Erectile Dysfunction and Low Testosterone

As you get older, it becomes more likely that you’ll experience erectile dysfunction.  In fact, about 30 million men have some form of it.  Dr. Werner talks about it here:

Erectile Dysfunction

Some statistics to know: even at age 40, five percent of men can’t achieve an erection rigid enough for penetration.  About 15 percent of men have significant problems getting or maintaining erections. In men older than 35 the cause is usually physical, and for men younger than 35, it’s generally a psychological issue.  But either way, medical help can often solve the problem.

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These are the main causes for erectile dysfunction or impotence

Arteries need to bring blood to the penis so that you can maintain an erection.  So, any damage to the arteries can lead to this problem.  If you have a history of coronary artery or heart disease, strokes, or peripheral vascular disease, this could affect the penile arteries. Even prior to these severe vessel diseases, you may have problems with erections.  You should also know that smoking is a main contributor as well as high blood pressure (especially if it’s uncontrolled), heart disease, high cholesterol, and diabetes. 

This system must be intact for an erection to occur.  So, if a patient has multiple sclerosis or damage to peripheral nerves from diabetes, he may have a problem getting an erection.

If you have low testosterone and thyroid hormones or high prolactin, this could be a cause of erection problems.

Sometimes this is an initial problem and sometimes a secondary problem.  This means that a psychological issue may be the reason you are not achieving an erection.  But the psychological issue could be a response to a physical problem.  Losing confidence in getting an erection can change your attitude or interest in sex.  At this point, achieving and maintaining an erection may be more difficult.

Erectile Dysfunction Treatment Options

Generally, a straightforward case of erectile dysfunction (for example, a 65-year-old diabetic who wants rapid treatment for sexual impotence) can be dealt with by a general urologist.  That starts with the doctor taking a thorough history and doing a basic evaluation.  This includes a physical exam focused on the problem with a measurement of penile sensation and a hormone check.  Options should be explained at this point.  Most often that would include an oral medication with side effects explained and the doctor writing a prescription.  Follow-up exams should be scheduled and if there are unpleasant side effects from the oral medicine, other options can be considered.

Oral Medications
Oral medications include Viagra, Levitra, and Cialis. 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 is effective for 36 hours. 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 should be taken on an empty stomach. Please be aware that none of these drugs will affect desire in any way. They will merely make a penis respond more quickly and remain firmer when it is stimulated and aroused.

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

Although all three of these medications work slightly differently, the basic functioning is the same. They block an enzyme that normally prevents erections from occurring. When a man is sexually aroused, nitric oxide is released, which causes a cascade of biochemical reactions: the blood vessels and tissues 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 not advised for men who are: currently using nitrates or have Retinitis Pigmentosis.

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

  • Unstable angina
  • Congestive heart failure
  • Taking multiple antihypertensive drugs
  • MI, heart attack, CVA (stroke), or life threatening arrhythmia within the last six months
  • Hypotension, decreased blood pressure (BP <90>170/110)
  • Patients on alpha blocks for high blood pressure or prostrate problems should not take Levitra or Cialis

Any men who fall into the above categories should see an erectile dysfunction specialist as there are very effective alternatives available for treating impotence.

Other reasons you may want to consider seeing a specialist include:

  • If there has been a sudden onset of erectile dysfunction
  • You are under 50 years old
  • You have Peyronie's Disease

Some men may choose to start the process with a specialist even if they do not fit these criteria since a specialist is able to take the time to evaluate, understand, and get to know a patient. Also, a patient may want to fully understand the physical aspects of his problem as well as the psychological issues and ramifications. Finally, the atmosphere in a specialist's office may be more personal and private.

Other Options
If a patient is unable to take one of the available oral medications or if the medications are not working as desired, there are effective alternatives available for treating impotence.

Oral medications work for 70% of men. For many of these men, it is truly a wonder drug, giving them excellent, predictable, and long-lasting erections.

Oral medications have revolutionized the treatment of erectile dysfunction. They have brought the issue into the open and have given many men hope.

However, for 30% of patients, the oral medications fail. For these men, the oral medication does not work well, does not work at all, or cannot be recommended from a medical point of view. These men are often more unhappy than before they sought treatment since they are convinced that they are alone and that there is no help for them.

This group, in particular, should see an erectile dysfunction specialist, as there are other excellent options for the treatment of their erectile dysfunction. Physicians who specialize in impotence are the most comfortable and confident at presenting, teaching, and performing alternate treatments.

One of the options available for the treatment of erectile dysfunction is the self-injection of medication into the penis. This often sounds scary to the patient and not particularly appealing. However, in reality, the technique does not involve a traditional syringe and does not hurt. Often, once a patient understands the reality of his treatment, he is willing to consider this highly popular and effective treatment technique.

The medication is delivered to the penis using a device that is similar to the ones used by diabetics. A disposable syringe is placed on the injector, the device is placed against the side of the penis, and a button is pressed. A spring then pushes a very thin needle into the penis and, at the same time, pushes the medication into the penis.

Men normally agree that the "injection" does not hurt. Most patients describe it as either painless or as if they have been flicked with a rubber band. The injection is extremely quick and uses a very fine needle (usually a 29 or 30 gauge). Additionally, since the side of the penis does not include many pain receptors, there is little sensation.

