Erectile Dysfunction: The Basics

What is Erectile Dysfunction?

Erectile dysfunction (aka impotence) is defined as “the persistent inability to achieve or sustain and erection sufficient for satisfactory sexual intercourse.” This can be a total inability or inconsistent ability, or a tendency to sustain only brief erections.

Although it is common (at least 50% of men over 50 year old have some loss of function), it is NOT normal, no matter what the patient age. Unfortunately, only 10% of men seek treatment and many (50%) discontinue treatment once they start it. This is because they are understandably embarrassed to raise this issue with their physicians and they may get inadequate information about the many treatments that are available to them.

It is even more unfortunate when you consider that it 1) affects the quality of life 2) makes men feel worse about their general health and 3) may be a symptom of an underlying disorder (for example, diabetes, cardiovascular disease, etc). Men do not realize that there are a variety of very satisfying treatments and there is no need to suffer in silence.

What are the causes?

In the most basic analysis, an erection consists of blood flowing into the corpora cavernosa (AKA erection bodies) and being trapped there. A problem with either blood getting in or staying in causes ED.

Potential causes are many and include: vascular (high blood pressure, elevated cholesterol, diabetes, cardiovascular disease), diabetes, trauma (spinal cord injury or injury to the pelvis), neurologic disease (stroke, Parkinson’s disease), radiation to the pelvis (for prostate or rectal cancer), endocrine disease, surgery in the pelvis (radical prostatectomy, surgeries for rectal cancer or bladder cancer), medication side effects (especially medications used for high blood pressure), alcohol, tobacco, cocaine, etc. Is this just the man’s problem?

This is a “couples disease”. Even though the problem is not Psychologic (i.e. it’s not “all in your head”), ED causes depression, anxiety, loss of feelings of masculinity and self-esteem. This of course affects relationships and may set up a “vicious cycle” where the partner feels unattractive and so stops initiating intimacy, the man then feels unattractive, etc. This can be devastating to the couple. Very few couples can or want to give up their physical intimacy without any problems!

Is there treatment?

Luckily, there are treatments. These include pills, injections, penile suppositories, vacuum devices, and surgery.

What about pills?

Phosphodiesterase inhibitors are the name of the oral drugs used to treat erectile dysfunction. The most common medications are sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra). They work by blocking a chemical that stops erections. Viagra was introduced in 1998 (the others in 2003) and revolutionized the way that men and their partners were treated for erectile dysfunction.

Keys to using pills successfully

  • These medications all act as “amplifiers”, meaning that men still need visual or tactile stimulation to have an erection.
  • The pills may not work the 1st few times, so it is worth trying the pills several times before deciding that they do or don’t work.
  • The pills (especially Viagra) should not be taken after a large meal, as they will not absorb as well. They should be taken before a meal or after a snack.


Generally these medications are safe. Side effects are common (around 30% of men have them) and include: headache, flushing (feeling hot), upset stomach, stuffy or runny nose, and back pain (especially Cialis).

These medications should NOT be used if you are taking (or have at home) nitroglycerin or medications containing nitrates (ask your doctor or pharmacist if you have a question about this), as the combination may cause a dangerous drop in blood pressure.

These medications should be used with caution if you are taking medications for enlarged prostate (BPH) such as flomax/tamsulosin, hytrin/terazosin, etc. Again, ask your doctor or pharmacist if you have questions about this or if you have any other less common medical conditions that would make you change the dosage of the pills.

What if pills don’t work?

If pills don’t work or if the patient cannot tolerate them, alternatives include injections, suppositories, vacuum devices, or surgery.

What are vacuums?

A vacuum device (VED) is an external device (not a drug) that goes over the penis. When pumped, it pulls blood into the penis then a special ring is placed over the base of the penis to keep it erect.

Vacuum Erection Device (VED)

VEDs are generally safe (although there have been some very rare but serious complications) but unfortunately many men simply do not like them. They can only work well in the setting of a stable relationship and many men simply stop using them.

Benefits of VEDs are that they are inexpensive with limited side effects; however, the VED also has many drawbacks. Notable drawbacks include: penile pain, numbness, pain with ejaculation, decreased satisfaction, unnatural erection, and cumbersome sensation.

