Erectile dysfunction (ED)also known as impotence is a type of sexual dysfunction characterized by the inability to develop or maintain an erection of the penis during sexual activity. Erectile dysfunction can have psychological consequences as it can be tied to relationship difficulties and self-image.
Erectile dysfunction (ED) is defined as the persistent inability to attain and maintain an erection that is sufficient to permit satisfactory sexual performance (rx). The current pharmaco-therapeutic research in ED focuses on underlying endothelial dysfunction as the root cause for ED and introduction of phosphodiesterase type 5 inhibitors to potentiate nitric oxide (NO) action and cavernosal smooth muscle vasodilation, has revolutionized modern ED treatment over the past two decades (Rx). In contrast to Western Medicine, the traditional and complementary medicine (TCM) aims at restoration and better overall bodily regulation with medicine to invigorate qi (energy) in vital organs such as kidney, spleen, and liver; to enhance physical fitness, increase sexual drive, stabilize the mind and improve the overall situation resulting in natural and harmonious sexual life (rx).
Types of Erectile Dysfunction
There are two different types of premature ejaculation
- Primary (lifelong)
- Secondary (acquired)
- Algorithm for the diagnosis and treatment of erectile dysfunction.
||Physical and mental health problems|
|Relationship problems/partner dissatisfaction|
||Central nervous system—spinal cord injury, multiple sclerosis, stroke|
|Peripheral nervous system—neuropathy|
||Arterial insufficiency/peripheral arterial disease|
|Chronic obstructive pulmonary disease|
||Benign prostatic hypertrophy|
|Lower urinary tract symptoms|
Pathophysiology of Erectile Dysfunction
ED may result from organic causes (e.g., vascular, neurogenic, hormonal, anatomic, drug-induced), psychological causes, or a combination of both. A normal sexual erectile response results from the interaction between neurotransmitter, biochemical, and vascular smooth muscle responses initiated by parasympathetic and sympathetic neuronal triggers that integrate physiologic stimuli of the penis with sexual perception and desire. Nitric oxide produced from endothelial cells after parasympathetic stimuli triggers a molecular cascade that results in smooth muscle relaxation and arterial influx of blood into the corpus cavernosum. This is followed by compression of venous return, which produces an erection.
Causes of Erectile Dysfunction
Erectile dysfunction (ED) can have many causes, such as certain medical conditions, medications and stress. It’s important to identify the cause of erectile dysfunction and treat any underlying conditions.
When a man becomes sexually excited (aroused), his brain sends signals to the nerves in his penis. The nerves increase the blood flow to the penis, causing the tissue to expand and harden. Anything that interferes with the nervous system or the blood circulation could lead to erectile dysfunction. Anything that affects the level of sexual desire (libido) can also cause erectile dysfunction because a reduced libido makes it more difficult for the brain to trigger an erection. Psychological conditions, such as depression, can reduce libido, as can changes in hormone levels (chemicals produced by the body).
- a. Psychological causes
Starting with feelings of sexual excitement, a number of things can interfere and cause or worsen erectile dysfunction like:
- Depression, both mild and severe
- Fatigue (due to disease, syndrome, and general weakness)
- Relationship problems due to stress, poor communication or other concerns
- b. Physical causes
The majority of these cases are secondary to diseases and disorders. These physical causes can further be classified into.
Diseases and disorders that cause erectile dysfunction are:
- Heart disease
- High blood pressure
- Diabetes (It is one of the major causes. 35-50% men with diabetes experience ED)
- Obesity or overweight
- Metabolic syndrome
- Parkinson’s disease
- Multiple sclerosis
- Low testosterone
- Peyronie’s disease (development of scar tissue inside the penis)
There are four main types of health conditions that can cause physical problems resulting in erectile dysfunction. These are:
- conditions affecting the flow of blood to your penis – vasculogenic
- conditions affecting your nervous system, which is made up of your brain, nerves and spinal cord – neurogenic
- conditions affecting your hormone levels – hormonal
- conditions affecting the physical structure of your penis – anatomical
Injuries and surgery
- Penis injuries or surgical treatment of the penis, pelvis or surrounding areas can sometimes lead to erectile dysfunction. Erectile dysfunction is also thought to occur in up to 15-25% of people who experience a severe head injury.
Examples of vasculogenic conditions that cause erectile dysfunction include:
- Cardiovascular disease – a disease of the heart or blood vessels, such as atherosclerosis (hardening of the arteries)
- High blood pressure – (hypertension)
- Diabetes – a condition caused by high blood sugar levels. This can affect both the blood supply and the nerve endings in your penis, so it is also a neurogenic condition
Erectile dysfunction is strongly associated with cardiovascular disease. For this reason, it may be one of the first causes your GP considers when making a diagnosis and planning your treatment.
Examples of neurogenic conditions that cause erectile dysfunction include:
- Multiple sclerosis – a condition that affects the body’s actions, such as movement and balance
- Parkinson’s disease – a condition that affects the way that the brain coordinates body movements, including walking, talking and writing
- A spinal injury or disorder
- A stroke – a serious condition that occurs when the blood supply to the brain is interrupted
Examples of hormonal conditions that cause erectile dysfunction include:
- Hypogonadism – a condition that affects the production of the male sex hormone, testosterone, causing abnormally low levels
- An overactive thyroid gland (hyperthyroidism) – where too much thyroid hormone is produced
- An underactive thyroid gland (hypothyroidism) – where not enough thyroid hormone is produced
- Cushing’s syndrome – a condition that affects the production of a hormone called cortisol
Peyronie’s disease, which affects the tissue of the penis, is an example of an anatomical condition that can cause erectile dysfunction.
In some men, certain medicines can cause erectile dysfunction, including:
- Diuretics – these increase the production of urine and are often used to treat high blood pressure (hypertension), heart failure and kidney disease
- Antihypertensives – such as beta-blockers, that are used to treat high blood pressure
- Fibrates – medicines used to lower cholesterol levels
- Antipsychotics – used to treat some mental health conditions, such as schizophrenia
- Antidepressants – used to treat depression and some types of pain
- Corticosteroids – medication that contains steroids, which are a type of hormone
- H2-antagonists – medicines used to treat stomach ulcers
- Anticonvulsants – used to treat epilepsy
- Antihistamines – used to treat allergic health conditions, such as hay fever
- Anti-androgens – medication that suppresses androgens (male sex hormones)
- Cytotoxics – medication used in chemotherapy to prevent cancer cells from dividing and growing
Speak to your GP if you are concerned that a prescribed medicine is causing erectile dysfunction. Alternative medication may be available. However, it is important never to stop taking a prescribed medicine unless you are advised to do so by a qualified healthcare professional who is responsible for your care.
