Diagnosis

Erectile dysfunction FAQs

Urologist Tobias Kohler, M.D., answers the most frequently asked questions about erectile dysfunction.

Hi. I'm Dr. Kohler, a urologist at Mayo Clinic. I'm here to answer some of the important questions you may have about erectile dysfunction.

Problems with erectile dysfunction are super common. If you look at the decade of life, that predicts what percent of men will have problems. So, for example, 50% of 50-year-olds, 60% of 60-year-olds, so on and so forth, will have problems with erections. But that does not necessarily mean that as you get older, you have to have problems of the penis. There are plenty of men in their 60s, 70s and 80s and 90s with great sex lives. In other words, if you take great care your penis, your penis will take great care of you.

So the things that you can do to take care of yourself to help with erections include exercising, eating well, including a diet high in fruits and vegetables, having a slimmer waistline, sleeping well, quitting smoking. A lot of these things I mentioned are as powerful as medications in helping with erections and improving your sex life.

The penis and overall health is so strongly connected, it's really important to remember that the penis is one of the most powerful predictors we have, especially in young men, for heart attacks. The blood vessels that feed the penis are relatively small. Blood vessels in the heart and the neck are a little bit bigger. So therefore, the penis can predict heart attacks or strokes years in advance when they may occur.

Yes and no. So when we talk about what truly is a problem with erectile dysfunction, the definition is a problem that lasts greater than three months and is a consistent inability to obtain or maintain an erection adequate for intercourse. So when young men get problems with erections, which is very, very common because it's normal to have bad nights here and there. And so, if it happens occasionally, you don't need to be as worried about that. But if you have consistent problems, you absolutely should and must get checked out by a doctor to figure out what's going on, not only because there are great treatments available, but because we may discover underlying medical problems.

When young men have problems with erections, most of the time it's a confidence issue. And so, there are different ways to deal with that. One way is to give medications to get the confidence back. Another way is to use specialists trained in behavioral techniques to get confidence back, so sexual counselors or therapists can really help with this problem.

Modern day, we have several new, exciting, experimental things, such as shockwave therapy of the penis or platelet-rich plasma or stem cell therapy. These are not ready for prime time, and so you should not, as a patient, have to spend your hard-earned money to see whether or not this works for you. It's better to be part of a clinical trial to see if that works or to go with more traditional therapies at this point.

If you want to be a great partner for your medical team to help solve problems with erections, the number one thing you can do is book an appointment. Just like anything else in life, you have to take the initiative, set up an appointment for your physician, say, "Doc, I have a problem with sex." Never hesitate to ask your medical team any questions or concerns you have. Being informed makes all the difference. Thanks for your time and we wish you well.

For many people, a physical exam and answering questions (medical history) are all that's needed for a doctor to diagnose erectile dysfunction and recommend a treatment. If you have chronic health conditions or your doctor suspects that an underlying condition might be involved, you might need further tests or a consultation with a specialist.

Tests for underlying conditions might include:

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Treatment

The first thing your doctor will do is to make sure you're getting the right treatment for any health conditions that could be causing or worsening your erectile dysfunction.

Depending on the cause and severity of your erectile dysfunction and any underlying health conditions, you might have various treatment options. Your doctor can explain the risks and benefits of each treatment and will consider your preferences. Your partner's preferences also might play a role in your treatment choices.

Oral medications

Oral medications are a successful erectile dysfunction treatment for many men. They include:

All four medications 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.

Taking one of these tablets will not automatically produce an erection. Sexual stimulation is needed first to cause the release of nitric oxide from your penile nerves. These medications amplify that signal, allowing normal penile function in some people. Oral erectile dysfunction medications are not aphrodisiacs, will not cause excitement and are not needed in people who get normal erections.

The medications vary in dosage, how long they work and side effects. Possible side effects include flushing, nasal congestion, headache, visual changes, backache and stomach upset.

Your doctor will consider your particular situation to determine which medication might work best. These medications might not treat your erectile dysfunction immediately. You might need to work with your doctor to find the right medication and dosage for you.