What about injections?

Drugs may be injected directly (using a tiny needle) into the penis. Several drugs and drug combinations are available, including alprostadil (Edex, Caverject), phentolamine, and papavarine (usually given in combination as Bimix or Trimix). The patient can usually get an erection within 5-10 minutes, and it should last between 20 minutes to an hour.

Injections do require training and may take time/effort to get the correct dose. We always do the first injection in clinic, which helps the patient learn technique and also provides information about the dosing. Patients are usually anxious about penile injections but are almost always surprised that the injection can be painless. The patient will be observed in clinic to make sure the erection resolves. They will be provided instruction on how to slowly titrate the injection for best effect, being cautious to avoid potential side effects (aka, priapism).

It is very important to alternate injecting the left and right side of the penis [link to diagram and info sheet] and to not use injections more than 3 times per week.

Benefits of injections include: effective, mimics normal erection, normal sensation, discreet. Risks of injection include: prolonged erection (priapism), penile scarring causing penile curvature, pain with injection, bruising, and decreased long-term satisfaction.

Although, penile injections work well, there is a high drop off in use over time due to the above risks with injections.

What about suppositories?

Urethral suppositories (aka, MUSE) contain alprostadil (see “Injections”). The pellet is given via a delivery system into the urethra (urinary channel) and dissolves in the urethra. Advantages of urethral suppositories include: no needle, mimics normal erection, normal sensation, discreet, rare scarring or prolonged erection (aka, priapism). Disadvantages include cost, burning with urination, penile pain, expensive, decreased reliability, urethral bleeding, and poor long-term satisfaction.

Penile implants

A penile implant is the most efficacious method to treat erectile dysfunction. Satisfaction rates are high (> 90%). They allow the patient to have an erection at any time in a reliable manner. Penile implants are inserted in the operating room through a small opening in the skin. There are three components to the penile prosthesis, which are all connected. The first component are the inflatable cylinders that are inserted into the shaft of the penis. The cylinders become filled with sterile saline when the scrotal pump (second component) is manually compressed. This cycles saline from a reservoir (third component) into the cylinders in the penis. The pump is compressed at the completion of sexual activity, the deflate the penile cylinders and discontinue the erection. All components of the device are underneath of the skin are well concealed.

Some surgeons will recommend using a VED before surgery to stretch the corporal bodies to allow a longer penile implant.

Preparing for Penile Implant Surgery

To help you prepare for surgery, you will need the following appointments:

Appointment with the Preoperative Center

At the Preoperative Center, you will have routine tests that you will need for your surgery (like blood tests, X-rays and EKGs). You will also meet with a nurse who will review specific instructions that you should follow before your surgery. For example, they will tell you which medicines and foods you may need to avoid before surgery.

The Day of Your Surgery

Wear loose fitting clothing on the day of surgery.

When you arrive at the Hospital Admissions Department.

After registering, you will go to Ambulatory Surgery and then change into a hospital gown.

Then you will be brought to the “pre-op hold and prep” area.

  • Here you will have your vital signs (like your heart rate and blood pressure) checked and have a chance to speak with your surgeon. You will also meet the anesthesiologist. They will place an intravenous line (IV) in your arm and will give you medicine through the line to make you sleepy.
  • You will be in the pre-op hold and prep area for about 1–2 hours. You may want to bring something to read or watch

Next, you will be taken to the operating room.

The anesthesiologist will attach you to various monitors. They will also give you oxygen through a small mask placed over your nose and mouth. Soon after this, you will drift off to sleep.

When the surgery is over, you will be taken to the recovery room.

  • When you arrive in the recovery room (also known as the Post-Anesthesia Care Unit or PACU), you will be very sleepy but able to hear those around you.
  • You can expect to be in the PACU for about 2 hours. You will leave the PACU once you appear to be recovering well and in most cases are discharged home on the same day.

Recovery at Home:

You will have an incision (wound) either over the upper scrotum (penoscrotal) or above the penis (infrapubic). You may have a second incision over the right or left lower abdomen that can be used to place the pressure regulating balloon.