Possible psychological causes of erectile dysfunction include:
- Depression – feelings of extreme sadness that last for a long time
- Anxiety – a feeling of unease, such as worry or fear
Erectile dysfunction can often have both physical and psychological causes. For example, if you have diabetes, it may be difficult for you to get an erection, which may cause you to become anxious about the situation. The combination of diabetes and anxiety may lead to an episode of erectile dysfunction. There are many emotional issues that may also affect your physical ability to get or maintain an erection. These include:
- Relationship problems
- Lack of sexual knowledge
- Past sexual problems
- Past sexual abuse
- Being in a new relationship
- Certain medications (like for depression or high blood pressure)
- Tobacco use
- Alcoholism and other forms of substance abuse such as cocaine and heroin
- Treatments for prostate cancer or enlarged prostate using hormones and allopathic drugs
- Surgeries or injuries that affect the pelvic area or spinal cord
- Lifestyle problems like obesity as mentioned above
Other possible causes of erectile dysfunction include:
- Excessive alcohol intake
- Using illegal drugs, such as cannabis, heroin or cocaine
- Men who cycle for more than three hours per week may be recommended to try a period without cycling to see if this helps to improve erectile dysfunction. Riding in the correct position with a properly fitted seat may also help to prevent regular cycling from leading to erectile dysfunction.
- Psychological causes – (e.g. depression, anxiety, and stress involving the workplace) used to be considered some time ago as the most common reason for ED [Rx], especially in young men, but are now thought to be the primary factor in only a few cases. However, secondary psychological problems are expected in all cases associated with ED.
- Vasculogenic – The most common single cause, due to low blood inflow (e.g. large vessel atherosclerosis). The incidence of ED in atheromatous aortoiliac and peripheral vascular disease is about 50%. On the other side, increased outflow, also known as a venous leak or venogenic ED, may be responsible. The venous outflow regulatory mechanism depends on the completeness of trabecular smooth muscle relaxation and the expandability of the erectile tissue, defined as the ability to achieve maximal corporal volumes at low intracavernosal pressures. Arteriogenic and venogenic ED can also coexist in the same patient.
- Diabetes mellitus – is a common cause of organic ED, up to 75% of diabetic patients accusing poor erections. It is hypothesized that cavernosal artery insufficiency, corporal venoocclusive dysfunction, and/or autonomic neuropathy are the major organic pathophysiologic mechanisms leading to persistent erectile impairment in men with diabetes mellitus.
Hypogonadotropic hypogonadism is rare, its main characteristic being the delayed puberty;
Hypogonadotropic hypogonadism – (Klinefelter’s syndrome, surgical orchiectomy) may decrease libido while potency may persist.
Late-onset hypogonadism – may lead to ED by decreasing the hormonal levels in a patient who previously had a normal androgenic function.
Hyperprolactinemia – (pituitary adenoma, craniopharyngioma, drugs) is associated with low or low– normal levels of serum testosterone, its effects on erectile function appear to be centrally mediated. Hyperthyroidism is commonly associated with diminished libido and, less frequently with ED, while ED associated with hypothyroid states has been reported and may be secondary to associated low levels of testosterone secretion and elevated levels of prolactin.
- Renal failure – Approximately 50% of dialysis-dependent uremic patients suffer from ED, but improvement after transplantation occurs in many patients mostly because of reversal of the anemia associated with chronic renal failure and improvement in uremic neuropathy. In this case, the psychogenic etiology cannot be neglected
- Neurogenic – It is estimated that 10–19% of the organic ED are neurogenic [rx]. The main causes are:
intracerebral (Parkinson’s Disease, cerebrovascular disease–especially efferent pathways from the medial preoptic area may be affected in addition to higher cortical functions, affecting sexual response; other causes are: stroke, encephalitis, or temporal lobe epilepsy)
spinal cord (trauma – psychogenic erections are not possible in patients with complete lesions above T12; up to 75% of patients with multiple sclerosis have sexual disfunction; myelodysplasia).
peripheral nerves are also affected in alcoholic neuropathy, diabetic neuropathy (most common cause), after surgery (radical pelvic surgery), and trauma.
Trauma – pelvic fractures with the ruptured posterior urethra. The damage to the neurovascular bundle or to the internal pudendal or common penile artery at the time of injury is predominantly responsible for most of the ED seen following these injuries. Perineal trauma, considered as a ‘hidden’ cause of ED, is often considered to be psychogenic, but neurovascular lesions may occur. Bicycle accidents and extensive bicycle riding account for a significant portion of these blunt perineal injuries, most of them during childhood.
Penile diseases – vascular lesions in priapism, Peyronie’s disease, or other traumatic lesions of tunica albuginea or congenital deformities, can cause ED.
Malignant diseases – lower abdomen or pelvic organ malignancies may cause organic ED. However, in the vast majority of malignancies, the psychogenic etymology is considered the most important
Iatrogenic – consists in aortic or peripheral vascular surgery, renal transplantation (especially if second contralateral transplantation is performed with end–to–end hypogastric artery anastomosis), perineal irradiation (leads to fibrosis of cavernosal erectile tissue), cavernosal spongiosis shunts performed for the emergency treatment of priapism, abdominal perineal resection of the rectum, radical prostatectomy or cystoprostatectomy (the incidence of ED can be lowered to 40%–60% if nerve sparring techniques are used), transurethral sphincterotomy (should avoid incision at the 3 o’clock and 9 o’clock positions to prevent thermal injury to the cavernosal arteries). Other procedures may cause psychogenic ED.
Symptoms of Erectile Dysfunction
Intermittent function (variability, situational)
Loss of sustaining capability
Excellent nocturnal erection
Response to phosphodiesterase type 5 inhibitors is likely to be excellent
Consistently poor response
Erection better in standing position than lying down (in the presence of venous lear
Diagnosis of Erectile Dysfunction
Criteria Involved in Diagnoses
Ejaculatory Latency Time [ELT]
- Ejaculatory Latency Time measure the time it takes for ejaculation to occur after penetration
- For men with female partners, this Ejaculatory Latency Time is called Intravaginal Ejaculatory Latency Time [IELT], which measures the time it takes for ejaculation to occur after vaginal penetration.
