Sex and the Prostate: Overcoming erectile dysfunction when you have prostate disease

If you are concerned about erectile function, it’s important to understand what erectile dysfunction really is. Failing to have an erection one night after you’ve had several drinks — or even for a week or more during a time of intense emotional stress — is not erectile dysfunction. Nor is the inability to have another erection soon after an orgasm. Nearly every man occasionally has trouble getting an erection, and most partners understand that.

Erectile dysfunction is the inability to attain and maintain an erection sufficient for sexual intercourse at least 25% of the time. The penis doesn’t get hard enough, or it gets hard but softens too soon. The problem often develops gradually. One night it may take longer or require more stimulation to get an erection. On another occasion, the erection may not be as firm as usual, or it may end before orgasm. When such difficulties occur regularly, it’s time to talk to your doctor.

Erectile dysfunction can have many causes, including some forms of prostate disease and medications and surgery for prostate cancer. Fortunately, in many cases, this problem can often be effectively addressed. Some men find relief by taking medications to treat erectile dysfunction. If these aren’t effective for you, a number of other options, including injections and vacuum devices, are available. The possibility of finding the right solution is now greater than ever.

This article explores why men may develop erectile dysfunction as a consequence of some prostate diseases, and details the current treatment options to restore sexual functioning.

The basics: How an erection occurs

At its most basic level, an erection is a matter of hydraulics. Blood fills the penis, causing it to swell and become firm. But getting to that stage requires extraordinary orchestration of body mechanisms. Blood vessels, nerves, hormones, and, of course, the psyche must work together. Problems with any one of these elements can diminish the quality of an erection or prevent it from happening altogether.

Nerves talk to each other by releasing nitric oxide and other chemical messengers. These messengers boost the production of other important chemicals, including cyclic guanosine monophosphate, prostaglandins, and vasoactive intestinal polypeptide. These chemicals initiate the erection by relaxing the smooth muscle cells lining the tiny arteries that lead to the corpora cavernosa, a pair of flexible cylinders that run the length of the penis (see Figure 1).

Figure 1: Anatomy of the penis

The penis is made up of three cylindrical bodies, the corpus spongiosum (spongy body)—which contains the urethra and includes the glans (head) of the penis—and two corpora cavernosa (erectile bodies), that extend from within the body out to the end of the penis to support erection. Blood enters the corpora cavernosa through the central arteries.

As the arteries relax, the thousands of tiny caverns, or spaces, inside these cylinders fill with blood. Blood floods the penis through two central arteries, which run through the corpora cavernosa and branch off into smaller arteries. The amount of blood in the penis increases sixfold during an erection. The blood filling the corpora cavernosa compresses and then closes off the openings to the veins that normally drain blood away from the penis. In essence, the blood becomes trapped, maintaining the erection.

As most people know, testosterone is important to the erection process. Certainly, a man needs a normal level of this hormone to start and maintain an erection. But for all the talk about hormones and virility, doctors don’t know exactly what role sex hormones play in normal libido or the ability to have erections.

Obviously, an erection isn’t permanent. Some signal — usually an orgasm, but possibly a distraction, interruption, or even cold temperature — brings an erection to an end. This process, called detumescence, or deflation, occurs when the chemical messengers that started and maintained the erection stop being produced, and other chemicals, such as the enzyme phosphodiesterase 5 (PDE5), destroy the remaining messengers. Blood seeps out of the passages in the corpora cavernosa. Once this happens, the veins in the penis begin to open up again and the blood drains out. The trickle becomes a gush, and the penis returns to its limp, or flaccid, state.

It’s usually difficult for a man to get another erection right away. The length of the interval between erections varies, depending on a man’s age, his health, and whether he is sexually active on a regular basis. A young, sexually active man in good health may be able to get an erection after just a few minutes, whereas a man in his 50s or older may have to wait 24 hours. One reason may be that nerve function slows with age.

Indeed, erections may work on a use-it-or-lose-it principle. Some research suggests that when the penis is flaccid for long periods of time — and therefore deprived of a lot of oxygen-rich blood — the low oxygen level causes some muscle cells to lose their flexibility and gradually change into something akin to scar tissue. This scar tissue seems to interfere with the penis’ ability to expand when it’s filled with blood.

Why erectile dysfunction may result from prostate disease

In the past, it was thought that most cases of erectile dysfunction were psychological in origin, the result of such demons as performance anxiety or more generalized stress. While these factors can cause erectile dysfunction, doctors now think that 70% of the time the problem can be traced to a physical condition that restricts blood flow, hampers nerve functioning, or both. Such conditions include diabetes, kidney disease, multiple sclerosis, atherosclerosis, vascular disease, and alcoholism.

However, some types of prostate disease and treatments (particularly for prostate cancer) may also be responsible.

Prostate cancer

A sudden onset of erectile dysfunction may be a sign that a man has prostate cancer, so your doctor will likely order a prostate-specific antigen (PSA) test and do a digital rectal exam during the diagnostic workup to assess this possibility.

Surgery for prostate cancer can sever some of the nerves or arteries that are needed for an erection. For men who undergo a radical prostatectomy (removal of the prostate gland), the estimates of how many men will regain their ability to have erections vary widely, from 25% to 80%. Even so-called nerve-sparing surgical techniques lead to erectile dysfunction in up to half or more of all cases. The results depend on such variables as a patient’s age, the surgeon’s skill, and the tumor locations (if a tumor is too close to the nerve bundle, the nerves can’t be spared). Even when the nerves are not permanently impaired, it can still take six to 18 months for the tiny nerve fibers to recover from the trauma of surgery and restore sexual function.

Radiation treatment for prostate cancer can also harm erectile tissues. Both external beam radiation and radiation-emitting seeds implanted in the prostate (brachytherapy) lead to erectile dysfunction in about half of men who receive these therapies. However, these changes may not occur for up to two years after treatment.

Erectile dysfunction is sometimes a side effect of some hormone therapy medications prescribed for men with prostate cancer that has spread beyond the prostate. Among such hormone-based medications are leuprolide (Lupron), and goserelin (Zoladex). Others, such as flutamide (Eulexin) and bicalutamide (Casodex) may cause erectile dysfunction to a lesser degree. Even prostate cancer itself, in its advanced stages, can spread to the nerves and arteries that are necessary for an erection.