Before taking any medication for erectile dysfunction, including over-the-counter supplements and herbal remedies, get your doctor's OK. Medications for erectile dysfunction do not work in everyone and might be less effective in certain conditions, such as after prostate surgery or if you have diabetes. Some medications might also be dangerous if you:

Other medications

Other medications for erectile dysfunction include:

Penis pumps, surgery and implants

If medications aren't effective or appropriate in your case, your doctor might recommend a different treatment. Other treatments include:

Exercise

Recent studies have found that exercise, especially moderate to vigorous aerobic activity, can improve erectile dysfunction.

Even less strenuous, regular exercise might reduce the risk of erectile dysfunction. Increasing your level of activity might also further reduce your risk.

Discuss an exercise plan with your doctor.

Psychological counseling

If your erectile dysfunction is caused by stress, anxiety or depression — or the condition is creating stress and relationship tension — your doctor might suggest that you, or you and your partner, visit a psychologist or counselor.

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So what is erectile dysfunction (ED), anyway?



Why it happens

What causes erectile dysfunction?

Hormonal causes: elevated prolactin, hypothyroidism, hyperthyroidism, Mb Cushing. Low s-testosterone. Men who find it difficult to light sexually often think they have a lack of male sex hormone which is rarely the case. Hypogonadism as the only cause of impotence is uncommon. Medicines: antihypertensives (diuretics, beta-blockers, clonidine chloride and other centrally acting preparations), psychotropic drugs (benzodiazepines, SSRIs, tricyclic antidepressants, neuroleptics), cimetidine, 5-alpha-reductase inhibitors. Usually, sexual stimulation is enough to get things going, but men with ED have trouble staying firm through ejaculation. Lots of things can contribute, like age, high blood pressure, vascular disease, disease, stress, and more.



What you can do

Can ED medication help?

Background impotence / erectile dysfunction, i.e. inability to maintain an erection for satisfactory sexual activity, affects many men at some point in life.Epidemiological data suggest that 5-20% of all men exhibit moderate to severe erectile dysfunction. Yes, the good news is ED drugs, PDE5 inhibitors that are prescription medications, have been clinically proven to be effective treatments for ED. Wondering about side effects, an underlying cause, or an underlying condition? Find out if ED medication is right for you by getting medical advice from the expert providers through our platform, without any of the stress of an in-person doctor visit.



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What ED treatments are there?

A number of ED pills are prescribed in the United States. We worked with our expert medical advisors to determine which ED treatments to offer through our platform - from highly effective as-needed ED treatment (like the active ingredient in Viagra®) and daily ED meds (like the generic for Cialis®). Though not available through Hims, doctors sometimes prescribe other medications like vardenafil (Levitra®, Staxyn®) or even alprostadil, a penile injection.

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Frequently asked
questions about ED
medication