- With Premature Ejaculation, ejaculation tends to occur just on or before penetration or within 1 or 2 minutes after penetration
- A man’s time to ejaculate varies throughout his life and can be influenced by various factors, such as; levels of excitement, levels of anxiety, a new partner, new sexual activity/position, level of sexual experience, the length of time from the last ejaculation, the extent of foreplay, relationship/intimacy issues.
- It is important to remember that the problem with Premature Ejaculation is more about control than duration. So it is about how much-perceived control does a man has over his ejaculation.
- Men with Premature Ejaculation tend to have an inability to delay ejaculation associated with a lack of control.
The dissatisfaction of Self and/or Partner
- Premature Ejaculation has negative affective consequences to either 1 or both partners. Examples of those consequences are distress, bother, frustration, sadness, anxiety, sexual dissatisfaction, etc.
Withdrawn from Partner
Premature Ejaculation can result in avoidance of intimacy/affection, sexual intimacy, and intercourse. A useful and simple way to distinguish between physiological and psychological impotence is to determine whether the patient ever has an erection. If never, the problem is likely to be physiological; if sometimes (however rarely), it could be physiological or psychological. The current diagnostic and statistical manual of mental diseases (DSM-IV) has included a listing for impotence.
- Penile nerves function – Tests such as the bulbocavernosus reflex test are used to determine if there is sufficient nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger inserted past the anus.
- Nocturnal penile tumescence (NPT) – It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge. A significant proportion of men who have no sexual dysfunction nonetheless do not have regular nocturnal erections.
- Penile biothesiometry – This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis.
- Dynamic infusion cavernosometry (DICC) – a technique in which fluid is pumped into the penis at a known rate and pressure. It gives a measurement of the vascular pressure in the corpus cavernosum during an erection.
- Corpus cavernosometry – Cavernosography measurement of the vascular pressure in the corpus cavernosum. Saline is infused under pressure into the corpus cavernosum with a butterfly needle, and the flow rate needed to maintain an erection indicates the degree of venous leakage. The leaking veins responsible may be visualized by infusing a mixture of saline and x-ray contrast medium and performing a cavernosogram.In Digital Subtraction Angiography (DSA), the images are acquired digitally.
- Magnetic resonance angiography (MRA) – This is similar to magnetic resonance imaging. Magnetic resonance angiography uses magnetic fields and radio waves to provide detailed images of the blood vessels. Doctors may inject a “contrast agent” into the patient’s bloodstream that causes vascular tissues to stand out against other tissues. The contrast agent provides for enhanced information regarding blood supply and vascular anomalies.
- There is still controversy on the ideal endocrine workup for men with ED. A morning total testosterone or bioavailable testosterone is logical in men with decreased sexual interest, delayed ejaculation, reductions in ejaculate volume, failure of PDE5-inhibitor treatment, and men with ED and diabetes.
- Free testosterone measurements have significant intra-assay variability which limits their clinical utility in Canada and is not recommended. Bioavailable testosterone is clinically useful and recommended, but is not available in all areas of Canada. This form of testing generally allows us to measure the sacral reflex arc, an indirect measure of perineal neural integrity, and has limited clinical availability and utility.
- Drawbacks of intracavernosal injection include a degree of invasiveness and ultimately a subjective evaluation of penile rigidity by the assessor. Duplex ultrasound, on the other hand, is noninvasive and provides a quantitative component to the evaluation of blood flow.
- In this test, high-resolution ultrasonography and color-pulsed Doppler is used. Flow velocities are measured at the penis base, before and after vasodilator injections. In a normal Doppler study, the filling phase has characteristically high waveforms during systole and diastole.[rx]
- Penile angiography is a third-line study used for the evaluation of the penile vasculature. It is typically reserved for young patients with ED related to a traumatic arterial injury, or in patients with penile compression injury being considered for revascularization surgery.[rx]
- In this test, the internal pudendal artery is selectively cannulated, and then radiographic contrast is injected for visualization of the internal pudendal and penile arteries. Penile vascular anatomic variations exist, making it difficult for the angiographer to determine congenital from acquired abnormalities and limiting the utility of this modality.
- However, there is promise in that penile angiography could potentially serve as a diagnostic and therapeutic option in select patients. Some argue that in men with evidence of penile arterial insufficiency who have failed pharmacotherapy, contemporary endovascular treatment options may have utility.[rx] At this time, however, supportive literature is limited to case reports or small nonrandomized clinical trials.
Penile magnetic resonance imaging
- Several investigational vascular studies are underway. Penile magnetic resonance imaging (MRI) has promise in detailing penile anatomy and microcirculation. The use of MRI during the work-up of prostate cancer has recently become more popular. Given the proximity of the genitals, penile anatomy and vasculature are often depicted on these imaging studies. Vargas et al.[rx] evaluated 50 prostate cancer patients who underwent an MRI pelvis for staging prior to prostatectomy.
Treatment of Erectile Dysfunction
Non-surgical therapy includes
Psychological therapy – especially sex therapy is recommended for patients with evidence of psychogenic ED and no detectable organic cause. A short course (4 to 12 weeks) of sex therapy should be prescribed. Family planning may also help fighting ED if the cause is somehow interconnected [ rx].
Lifestyle changes – when ED is linked with obesity, initial stages of diabetes mellitus, etc. There is some evidence that ED may spontaneously subside if the general health status of the patient improves.
Medication Change – if ED is caused by medications.
Herbal or vitamin supplements – are being used for centuries in treating ED, and they still have some role. Although some studies suggest that there is a high rate of placebo responders, herbal supplements are clinically proved to improve sexual function [rx].
Pelvic floor – exercises may reduce ED, although there is only limited evidence supporting that theory [rx].
Hormonal therapy – more specific testosterone replacement, is proved as very effective if the cause of ED is the low level of testosterone. Some authors suggest that the testosterone level should be checked in all patients presenting for ED [rx]. However, if low testosterone is diagnosed, further testing is necessary to rule out a metabolic syndrome. Nowadays, testosterone is available in several presentations, including patches, gels, pellet, oral pills, and buccal agents. The literature suggests that the results are similar, regardless of the way of administration. The only major issue seems to be the correct indication for testosterone suppression.Recent evolutions developed a preparation of dihydrotestosterone, promising better results in hypogonadal men with a propensity to gynecomastia or boys with constitutionally delayed puberty [rx].Dehydroepiandrosterone – has a controversial role in improving the treatment of ED, although some data may suggest improvement of sexual function in treated men [rx].Human Chorionic Gonadotropin proved effective when administered to aged men with testosterone levels in the lower range of normal. The results included a decrease in fat mass, an increase in body mass, and no effect on muscle strength [rx].