Benign prostatic hyperplasia

Many men who have benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate, also experience erectile dysfunction and ejaculatory problems. Although BPH does not itself cause this condition, some of the treatments used for BPH can do so. For example, finasteride (Proscar), an antitestosterone drug prescribed for BPH, has been linked to erectile dysfunction in 3.7% of men who use it and to diminished libido in 3.3%. But alpha blockers such as terazosin (Hytrin), tamsulosin (Flomax), and doxazosin (Cardura) can improve the symptoms of BPH with a lower risk of sexual side effects. Transurethral resection of the prostate, a surgical technique often used when medication fails, also causes erectile dysfunction in a small percentage of men.

Hormonal disorders

Because testosterone helps spark sexual interest, one might assume that low levels of the hormone are to blame for erectile dysfunction. It’s true that when hormone deficiency is a factor in erectile dysfunction, sexual desire also suffers. And according to some estimates, 10%–20% of men with erectile dysfunction have hormonal abnormalities. The most common hormonal cause of erectile dysfunction is hypogonadism, or testicles that don’t produce enough testosterone.


This inflammation of the prostate gland can be either acute (usually caused by a bacterial infection) or chronic (usually not caused by an infectious agent). Symptoms include pain during urination, more frequent urination, and — possibly — a discharge from the penis or fever. Severe prostatitis can cause erectile dysfunction directly. In milder forms, the condition can produce painful ejaculation, which can certainly interfere with sexual pleasure and may lead to erectile dysfunction. Your doctor may prescribe antibiotics to treat the problem, but it can take several weeks for the infection to clear and for normal erections to return.

Diagnosing erectile dysfunction

If you’ve been having difficulty getting or sustaining erections, talk about it with your doctor. Such a conversation is never easy, but thanks in part to greater publicity about this problem and its treatment, many obstacles have been toppled.

You may recall the TV commercials that showed self-assured men going to the doctor’s office to discuss the problem and emerging relieved after having taken this important step. What’s misleading is that such commercials leave the impression that there’s not much to discuss — all you need is a prescription and your erections will come back. In reality, your doctor must diagnose the cause of your erectile dysfunction in order to recommend an effective treatment.

While therapy usually does involve medication, erectile dysfunction is sometimes a symptom of an underlying condition that requires its own treatment. Also, medication is more effective for some causes of erectile dysfunction than for others. For instance, if you’ve had prostate surgery, pills probably won’t work as well as other treatments. And if a psychological condition is significantly involved, you may benefit from counseling with a mental health professional trained in sex therapy.

Providing your medical history

At first, the doctor will probably ask you about your medical history. Do you have any chronic illnesses? What illnesses and operations have you had in the past? What medications are you taking, if any? Your doctor is also likely to ask about your psychological well-being and lifestyle: Do you suffer (or have you ever suffered) from depression? Are you under a lot of stress? Do you drink alcohol? Smoke? Use illegal drugs? Have you felt a loss of affection for your partner? Have you recently grown interested in a new partner?

As part of this health history, be prepared to tell your doctor specific details about the symptoms that brought you to the office and when they began. Your doctor might want to know how often you had sex before the problem started and if there have been weeks or months in the past when you’ve had erectile dysfunction. Your doctor may conduct a written or verbal screening test.

If the cause is clear — a recent operation for prostate cancer, for example — the conversation may move directly to your treatment options. Otherwise, you may need to answer more questions to help the doctor narrow down the possible causes and avoid unnecessary testing.

A key issue is whether the symptoms came on gradually or suddenly. Erectile dysfunction that comes on gradually often points to causes that involve blood flow or nerves. On the other hand, a sudden loss of sexual desire or the ability to have erections usually suggests that a medication or psychological difficulty, such as depression or stress, may be to blame. Don’t be embarrassed if the doctor asks you about early morning erections or whether you can achieve an erection if you masturbate. The ability to do so is an important clue in determining whether the problem is psychologically or physically based (see Table 1).

Table 1: Diagnosing the problem

Possible cause of erectile dysfunction What the doctor does
Vascular (circulatory system) Takes your blood pressure and listens to your heart. Checks pulse in groin and feet. Checks your abdomen for aortic aneurysm.
Neurological (nervous system) Tests reflexes of your knees and ankles, as well as anus. Checks for sensation in your legs and feet.
Hormonal (endocrine system) Assesses testicular size and breast development. Checks your thyroid gland.
Local (reproductive system) Examines your penis for Peyronie’s disease. Checks your prostate.
Psychological (stress, anxiety, emotional) Assesses the history of the problem, especially whether it started suddenly and if nocturnal erections are affected.

The physical exam

The physical exam for diagnosing the cause of erectile dysfunction usually takes about 10–15 minutes. The doctor will listen to your heart for signs of a murmur and other abnormalities that can affect blood flow. He or she will also take your blood pressure; both high and low blood pressure can impair blood flow. The doctor will check your pulse in several places — at the wrist, ankle, and groin. Slow or low pulse in any of these areas can mean that not enough blood is reaching tissues in the extremities, including the penis.

In addition, the doctor will examine your testicles, penis, and chest. Abnormally small testicles and enlarged breasts are sometimes signs of inadequate testosterone. Patches of scar tissue felt in the penis suggest Peyronie’s disease. Your doctor may check the prostate gland for signs of infection or cancer, by doing a digital rectal exam. Your doctor may also test for neurological problems by checking the reflexes in your legs, groin, and anus.

Your checkup will probably include tests for cholesterol (to assess your risk of cardiovascular disease) and triglyceride and blood sugar levels (to check for diabetes). The doctor might also ask for a urine specimen because the presence of blood could be a sign of a urologic disease, such as bladder cancer.


Now that medication can successfully treat most men with erectile dysfunction, many once routine diagnostic tests are used only when the doctor suspects the patient has an underlying problem requiring additional treatment.

Hormone tests. Checking testosterone levels used to be one of the first tests ordered for men with erectile difficulty, but that was before doctors realized that testosterone deficiency was rarely the source of the problem. Now, hormone testing is done for men whose medical exams suggest an endocrine problem and for those who have experienced a loss of sexual desire.

Your doctor also may want to check your blood levels of prolactin (a pituitary hormone that can block the action of testosterone) or thyroid–stimulating hormone (a good indicator of an under-active or overactive thyroid gland). These tests also used to be commonplace, but are now done only if your doctor thinks you might have a hormonal deficiency or imbalance.

