If ED medications don’t work, nothing will fix an erection.

Myth

Some patients don’t realize that the drugs are most effective once someone has used them repeatedly. It seems, for many reasons, that it takes up to 8 uses to assess whether the drug works. Anxiety can be an issue but familiarity with the effects plays a role, as well. In fact, some doctors recommend using the medication to masturbate first so that the effect is not experienced in what might be a pressure situation.

Nevertheless, Viagra and other drugs are ineffective for about 15% of patients receiving medications even under the best circumstances. Desire is necessary to kick off the cascade of events that lead to an erection. If there is no desire, whether it is psychological or hormonal, an erection will not occur just because a circumstance seems to warrant one. Desire is the initial ingredient in the recipe. A low testosterone, or an abnormal thyroid, or even a brain tumor may make it medically less likely that desire will be present. Psychological reasons can interfere with the initiation of desire, as can relationship issues.

Damage to nerve tissue from trauma, surgery, or from radiation therapy could also interfere with getting an erection. Desire may be present but the signals needed to transmit the message are damaged. This can occur with neurological diseases like multiple sclerosis (MS).

Most men with prostate cancer who have had surgery will have some issues with maintaining good erectile function. One article (Urology 1998;52:963-966), noted that 12 of 15 patients with erectile dysfunction (ED), who had a radical prostatectomy that spared both of the nearby nerves, were able to regain erections with the use of Sildenafil (Viagra). Nevertheless, many patients who undergo radical prostatectomy lose that capacity. As an aside, therapy by implantation of radioactive seeds, with external radiation with X-ray beams, or with proton therapy have fewer problems with erectile dysfunction but 40% to 50% of treated patients still experience some degree of erectile dysfunction.

For all of those who experience erectile dysfunction that is resistant to drug therapy (including those suffering from hormone deficiencies, e.g., testosterone), it is fortunate that other options exist.

The simplest, non-medication treatment is the use of a vacuum device. By creating a vacuum in a tube around the penis, blood is forced into the penis causing it to swell. The placement of a ring at the base of the penis keeps the blood from draining out when the vacuum tube is removed. The penis can release its blood volume when the ring is removed. The ring should be removed after 30 minutes to prevent damage to the penis. Some men find that the use of a ring, or tourniquet, alone helps them keep erections longer.

If that is not sufficient, a medication called alprostadil can be used, either as a penile suppository or as a penile injection. It is a vasodilator and causes blood to rush into the penis. When inserted into the penis as a pellet with an applicator, it is called MUSE for Medicated Urethral System for Erections. It is not easily used, has a number of contraindications including causing very low blood pressure, and is painful for many patients. Nevertheless, for some properly chosen patients, it works well and is satisfactory.

Alprostadil can also be injected directly into the tissue of the penis. There are potential problems such as scarring or prolonged erections, pain, bleeding, etc., but many well-chosen patients find it satisfactory.

Surgery is a last resort but many patients find that the placement of a rod, semirigid implant, or a newer, inflatable implant, gives satisfactory results.