Back in the 1980s, if a man gathered the courage to see a doctor about erection problems, he was often given one piece of well-meaning but deeply unhelpful advice.
‘Take a vacation and try to relax.’
The implication was clear: It’s all in your head. Stop worrying and the problem will disappear.
That was the prevailing wisdom at the time. Many doctors believed impotence, as erectile dysfunction was then commonly known, was largely psychological.
They were wrong.
As a urologist specializing in erectile dysfunction, I knew even then that most cases had a physical cause, often linked to conditions such as heart disease, diabetes or damage to the blood vessels caused by smoking.
But the condition carried enormous stigma, few men came forward for treatment, and misconceptions persisted even within the medical profession.
Four decades on, the picture could hardly be more different.
Many doctors believed impotence, as erectile dysfunction was then commonly known, was largely psychological. They were wrong
Erectile dysfunction is discussed openly in television commercials and online campaigns. Celebrities and politicians talk openly about using medication for the condition and there are now more treatment options than ever before.
Alongside familiar pills such as Viagra and Cialis are faster-acting medications, combination therapies and even experimental treatments designed to restore blood flow long-term, rather than simply produce an erection.
The result is that many men are left wondering which options genuinely work – and which are simply clever marketing.
Over the course of my career, I’ve prescribed, studied and evaluated most of them.
Now I’m sharing what I’d recommend, what I’d avoid, and where I think the future of erectile dysfunction treatment really lies.
To appreciate how far we’ve come, though, it’s worth remembering just how limited the options once were.
Dr Laurence Levine trained in urology at Harvard and is Professor of Urology at Rush University Medical Center in Chicago
When I first started my career, we had only a handful of treatments available – and many were cumbersome, invasive or plagued by side effects.
We had yohimbine, a stimulant derived from African tree bark that was thought to have aphrodisiac properties and had some evidence behind it. But it could cause anxiety, jitters, insomnia and even heart problems.
There were also injections we gave directly into the side of the penis that dilated blood vessels in the penis, producing an erection on demand. However, they came with risks, including scarring and prolonged erections that would not subside.
Vacuum therapy was another treatment option. These devices had been in use since the early 1900s and worked on a simple principle: a plastic tube was placed over the penis and sealed against the pelvis. Suction was then applied to draw blood into the penis, after which a constriction ring was placed at the base to help maintain the erection.
It worked, but the devices were cumbersome and, frankly, a bit of a mood killer.
The most effective but most invasive treatment was a penile prosthesis. Early implants, introduced in the 1930s, used rigid materials such as bone, cartilage and plastic.
Later, inflatable versions appeared, but these were, and still are, seen as an invasive option of last resort.
So, when Viagra appeared in the late 90s, it changed everything.
The drug, also known as sildenafil, was originally developed to treat angina chest pain.
It works by blocking an enzyme that regulates blood flow, helping blood vessels stay relaxed and improving circulation to the penis.
When Viagra appeared in the late 90s, it changed everything. The drug, also known as sildenafil, was originally developed to treat angina chest pain
In 2005, NASCAR driver Mark Martin raced a Viagra-sponsored Ford in the Nextel Cup Series, reflecting how the once-taboo treatment had entered the American mainstream
Sildenafil was originally developed as a treatment for angina, with the aim of improving blood flow to the heart.
But during clinical trials, researchers noticed an unexpected side effect: Many of the men who were using it started reporting they were having better erections.
When they decided to terminate the trial – it wasn’t as good a drug as they hoped for against chest pain – the men said they wanted to carry on taking it, because they were having better sex.
In the early days, some worried that Viagra could cause heart attacks. But this was completely wrong.
There are some men with heart disease who cannot exert themselves without significant chest pain.
We may not recommend Viagra to them because sex – not Viagra itself – could kill them.
But if you can manage to walk up a couple of flights of stairs, you’re probably fit enough for sex.
There was also a worry about priapism – prolonged erections. But I’ve never seen or heard of this happening when Viagra-type drugs are used alone.
And fears about tolerance – that patients will need to take ever more of the drug to achieve the desired result, if it’s taken regularly – also turned out to be unfounded.
Of course, our blood vessels and overall health changes as we age, and erectile dysfunction can worsen, meaning a man might need to adjust the amount he takes over time.
But research shows you’d need to take more than ten times the standard dose daily for an extended period before the body would develop tolerance.
My point here: it’s a very safe drug and effective in most patients.
In fact, I’d go as far as to say it was one of the most important drugs ever developed, alongside penicillin and statins.
Viagra didn’t just transform the treatment of erectile dysfunction; it spawned a new class of drugs with numerous similar tablets coming onto the market in the following years and changed the way we talk about men’s sexual health.
For millions, a condition that had once been embarrassing, difficult to treat and often ignored suddenly became discreetly manageable.
Roughly 65 percent of all men with erectile dysfunction, with any cause, will get a response to these medications. And Viagra is still the first line treatment I recommend because it’s cheap and gives the strongest erections.
But you do pay for this with a higher risk of side effects – mainly a stuffy nose, facial flushing, headache and stomach ache.
But there are several newer drugs now available to try, too.
Actor Michael Douglas praised erectile dysfunction medication for helping bridge the 25-year age gap with his wife, Catherine Zeta-Jones
Cialis, also known as tadalafil, tends to result in fewer of these side effects and has the other benefit of being a long-lasting drug.