Blood flow tests. A color duplex Doppler ultrasound, an imaging technique, can reveal problems with blood flow through the arteries or veins of the penis, such as venous leakage. A newer version, called penile Doppler, can be done in a physician’s office. If you’ve tried pills for erectile dysfunction but haven’t found them helpful, your doctor may inject prostaglandin, a fatty acid that widens blood vessels, into your penis to see if this causes an erection. If so, there’s a good chance that you will respond to one or more of the injectable drugs used to treat erectile dysfunction.

Nocturnal tumescence tests. If it’s unclear whether your erectile difficulties have a psychological or a physical cause, your doctor may suggest a nocturnal penile tumescence test. Psychological factors come into play when you’re trying to achieve or maintain an erection. But the psyche doesn’t affect nocturnal erections, which occur involuntarily during sleep. Physical causes affect both kinds of erections.

There are several ways to test for nocturnal erections. Medical devices may be attached to the penis to monitor its circumference or its rigidity throughout the night. A low-tech alternative is the postage stamp test. Simply paste a strip of postage stamps around your penis before going to bed. If the strip breaks by the morning, you’ve had at least one nocturnal erection. This confirms that erection is physically possible and indicates that the difficulty you’ve been having is probably due to psychological issues.

Table 2: Comparing the temporary treatments

Therapy Onset of action Duration of effectiveness Advantages Disadvantages
sildenafil (Viagra) 30–60 minutes 4–5 hours Oral medication, very effective (about 70%), few side effects Cannot be used by men taking nitrates or those with unstable cardiovascular disease
vardenafil (Levitra) 15–30 minutes 4–5 hours
tadalafil (Cialis) 30–45 minutes 24–36 hours
alprostadil injections (Caverject, Edex) 5–20 minutes 30–60 minutes Highly effective (about 80%), few side effects Requires training; injections unpleasant for many men; may cause penile pain or painful sustained erections (priapism)
alprostadil pellets (MUSE) 5–15 minutes 30–60 minutes Moderately effective (about 30%) Requires training; may cause penile pain, usually mild; may cause dizziness
vacuum pump Immediate While in use Highly effective (about 80%), no serious side effects Requires training; cumbersome and awkward; may cause penile numbness or bruising
penile band (Actis, Erecxel) Immediate While in use Effective when used properly, helpful for men with venous leakage who cannot sustain an erection May be awkward to use

Treating erectile dysfunction

If you are diagnosed with erectile dysfunction, you have a number of treatment options.

PDE5 inhibitors: Viagra, Levitra, and Cialis

Approved by the FDA in 1998, sildenafil (Viagra) revolutionized the way we think about — and treat — erectile dysfunction, largely because it is so easy to use and effective. In 2003, the FDA approved two closely related drugs, vardenafil (Levitra) and tadalafil (Cialis), but Viagra remains the best-known and most frequently prescribed oral medication for erectile dysfunction.

All three drugs work in a similar fashion, by affecting the normal physiology of the penis. In particular, they block PDE5, an enzyme that breaks down the erection-producing chemical cyclic guanosine monophosphate. This enables the penis to fill with blood and to stay erect long enough for intercourse. Of course, it’s important to realize that none of these drugs is an aphrodisiac. You’ve got to feel sexually stimulated in order for them to work.

The main differences between the three drugs have to do with timing: how quickly they begin to work, and how long their effects last (see Table 2). Levitra may start working slightly faster than Viagra (within a half-hour instead of an hour) although the FDA says that like Viagra, it should be taken about an hour before sexual activity. Some studies suggest that Levitra may help some men who don’t respond to Viagra. And while some doctors are skeptical about this claim, there’s no harm in trying Levitra or Cialis if Viagra doesn’t work for you.

Cialis stays active in the body much longer than the other drugs. Viagra and Levitra last about 4 to 5 hours (and sometimes up to 12 hours). But with Cialis, the window of opportunity ranges from 24 to 36 hours, which is why it’s sometimes called “the weekend drug.” Another minor difference is that while Viagra’s action may be delayed or impaired when taken with food (especially high-fat foods), that’s not the case with Levitra or Cialis.

Success rates. Because Viagra has been available the longest, there’s more research available on this drug. Pooled data involving studies of 6,659 men have shown that Viagra helped 83% of men have intercourse at least once. On the other hand, Viagra is not a panacea. A 2001 study of its long-term effectiveness, in the Journal of Urology, reported a somewhat lower overall success rate (69%). The success rates for Cialis and Levitra (59% and 69%, respectively) are similar to those for Viagra.

Viagra has proved beneficial for most men with erectile dysfunction resulting from spinal cord injuries. In one study, 83% of such men who took Viagra had improved erections. But for men with diabetes or advanced heart disease, the drug helps only about half of the time. The response is even lower — about 30% — for men who’ve had radical prostatectomy.

Side effects. So far, the risks and side effects of these three drugs seem to be roughly the same. They all work by relaxing smooth muscle cells, which widens blood vessels — primarily in the penis, but also in other parts of the body. The most common side effect is a headache, which occurs in about 16% of users (see Figure 2). Other reactions include flushing, upset stomach, nasal congestion, and urinary tract infections. But when the drugs are used properly, these side effects are relatively mild, and most disappear after a few hours. In rare cases, some men experience temporary, mild visual problems, mainly seeing a blue tinge, but also increased sensitivity to light and blurred vision. However, men with retinitis pigmentosa, a rare eye disease, should be very cautious about using these medications.

Figure 2: Side effects of Viagra

In 2005, reports linked Viagra use to another rare eye disease, nonarteric anterior ischemic optic neuropathy, which can lead to blindness. However, fewer than 50 possible cases were reported as of 2006, compared with the millions of men who have used erectile drugs without problems. Still, these reports serve as a reminder to men over 50 to get regular eye check-ups and to alert a physician to any unusual vision problems after taking a PDE5 inhibitor drug.