First-Line Therapy, are non-invasive treatments, which include:
- PDE5 inhibitors, such as Viagra, Cialis, and Levitra
- Androgen/Testosterone Replacement Therapy
- External Devices, such as rubber rings and vacuum devices
- Lifestyle modifications
- Counseling/Sex Therapy
Second-Line Therapy, are injectable treatments, which include:
- Penile Injection Therapy, such as Caverject
Third-Line Therapy, are surgical treatments, which include:
- Penile Prosthesis
- Vascular Surgery
It is important that all men receiving treatment for erectile dysfunction are supported with counseling.
- Outcomes of oral PDE5 inhibitors should be characterized/stratified based on serum testosterone levels.
- Additional research also is needed to characterize, in greater detail, the adverse events associated with the use of ED therapies such as their duration.
- The effect of lifestyle modification on PDE5 inhibitor use should be clarified.
- The cohort of patients who should not be sexually active with or without PDE5 inhibitors should be identified.
- PDE11 is present in the anterior pituitary and the testes. While studies, to date, have demonstrated no effect on spermatogenesis when PDE5 inhibitors are administered daily for 6 months in healthy individuals, further assessment of the effect of PDE5 inhibitors that cross-react with PDE11 in patients with abnormal spermatogenesis is needed.
- The applicability of PDE5 inhibitors after radical prostatectomy needs to be characterized.
- Whether vasoactive intracavernous therapy will cause improvement in spontaneous erectile function needs to be clarified.
- The role of testosterone therapy in men with sexual dysfunction with low, borderline normal, and normal testosterone levels should be better defined.
- Additional randomized controlled trials of various herbal therapies are needed.
- Additional prospective patient-partner satisfaction studies are needed using standardized questionnaires both pre-and post-penile prostheses implantation.
- The role of prophylactic antibiotics in penile prostheses implantation and the use of impregnated prostheses needs to be studied further.
- The efficacy and safety of combining pharmacotherapies and/or mechanical therapies such as oral and intrapenile vasoconstrictive therapies, PDE5 inhibitors and prostheses, or vacuum constriction and vasoconstriction devices should be explored.
- Additional research also is needed to evaluate the efficacy and safety of arterial reconstruction in the treatment of ED.
- No randomized controlled trial to date has addressed the particular efficacy of drugs in the management of venous-occlusive ED or defined those patients thought to have veno- occlusive dysfunction who would benefit from the surgical application.
- Cost-effectiveness analyses of the fixed and unfixed costs involved with the various ED treatment modalities need to be undertaken.
- A vacuum pump consists of a clear plastic tube that is connected to a pump, which is either hand or battery operated. You place your penis in the tube and pump out all of the air. This creates a vacuum that causes the blood to fill your penis, making it erect. You then place a rubber ring around the base of your penis to keep the blood in place, allowing you to maintain an erection for around 30 minutes.
- It may take several attempts to learn how to use the pump correctly, but they are usually effective. After using a vacuum pump, nine out of 10 men are able to have sex, regardless of the cause of their ED.
- If your erectile dysfunction doesn’t respond to treatment, or you are unable or unwilling to use PDE-5 inhibitors or a vacuum pump, you may be given a medicine called alprostadil. This is a synthetic (man-made) hormone that helps to stimulate blood flow to the penis.
Alprostadil is available as
- an injection directly into your penis – this is called an intracavernosal injection
- a small pellet placed inside your urethra (the tube that carries urine from your bladder to the tip of your penis) – this is called urethral application
- You may be trained to correctly inject or insert alprostadil. If your partner is pregnant, use a condom during sex if you are inserting alprostadil into your urethra. Alprostadil will usually produce an erection after five to 15 minutes. How long the erection lasts will depend on the dose.
- In men who did not respond to PDE-5 inhibitors, alprostadil injections were successful in 85 out of 100 men. Alprostadil inserted into the urethra is successful for up to two-thirds of men.
If a hormonal condition is causing erectile dysfunction, you may be referred to an endocrinologist (who specializes in the treatment of hormonal conditions). Hormones are chemicals produced by the body. Many hormonal conditions can be treated using injections of synthetic (man-made) hormones to restore normal hormone levels.
- There is considerable controversy about the importance of androgens in the initiation and maintenance of erectile function, and this subject has been extensively reviewed (some of the more recent reviews include). [rx–rx] Recent studies suggest it plays a permissive role in Erectile Function.
- Without adequate androgen levels expression of NOS and PDE-5 genes are altered.[rx] However, the overall consensus appears to be that testosterone plays more of a role in sexual desire, rather than a direct physiological role in ED.[rx] Therefore testosterone levels are more likely to be related to psychogenic rather than organic erectile health.
- Sphingosine-1-phosphate (S1P) is a biologically active sphingolipid that is generated upon cell activation from membrane phospholipids as part of the sphingomyelin cycle.[rx,rx] It is stored in red blood cells and in platelets.[rx] S1P acts on five types of G-protein-coupled receptors termed S1P1-S1P5 (originally termed EDG (endothelial differentiation genes)).
- Although long known and used since the initial demonstration of Brindley in 1983, it is in constant evolution and development. Most commonly used are papaverine (alkaloid isolated from opium), phentolamine and alprostadil (widely known as Caverject). Some authors report good results when using a combination of two or three agents [rx].
- Proved effective in treating ED during the last decades. The MUSE device, containing alprostadil, is the only FDA approved treatment.
Vacuum Erection Device (VED)
- It is one of the most common choices of noninvasive therapy for ED. It consists of a cylindrical component and a suction device that the patient places around the penis to create negative pressure and achieve an erection. Maintenance of erection is then accomplished with an elastic constriction ring placed at the base of the penis. Patients with significant peripheral vascular disease, those receiving anticoagulants, and diabetics are generally not good candidates for the VED.
Vacuum Constriction and Erection Devices
- The vacuum device is approved by the USA Food and Drug Administration (FDA) for the treatment of ED since 1982. Vacuum therapy (VT) works by creating a negative pressure environment around the penis through the use of cylindrical housing attached to a pump mechanism, which can be manually-operated or battery-operated.
