Most of the men I see with erectile dysfunction (ED) have ED as a result of a long-standing medical condition such as diabetes or hypertension. Over time these chronic illnesses have slowly compromised the small blood vessels in the penis in much the same way that small vessels of the heart get diseased. The result is a reduced or abnormal vascular performance of the penis.

Abnormal blood flow means abnormal erections. Viagra, Cialis, Stendra, and Levitra all try to stimulate normal blood flow to the penis by relaxing the penile arteries. The side effects of headache and stuffy nose often occur because blood vessels in the head and nose can do the same thing as a result of the medication. This abnormal blood flow is called “organic ED”. If the blood vessels are damaged enough, pills like Viagra won’t work.

So, for men with organic ED, what now? When Viagra doesn’t work, there are a number of options that essentially fall into three main categories:

1. Vacuum Erection Devices (VED)
2. Penile Injections (Trimix)
3. Inflatable Penile Prosthesis (IPP)

A vacuum erection device is an external device that pulls blood into the penis to obtain an erection. However, professionally, I don’t like it. It’s cumbersome and can be painful to use. Additionally, many insurances have stopped paying for it. I have very few patients who actually like this device.

Penile injections are a very good way to obtain an erection. They work to stimulate the blood vessels of the penis but in a slightly different and in a more direct way than the pills. A special combination of medications called Trimix is prescribed that compounding pharmacies can fill. One vial can deliver 20-30 injections, so the overall cost is comparatively low. The medication is administered in a clinical setting or office for the first time, but then the patient is able to inject himself (or have his partner do it) at home. It works for about 95% of men, but many do grow tired of the injection process.

Because of dissatisfaction with the vacuum erection device and Trimix, an inflatable penile prosthesis is an excellent choice. I often do this procedure for men who have erectile dysfunction as a result of prostate cancer treatment.

In this surgery the patient has two cylinders inserted in the penis that replace the spongy tissue that collects blood in a normal erection. A reservoir of water is placed next to the bladder and a little pump is put in the scrotum. When an erection is desired, the patient simply squeezes the pump and an erection is obtained. There is a 1-5% risk of infection after this procedure, which means that the device would have to be removed or replaced if that were to occur. Despite this small risk, an inflatable penile prosthesis has the highest satisfaction rates and the highest partner satisfaction rates of all the treatments discussed.

In closing, if the little blue pill isn’t working like you hoped it would, make an appointment with your doctor and talk about your options.