The three most common medications used for injections are papaverine, phentolamine, and prostaglandin E1. All three act by relaxing the smooth muscles and causing the arteries to dilate. This activates the trapping mechanism. Prostaglandin E1 received FDA approval in 1996 for erectile dysfunction treatment. It is currently marketed and available in prescription plans under two brand names, Caverject Impulse and Edex.

The different medications have different characteristics. The papaverine and phentolamine come in a liquid, do not need to be refrigerated, and have the least discomfort associated with them. Prostglandin E1 is a powder that is mixed with a fluid prior to use (this is due to the fact that it is stable as a powder at room temperature, but not as a liquid). Prostaglandin E1 can cause some ache. Although it is not medically concerning, it can be uncomfortable. However, in most cases, the discomfort is short-lived. Discomfort is experienced by approximately 20% of patients and is most common in patients who have neurological erectile dysfunction such as diabetes or post-radical prostatectomy.

The two main potential complications from the injections are the development of scar tissue and the possibility of a prolonged erection. This risk is significantly minimized when you are seeing a physician who is very experienced with this treatment option and the appropriate dosing levels. Also, the risk of scarring is greatly reduced if the penis is compressed for five minutes after the injection and the site of the injection is varied.

Penile injections were developed approximately 30 years ago and were the second method developed for the treatment of erectile dysfunction. The first treatment method was surgical and involved the insertion of a penile implant.

Experience suggests that many men are successfully treated with injectable medication. Their erections are often much stronger and more reliable than those from the oral medications. In some ways, the injection is a more spontaneous solution for treating impotence since it can be used right before a sexual encounter. With foreplay and the medication, the individual gets a good, strong erection. Additionally, and importantly, some studies suggest that men who use the injections on a regular basis have a high likelihood of seeing improvements in their spontaneous erections.

Evaluating and Diagnosing Erectile Dysfunction

A first appointment should last between 45 and 60 minutes. It should include:

The physician will take a thorough medical history in order to place your erectile dysfunction within a medical context. He will also take a full sexual history. This may include questions such as:

  • How long have you had the erectile dysfunction?
  • What happens when you try to have intercourse?
  • Do you have decreased rigidity?
  • Do you have difficulty maintaining your erection?
  • At what point do you lose your erection?
  • Do you wake up at any point with an erection?
  • How rigid are the nocturnal erections?
  • What is your sexual interest level (libido) like?
  • Does your penis have a curve, bend, or twist in it when it is rigid?
  • Is your ejaculation normal?
  • Is it early (premature) or delayed?
  • What is the status of your relationship?
  • How is the relationship going?
  • How is your erectile dysfunction affecting the relationship?

Your physician will explain to you how erections work (in terms that you will understand). He will explain why yours may not be working.

Physical Examination
Your physician will perform a focused physical examination on your penis and testes. In general, you should have a regular (general) physical examination either before or after your appointment.

Your physician will usually measure the threshold for perceiving vibration of your penis (biothesiometry). Depending on your situation, he may perform specialized testing to assess the function of your penis. This may include:

  • An ultrasound to measure the blood flow through the penis.
  • A Rigi-scan to measure the quantity and quality of your nighttime erections.
  • A blood test to measure your hormone levels.

Once your physician has completed your evaluation, he will review impotence treatment options with you. He will consider these options in light of the history, physical, and specialized testing that has been performed.

Finding a Doctor for Erectile Dysfunction

All urologists are not impotence specialists. Urologists are physicians whose training has included specialization in the surgical and medical treatment of the "genitourinary system." This includes kidneys, bladder, ureter (the tubes that connect the bladder and the kidneys), prostate, penis, and testes.

The conditions that urologists treat include cancer (kidney, bladder, prostate, testicular, and penile), stones (kidney, ureter and bladder), urination problems (incontinence, benign prostatic hypertrophy, and stricture), trauma, and infection. One of the many conditions is impotence. It is usually one of the last topics listed in a urology textbook and is given little emphasis in urology residency programs.

Because of the broad spectrum of areas covered under urology, many urologists specialize in a particular area of expertise. A general urologist must keep abreast of major advances in a multitude of fields, and it isn't realistic for him/her to truly specialize in more than one or two areas.

Each year, a small number of urology residents elect to further specialize in the area of erectile dysfunction. These physicians undergo an additional 1 to 2 years of training under the most prominent physicians in the field. They are in the best position to perform a thorough evaluation of an impotence patient. They can also structure their scheduling to accommodate the needs of their patients with erectile issues.

Herbal Alternatives for treating Erectile Dysfunction

For many years, Yohimbe, which is found in Rubaceae and related trees, was considered an impotence remedy. The efficacy of Yohimbe has been debated for a number of years. Many studies have concluded that it is no better than a placebo. Others have concluded that it does improve erections, though modestly. It is still occasionally used for men with very modest erectile dysfunction, especially when a lack of desire and psychological factors are major issues. A multitude of multivitamins or herbal supplements are marketed for erectile dysfunction. At the moment, there are no reliable studies that prove the efficacy of any of these medications. The supplement combinations are not regulated by the FDA, and some may be not only ineffective, but also harmful. Some include hormones, which remain controversial when used by patients with normal hormone levels.

Herbal supplements must be viewed with a fair amount of caution and skepticism until there is evidence that they are safe and effective.


To learn more about erectile dysfunction and treatment options, please call Dr. Werner's office at (646) 380-2700 in NYC, (914) 997-4100 in Westchester, or (203) 831-9900 in Connecticut, or send us an email at