- The vacuum draws mixed arterial and venous blood into the corporal bodies and distends the corporal sinusoids to create an erected penis. If a pre-loaded constriction band is applied over the base of the penis to prevent the outflow of blood and maintain tumescence for intercourse, it is considered a vacuum constriction device (VCD). It is recommended that the constriction band be removed within 30 mins to return the penis to its flaccid state, as prolonged application of the constriction band can compromise both arterial and venous blood flow (rx).
Penile Vibratory Stimulation (PVS)
- The penile vibratory stimulator is a battery operated device with oscillating discs that can provide excitation of afferent penile nerves at various regulated frequency and amplitudes. PVS has been utilized to activate the ejaculatory reflex for patients with spinal cord injury above T10 seeking to collect retrogradely ejaculated semen infertility treatment (rx).
- The Viberect is a vibratory stimulation handheld device approved by the FDA for the treatment of ED. It is clamp-shaped with two oscillating discs facing each other near the tips, and the glans penis is placed between the two oscillating discs to receive concurrent dorsal and ventral stimulation at adjustable frequencies and amplitudes.
Low-Intensity Extracorporeal Shock Wave Therapy (LIESWT)
- The use of shock wave therapy has revolutionized the treatment of many aspects of medicine. High-intensity extracorporeal shockwave therapy has been used for the treatment of nephrotic-urolithiasis while medium intensity shockwave therapy is used by orthopedic surgeons to treat joint pain as well as tendinitis. Low-intensity shockwaves therapy was first noted to improve ischemia-induced myocardial dysfunction in animal studies when low-intensity shockwaves were applied to porcine myocardium (Rx).
- Papaverine is an opium alkaloid that acts as a non-specific PDEi that increases intracellular cAMP and cGMP leading to corporal smooth muscle relaxation (rx). Intracavernosal papaverine injection was the first clinically effective pharmacological therapy for ED and led to a full erection in at least half of the patients in early studies (rx,rx).
- Alprostadil is a potent vasodilator and smooth muscle relaxant identical to the naturally occurring PGE1. PGE1 binds with specific receptors on smooth muscle cells and activates intracellular adenylate cyclase to produce cAMP, which in turn induces tissue relaxation through a second messenger system (rx).
- PGE1 is the only FDA approved form of intracavernosal therapy and is available commercially as EDEX, or Caverject. Its efficacy was demonstrated in several clinical trials where the rate of responders ranged from 40% to 80% (rx,rx). The most common adverse event is penile pain, which is not related to the injection of the medication itself. In men with prolonged use the pain is usually self-limited (rx).
Vasoactive Intestinal Peptide (VIP)
- VIP is a neurotransmitter with regulatory actions on blood flow, secretion, and muscle tone with intracorporal adenylate cyclase activation and smooth muscle relaxation. VIP has been shown to elevate cAMP intracellular concentrations without affecting cGMP levels. However, when VIP is given alone it may not induce erection and requires combination with phentolamine or papaverine for it to be effective (rx).
- Common associated adverse effects were facial flushing and headache. VIP in combination with phentolamine is currently being used in the UK and Europe and is seeking regulatory approval for use in the United States.
- Phentolamine blocks postsynaptic adrenergic α1 receptors preventing smooth muscle contraction. However, it also may interfere with prejunctional α2 receptors, which may counteract the process (rx). Consequently, this may be a reason phentolamine is not prescribed as monotherapy, and frequently is combined with papaverine, alprostadil or VIP.
- The use of IUS involves the placement of a prostaglandin E1-loaded pellet within the urethra before sexual intercourse. After insertion of the pellet, the patient should massage that area of the penis to help disperse the medication. The drug is absorbed through the urethra into the corpora cavernosa and increases the intracellular levels of cyclic AMP (cAMP), leading to decreased intracellular Ca2+ levels, increased smooth muscle relaxation and tumescence[rx].
- ICI involves the use of vasoactive substances injected directly into the corpora cavernosa via a small needle. These vasoactive agents include prostaglandin E1, papaverine and phentolamine (and sometimes atropine), which work alone or in combination to elicit an erection.
- Prostaglandin E1 has been approved by the FDA as a single-agent ICI for erectile dysfunction and increases cAMP levels. Papaverine is a nonspecific phosphodiesterase inhibitor that leads to increased levels of cAMP and cGMP.
- While limited in its utility, transurethral alprostadil (prostaglandin E1 (PGE1)) is a reasonable first-line or combination ED therapy. First brought to market in 1994 and marketed as Medicated Urethral System for Erection, transurethral alprostadil has shown limited efficacy, with response rates of 27–53 % when compared with 66–96 % for intracavernosal injected alprostadil [rx].
- In addition, the formulation requires placement into the penile urethra, with penile pain in 25–43 % of patients. However, combination therapy with sildenafil has been shown to salvage the effects of MUSE® in nonresponders [rx] and is also beneficial in men whose penile nerves have been compromised as it bypasses the need for intact neurological pathways for erection.
Penile Prosthesis Implant
- Penile prosthesis implant remains the most effective and permanent treatment for ED. Penile prosthesis implants can be broadly divided into malleable and inflatable prostheses (rx). A malleable penile prosthesis, also known as a semi-rigid prosthesis, does not allow for a (physiological) flaccid state of the penis.
- The patient can bend the prosthesis upwards for sexual intercourse and downwards for concealment. Although the angle of prosthesis concealment has improved with recent devices, however, due to the constant rigid state of the penis, they are still less comfortable compared to their inflatable counterparts, are more likely to cause social embarrassment, and associated with a higher risk of implant erosions (rx).
Low-Intensity Shockwave Therapy
- Extracorporeal low-intensity shockwave therapy (LIST) to the penis has recently emerged as a novel and promising treatment modality for ED. LIST has been previously used to treat a wide variety of urological and non-urological conditions [rx]. The mechanism of action for this treatment consists of sending acoustic waves that generate pressure impulses, which can treat patients with kidney stones, tendinitis, and peripheral vascular disease [rx].
- For the treatment of ED [rx], it is hypothesized that LIST causes cell membrane microtrauma and mechanical stress, which causes an upregulation of angiogenic factors such as vascular endothelial growth factor (VEGF), NO synthase, and von Willebrand factor, which increase angiogenesis and vascularization of tissues [rx]. As such, it is postulated that LIST increases blood flow and endothelial function and results in an improvement in erectile function.
- Following the breakthrough in ED treatment using PDE5-inhibitors, Western medicine has now moved on to a new frontier of regenerative medicine, with stem cell and gene therapy leading the way (rx). There is a practical need for novel therapy as a significant portion of diabetic or post-prostatectomy ED patients do not respond to oral pharmacotherapy.
