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Erectile Dysfunction: A Range of Causes,
A Range of Treatments

While erectile dysfunction (ED) is often associated with aging, it can be caused by a variety of other factors, according to Gregory Bernstein, MD, FACS, of Washington Urology: physical conditions, such as high blood pressure, high cholesterol, or diabetes; lifestyle issues, such as smoking or obesity; mental or emotional conditions, such as depression; and treatments for other diseases, most notably prostate cancer.
Dr. Bernstein said none of these necessarily cause ED; rather, they are risk factors and conditions to consider. More importantly, ED in younger men can be a harbinger of other conditions such as cardiovascular disease. Thus, he said, “a referring physician may have a lower threshold about when to refer a patient to a urologist than with older patients.”

Keep in Mind

  • ED in younger men may be a harbinger of other conditions, including cardiovascular disease.
  • Oral medications are a first-line treatment that referring physicians or urologists can prescribe.
  • Urologists have a range of other options to treat ED, including suppositories, injections, vacuum devices, and penile prosthesis surgery.

Oral Meds as First-Line Treatment

Dr. Bernstein characterized oral medications as the first line of treatment. He often suggests PCPs give patients a trial dosage, unless contraindicated because of other medical conditions. If the trial works, the patient may continue under the care of his PCP. If it does not work, this is valuable information for evaluation if he chooses to see a urologist.

Other Options

If oral medications do not work or are contraindicated, the urologist may explore other non-surgical options with the patient, such as intra-urethral suppositories, penile injections, or a vacuum pump device. The patient learns how to use the preferred method in the doctor’s office.
Surgery, in the form of a penile prosthesis, has been a “major game-changer for some men,” Dr. Bernstein said. In this outpatient procedure, small inflatable cylinders are implanted within the erection bodies of the penis; the man inflates them via a pump placed in the scrotum and deflates them after intercourse. The prosthesis can be replaced if needed (it has a life of 15–20 years), but will be needed for an erection going forward.

A Word about Prostate Cancer

Many men are concerned about ED after prostate cancer surgery. Dr. Bernstein recommends oral medications, but may suggest moving on to other options more rapidly if the orals are unsuccessful. Some erectile function can return 1–2 years after prostate cancer surgery, so penile prosthesis is generally not offered until at least 12 months out.

Testosterone and ED

Low testosterone may lead to ED, but that is not the only reason to measure levels. Recognition is growing about the role of testosterone in overall health. Dr. Bernstein noted many men request their level be tested, and many physicians now include the test in a full health evaluation.

Gregory Bernstein, MD, FACS, is a member of Washington Urology. He attended Boston University School of Medicine and completed his internship and residency at Walter Reed Army Medical Center. He was Chief, Urology, at Dewitt Army Hospital at Fort Belvoir. Board-certified in urology, he is Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences in Bethesda. Dr. Bernstein has expertise in male health, erectile dysfunction, low testosterone, and infertility.


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