Drug interactions. Within several hours of taking PDE5 inhibitor drugs, blood pressure tends to drop slightly: The top (systolic) number dips 8–10 mm Hg, while the bottom (diastolic) number goes down by 5–6 mm Hg. So it’s very important to avoid taking these drugs with medications that contain nitrates, which also lower blood pressure. Interactions between these two types of drugs can cause life-threatening drops in blood pressure. (The nitrates and nitrites found in food don’t pose a problem.) Men who take long-acting nitrates, including isosorbide dinitrate (Isordil, Sorbitrate, and others) and isosorbide mononitrate (Imdur, Ismo, and others), or who use nitroglycerine patches or paste should not take PDE5 inhibitor drugs. And they should not use short-acting, under-the-tongue tablets or a spray form of nitroglycerine within 24 hours of taking either Viagra or Levitra. For Cialis, the ban extends to 48 hours.

Men who take medications known as alpha blockers should be cautious about taking PDE5 inhibitors. These drugs, which include doxazosin (Cardura), terazosin (Hytrin), and tamsulosin (Flomax), are used to treat BPH and high blood pressure. If you take an alpha blocker, ask your doctor before taking any PDE5 inhibitor. For example, Viagra shouldn’t be taken within four hours of taking an alpha blocker.

Other considerations. Although the PDE5 inhibitors are expensive, many health insurance plans (including Medicare) cover them, although most have a limit of four pills per month. Perhaps even more important considerations are the sometimes complicated and unexpected challenges that these medications may present to your sexual relationship. Some partners who’ve grown comfortable in a relationship without intercourse may need time to shift gears, so to speak, if the drug is successful. Use of these drugs may raise other issues for couples. Should you tell your partner before or after you’ve started taking it? Will this put pressure on your partner to have sex? Should you take the medication and just hope your partner will be in the mood? The best way to address these questions is to talk about them with your partner. Particularly if you’re in an established relationship, your partner should know that you have a prescription for one of the drugs, and the two of you can decide together how and when to use it.


What if PDE5 inhibitors don’t work for you? Many men who can’t use these drugs or find them ineffective are able to get erections by injecting one or more prescription drugs into the side of the penis. The very idea may make you squeamish, and it’s certainly not as easy as taking a pill. But the needle isn’t very big (about half an inch long, the same size as those used to inject insulin), and drug injections can produce results.

Indeed, for men whose erectile dysfunction is caused by diabetes, injection therapy is more effective than Viagra. And it’s the single most effective treatment available for men who experience the problem as a result of prostate surgery. Many men learn the technique quickly after a demonstration by a doctor or nurse in the doctor’s office (see Figure 3).

Figure 3: Injection therapy

This simple and highly effective method produces an erection within five to 20 minutes after a man injects medication into the base of the penis, causing the smooth muscle tissue of the penis to relax and allowing blood to flow into the corpora cavernosa.

There are several injectable drugs, all of which work by relaxing the smooth muscle tissue of the penis and allowing blood to flow into the corpora cavernosa. The only one specifically approved for erectile dysfunction is alprostadil (Caverject, Edex). However, a number of older drugs that were approved for other uses are also effective for erectile dysfunction. They are papaverine (Pavabid, Genabid, Pavatine, and others), phenoxybenzamine (Dibenzyline), and phentolamine methylate (Regitine).

An erection usually occurs within five to 20 minutes of an injection and lasts for 30–60 minutes. The effectiveness varies according to the drug used. For example, studies show that the response rate to papaverine is 65%, but for alprostadil, it’s more than 80%. Doctors typically prescribe these drugs in some combination rather than singly; many men who don’t respond to any of these drugs alone can get erections when they combine two or more. A preparation called Trimix contains a mixture of papaverine, phentolamine methylate, and prostaglandin. One study found Trimix aided 62% of men who did not otherwise respond to injection treatments.

The main side effects of the injections are mild to moderate pain, bruising, or scarring. Like Viagra, injectable drugs can also cause low blood pressure. Although rare, this side effect is most likely to occur if a man takes too large a dose or if he injects himself more than once in 24 hours.

Another rare complication is priapism, an erection that lasts too long. Any man who has an erection that lasts for more than three hours after an injection should go to an emergency room. An erection that lasts longer than six hours can cause scarring and complete loss of erectile function. Because of these potential side effects, doctors prescribe the lowest effective dose. A doctor or nurse usually gives a patient an injection in the office to establish what that dose is before writing a prescription.

If you’re using injectable drugs, there are some things you can do to help the therapy feel more natural for you and your partner. One is to take a low dose and ask your partner for manual or oral stimulation to help achieve a full erection. That way, your partner will feel more involved. You might also suggest that your partner watch you inject yourself once or twice to help overcome any initial discomfort with the process. But if you’re more comfortable doing this privately, that’s fine, too. What’s most important for the treatment’s success — and for your emotional well-being — is that you and your partner feel at ease with it.

MUSE therapy

In addition to being available as an injectable drug, alprostadil comes in the form of tiny pellets designed to be inserted into the penis shortly before intercourse. The pellet form is an alternative to injections. These pellets are part of a therapy called “medicated urethral system for erection,” but your doctor will probably just use the acronym MUSE. This method of treatment uses a disposable plastic applicator to insert a pellet about an inch into the urethra (see Figure 4). From there, the drug is quickly absorbed by the surrounding tissue and reaches the corpora cavernosa, where it dilates the arteries.

Figure 4: MUSE

Using a slim applicator, a man inserts a tiny pellet containing one of the medications used for injection therapy about an inch inside the tip of his penis to attain an erection.

Though an early study reported that MUSE enabled 65% of men to have intercourse successfully at least once, clinical experience has shown that it is effective in only about 30% of men. Although some men consider MUSE easier to use than injections, about 10% of those who try it find the application process mildly painful, and about 3% become dizzy and develop low blood pressure. Because of the risk of low blood pressure, you should not use MUSE more than twice in 24 hours. Like injectable drugs, MUSE is available only by prescription and must first be used in the doctor’s office to determine the lowest effective dose.

Devices to help achieve or maintain an erection

If none of the medications are helpful or appropriate for you, or if you just don’t want to use them, there are other options. In particular, you can turn to a number of different devices to produce or maintain an erection.

Penile band. A penile band may help men who can get an erection but can’t sustain it because of venous leakage. These ringlike devices, which don’t require a prescription (Actis, Erecxel), fasten around the base of the erect penis to keep blood from escaping. Penile bands are completely effective when used properly.

