Erectile Dysfunction

what causes it?

Characterized by the inability to get or keep an erection for sexual intercourse, erectile dysfunction is common (up to 50%) and can cause distress and low self-esteem, especially when it has a negative impact on the relationship.

Organic Erectile Dysfunction

  • the most common cause of ED, especially in older men
  • involves abnormalities in the penile arteries, veins, or both
    • arterial insufficiency, usually caused by arteriosclerosis (hardening of the arteries) or trauma
      • controllable risk factors: obesity, lack of exercise, high cholesterol, high blood pressure, cigarette smoking
    • venous leak
      • the real problem is not with the veins but atrophy (wasting away of tissue) and fibrosis (growth of excess fibrous tissue) of the smooth muscle tissue in the body of the penis (cavernous smooth muscle) surrounding the veins


  • closely related to erectile dysfunction
  • men with depression should be fully evaluated for medical illness as well as psychological factors.

Neurologic causes

  • Diabetes, chronic alcoholism, multiple sclerosis, heavy metal poisoning, spinal cord and nerve injuries, and nerve damage from pelvic operations can cause erectile dysfunction.


  • A great variety of prescription drugs can cause erectile dysfunction such as blood pressure medications, anti-anxiety and anti-depressant medications, glaucoma eye drops, and cancer chemotherapy agents

Hormonal abnormalities

  • increased prolactin (a hormone produced by the anterior pituitary gland), steroid abuse by bodybuilders, too much or too little thyroid hormone, and hormones administered for prostate cancer
  • Low male sex hormone (androgen) levels can contribute but are rarely the sole factor responsible

Safe and effective Erectile Dysfunction

with our evidence-based treatments

Low-Intensity Extracorporeal Shockwave Therapy (Li-ESWT)

First used as a non-invasive treatment for urinary stones, Li-ESWT uses acoustic shockwaves, at a much lower intensity than that used to treat urinary stones, to stimulate the development of new blood vessels in erectile tissues, addressing the underlying pathology.

An erection requires a good amount of blood to flow into the penis and not flow out too quickly to maintain rigidity. In men suffering from ED due to reduced blood flow to the penis Li-ESWT results in increased blood flow to the penis, allowing them to attain and maintain erections for sexual performance.

Li-ESWT might not treat only symptoms but possibly cure the cause of organic erectile dysfunction, which has long been viewed as an irreversible condition.

Shockwave therapy lasts for fifteen minutes per session, during which a probe is lightly placed on various areas of the penis. There is no pain but a tingling or tapping feeling. Treatment sessions are done 1 to 3 times a week for six to eighteen times depending on the severity of the erectile dysfunction as more sessions have been shown to have better efficacy.


Neurotoxins inhibit the release of acetylcholine at the neuromuscular junction, decreasing smooth muscle resistance and improving penile blood flow allowing for stronger, more sustained erections.

Studies show that it can work for patients that did not respond to other therapies, decreasing the number of patients requiring penile implant surgery.

Unlike vasodilator injections which have to be performed before every sexual intercourse, a single neurotoxin injection will last for months. Furthermore, the risk of serious complications like priapism is much lower.


Oral Phosphodiesterase Inhibitors (PDEI)

  • Need to be taken 15 to 60 minutes before intercourse
  • Up to 40% of patients may fail to respond
  • Drug interactions with nitrates
  • Possible side effects include
    • Headache
    • flushing (reddening and warming of your face)
    • low blood pressure
    • vision changes such as blurry vision, seeing halos (circles around objects), or changes in how red and green look
    • hearing changes such as tinnitus (ringing in your ears) and hearing sounds differently
    • nausea or abdominal upset

Vasodilator Injections for Erectile Dysfunction

  • Sterile mixture of prostaglandin E1 and other vasodilators - commonly a triple mixture or trimix
  • Needs to be injected (!!) into your penis several minutes before having sex each time, every time
  • May cause pain, redness and irritation at the injection site or priaspism (may cause permanent damage to penile erectile tissue)

Androgen replacement for Erectile Dysfunction

  • Androgen levels decline 1-2% annually after 30 years old
  • Erectile dysfunction may be one of the symptoms of andropause, associated with other symptoms such as reduced energy levels, reduced libido, lack of motivation and sleep disorders, fatigue, mood swings and poorer mental function
  • Treatment options include oral medication, intramuscular injection or subcutaneous pellet implantation
  • Monitoring with blood tests and symptom reviews are performed at regular intervals.


Vacuum constriction device (vacuum pump)

  • erection obtained by the vacuum constriction device is not the same as an erection achieved naturally - penis tends to be purplish in colour and can be cold or numb
  • There may be bruising or reduced ejaculatory force

Surgical implant

  • surgery to implant malleable (bendable) or inflatable prostheses
  • may destroy the natural erection reflex - might never again have natural erections

1Aesthetics's View on Erectile

dr wan's perspective

To Dr Wan, it is important to evaluate patients in detail in order to uncover any underlying causes for erectile dysfunction instead of giving out blue pills like candy.

Oral PDE-I drugs have been commonly prescribed for erectile dysfunction but they require planning (unsexy!) for intercourse, have side effects and drug interactions, may not work, and most importantly they only address the symptoms but not the underlying problem. Other solutions like injections, pumps, surgical implants are even less sexy and even a little scary.

Dr Wan prefers long-lasting hassle-free treatments that target the root processes that lead to erectile dysfunction, allowing better spontaneity. For example, for erectile dysfunction especially non-responsive to non-invasive treatments, injectable medications can be used. However, the traditional prostaglandin/trimix injections have to be injected before each sexual intercourse, whereas neurotoxin injections produce improvements lasting months.

Shockwave therapy has been shown to be quick, safe, effective and comfortable. What’s more, it is not cumbersome, increases spontaneity, and may even reverse the underlying causative factor in erectile dysfunction. In Dr Wan’s opinion, shockwave therapy is a promising and legitimate treatment option that all suitable patients should definitely consider.

Dr Wan Chee Kwang

Dr Wan Chee Kwang


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