- To date, stem cells derived from different sites including adipose tissue-derived stem cells, bone marrow mesenchymal stem cells, and muscle-derived stem cells have been investigated using animal models for ED, to study their effects on neural, vascular, endothelial, or smooth muscle regeneration (rx,rx).
- Gene therapy is a potential therapeutic option that is another area of investigation for the treatment of ED. Genetic material can be easily injected into the penis, which is advantageous as this direct-injection avoids potential systemic complications. Furthermore, the effects of gene therapy are more prolonged in the penis because of a slow turnover rate of the tunica albuginea [rx].
- In the first human trial, Melman et al.administered a single-dose cavernosal injection of maxi-K, a ‘naked’ DNA plasmid carrying the human cDNA encoding the gene for the alpha subunit of the human smooth muscle Maxi-K channel [rx].
Stem Cell Transplant
- Stem cell therapy is a new treatment option that offers the potential to reverse the underlying causes of ED and reduce patient reliance on the transitory effects of PDE5-I medications. It has been studied in several animal models in subjects who poorly respond to PDE5-Is (cavernous nerve injury and DM).
- Stem cell regenerative therapy is based on the rationale that stem cells can differentiate into a wide variety of cells including endothelial cells, Schwann cells, smooth muscle cells, and neurons [rx]. In ED research, three types of stem cells are commonly used: adipose tissue-derived stem cells, bone marrow-derived stem cells, and muscle-derived stem cells.
Surgery for erectile dysfunction is usually only recommended if all other treatment methods have failed. It may also be considered in
- younger men who have experienced a serious injury to their pelvic area – for example, in a car accident
- men with a significant anatomical problem with their penis
Surgical techniques used in the treatment of ED aim to restore erection by means of the intracavernous prosthesis or to cure other causes that led to ED.
Penile prostheses – are represented by several constructive models: semirigid rod, positionable, two-piece inflatable or three pieces inflatable. Although the cost and high invasiveness of the procedure may reduce its expansion in the general population, the results are generally better, in terms of erection, personal and partner satisfaction. Future evolutions will most likely try to improve the long term mechanical reliability [rx].
- Vascular surgery – for ED became widespread at the end of the 1980s, but the poor long term results have somehow compromised the initial enthusiasm. The American Urological Association Guidelines still considers this type of intervention as experimental, due to the lack of consistent data and standardized procedures [rx]. The main procedures used today are penile revascularization and penile venous surgery recommended only for selected patients and offering fair long– term results.
- Penile Revascularization Surgery – Approaches to penile revascularization include repair of arterial stenosis and penile venous ligation, depending on the ED etiology. Neither of these approaches, however, has a substantial evidence base, with only grade D recommendations offered in the absence of prospective, randomized studies (reviewed in [rx]). However, the consensus at this time is that penile revascularization can be offered to nonsmoking, nondiabetic men <55 years old with isolated arterial stenoses without generalized vascular disease. A consensus for penile venous ligation has not been reached, given the absence of evidentiary support.
Penile implants are a type of surgery that may be considered. These can be:
- semi-rigid implants – which may be suitable for older men who do not have sex regularly
- inflatable implants – which consist of two or three parts that can be inflated to give a more natural erection
Penile implants are not usually available on the NHS and inflatable implants may be very expensive. However, around three-quarters of men report being satisfied with the results of this type of surgery.
- If your erectile dysfunction has an underlying psychological cause then you may benefit from a type of treatment called sensate focus. If conditions such as anxiety or depression are causing your erectile dysfunction, you may benefit from counseling (a talking therapy).
- Sensate focus is a type of sex therapy that you and your partner complete together. It starts with you both agreeing not to have sex for a number of weeks or months. During this time, you can still touch each other, but not in the genital area (or a woman’s breasts). The idea is to explore your bodies knowing that you will not have sex.
- After the agreed period of time has passed, you can gradually begin touching each other’s genital areas. You can also begin to use your mouth to touch your partner, for example, licking or kissing, them. This can build up to include penetrative sex. You can find out more about sensate focus from the College of Sexual and Relationship Therapists (COSRT).
- Psychosexual counseling is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your erectile dysfunction. By talking about the issues, you may be able to reduce any anxiety that you have and overcome your erectile dysfunction.
- The counselors can also provide you with some practical advice about sex, such as how to make effective use of other treatments for erectile dysfunction to improve your sex life. For information and advice about sexual arousal, read about good sex. Psychosexual counseling may take time to work and the results achieved have been mixed.
Cognitive-behavioral therapy (CBT)
- Cognitive-behavioral therapy (CBT) is another form of counseling that may be useful if you have erectile dysfunction. CBT is based on the principle that the way you feel is partly dependent on the way you think about things. CBT helps you realize that your problems are often created by your mindset. It is not the situation itself that is making you unhappy, but how you think about it and react to it.
Your CBT therapist can help you to identify any unhelpful or unrealistic thoughts that may be contributing to your erectile dysfunction – for example, to do with:
- your self-esteem (the way you feel about yourself)
- your sexuality
- your personal relationships
Your CBT therapist will be able to help you to adopt more realistic and helpful thoughts about these issues.
Pelvic floor muscle exercises
- Some studies have suggested that, in a few cases, it may be beneficial to exercise your pelvic floor muscles. These are a group of muscles around the underside of the bladder and rectum, as well as at the base of the penis. Pelvic floor muscle exercise involves strengthening and training the muscles used to control the anus (back passage) and urinate. If your GP feels this type of exercise could be beneficial, then you may want to discuss it with a physiotherapist to learn it correctly. By strengthening and training these muscles, you may be able to reduce the symptoms of erectile dysfunction.
- Some complementary therapies, such as acupuncture, have claimed to treat erectile dysfunction. However, there is little evidence they are useful. In some cases, they may even include ingredients that could interact with other medications and cause side effects. Always speak to your GP before using any complementary therapies. Counseling may be required if the underlying cause of your erectile dysfunction is psychological
You are having problems with erectile dysfunction.
You want to fix these problems naturally.
- “Naturally,” means not taking any pills that are advertised in commercials along with a couple holding hands in a bathtub on the beach – what is that anyway? We’re talking about Viagra, Cialis, Levitra, and similar pills.