Vacuum erection devices. Until prescription medications came along, the only proven at-home therapy for erectile dysfunction involved using a vacuum pump. With this therapy, you lubricate your penis and put it into an airtight plastic cylinder that’s attached to a handheld pump (see Figure 5). Some pumps are manual, while others operate on a battery. In either case, air is pumped out of the cylinder to create a vacuum, which increases blood flow to the penis. Once an erection occurs, which usually takes about five minutes, you remove your penis from the cylinder and fit a rubber ring around the base of the penis to prevent blood from draining away. The erection lasts until the ring is removed.

Figure 5: Vacuum device

This technique creates an erection by way of a vacuum pump. A man lubricates his penis and puts it into an airtight plastic cylinder attached to a handheld pump. Air is pumped out of the cylinder to create a vacuum, which increases blood flow to the penis and causes an erection.

Vacuum pumps are noninvasive and highly effective, working for about 80% of men. Their advantage over medication is that they can be used as often as a man wants. But there are several disadvantages. Having to fuss with the pump can interrupt lovemaking. And some men find the pumps difficult to use.

In addition, the erection doesn’t feel as natural as one produced by a drug. Although firm, the erection can be somewhat floppy because it starts above the base of the penis. About 10% of men have side effects, such as pain, bruising, or difficulty ejaculating, any of which can cause discomfort during sexual activity. Also, these pumps are not an option for men with blood disorders, such as blood-clotting irregularities or leukemia.

Surgical implants

Surgical implants should be considered only after you’ve tried other, less invasive options. Penile implants date back to the 1930s, when a piece of human rib was surgically placed inside a man’s penis. Since then, the process has been refined, and now there are two kinds of implants.

Silicone rods. One type of implant consists of two pencil-thin silicone rods that are placed in the penis above the urethra. The operation is done on an outpatient basis and takes about an hour. The penis remains permanently erect, although it can be pointed down along the thigh to conceal it under clothing.

Inflatable cylinders. Another kind of penile implant consists of two inflatable cylinders positioned in the corpora cavernosa, which produce an erection when filled with saline fluid (see Figure 6). The fluid is pumped from a reservoir implanted in the abdomen or the scrotum. Although an inflatable implant produces a more natural erection than a silicone rod, it’s more prone to complications, like infections and malfunction. About 5% of men need a second operation to replace the implant.

Figure 6: Surgical implant

This implant consists of two inflatable cylinders surgically placed in the corpora cavernosa to produce an erection when filled with saline fluid. The man pumps the fluid by hand from an abdominal reservoir by using a pump located in his scrotum. A different form of implant (not shown) includes two surgically inserted flexible rods that create a permanent erection. The penis can be pointed downward when not in use.

Vascular surgery

Vascular surgery is used only for men whose erectile dysfunction results from specific blood vessel problems. There are two types of such operations, but neither has a high rate of success. The first — for men whose problem involves the leakage of blood from certain vessels during an erection — ties off those vessels so they retain blood.

The second type of vascular surgery is used when the problem is the blockage of isolated blood vessels. In such cases, the surgery entails bypassing the blocked vessels to allow more blood into the penis. Bypass operations are reserved mainly for patients whose blood flow problems result from injuries such as pelvic fractures. For each of these operations, the success rate in restoring normal erectile function is less than 30%.

Hormone therapy

Testosterone supplements are appropriate only if you have abnormally low levels of this hormone. The supplements can help boost your libido and improve your ability to have erections. These supplements are now nearly always given in gel form, which you apply daily to your shoulders. Other forms are less convenient (doctor-administered injections) or cause skin irritation (skin patches). The exact role that low testosterone plays in erectile dysfunction remains unclear. However, at least one study suggests that combination treatment with testosterone gel and Viagra may improve response for men with low to low-normal testosterone levels who did not respond to Viagra alone.

Originally published Jan. 1, 2007; last reviewed April 22, 2011.


  1. Paul Alexander

    Whether you currently suffer from ED or are hoping to sidestep this condition, try these tips to overcome ED for better health and a better sex life.

    Start walking. According to one Harvard study, just 30 minutes of walking a day was linked with a 41% drop in risk for ED. Other research suggests that moderate exercise can help restore sexual performance in obese middle-aged men with ED.

    Eat right. In the Massachusetts Male Aging Study, eating a diet rich in natural foods like fruit, vegetables, whole grains, and fish — with fewer red and processed meat and refined grains — decreased the likelihood of ED.

    Pay attention to your vascular health. High blood pressure, high blood sugar, high cholesterol, and high triglycerides can all damage arteries in the heart (causing heart attack), in the brain (causing stroke), and leading to the penis (causing ED). An expanding waistline also contributes. Check with your doctor to find out whether your vascular system — and thus your heart, brain, and penis — is in good shape or needs a tune-up through lifestyle changes and, if necessary, medications.

    Size matters, so get slim and stay slim. A trim waistline is one good defense — a man with a 42-inch waist is 50% more likely to have ED than one with a 32-inch waist. Losing weight can help fight erectile dysfunction, so getting to a healthy weight and staying there is another good strategy for avoiding or fixing ED. Obesity raises risks for vascular disease and diabetes, two major causes of ED. And excess fat interferes with several hormones that may be part of the problem as well.

    Move a muscle, but we’re not talking about your biceps. A strong pelvic floor enhances rigidity during erections and helps keep blood from leaving the penis by pressing on a key vein. In a British trial, three months of twice-daily sets of Kegel exercises (which strengthen these muscles), combined with biofeedback and advice on lifestyle changes — quitting smoking, losing weight, limiting alcohol — worked far better than just advice on lifestyle changes.

  2. Elizabeth Lizzie

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    Contact him for the following and see the great work of Dr Komoh:
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  3. Jasmine

    This is the first time to use the service of [ dr_mack@ yahoo. com ] ✨ 🍰 ✨ It felt good to have my lover back.

