending on the study, and about 50% of men between 40 and 70 at one time or another will suffer from transient ED. In a United Nations report, the most conservative projection for 2025 is a total of 322 million cases compared to 152 million in 1995. Currently greater than 18 million Americans have ED.^4-7

The causes are usually a combination of the following:

Chronic health issues - Metabolic problems, especially diabetes and renal dysfunction, lead to hormonal dysfunction, especially in terms of sexual hormones, as well as circulation and peripheral neuropathy complications. It is estimated that 1 of every 2 men with diabetes suffers from ED.⁸

Cardiovascular disorders such heart disease and hypertension can cause endothelial dysfunction that result in ED. Of interest, ED is a strong predictor of heart attack, stroke, and death from cardiovascular diseases.⁹ And psychological factors including anxiety and depression can also cause impotence. Lastly, ED can occur from complications secondary to medical procedures such as prostate surgery, radiation and chemotherapy.

Lifestyle factors - Unhealthy lifestyle has been identified as a major risk for factor for ED. The specific lifestyle factors identified were stress, obesity, lack of physical exercise, excessive alcohol intake and smoking. Certain physical activities also increased risk for ED. Cyclists, for example, have a higher likelihood for ED compared to other athletes.^10,11

Medications - Use of certain illegal/recreational drugs as well as certain prescription drugs are known to cause so-called drug-induced ED including antidepressants and other psychiatric medications, antihistamine medications, some anti-hypertensive drugs and diuretics ("water pills"), Parkinson's disease medications, chemotherapy, hormonal medications and opiate analgesics. And recent data suggests that taking multiple medications increases the risk for ED.^12,13

Age - ED is more common in men above fifty, so age is always thought of as a major risk factor. However, although “ED becomes more common as you get older… male sexual dysfunction is not a natural part of aging".¹⁴

So, what's the current treatment?

Control chronic health issues and ‘change your lifestyle’ - Stop smoking and increasing one’s physical activity is especially beneficial. Additionally, simple pelvic floor exercises performed several minutes a day can help in achieving and sustaining an erection.¹⁵

Kegel exercises, for example, are prescribed for treating male urinary incontinence. It consists of tightening or tensing pelvic muscles and has been shown to have additional benefits such as improved sexual function, more intense orgasms and better erections. And pelvic muscle exercises may be enhanced by electrical stimulation and biofeedback techniques.^16,17

Drugs and Supplements

Impotence drugs - Initially developed for the treatment of cardiovascular problems, serendipitous events showed increased sexual potency as a common side effect. Since its approval in 1998, Viagra (sildenafil) has become a blockbluster drug earning billions of dollars. Its main competitors are tadalafil (Cialis) and vardenafil (Levitra).

Hormones – Replacement usually consists of testosterone or supplementation with the hormone dehydroepiandrosterone (DHEA).

Topicals include creams and oils for the penis or sexual enhancement trans-dermal patches.

Nutritional Supplements are marketed as ED treatments and aphrodisiacs including amino acid arginine, bioflavonoids, zinc, vitamin C, vitamin E, and flaxseed meal propionyl-L-carnitine, oral L-citrulline as well as the following herbal remedies:^18,19

The red ginseng from the Panax ginseng plant is one of the most widely used herbal remedies for ED. Several studies have demonstrated its efficacy, especially in psychogenic ED. Ginkgo biloba is another oriental ED remedy which has been reported to be effective when ED is secondary to ongoing anti-depressant therapy. Other herbs include Maca which comes from the root vegetable Lepidium meyenii, a traditional herbal remedy from the Andes region, and Yohimbe, from the African tree Pausinystalia yohimbe, has been used as pharmacological agents in the treatment of ED for over 70 years.^20-22

Implants and Pumps - It is surprising to see the variety of penile prostheses and implants available. One type involves surgically implanting malleable or semirigid rods into the two sides of the penis. Another type involves inflatable rods. The implants are made from different materials such as silicone or polyurethane. Except for slight scars from implantation, the prostheses are usually not noticeable externally.

