The Rise and Fall of You

When performance anxiety is the main cause of ED, just knowing a pill is available can be enough to help a man perform without taking it, Feldman says. “It’s like ‘In case of erectile emergency, break glass.’”

Pryor prescribes drugs for men who are dealing with intractable psychological causes of ED. “I’ll prescribe Viagra and tell them to go see the therapist the same day,” he says. “That way, they get some immediate good result at the same time that they’re hopefully addressing the long-term problem.”

Pumped Up

Not everyone is a good candidate for the new drugs. If you’re taking a nitrate drug for angina, for instance, “nitrates and PDE-5 inhibitors together can really lower the blood pressure and cause cardiac arrest or fainting,” Pryor says.

Such patients can turn to injections of alprostadil, a synthetic version of the hormone prostaglandin E that relaxes the smooth muscles in the penis. An injection will produce an erection within 5 to 20 minutes that will last for an hour or longer. Less effective is a pellet form of the drug called MUSE (for medicated urethral system for erection) that is absorbed through the tip of the penis. Pryor says some men can use MUSE together with a PDE-5 inhibitor to get a better erection.

In the most-awkward-to-use department, there are vacuum-constriction devices, which work like this: You place a pump, powered by batteries or by hand, over your penis, and pump to create a vacuum. That draws blood into the shaft of the penis. Then you place a constriction band at the base of the penis to maintain the erection, and you’re good to go for up to 30 minutes. “The constriction band acts as an artificial valve and keeps blood flow in,” Feldman says. “It’s good for venous cases.”

Many men opt for a penile implant, which can be either a malleable rod or an inflatable device placed in the penis. The surgery is an outpatient procedure that lasts about 30 to 90 minutes. Inflatable implants are operated by squeezing bulbs placed in the scrotum that can fill the implant with fluid from a reservoir and drain it again. The implants don’t interfere with orgasm or ejaculation, and the bulbs are difficult for a partner to detect.

Studies show that most couples are very satisfied with whatever treatment they’re using—drugs, injections, implants, and even vacuum devices. Patients report an 85 percent satisfaction rate with an implant, for example. But maybe satisfaction across the board isn’t surprising, given the alternative to treatment. As Pryor observes, patients “really want to have sex and so, by definition, are more likely to like it,” however it’s accomplished.

He hopes that soon, primary-care physicians will routinely ask men if they’re having problems with erections, both for quality-of-life reasons and as a first indicator of cardiovascular disease. In the meantime, Pryor is glad that PDE-5 inhibitors have made his patients less shy about seeking treatment.

He remembers one man who, before Viagra came along, waited three years to ask for help. A series of injections eventually gave the patient enough confidence to perform on his own. “His wife had fire coming out of her nostrils, because she was so upset that he hadn’t come in sooner,” Pryor says. “Don’t delay. If you have a problem and it bothers you, just get it treated.”