  4. Hi ,

    I am facing a irregular problem of maintaining erection.One month i get good erection and i do sex regularly but suddenly in next or month later i do not get sexual desire or not able to achieve erection. This problem will remain for a month or so and then following months or two i will get erection again. Second scenario is If i stop intercourse for two months then 3rd or 4th month i will have good erection..please advise is it start of some big problem or just phycological issue. I am also using medication for stomach upset called IBS disease.i work from 2pm afternoon till 12.30 in night.i do face sleep issues when i have to visit bathroom for urination and defection.
    Many thanks in adcance

  5. KRamaswamy

    I have had BPH prostate surgery in early 2015. I have difficulty in my erection for sex. When I try for orgasm, I feel some pain inside the penis and also a great fear. Therefore, penis does not remain erectile and I get a feeling of frustration and humiliation. I am 82 years and am fit and fine in all other respects healthwise. Please advice. I do not wish to have any medication or surgery. I would very much like natural therapy to get back. Shall feel indebted. Thanks

  6. KRamaswamy

    Each and every detail is very informative and educative. I am 82 years but find great interest in sex. I have had benign (BPH) prostate surgery in early 2015. I find pain when I try to reach orgasm and my pennis does not remain in erectile position for as much time as I want to. I feel some pain inside and also a great fear which kills all my instincts. I would very much like to avoid any medication whatsoever but would certainly like to recover my spirits of enjoying sex which I used to. Any suggestion will be of great value to me for which I shall feel indebted. Thanks

  7. Allen

    Following prostrate radiation therapy (seed implants) I began having difficulty getting and maintaining a large and firm erection. Viagra, Levitra, Cialis, and other drugs are too expensive for regular use. I’m now working with my urologist to get the right formula of Trimix for me. The first two formulas failed to produce the desired results and the next injection will be 0.3, the next stronger step. I’m a very large man and I’m wondering if size indicates a larger or stronger dosage is going to be needed. I’m also a very healthy person but in my 70’s. Any advice ?

  8. Bob

    Have not an erection for years am now 60. Also a chronic condition exists am taking meds. Have been trying to regain sex life. I used trimix to no avail. Would definitely appreciate any advice.

  9. JAMES

    For more than 12 years i have suffered from the problem of weak erection, and for that 12 years you have no idea what i went through in the hands of my various partners. It got to a point that i was running away from my duty as a man.I started searching for solution every were and i became addicted to some certain drugs all because i want to make a difference and show my strength sexually. One day i decided to open up to a friend of mine and that was how i was told about Dr mack. I was given his contact i contacted him and i was told what to do and how to get his products which i did and within the space of days i was cured permanently without any side effects. Today i am super active sexually (lol) and i can perform extensively in bed today as a real man. For his product on erectile dysfunction,premature ejaculation and weak erection problems contact him on (dr.mack201 @ gmail. com).

  10. joe hudson

    i’m very old but the urge still exists.I have a penal implant that has gone bad,need advice all doctors i have spken to warn me of very bad infections.Wasn’t warned as much when it was done. all I can say is help if U can.
    J Hudson

  11. jpbulla

    can u please make recommendations?

  12. Jiteshkumar

    Is there any treatment or remedy to overcome dry ejeculation after surgery of prostate?

  13. hawkin

    I have consulted more than 7 doctors for my ED problem, but the medicines are not permanent and i lost huge amount, recently i read one of the guide from online and i followed the natural treatment method step by step within few days i recovered fully from ED, Read the full guide from here >> ( ) <<
    Have a great day, best guide to overcome from ED


  14. Kingsauger

    I have had BPH since the early age of 50+. It caused me to seek the medical help of an urologist in my early-mid 60’s. I was having to urinate 10-15/day, never completely emptying my bladder. Prescribing Hytrin, a beta blocker, helped for a while, as the medication relaxed the prostate enough to allow passage of more urine. However, it is a blood pressure med. and I was already taking a B.P. med. for that. It was lowering my B.P. to unsafe levels, so the doctor suggested doing laser TUR to reduce the size of the prostate. Afterward my urination was more complete, and solved that problem, but created another in the process. It dropped my libido 50% or more, and introduced a new problem, moderate E.D. I lived with that 10-15 years until, recently, when I was diagnosed with a blocked bowel, not related to the E.D. problem whatsoever. After successful surgery to repair the digestive problem, I was retaining more urine than doctors considered safe, so pressured me to have the TUR, (transurethral resection) surgically in an attempt to remove any scar tissue left over from the laser process. They didn’t warn me that it might lead to impotence or 100% E.D. It has been over 3 months and my condition hasn’t changed. Oh yes, my urination has normalized, but at a loft price to pay. Whether

  15. bruce scott

    I have a erection problem its not strong.i can’t take two minutes and i ejaculate quick and my penis fall and it will take some time to erect again.

  16. Hassan

    I am 63 years and like many people in this age group, I have BPH. My doctors’s drug of choice is Tamsulosin 0.4mg at first it was OK. It even improved my sex life. Later I realized it was ineffective and did not prevent me from waking up 4-6 times at night. My Doctor added Spasmolyte 20mg. One morning one at night. I realized that my erection was seriously compromised. Need to mention that before it I could see the weakness in erection but it made it worst – or so I thought. But it improved my night sleep somehow.
    I went to iherb and bought Saw palmetto first tablet was only yesterday, I also bought L-Arginine – not used yet.
    I decided to read about them in the web before starting and I am very appalled by what I read – none of them seem to be encouraging. Pls advise

  17. Mark

    I have been injecting myself with trimix for about two years. I seem to have developed scarring on my corpus cavernosa because when erect my penis has begun to curve pretty radically. Will this subside with non-usage or is this now a side effect that cannot be fixed? Please let me know.

    • Jp

      Please let me know about the side affect as well – i have been using Tricia mix as well and have had the same thing happen to my penis
      Strange curve ?

  18. Williams Anderson

    For the ED and low libido I recommend to see an specialist, my dad was diagnosed with bph and the doc prescribed him alpharise for it, it has been very effective.

  19. Victor Lee

    This is the latest cure of erectile dysfuntion. Go for electric shock wave therapy. It will work for 90 percent of men.
    This treatment of 6 times or 12 times is a permanent solution and you are back to your young days.


    For the last 4 years i have slightly enlarged Prostate. I urinate very frequently, with a gap of every 30 minutes. But thanks God not during nights. Besides I have absolutely no erection. As if my Penis is all dead. occasionally i Take medicines like Viagra or Men Max, Forta from GNC etc. It does work but other than these i just don’t feel i can ever have sex.

    Can you please advise.