- Fun fact about Viagra: Viagra has saved the lives of many tigers. Asian poachers harvest tiger bones and sell them for use in medicines. One function of tiger bones in medicine is curing erectile dysfunction. Since Viagra was invented, tigers have been less used for this issue. Now that you’ve learned something today, let’s get into some natural erectile dysfunction cures that don’t require taking pills.
Raise Your Testosterone
- This is VITAL to increasing your sex drive. You may be thinking, “My sex drive is strong, I just can’t fulfill the wishes caused by my sex drive.” Although normal testosterone levels are not required to maintain a normal erection, if testosterone levels dip low enough, they could be the cause of your erectile dysfunction.
- You will notice as you read on in this article, that many of the natural cures for erectile dysfunction are also ways to raise your testosterone levels naturally. To read more on naturally increasing your testosterone levels, check out the TestShock program.
Exercise for Erections
- Exercise gets the blood flow moving, which is clearly important for getting blood into your nether regions. Exercise is a good way to prevent the onset of erectile dysfunction, but can also reverse the effects after you are experiencing the symptoms. It is advised to walk – not run – to get the blood flow moving.
- Running lowers your testosterone levels and can raise cortisol levels and stress on your body. Weight lifting is a good way to get the blood flow moving while also raising your testosterone levels naturally. Also, moving your pelvic regions around your penis is a great way to increase continence. According to this study, doing Kegel exercises can help with erectile dysfunction.
Eat for Erections
- Maintaining a healthy and balanced diet is important in reversing the effects of your erectile dysfunction. A diet rich in fruit, veggies, grains, and fish can help with the symptoms. (3)
- Both exercise and diet have been proven important for preventing erectile dysfunction because studies show that a man with a 42-inch waist is 50 percent more likely to have erectile dysfunction than a man with a 32-inch waist. (4)
Stay on the Same Sleep Schedule
- In a study published by Brain research in 2011, results showed that men who do not have a consistent sleep schedule have problems maintaining normal or high testosterone levels. The results also showed that hormonal depletion is a cause of sexual dysfunction.
- If you do not have a bedtime, then you need to get one. Go to sleep and wake up at the same time on a consistent basis. The amount of quality sleep you get is important as well. Not sure whether or not you are getting enough sleep? A good way to know is to simply stop using an alarm.
- Do a week or two of testing where you can find the amount of sleep you need so that you can wake up without an alarm every morning. This is when you know you got enough sleep in the night.
- Erectile dysfunction can be a result of vascular disease. The process occurs when the blood that is supposed to go to the penis is restricted due to narrowing arteries.
- Not only smoking tobacco but also smokeless tobacco, can narrow the arteries and restrict the blood vessels necessary to get an erection. If you smoke, this is possibly the cause of your erectile dysfunction. If the dysfunction is bothering you, consider quitting the habit to get your erections back.
Stop Drinking So Much
- Everyone who has heard the term “Whiskey Dick” knows that alcohol can cause temporary sexual dysfunction. But alcohol is a powerful depressant and high exposure to alcohol can result in full-blown erectile dysfunction. (3)
- To add to the concerns, alcohol does a great job at lowering testosterone levels. So maybe cut back on the drinks if you feel this may be the cause of your erectile dysfunction.
Check Your Medications
- Erectile dysfunction can be a common side effect of certain medications. Medications that have been known to cause erectile dysfunction are medications for high blood pressure, antidepressants, diuretics, beta-blockers, heart medications, cholesterol medications, antipsychotic drugs, hormone drugs, corticosteroids, chemotherapy, and medications for male pattern baldness.
- Look up your specific medication or ask your doctor if your erectile dysfunction could be a result of the medication you are taking.
Acupuncture can be used to cure erectile dysfunction.
- According to this study, acupuncture can improve the quality of your erection and it cured erectile dysfunction in 39% of its participants. In TCM, the meridian system is thought to represent a path through which the life energy qi flows and as discussed in the earlier section, the “Jing” (kidney) qi plays an important role in penile erection.
- Acupuncture helps to correct the imbalances to relieve physical symptoms by stimulating various meridian points. The Shensu (BL23), Zusanli (ST36) and Neiguan (PC6) points represent important acupoints for penis stimulation and thus has a positive homeostatic effect on the autonomic nervous system, and potentially modulate NO release (rx,rx).
Ingest These Natural Remedies
- There are plenty of non-pill natural remedies you can ingest in order to cure your erectile dysfunction. Taking high doses of L-Arginine has been known to widen the blood vessels in the penis which can stimulate the blood flow and cure erectile dysfunction.
- Yohimbe taken from the bark of an African tree has been known to cure erectile dysfunction. BEWARE the side effects of Yohimbe are riskier than previously mentioned remedies. This should not be used without a doctor’s supervision.
- Two more untested natural remedies are ginkgo and horny goat weed. Gingko can help to increase blood flow to the penis but has no proof that it cures erectile dysfunction. Horny goat weed has been known to increase sexual performance but has not been formally tested for humans.
Drink These Juices – Pomegranate, Watermelon
- There are two juices that you can drink to help with erectile dysfunction: Watermelon and Pomegranate. A component of watermelon called citrulline, when eaten in high amounts, can increase blood flow to the penis. Although no proof exists that pomegranate juice helps with erectile dysfunction, results of a 2007 study testing the relationship were promising.
- Yohimbine is an indole alkaloid derived from the bark of the African Yohimbe tree (rx). Yohimbine has been noted to treat fatigue, depression, diabetes, and sexual dysfunction. A meta-analysis of seven placebo-controlled trials (rx) deemed yohimbine superior to placebo for the treatment of ED with rare adverse events.
- The proposed mechanism of action (rx) is via the inhibition of central alpha-2-adrenergic receptors, decreasing central inhibition of arousal, and increasing penile nerve stimulation resulting in increased NO. Common side effects include a headache, sweating, agitation, hypertension, and insomnia. Contraindications include patients on tricyclic antidepressants, anti-hypertensives, and central nervous system stimulants.
- Ginseng is the most common ingredient among top-selling supplements for men’s sexual health (rx). The English word ginseng derives from the Chinese term tension. Ren means “person” and she means “plant root”. This plant has been named in this manner as its roots resemble the lower limbs of a human, Traditionally, ginseng has been used to restore and enhance the normal well-being of the body.
- The effects are due to ginseng’s reactions with the central nervous system, metabolism, immune function, and cardiovascular system. The principal active compounds are triterpene saponins known as ginsenosides. Animal studies have suggested that specific ginsenosides may be responsible for ginseng-mediated effects on copulatory behavior (rx). Ginsenoside induces smooth muscle relaxation by hyperpolarizing the smooth muscle membrane via activation of large-conductance KCa channels (rx).