A single Cialis tablet can remain effective, in some men, for up to 36 hours – not that they’re walking around with an erection, but if they get aroused, they can get a proper response.
Viagra will generally be out of the system after six to 12 hours. Cialis is even more effective if you take a small dose of 5mg daily.
The drug builds up in the system and you reach a steady state. This can be bolstered by an as-and-when larger dose, if needed.
Some men prefer this as it means they are ready to go, so to speak, without having to rely so much on timing with medication.
There is evidence of other benefits to daily tadalafil, such as improving urinary symptoms caused by an enlarged prostate.
Daily tadalafil may improve the quality of spontaneous nighttime erections, which experts believe helps keep penile tissue healthy by improving oxygen delivery.
Over time, this may contribute to better overall erectile function, although it is not a cure for erectile dysfunction and does not appear to reverse underlying disease.
There is also emerging evidence that tadalafil may even be linked to better cardiovascular health.
There’s also vardenafil – a Viagra me-too that works more or less the same way in terms of duration and side effects.
And, more recently, we have avanafil – brand name Stendra – which the developers claimed worked in 15 minutes.
In my experience, this can vary between men – some are more sensitive than others – and depends on what’s been eaten beforehand as food in the stomach can slow the drug’s absorption.
You can’t take any of these drugs if you’re using medications such as nitroglycerin for heart disease, because the combination can cause a dangerous drop in blood pressure.
Some patients also report a temporary blue tinge to the vision, particularly with Viagra, caused by the drug’s effect on a related enzyme in the retina. It’s harmless and short-lived, but when it was discovered it prompted restrictions on its use by pilots because of concerns about visual distortion.
For most patients, however, the drugs are both safe and remarkably effective.
More recently, there have been combinations of these drugs in a single pill, which are an exciting development.
The best of these contain sildenafil – which gives a bigger benefit than other medications – and tadalafil, for a longer duration. They also contain a drug called apomorphine, which stimulates the brain’s sexual arousal centers.
Some also contain other active ingredients such as oxytocin, which is a naturally occurring hormone involved in feelings of intimacy and bonding, and PT-141, a peptide that has a similar effect to apomorphine.
Roughly 65 percent of all men with erectile dysfunction, with any cause, will get a response to these medications
Newer treatments, including Rugiet Ready and BlueChew, have proved effective for some patients who didn’t get satisfactory results from Viagra or Cialis alone
I’ve recommended some of these newer treatments, including Rugiet Ready and BlueChew, and they’ve proved effective for some patients who didn’t get satisfactory results from Viagra or Cialis alone.
Both are designed to dissolve under the tongue, allowing the medication to be absorbed through the lining of the mouth rather than the digestive tract. This can lead to a faster onset of action.
The downside is the price. At around $7 a pill, they’re roughly ten to 20 times more expensive than generic sildenafil or tadalafil, which can cost well under $1 a tablet with pharmacy discount programs.
Shockwave therapy has emerged over the past decade as another potential treatment for erectile dysfunction. During the procedure, a handheld device delivers thousands of tiny pulses of low-intensity sound energy into the penis. Researchers believe these pulses may trigger repair processes that improve blood flow.
But not all shockwave machines are the same. There are two types: radial and linear.
I’m skeptical of radial shockwave therapy. These are the machines most commonly advertised by private clinics, often costing patients thousands of dollars out of pocket, yet I don’t believe the evidence shows they work.
Linear shockwave therapy is different. It may stimulate the growth of new blood vessels, helping to restore blood flow to the penis.
That said, it’s not a treatment for everyone. The patients I think are most likely to benefit are younger men with mild to moderate vascular erectile dysfunction who still respond to tablets but would prefer not to rely on them. Men with severe erectile dysfunction after prostate cancer surgery or advanced vascular disease are much less likely to benefit.
Another experimental treatment is Botox.
The theory is that Botox relaxes the muscles surrounding the blood vessels in the penis, allowing them to widen more easily and improving blood flow in some men whose erectile dysfunction is caused by excessive tightening of those muscles.
A handful of small studies have reported encouraging results, but the evidence remains limited and the treatment has not entered mainstream practice.
The same is true of a host of other therapies now being marketed for erectile dysfunction, including platelet-rich plasma (PRP), amniotic tissue injections and various peptides.
While they’re often promoted as cutting-edge solutions, there is little high-quality evidence that they work. Before considering any of these treatments, I always encourage patients to ask what clinical trials support them, who is providing them and whether there’s robust science behind the claims. In most cases, the answer is: not yet.
For men who haven’t responded to anything else, the newest versions of the penile implant are no longer a last resort, in my view, but actually an excellent option. Modern devices are more reliable, feel more natural and carry a lower risk of complications than ever before.
The one-hour outpatient procedure has high satisfaction rates for both the man and his partner, a low risk of infection and can restore reliable erections on demand without affecting sensation, orgasm, ejaculation or urination.
Despite this, only around 20,000 to 30,000 American men have one implanted each year. In my view, that’s largely because of stigma.
Men often see it as a last resort, when they should think of it like a hip replacement: it doesn’t change who you are, it simply restores a function you’ve lost.