  21. francisca

    my guy suffered from priapism and as a result he was operated and after the operation he does not have erection…please is there any way he can regain his erect ion? please help me

  22. Doug

    I’m 27 with a 24 year old girlfriend we are looking to get married and now I suffer from Ed and I have never numbness from my head of the penis to my anus idk how to get back to normal I’m panicking I can’t enjoy sex I haven’t had and orgasm in two months I need help

  23. fahed ae alomari

    i need more information about prostate

  24. Khan Mohammad

    Very much interesting and healing informations. Thanks

  25. Laureen

    Very happy to share my testimony! The great man who cures all known diseases, Dr Sebi is a healer, pathologist, herbalist, biochemist and naturalist, who immigrated from Honduras and who has committed his life to the service of helping people cure their diseases. In 1988, he took on the Attorney General of New York in a Supreme Court trial where he was being sued for false advertisement and practice without a license after placing ads in a number of newspapers, including the New York Post where he had announced: “Aids has been cured by the Usha Research Institute, and we specialize in cures for Sickle Cell, Lupus, Blindness, Herpes, Cancer, Als and others. Pre-trial, the judge had asked Dr. Sebi provide one witness per disease he had claimed to cure however when 77 in person witnesses joined him in court, the judge had no choice but to proclaim the Doctor NOT GUILTY on all accounts, proving he did in fact have the cure to all the diseases mentioned in the newspapers. Several celebrities have sought out healing through the Doctor including: Michael Jackson, Magic Johnson, Eddie Murphy, John Travolta and the deceased Lisa Left Eye Lopes who proclaims in the video: “I know a man who has been curing AIDS since 1987”.. i want to inform the public how i was cured from ALS(MND) by Dr Sebi, i visited different hospital but they gave me list of drugs which is very expensive to treat the symptoms and never cured me. I was browsing through the Internet searching for remedy on ALS and i saw comment of people talking about how Dr Sebi cured them from ALS, CANCER, HERPES, DIABETES and so on… when i contacted him he gave me hope and send a Herbal medicine to me through courier service that i took and it seriously worked for me, am a free person now without problem, my ALS result came out negative. I pray for you Dr Sebi. Am fully cured. you can also get your self cured my friends if you really need my doctor help, you can reach him now: (drsebiherbalisthealinghome12@gmail. com) You are indeed a HERO!

  26. Samir Bhattarai

    my erection was alright ..but 5-6 days before I noticed discharge of white viscous liquid from my penis..a bit pain I notice now around glans..I didn’t have sex yet.I m just 20..but I do agree that my penis used to erect most times when I slept n in morning .I used to masturbate but now I m scared that if I have STDs or uti or prostate infection ..what shud I do? what test to b done to diagonise what has actually happened..will antibiotics work or not..5 days later I recognise my penis didn’t erect .m scared ..can it b treated permanently? pls help.

  27. Lindsey

    I had radical prostate surgery last September and have had ED since. I would like to know why my penis is quite blue in color and usually very cool at the penis tip. Is this due to low blood flow. I do use the injection method but that only works part of the time and not very erect. Sexual arousal is there with my wife but even with the injection, the penis is still soft and very difficult penetration.

  28. georgebenjamin

    Unbelievable, i remembered i was once here in need of help on how to go about the problem of poor penis erection i was

    having, i must say those years was so frustrating, the experience was something outside the world of being normal, i could

    have sworn that i was witnessing my marraige crumbling to nothing, my wife had to join me in search of various kind of

    help, and the search lasted for 1year 4months and like a dove sent from heaven , a cousin to my wife referred me to “Dr

    christopher onome”, a specialist with a distance full of knowledge, with his vaccines/medications and his advice on what to

    stay clear off and how to approach the problem , in less than 3 weeks i was doing fine sexually, am indeed proud to say am

    now a father of a bouncing baby boy and up to this moment am still thinking this all some very big dream that everything is

    actually back to normal, i believe i will forever be greatful for his guidance, so am recommending all those who are

    currently in the condition i was in back then, or know someone who is in any related problems like unnecessary bleeding,

    Virginia odour, poor penis erection, inability to release sperm (low sperm count), kidney problems, blood in the urine or

    whatever is there that’s not normal should try and contact him through his

  29. Jeffrey C. Le Doux

    I have been having pretty good success with TriMix. Currently I use 0.2 ml of the solution. It provides a reasonable erection. My wife has had 3 back surgeries in the last 18 months. This has its own problems with our situation. About a week and a half ago in the she’s on top position I achieved penetration. She was very warm inside, and we both had an excellent result. The last two times I have achieved penetration, but could not get to the hot spot. She had multiple orgasms both times (including last night. I need some suggestions so I can also get there. I was not even able to manually reach an orgasm. I feel that am doing something wrong or at lest not right. Should I take it slower and easier. Should I up the dosage a bit. When I was instructed I was informed that the dose could go from 0.1 to 0.3 ml for the injection. Should I titrate up a bit to improve the erection?
    I should note that I have been on Androgen Deprivation Therapy for 16 months. P.S.A. is currently 0.56 ng/ml and Testosterone is undetectable. (The name of the drug is Firmagon, somebody is a comic.) I did not get all the information about the side effects for 9 months. When I said I was angry, upset and depressed my Urologist finally provided all the information and offered me a a candidate for penile injections. I have been using them for 6 months with some (though not constant) success, I can still orgasm without the TriMix, but cannot achieve penetration without it. My wife’s back is improving, but very slowly.
    Can anyone give me some advice on solving my dilemma?

  30. Apollo51

    My husband and I have lived together 20 years. His ED started in his early 30’s and has gotten worse. He is now 54. He is in denial and too embarrassed to admit to his doctors. He downplays the impact on our relationship. In the meantime, we live a sexless marriage with no intimacy whatsoever. Yes, we have been through counseling, where he makes idle promises. Viagara and Cialis are “too inconvenient” for him. His Dr. tells him all his labs are “normal”.

    Suggestions, anyone?

  31. Paul attwell

    My husband as started with ED in the last 6 to 7 months he is 63 years old and as a benign enlarged prostate, he takes tamlasolin, causing a problem at moment as he is becoming very depressed through it, tried viagra but this is not working is there anything else which will work .

  32. David Asomani

    Beautiful article. Insightful and simple.

  33. Merchant of Light

    One last thing…the injection needles are very short and small diameter. No danger about injecting in the wrong spot, or too deep. The shaft of the prnis has very few nerves… So you feel nothing except a small pin prick. There is no pain from injecting the medicine….nothing like getting an intramuscular shot , where the tissues are forced apart to make room for the medicine. The spongy carvernosa tissue readily accepts the volume of medicine…no pain at all. Now, the first time or two…the psychology of it might get to you…. But just “do it!”. She will be so glad that you did!