- Tribulus Terrestris is a dicotyledonous herbal plant of the Zygophyllaceae family, used to increase serum testosterone levels, which has only been shown in animal studies (rx). A prospective, randomized, double-blind study of 30 men showed that Tribulus Terrestris was not more effective than placebo on improving IIEF scores or serum total testosterone (rx). Two accounts of hepato-nephrotoxicity have been reported in young men who ingested high doses of this herbal medication (rx,rx).
Horny Goat Weed (Epimedium spp)
- The Epimedium plant is a flowering perennial found throughout Asia and parts of the Mediterranean. Horny Goat Weed’s active ingredient is icariin, a flavonol glycoside, and reputed to improve cardiovascular function, hormone regulation, modulation of immunological function, and antitumor activity (rx).
- Icariin has also been shown to have a PDE5i effect. Animal studies have been carried out showing improvements in penile hemodynamic parameters. There is one report of tachyarrhythmia and hypomania with the use of this herb (rx).
Tongkat Ali (Eurycoma longifolia Jack)
- Tongkat Ali is a well-known herb in Malaysia and Singapore and is commonly used especially by the Malay ethnic group for treating diseases and enhancing general health and sexual health (rx). It is a flowering plant of the family Simaroubaceae.
- Quassinoids isolated from Tongkat Ali has been reputed to be anti-tumor, anti-malarial, anti-amoebic, and anti-inflammatory. Its leaves are used for washing itches, its fruits for the treatment of dysentery, its bark used as a vermifuge, the taproots used for the treatment of hypertension, and the root bark for treatment of diarrhea and fever.
- The roots extracts are used for sexual dysfunction, aging, malaria, cancer, diabetes, anxiety, aches, constipation, exercise recovery, fever, increased energy, increased strength, leukemia, osteoporosis, stress, and syphilis. Animal studies done on middle age sex rats showed enhancement of the sexual qualities in terms of hesitation time among middle-aged rats (rx).
- Ginkgo Biloba is promoted to treat conditions ranging from hypertension to Alzheimer’s dementia. There is evidence that shows an improvement of memory enhancements in the geriatric population (rx), improvement in terms of cognitive function via an effect on cerebral vasculature (rx), improvement of claudication distance, and cutaneous ulcers in patients with peripheral vascular disease (rx).
- Ginkgo Biloba extract is proposed to induce NO in endothelial cells and thus causing relaxation of vascular smooth muscles. Animal studies have reported relaxation of rabbit corpus cavernosal smooth muscle cells with the use of Ginkgo Biloba (rx). Adverse effects include headaches, major bleeding (in a patient who is taking warfarin concurrently), and seizures with reported fatality (rx).
- Low levels of physical exercise can be associated with ejaculatory and erectile disorders. And higher levels of physical exercise have been shown to improve erectile function in hypogonadal men undergoing testosterone replacement therapy (rx). There are, however, no proven physical exercises that can improve erections directly.
- Jelqing is a penile massage technique of ancient Arabic origin (rx). Men who practice jelqing will stretch their penises while in a semi-erected state and repeatedly milk their penises from base to glans, with their thumb and index finger touching to form an “OK” hand sign around their penile shaft.
- This massage can be done daily with the aim to achieve greater penile length and harder erections. Unwanted side effects of bruising, pain, and fibrosis had been reported. No studies have been done to evaluate the efficacy of jelqing objectively.
- Qigong is a form of breathing exercise commonly practiced in Asia to maintain health (rx). In a cross-sectional population-based comparison study in Taiwan, individuals practicing Qigong demonstrate higher SF-36 scores in the domains of physical functioning, role limitations due to physical problems, bodily pain, general health, and vitality (rx). Techniques to concentrate the energy or qi in the pelvis or genitals are regularly practiced, but the effects of Qigong on ED have not been studied.
Homeopathy Medicines for Erectile Dysfunction
These are some of the many homeopathic remedies which cater to relieve ED specifically.
- Agnus castus – This remedy may be helpful if problems with impotence develop after a man has led a life of intense and frequent sexual activity for many years. A cold sensation felt in the genitals is a strong indication for the Agnus castus. People who need this remedy are often very anxious about their health and loss of abilities and may have problems with memory and concentration.
- Argentum nitricum – This remedy may be helpful if a man’s erection fails when sexual intercourse is attempted, especially if thinking about the problem makes it worse. People who need this remedy are often nervous and imaginative. A person who needs Argentum nitricum is usually warm-blooded, with cravings for both sweets and salt.
- Caladium – This remedy may be helpful to a man whose genitals are completely limp, despite having sexual interest. Nocturnal emissions can occur without an erection, even if dreams are not sex-related. A person who needs this remedy often craves tobacco.
- Causticum – This remedy may be indicated if physical pleasure during sex has diminished and sexual urges are reduced. The person feels tired and weak and may experience memory loss, with a compulsive need to check things (to see that doors are locked, etc.) Prostate problems may be associated with impotence, and urine may be lost when the person coughs or sneezes.
- Lycopodium – commonly called club moss, is a wonderful homeopathic remedy.
People who need this remedy may have problems with erections because of worry, and can also be troubled by memory loss. They often lack self-confidence (though some may overcompensate by acting egoistically). People who need this remedy often have digestive problems with gas and bloating, and an energy slump in the late afternoon and evening.
- Selenium metallicum – Selenium is a nutrient needed by humans in micro amounts. It is widely distributed in nature. Brazilian nuts, sea-foods, yeast, whole grains are all excellent sources of selenium. A homeopathic remedy is highly potent and has a wide curative spectrum for disorders like impotency, chronic fatigue syndrome, sterility, depression, etc.
- This remedy is often helpful to men who have diminished sexual ability, especially if the problem starts after a fever or exhausting illness. The person feels weak and exhausted, but interest is usually still present. Erection is slow, insufficient, weak, and has involuntary seminal emissions. Unusual hair-loss (body hair or eyebrows) can also suggest a need for Selenium.
- Staphysagria – Staphysagria is a homeopathic remedy made from the seeds of the Delphinium Staphisagria, which has lovely purple-blue flowers, and in its raw form is highly poisonous, historically used to kill vermin. The homeopathic remedy, through its preparation, is no longer toxic yet remains extremely powerful.
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