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What is erectile dysfunction (ED)?

Men who have ED have a problem getting or keeping an erection that’s firm enough for sexual satisfaction.

Most men have difficulty with erections from time to time. In some men, it is a regular, more severe problem. It can cause low self-esteem, performance anxiety, depression and stress. ED may affect the quality of a marriage or intimate relationship. The good news is there are many safe and effective treatments.

ED can be an early warning sign of a more serious illness, such as heart disease, high blood pressure or diabetes mellitus. Diagnosing and treating the condition that causes E D can improve your overall well being, as well as help restore your sexual health.

How do erections occur? When a man is not sexually aroused, his penis is soft or limp. During sexual arousal, nerve messages release chemicals that increase blood flow into the penis.

The blood flows into two erection chambers made of spongy tissue inside the penis. The “smooth muscle” in the erection chambers relaxes, which allows blood to enter and remain in the chambers. The pressure of the blood in the chambers makes the penis firm, producing an erection.

After a man has an orgasm, the blood flows out of the chambers and the erection subsides.

What causes erectile dysfunction?

ED can result from medical, physical or psychological factors. ED may be caused by a combination of factors that could also include medicine, alcohol or drugs. The physical and medical causes of ED include three basic problems:

  1. Not enough blood flows into the penis. Many conditions can reduce blood flow into the penis, causing ED. Heart disease, diabetes and even smoking can contribute to ED.
  2. The penis cannot store blood during an erection. A man with this problem, called venous leak or cavernosal dysfunction, cannot maintain an erection because blood does not remain trapped in the penis. This condition may occur at any age.
  3. Nerve signals from the brain or spinal cord do not reach the penis. Certain diseases, injury or surgery in the pelvic area can damage nerves in the penis.

Sexual activity requires the mind and body to work together. Psychological, emotional or relationship problems can cause or worsen ED. These include:

  • depression
  • relationship conflicts
  • stress at home or work
  • anxiety about sexual performance

Many prescription and over- the-counter medications cause erectile difficulties as a side-effect. Marijuana, cocaine, heroin, and alcohol use can also lead to sexual problems.

Your health care provider can treat many causes of ED. But, you may be sent to see a urologist. Urologists perform specialized evaluations, prescribe medications and perform surgery to correct erection problems. If your E D is due to a hormonal problem, such as a low testosterone level or is related to diabetes, you may be referred to an endocrinologist (a doctor who specializes in hormones, their function, and the organs that produce them).

Your health care provider may also refer you to a mental health professional. These specialists treat psychological or emotional causes of E D. Even if your ED is not caused by these factors, it may contribute to them.

It may be helpful to get counseling, alone or with your partner, in addition to getting medical therapy for ED.

How is erectile dysfunction diagnosed?

ED is diagnosed by a urologist or other medical professional through a brief physical examination. A careful medical, social, psychological and sexual history is also taken. Sometimes blood tests are also done.

Medical History

Your health care provider may ask you about your ED experience. He or she will want to know if you have other conditions that might contribute to your ED. These include endocrine problems or depression. Some questions about your sexual history and performance may seem very personal. You may be embarrassed, but answering honestly will help your provider find the best treatment for you.

Your health care provider is likely to ask you about:

  • your current sexual function
  • when you started noticing changes
  • any past medical or sexual problems
  • surgery or injury to the pelvic area
  • current and past medications (prescriptions, over-the-counter, dietary supplements, etc.)
  • your lifestyle and personal habits (drinking alcohol, smoking, stress, using illicit drugs, etc.)
  • your relationship with your current and past partners

The Physical Exam

Your health care provider will check your overall health and physical condition. He or she will look for signs of problems with your circulatory (blood), nervous and endocrine (hormonal) systems.

This includes checking your blood pressure, penis and testicles. They may also perform a rectal exam to check the prostate gland. These exams are not painful and may provide important information about the cause of your ED. Men with E D may have tests to check for:

  • low levels of the hormone testosterone
  • elevated levels of sugar in your blood or urine, which are signs of diabetes
  • elevated levels of blood cholesterol and other lipids (fatty substances)
  • Additional tests can determine if you have problems with the nerve or blood supply to the penis.

How is erectile dysfunction treated?

Your health care provider may be able to improve your ED by treating underlying causes such as:

Lifestyle or Psychological Factors

Changing certain habits, such as stopping drug or alcohol use may improve or eliminate ED. Psychological problems, such as relationship conflicts, depression or performance anxiety, can also be treated.

Prescription or Nonprescription Drug Use

If ED is a side effect of a prescribed medication you are taking, your health care provider may be able to adjust the amount you take, or switch you to a different drug. Do not stop taking your medicine or change your dosage without talking to your provider first.

Hormone Therapy

If a blood test shows that your testosterone level is too low, your health care provider may prescribe testosterone replacement therapy. This may help if you experience low sex drive in addition to ED.

Medication for ED

The oral medications sildenafil citrate (Viagra®), vardenafil HCI (Levitra® and Staxyn®), tadalafil (Cialis®) and avanafil (Stendra®) are considered safe and effective for treating ED for many men. These drugs are known as phosphodiesterase type 5 (PDE-5) inhibitors. They work to relax muscle cells in the penis for better blood flow and to produce a rigid erection. They can be effective regardless of age or race. However, they only work if a man is sexually stimulated. Even men with severe or complete E D may respond to these treatments.

What other treatments are available for erectile dysfunction?

Other safe and effective options include vacuum erection devices, self-injection therapy, intraurethral therapy and penile implants. These other methods are especially useful for men who cannot take a PDE-5 inhibitor or do not have a satisfactory response to the medication.

Vacuum Erection Devices

Vacuum erection devices (VE Ds), can be used by any man with ED, regardless of his age or the underlying problem. VE Ds come in a variety of models, but the basic unit is a clear plastic cylinder that fits over the penis. A pump is connected to the cylinder that draws out air.

This creates a negative pressure that draws blood into the penis, causing an erection to form.

Once an erection occurs, an elastic ring is slipped around the base of the penis. The ring helps hold the blood in the penis. The ring can be left in place safely for up to 30 minutes.

Self-Injection Therapy

This treatment involves injecting a small amount of medication, most commonly alprostadil (or prostaglandin), into the base of the penis before sexual activity. For most men, the feeling of the injection is no worse than a pinch. This treatment is easy to use and works for many men. Most men who do not respond to PDE-5 inhibitor treatment will respond to injection therapy. The most common side effect is penile pain. Bruising at the injection site and scarring may also occur.

Intraurethral Therapy

This treatment is a variation of self-injection therapy. Instead of injecting the penis, a man inserts a tiny medicated pellet of alprostadil into his urethra. Although generally safe, this method is less effective than self-injection therapy. Possible side effects include pain in the penis or groin area, prolonged erection and low blood pressure. Alprostadil may irritate the vagina of a female partner, causing mild burning or itching. This therapy should not be used if a man’s partner is pregnant or planning to become pregnant.

Surgical Treatments

Surgery to correct problems with blood vessels to the penis may help in rare cases, particularly for young men who have had injuries to the pelvis or penis. It also may be recommended for men born with certain types of blood vessel abnormalities.

Penile Implants

A penile implant requires surgery. This option is for carefully selected men.

Two basic types of implants are available. With malleable or bendable implants, two rods are inserted into the corpora cavernosa. To have an erection, a man bends his penis upward into an erect position. With an inflatable implant, a pair of inflatable cylinders is attached to a fluid reservoir and a pump hidden inside the body. To have an erection, a man presses on the pump. This transfers fluid into the cylinders, making the penis rigid.

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