  34. Merchant of Light

    Forgot to mention, I am now 67.

  35. Merchant of Light

    Don’t suffer another day with ED problems! See urologist NOW! 16 year user of Viagra. US pricing of Viagra ($44/pill) is war on men! Buy Canadian for about $14/pill. Name brand! Drugs from India are Total scam…don’t work! For me, Viagra gradually stopped working in 16th year. Take testosterone shots, feel better, but did not help erection problems. Results of Doppler ultrasound indicated I had a “leakage” problem. Urologist recommended implant surgery. (Be careful, this how he makes the most money, as Medicare pays for this!) I chose trying the direct injections! Works fabulous! Rock hard in minutes, lasting for two-three hours. I can control how much Tri-mix to inject! Cheaper than viagra or anything else. I disagree with diagnosis of “leakage”. Believe that inflow was insufficient to cause swelling of penis and subsequent squeezing off of exiting blood flow through veins. Do your homework! Study the chemistry and mechanics of erections! Wife is ecstatic about regained ability to have multiple orgasms regularly! And I feel like a king!

  36. Warren Johnson

    I have had ED issues since I was in my 40s.viagr, pump, and injection has really not worked.. I am 77 and really not in bad health. I take blood pressure medication. I hear there is a procedure to test and open the veins and atteries in the penis.Anyadvice on this?

  37. eddy

    I am a 65 years old i have e d problem since last 2 years i have tried all pills viagra etc i have tried even esteem e d pump but no results these are the things prescribed by urology dr. Please advise

  38. Hilda Ramirez

    Good day! My husband is having erection problems, his erection is weak, as soon as we start intercourse brings erection to end,we tried Levitra and didn’t work, he is having lower abdominal pain, because he doesn’t have an orgasm, he is diabetic and has hypertension. He was doing so-so, but the last 4 weeks started getting worse. How can I help him, he is so depressed and wants me to find someone else to satisfy me, I tell him, I don’t care, because I Love him. Please help us.

    • Elvis

      Hilda, I hope you are getting what you need. We have same problem and she won’t let me get someone to satisfy her. I do oral on her clit but at the same time put two fingers in her vagina pointing to the upper side and rub her G spot which is identifiable by the tough spot about 1″ in diameter. She says it is the most intense orgasm she has ever had. Good luck

  39. Fahed AR Alomari

    i start to have erection disfunction , is that because prostate problem
    please advice what I should do.

  40. Fahed AR Alomari


    I am 57 years old , start to feel some prostate symptoms from 4 years.
    first time it was urine problem the doc. prescribe medicine name OMNIC , i stop after some time then two month back i had some blood with urine discharged.
    Doc said don’t worry and he proscribe for again OMNIC once a day
    I need your advice .

    • Jp

      I am also 57 and have been having prostage problems for 3-4 years
      My erections are only 50 % of what they used to be and I have tried viagra ( bad headache )
      And am now doing injections with some sucksess, also seams my size had changed and my wife is noticing I am much smaller !
      What to do ! Very frustrated – Help

  41. Joseph

    Hello everyone. I’m 64, and will be beginning prostate cancer treatments next month. I’m honestly really worried about ED as a side effect, and have been noticing it with my medication already. I am prescribed doxorubicin currently and I can easily afford it with my insurance, but my doctor has suggested viagra as a safe complimentary drug and there is no way I can afford it. I have had my Dr’s unofficial assurance about Canadian pharmacies that ship medication with a prescription. I am a little worried about these sources, does anyone have any experience or insight at all? Thank you for any help!

  42. B Collins

    I have struggled with chronic military service connected non-bacterial prostatitis (NBP) since discharge over 40 yrs. ago. Recently had several surgeries performed to damaged prostate gland, but still struggle with minor pain, and somewhat with voiding. I also have struggled with ED for 20 yrs. or so. My Urologist says their is no connection, but I believe that my prostatitis cond. could potentially contributing to my ED. I’m I correct?

  43. C Smith

    I am 65 and have had ED for 4 years or so. I used Viagra but side effects were a problem and did not work. I now take 20mg tadafil which also does not work at all. Testosterone levels are ok. I cannot get an erection at all. NO heart problems but do have diabetes and have had since 2000. It is under control by diet and metformin (in past) and now insulin (20units Lantus once a day) because of long term use of metformin concerns. No erection with masturbation. Vacuum pump does not work other than slight erection which disappears after removal. I am nervous about injections or implant. Are there any other medications which can be suggested? Would a urologist be a specialist I should see?

  44. nana kwame ayiah.

    am from ghana,aged 31yrs suffering from prostate disorders .i want to know that can you give birth whiles suffering from prostate.

  45. Adam

    Thanks to Dr Olumba for the help and for his herbal medication, which help me out of my 5 years plus of weak erection, i am so grateful,it was a shame to me. But i thank God today that my life and body is working properly again. if you are having Erectile Dysfunction or Weak Erection contact Dr Olumba,Email him, or call him +2347068002488

  46. leo west

    Thanks to Dr Olumba for the help and for his herbal medication, which help me out of my 5 years plus of weak erection, i am so grateful,it was a shame to me. But i thank God today that my life and body is working properly again. if you are having Erectile Dysfunction or Weak Erection contact Dr Olumba,Email him, or call him +2347068002488

  47. pvreddy

    Dear sir,I am 40 years old since two three years I am getting early discharge problem,I don’t have errection problem. I approached dr. Sreedhars his treatmeting and he going to test NPT it’s too cost for this can help and stop early discharge. Please advise me.

  48. I have tried pills they did not work so I guess I will try the injection where can I go to try them

  49. Nasir khan

    hi I am nasir I want to ask about penis disease. my desire of erection is so weak I got this problem 6 months before. my penis is thin frm the beginning what are the remedies and tell me about some medicine for it

  50. iftikhar ahmed khan

    its a very best for patient and for knowledge .i want get this think for treatment can possible.

  51. collins

    hi,am unable to erect after the first round,what may be the causes and what are the remedies

  52. magson

    how do sustain long term erection during sex, and satisfaction

  53. nidhi

    hi.. kindly answer my query man having sex regularly for last 25 days but last week noticing he is not able to get erection even though he is trying to have it. is its a start of problem.

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