Unlike a penis implant, a penis pump or a vacuum constriction device (VCD) is not surgically implanted inside the penis but is attached externally. The VCD is a hollow tube with a hand-powered or battery-powered pump. The tube is placed over your penis, and then the pump is used to suck out the air inside the tube. This creates a vacuum that pulls blood into your penis. Once you get an erection, you slip a tension ring around the base of your penis to hold in the blood and keep it firm. You then remove the vacuum device. The erection typically lasts long enough for a couple to have sex. You remove the tension ring after intercourse.²³

Reconstructive Surgery - ED can also be caused by decreased blood circulation to the penis. Vascular reconstructive surgery helps normalize blood flow in this situation. “Vascular reconstructive surgery of the penis generally involves bypassing blocked arteries by transferring an artery from an abdominal muscle to a penile artery so that it creates a path to the penis that bypasses the area of blockage that is inhibiting blood flow to the penis".²⁴

Sexual therapy - Psychological counseling and sexual therapy may help in resolving ED. “Sexual Medicine is a discipline of medicine that deals with sexual problems - physical as well as psychological… Sexual medicine has four dimensions: the promotional dimension (increases awareness and helps individuals have a healthy and fulfilling sex life); the preventive dimension (counseling); the curative dimension (clinical treatment of specific sexual disorders) and the rehabilitative dimension (helps patients regain sexual health)".²⁵

Alternative Treatments - With the increasing popularity of complementary and alternative medicine (CAM), many therapies including acupuncture are marketed for ED treatment as well as hypnosis for psychogenic ED. A study published in 1996 reported that hypnosis was superior to testosterone or trazodone “in the treatment of non-organic male sexual dysfunction".^26,27

OK, what really works?

Controlling your ongoing health issues, changing your lifestyle and sexual therapy is probably still the best therapy. However, their effectiveness comes gradually and therapy takes a long time before the effects become evident. So most people take the easy way out...drugs.

There is no doubt, sildenafil (Viagra) and other officially approved drugs are effective.  According to experts at Mayo Clinic: “All three medications work in much the same way. These drugs enhance the effects of nitric oxide, a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation. These medications vary in dosage, how long they work and their side effects.”

However, there are some downsides to the impotence drugs:

ED drugs only treat the symptoms but do not cure the sexual dysfunction itself. “Oral sildenafil therapy, while effective in circumventing the cause of ED, provides only short-term symptomatic relief of the condition.” As most drugs do, they can have potentially serious side effects, including heart attack, chest pain, and heart failure. Cardiac patients taking nitrates need to be aware of the potential life threatening drug interaction with impotence drugs. And it’s important to note that the efficacy and safety of ‘topical’ ED drugs have not been fully tested.²⁸

There is an increased incidence of risky sexual behaviors, one of the consequences of the widespread use of sexual enhancement drugs. This, in turn, has led to the increased incidence in STD’s including HIV and hepatitis.²⁹

WARNING: COUNTERFEIT DRUGS !!!  Because of their popularity, ED drugs are often sold over the Internet as scams. Victims usually keep their condition secret to avoid embarrassment and are unlikely to report to the authorities their misfortune. The U.S. FDA, the European Medicines Agency (EMA) and other regulatory bodies regularly issue warnings about identified counterfeits.^30,31

As far as the other treatments here’s what we know…

The evidence to support the effectiveness of supplements and herbal remedies is minimal, limited and sometimes contradictory and there are significant doubts about the long-term safety of DHEA supplements. However, systematic reviews which analyzed clinical data on yohimbe and ginseng drew “cautiously positive conclusions".³²

Some herbal products which are purported to be traditional aphrodisiacs may actually have been “spiked” with ED drugs such as sildenafil, tadalafil and/or vardenafil.  An FDA investigation of a number of these sexual enhancement supplements found that a third of them actually contained ingredients similar to the class of prescription drugs that includes Viagra (sildenafil citrate), Cialis (tadalafil) and Levitra (vardenafil HCl). These ingredients are not listed in the labels of the said products and could lead to serious and even fatal interactions with other drugs, especially with nitrates, with nitroglycerin being the most commonly prescribed.³³

Data and evidence supporting acupuncture are so far insufficient.³⁴ Surgery is difficult and expensive and is usually performed as a last recourse. These rather invasive treatments can cause complications including infection that can lead to permanent damage. On the other hand, pumps are cumbersome to use and indiscrete.

The Bottom Line

Seems, just about everybody gets emails marketing “sexual enhancement supplements.” But, be careful, Internet frauds involving ED remedies are very common and self-medication is strongly discouraged as it can lead to irreversible damage and even death.

ED is a health disorder like any other and is treatable and even curable, so it is important to know the root causes of sexual dysfunction and to consult a health care professional.

Unfortunately, many do not have the patience to control their ongoing health issues or change their lifestyle. When it comes to sex, instant gratification is the name of the game.

