Treatment Options:
There are five ways to treat erectile dysfunction: medications, vacuum erection devices, injections, intra-urethral pellets, and surgeries.

Oral Medications:
Viagra, Levitra, and Cialis are currently available for impotence.
All three medications should be taken approximately 60 minutes prior to engaging in sexual activity. Viagra and Levitra are effective for approximately 4 hours. Cialis (the weekend drug) is effective for 36. Viagra is less effective if it is taken within hours of having eaten fatty foods, so those types of food should be avoided when taking Viagra. Ideally, Viagra would be taken on an empty stomach. Please be aware that none of these drugs affect your desire in any way. They will merely make your penis respond more quickly and dramatically when your penis is stimulated and you become aroused.

The maximum dosage of Levitra/Cialis is 20 mg, and of Viagra, 100 mg. This should not be exceeded in any 24-hour period. Even if a lesser dosage is used, it should only be used once in any 24-hour period.

Although all three of these medications work slightly differently, the basic functioning is the same. When a man is sexually aroused, nitric oxide is released, which causes a cascade of biochemical reactions: the blood vessels and tissue of the penis relax and dilate, allowing blood to rush in and an erection to occur. These oral medications block the enzyme, PDE5, which reverses this cascade.

Please note that all of these drugs are contraindicated for men who are currently using nitrates or who have Retinitis Pigmentosis.

Other men who may not take the available oral medications are those with a predisposition to potentially hazardous cardiovascular events. Their conditions include:

* Unstable Angina

* Congestive Heart Failure

* Multiple Antihypertensive drugs

* MI, heart attack, CVA (stroke), or life threatening arrhythmia within the last 6 months

* Hypotension, decreased blood preasure (BP<90/50) or Hypertension, increased blood preasure(BP>170/110)

* Patients on alpha blocks for high blood pressure or prostate problems should also not take Levitra/Cialis. The only alpha blocker permitted to be taken with Cialis is Flomaz (0.4 mg )

*Patients on alpha blocker may take Viagra but may not take it within 4 hours of having taken the alpha blocker.

Yohimbine is another oral medication that predated the above listed pharmaceuticals. Its efficacy is controversial, although it is generally believed to produce modest improvement in erectile dysfunction. It must be taken three times each day consistently, not only prior to intercourse.

Vacuum Erection Devices
These devices are external and go over the penis. A seal is created between the device and the skin around the penis. The air in that space is removed and this creates a vacuum around the penis, which draws blood into the penis. A ring is then placed around the base of the penis, which holds the blood in, and the vacuum pump is removed. The patient will then maintain the erection while the ring is on and will have intercourse with the ring on. This method has proved effective. It is most commonly used by older men in long-standing relationships.

It is important to use only FDA approved devices, which have valves that limit the amount of vacuum pressure that can build up around the penis. If too much pressure builds up, the penis can be damaged.

Penile Injections
Penile injections are successful in 90-95% of patients (even in those cases where Viagra is not.) They result in a rapid onset of an erection and they are used immediately prior to intercourse. For most patients, they produce an erection that is of increased rigidity and duration. Many patients who are not satisfied with results from Viagra use the injections with great success.

Injections are not painful. Most of the time, they can be given with an auto-injector. Men describe this sensation as similar to that of a flick of a rubber band.

The three main medications used for injections are Alprostadil, Papaverine, and Phentolamine. They can be used in various combinations. The Alprostadil is available in prescription form in kits. These include a vial of powdered medicine, a syringe with the fluid needed to dilute it, and a self-locking case for disposal of the used needles.

Intraurethral Delivery Systems
The Alprostadil may be made into a small pellet in high concentration. This is then placed, via an applicator, into the urethra (the tube men from which men urinate and ejaculate). The medication diffuses through the urethral tissue into the blood stream and the erectile tissue. It has worked in many men, although in general it is less effective than injecting the same medication into the penis. Side effects may include urethral burning and lowering of blood pressure.

Surgeries
There are two classifications of surgeries:

· The most common is the insertion of one of several types of a penile prosthesis. The most sophisticated are very natural in appearance. They are inserted through a small incision, usually in the scrotum. Two cylinders are placed into the penis itself near the erectile tissue. A small pump is placed into the scrotum, and a reservoir is placed under the abdominal wall. When the man wants an erection, he transfers the fluid via the pump from the reservoir into the erection chambers, thus getting a rigid, well-maintained erection. When he is finished with intercourse, he can deflate the prosthesis. Penile sensation and orgasmic ability are basically unchanged with this procedure. This procedure, though invasive, does have a very high patient satisfaction rate.

· A very small percentage of patients are candidates for penile re-vascularization. In this situation, when there is a blockage or damage to the penile artery it can be bypassed, giving a better blood supply to the penis.