  • You might feel some pain at your incision, which is normal.
  • Your incision will be closed with stitches. These will dissolve (melt away) and do not need to be removed.
  • You may have a drain to reduce swelling/bruising.
  • You may have pressure wrap around the penis and scrotum to reduce swelling/bruising.
  • You may have a urethral catheter.
  • You will likely see discharged the same day as surgery and see a member of the urology team the following day for dressing removal, drain removal, and/or urethral catheter removal.
  • The penile implant will be left partially inflated for the first two weeks.

You will receive pain medicines and other medicines.

Most people have some pain for the first couple of weeks after surgery, but the pain is usually not very bad. Your surgeon will prescribe pain medications and discuss use of Tylenol and/or ibuprofen to take on a scheduled manner to reduce the need for narcotic pain medications.

You will slowly introduce foods to your diet.

Most patients start eating again the day of surgery. Advance your diet as able.

You will recover quicker by doing certain activities.

  • To help improve your circulation (blood flow), wiggle your toes and ankles every once in a while. Do not cross your legs.
  • To help prevent lung problems, take deep breaths and cough.
  • Change positions in bed (from side to side) every few hours. This will help prevent muscle aches and other issues related to surgery.

You may start walking the day of your surgery.

Walking is very important since it helps to prevent blood clots (clumps that form when your blood thickens) in your legs. Even a short walk will help a lot.

Postoperative Day 1:

You may have an appointment with your surgeon the following day for removal of the penoscrotal bandages, drain, and/or urethral catheter. You may have been asked to keep track of output from the drain.

The penile implant will be left partially inflated for the next two weeks. The surgeon will instruct you on the location of the control pump in the scrotum. You should feel for this scrotal pump daily and ensure that the pump remains in the scrotum.

Postoperative Day 14:

A member of your surgery team will meet with you to deflate the penile prosthesis. You will be given instructions on how to inflate and deflate the penile prosthesis. Some patients may need to wait an additional two weeks if there is persistent swelling that precludes the ability to inflate/deflate the penile prosthesis.

Once you are able to demonstrate how to use the device, you will be provided instructions on a protocol to inflate/deflate the penile prosthesis. Most patients can use the penile implant 4-6 weeks after surgery.

The penile implant acts as a tissue expander. Your surgeon may recommend inflating and deflating the device daily for the first 3-6 months after surgery. This will serve many purposes such as making the patient more familiar with the device and continuing to passively expand the corpora to gain potential penile length.

Recovery at Home: Home Care Instructions

Here are some tips for caring for yourself at home. We will give you more detailed instructions before you leave the hospital.


  • Try to get some activity each day. Walking is a good choice.
  • Do not drive if talking prescription pain medicine.


  • Take your usual medicines as prescribed, unless you were told otherwise.
  • You may be prescribed an antibiotic for the first 5-7 days after surgery.

Eating and drinking

  • Drink a lot of water every day. Restart your usual diet when you feel ready.

Preventing constipation

Anesthesia and pain medicine can affect your bowel movements. It will take time for your bowel movements to be normal. To prevent constipation:

  • Drink apple juice, prune juice and plenty of water.
  • Eat high-fiber foods (whole grains, leafy greens, and other vegetables and fruits).
  • Try a fiber supplement (for example, Metamucil or Citrucel) and a stool softener (for example, Colace).

Bathing/Caring for Your Incision

  • You can shower 48 hours after surgery. If you had a first stage urethroplasty, wait until the dressing is removed to shower.

Returning to work

  • When you return to work will depend on your recovery and the type of job you have. On average, most patients tend to return to work after the penile implant is deflated two weeks after surgery.

Call your surgeon if you have any of the following:

  • Your incision becomes red or swollen, opens or drains pus
  • The skin around your incision becomes warmer than elsewhere
  • Temperature greater than 101F (38C)
  • Chills
  • Nausea or vomiting
  • Severe pain not controlled by pain medications


• Every day things usually get a little easier.

• Do not be afraid to take pain medicine when you are uncomfortable.

• Walk, walk and walk some more. It will help speed your recovery.

• Ask us about anything that concerns you.