Published April 13, 2012, updated July 30, 2012

References

1. O’Leary S, The Marketing Genius of Erectile Dysfunction, Huffington Post, October 18, 2010
2. Erectile Dysfunction, MedlinePlus
3. A Visual Guide to Erectile Dysfunction, WebMD
4. Nicolosi A et al, Epidemiology of erectile dysfunction in four countries: cross-national study of the prevalence and correlates of erectile dysfunction, Urology. 2003 Jan;61(1):201-6
5. Johannes CB et al, Incidence of erectile dysfunction in men 40 to 69 years old: longitudinal results from the Massachusetts male aging study, J Urol. 2000 Feb;163(2):460-3.
6. McKinlay JB, The worldwide prevalence and epidemiology of erectile dysfunction, International Journal of Impotence Research (2000) 12, Suppl 4, S6±S11
7. Selvin E et al, Prevalence and risk factors for erectile dysfunction in the US, Am J Med. 2007 Feb;120(2):151-7
8. Meuleman EJ, Prevalence of erectile dysfunction: need for treatment?  Int J Impot Res. 2002 Feb;14 Suppl 1:S22-8
9. Erectile Dysfunction Strong Predictor of Death, Cardiovascular Outcomes, ScienceDaily, March 16, 2010
10. Horasanli K et al, Do lifestyle changes work for improving erectile dysfunction? Asian J Androl. 2008 Jan;10(1):28-35
11. Blakeslee S, Serious Riders, Your Bicycle Seat May Affect Your Love Life, Health, The New York Times, October 4, 2005
12. Drugs that may cause impotence, MedlinePlus
13. Stein J, Taking more medications may raise risk of erectile dysfunction, The Los Angeles Times, November 15, 2011
14. Mock K, Epidemiology and age-related risk factors of erectile dysfunction, Wien Med Wochenschr. 2000;150(1-2):2-3
15. Agostini LCM et al, Erectile dysfunction association with physical activity level and physical fitness in men aged 40–75 years, International Journal of Impotence Research 23, 115-121 May/June 2011
16. Kegel Exercises: Treating Male Urinary Incontinence, MedicineNet 
17. Dorey G et al, Pelvic floor exercises for erectile dysfunction, BJU Int. 2005 Sep;96(4):595-7
18. McKay D, Nutrients and botanicals for erectile dysfunction: examining the evidence, Altern Med Rev. 2004 Mar;9(1):4-16
19. Cormio L et al, Oral L-citrulline supplementation improves erection hardness in men with mild erectile dysfunction, Urology. 2011 Jan;77(1):119-22
20. Jang DJ et al. Red ginseng for treating erectile dysfunction: a systematic review, Br J Clin Pharmacol. 2008 Oct;66(4):444-50. Epub  2008 Jun 9
21. Cohen AJ, Ginkgo biloba for antidepressant-induced sexual dysfunction, J Sex Marital Ther. 1998 Apr-Jun;24(2):139-43
22. Zenico T, Subjective effects of Lepidium meyenii (Maca) extract on well-being and sexual performances in patients with mild erectile dysfunction: a randomised, double-blind clinical trial, Andrologia. 2009 Apr;41(2):95-9
23. Erectile Dysfunction: Vacuum Constriction Devices, WebMD
24. Erectile Dysfunction: Vascular Reconstructive Surgery, WedMD 
25. Sexual Medicine, Web Health Centre
26. Erectile Dysfunction Doesn't Have to End Your Healthy Sex Life, Hypnosis network
27. Aydin S et al, Efficacy of testosterone, trazodone and hypnotic suggestion in the treatment of non-organic male sexual dysfunction, Br J Urol. 1996 Feb;77(2):256-60
28. Viagra (sildenafil citrate), Product Label, Pfizer 
29. Carey JW et al, Drug use, high-risk sex behaviors, and increased risk for recent HIV infection among men who have sex with men in Chicago and Los Angeles, AIDS Behav. 2009 Dec;13(6):1084-96
30. Savaliya AA et al, Screening of Indian aphrodisiac ayurvedic/herbal healthcare products for adulteration with sildenafil, tadalafil and/or vardenafil using LC/PDA and extracted ion LC-MS/TOF, J Pharm Biomed Anal. 2010 Jul 8;52(3):406-9
31. Hidden Risks of Erectile Dysfunction "Treatments" Sold Online, For Consumers, U.S. FDA, February 21, 2009
32. Ernst E, Complementary and alternative medicine (CAM) for sexual dysfunction and erectile dysfunction in older men and women: An overview of systematic reviews, Maturitas. 2011 Jul 20
33. Cordaro FG et al, Selling androgenic anabolic steroids by the pound: identification and analysis of popular websites on the Internet, Scand J Med Sci Sports. 2011 Jan 7
34. Lee MS et al, Acupuncture for treating erectile dysfunction: a systematic review, BJU Int. 2009 Aug;104(3):366-70