The inability to achieve an erection firm enough for sexual intercourse is defined as impotence, or erectile insufficiency. Many men feel embarrassed about this condition and are often hesitant to talk about it to a physician.

There are a number of factors involved in successfully achieving a firm erection. First, there has to be the desire to achieve it. Depression, anxiety, and a strained relationship will impair the quality of an erection. Having low testosterone levels will also diminish a man's sexual drive, and thus impair the quality of the erection. Diminished blood flow into the penile arteries secondary to either medications, smoke, diabetes, or increased cholesterol levels impair, or diminish, the rigidity of an erection. If the veins to the penis cannot trap the arterial blood flow to the penis, a shot-lasting erection will ensue. If the nerves that send the messages to the penis that it should get an erection are damaged, impotence can also result. Damaged erectile tissue of the penis can also prevent erections from occurring.

TREATMENT OPTIONS
There are some medications that are known to affect erections, especially in blood pressure and antacid families. Changing these medication for others may improve erections. If psychological factors are felt to be impairing the quality of erections, then they should be dealt with. If testosterone levels are measured and are low, testosterone supplementation may improve one's erections. For other causes of erectile dysfunction, the treatment options are the same.

• Vacuum erection devices
  This is the most conservative treatment option. This consists of a hollow cylinder that the penis is placed into. The cylinder is attached to a hand pump that creates negative pressure in the cylinder thereby drawing blood into the penis resulting in an erection. In order to sustain the erection, a circular rubber band is placed at the base of the penis before the cylinder is withdrawn. This traps the blood in the penis and intercourse can then ensue. The circular rubber band should not be left in place for longer than 30 minutes at a time.

• Intreurethral suppositories/ MUSE
  This is a thin urethral pellet which is placed into the urethra prior to intercourse with an applicator. It should be used 5 to 10 minutes after urinating since this will allow the urethra to be lubricated for the insertion of the applicator. The pellet dissolves into the urethra, releasing a medication which draws blood into the penis, resulting in an erection. The erection may take 10 to 15 minutes to occur and may last for another 10 to 20 minutes. The main side effect of MUSE is pain in approxiamtely 10% of the cases. Occasionally, there can be a drop in blood pressure as well. The medication cannot be used more frequently than every 12 hours.

• Penile injections
  A medication that draws blood into the penis is injected into the base of the penis with a tiny needle prior to intercourse. An erection ensues 10 to 15 minutes later. The frequency of side effects from penile injections are few. One potential side effect is priapism, or an erection that will not come down after 3 to 4 hours. To diminish this possibility, the dosing for penile injections is done in the office. Injections should not be given more than every two to three days. Rarely, penile scarring may occur if the injections are used too frequently.

• Penile prosthesis
  This requires a surgical procedure, and a one or two night hospital stay. Penile prosthesis has the highest patient satisfaction rate. These devices are placed under the skin into the penis. There are different models. Some are inflatable with the pump being in the scrotum. Others are semi-rigid and consist of semi-rigid rods which are placed into the penis. It is recommended that a six week healing process be allowed before penile prosthetic device is used.

• Oral tablets
  One tablet that supposedly has mild aphrodisiac effect is called yoimbine. It however, is prescribed for the occasional patient whom we believe it could help. It does not help most patients.

  There has been much press given recently to a new medication released on the market in late 1998 called Viagra, or sildenafil. It is supposed to work in about 50% of patients regardless of the etiology (origin) of the impotence. It supposedly has few side effects. Whether or not it will live up to its billing remains to be seen.