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.

man looking inside shorts erectile dysfunction
physical causes ed

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

Evidence-Based Treatments

to treat erectile dysfunction safely and effectively

storz masterpuls
storz ED

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.


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
blue pills
ed injection

Prostaglandin E1 Injections

  • Needs to be injected (!!) into your penis several minutes before having sex
  • May cause redness and irritation at the injection site

Androgen replacement

  • 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

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.

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 suitable patients should definitely consider.

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