What is the main cause of erectile dysfunction?
Erectile dysfunction can be caused by psychological factors, medical conditions and certain medications. In younger men with variable or situational ED, stress and anxiety can restrict blood flow to the penis at exactly the wrong moment. In men with ED that doesn’t vary with different partners or different situations, underlying problems with nerves, blood vessels or hormone production may be present.
The providers through our platform can help identify the erectile dysfunction cause and treat your ED. In addition, they can recommend testing to make sure that you don’t have undiagnosed underlying health problems (i.e. cardiovascular disease that could predispose to a heart attack).
How do ED pills work?
Get stimulated and the pills can take it from there.
Sexual arousal triggers a response in your body that then triggers nitric oxide production, which relaxes the blood vessels and smooth muscle in the penis. This lets blood rush into the penis, which gets hard as a result. There is an enzyme in the penis called phosphodiesterase that shuts this process off when sex is over. ED pills work by blocking PDE5 and preventing this shut off. That keeps your erection going longer and stronger.
What is the safest drug for erectile dysfunction?
Your provider will help determine which drug for erectile dysfunction is most appropriate for you. All of the oral medications available in the United States for ED treatment are approved by the FDA based on extensive, high quality clinical trials. These trials have uniformly demonstrated that ED medications are safe and effective for the vast majority of men. Just like with any doctor’s visit, it is important to be honest during your online ED visit so that your provider can identify risks that these medications might pose to you based on your specific medical history and medications. ED pills may not be right for you If you have chest pain with mild exertion, very low blood pressure or take certain medications such as nitroglycerin. If you fall into these categories, consult with a urologist in person about alternative treatments such as MUSE urethral suppositories or penile injection therapy.
Which erectile dysfunction drug is best?
Head to head clinical studies have generally demonstrated that no particular erectile dysfunction medication is superior to the others. Rather, each medication has particular advantages and disadvantages that are important to understand when selecting the treatment that is best for you.
What is the most effective pill for ED?
The most effective pill must work in concert with your body, lifestyle and, in some cases, your mind. Although all PDE5 inhibitors have all been clinically proven to be effective for treating ED, some may act faster, last longer, work regardless of food intake, etc. With enough information, a qualified medical provider can help you find an ED medication and dosage that is right for you. You may connect with providers and receive ongoing care through our platform.
What are the side effects of ED medications?
In general, ED treatment side effects are mild and temporary. Common side effects include headaches, flushed skin, nasal congestion (stuffy nose), runny nose, back pain and upset stomach. Medical providers can help you address side effects from ED medication such as PDE5 inhibitors. You may connect with providers and receive ongoing care through our platform.
However, ED medications can very rarely cause serious side effects such as priapism (a prolonged, painful erection that can result in permanent erectile dysfunction if not treated immediately). Serious adverse events such as hearing or vision loss have also been reported in patients taking ED pills, although it is not clear if these adverse events were caused by the ED medication.
Are ED drugs available over-the-counter?
In the United States, erectile dysfunction medications are prescription drugs and cannot be legally sold over-the-counter. Any website, doctor or person who sells ED medications without a prescription is breaking the law and may be selling potentially dangerous counterfeit drugs. According to Pfizer, the manufacturer of Viagra, Viagra is one of the most counterfeited drugs in the world.
Hims offers access to safe, effective care that is more convenient than visiting a doctor in-person for ED medication. You’ll be connected to a board-licensed medical provider, who will evaluate you, and can prescribe FDA-approved ED treatment if indicated for your situation. If prescribed, treatment is delivered straight to your home.
Can you take Viagra or other PDE5s with a heart condition?
FDA recommends that men who’ve suffered from all heart disturbances, heart attacks as well as strokes exercise caution regarding ED drugs.
If you suffer from high blood pressure, heart disease and erectile dysfunction, talk to a medical provider to learn which ed treatments are appropriate and which are not. For example, alternative treatments or reduced dosage medication may be advisable while dangerous interactions between common heart medications (ie, nitrates) and PDE5s should be avoided.
What blood pressure medication does not cause erectile dysfunction?
Diuretics, alpha blockers and beta blockers are some of the high blood pressure medications commonly associated with ED. However, untreated high blood pressure can also cause erectile dysfunction, so it is important to get your blood pressure under control for both your health and your erection. If you start experiencing erectile dysfunction after beginning BP medication, talk to the prescribing doctor.
How can I improve my erectile dysfunction?
The best way to improve your erectile function is to take a holistic approach. ED medications work best in the long term when combined with positive lifestyle changes that promote overall health. Eating a heart-healthy diet, exercising, and avoiding health-harming behaviors like cigarette smoking can make a big difference and allow you to enjoy a whole lifetime of healthy sexual function.
Therapy: If your erectile dysfunction has a psychological cause, therapy can provide useful, practical tools that help in the moment, and may help you to deal with the root cause of anxiety or depression.
Reduce alcohol consumption: If you frequently experience ED after drinking alcohol, the alcohol may actually be the cause of your erectile dysfunction. Try having sex without alcohol to see if that solves the problem.
Can an enlarged prostate cause ED?
No, an enlarged prostate cannot cause ED. However, ED and prostate enlargement (also called BPH, benign prostatic hypertrophy) are both common problems that occur with increasing frequency as men age. Interestingly, once a day Cialis (tadalafil) is not just an FDA-approved treatment for ED. It is also approved to treat urinary symptoms that can result from an enlarged prostate like a weak stream, urinary frequency, and urinary urgency. If you have both ED and symptoms from an enlarged prostate, once daily Cialis (or generic tadalafil) might be a great treatment option.
Can low testosterone cause ED?
Yes, low testosterone can cause ED in some men. However, the threshold level of testosterone needed to maintain normal erectile function is actually fairly low. Although testosterone deficiency is a common condition, most affected men have symptoms other than erectile dysfunction. You should be evaluated for testosterone deficiency if you have ED and have noticed that you are more fatigued than you would expect, have low desire, and/or trouble maintaining your muscle mass. Testosterone deficiency is not likely to be the cause of ED in men with normal sexual desire, energy and physical strength.