Frequently, erectile dysfunction (ED), or the inability to keep an erection firm enough for sex, is an early indicator of a more serious medical condition like cardiovascular disease. Before anything else, the number one treatment for ED is modifying the risk factors of other possible medical problems. This includes avoiding smoking, maintaining an ideal body weight through diet and exercise, limiting alcohol intake, as well as treating any other pre-existing conditions, such as diabetes or hypertension. Modifying your risk factors is the most sustainable treatment for ED, as it often addresses the root of the problem. But when lifestyle changes aren’t enough, men have a variety of additional options: Oral medications Suppositories, injections and devices Surgery Oral Medications As you’ve probably seen on TV, there are several well-known oral medications available for treatment of ED. These oral pills are taken on an as-needed basis. They usually start to work in 20 to 30 minutes, and I usually suggest my patients wait about 30 to 60 minutes before having sex. Your erection may continue after you ejaculate but should not continue more than four hours. I also recommend waiting at least 24 hours before taking it again. While oral medications can be very effective, there are several stipulations before we can prescribe them. You must first be healthy enough to engage in sexual activity. If there’s any concern from a cardiovascular standpoint, sex may be out of the question altogether. If you are healthy enough to be sexually active, the next requirement is that you do not take any form of nitrate therapy, which are blood-pressure lowering medications used for treating any form of chest pain. Taking nitrates with oral ED pills can dangerously lower your blood pressure. You should also avoid oral medications for ED if you have liver disease or a rare eye disorder called non-arteritic anterior ischemic optic neuropathy (NAION), a condition that causes loss of blood flow to the optic nerve. Suppositories, Injections and Devices For those who cannot meet the health requirements, or are unsuccessful with oral medications, there are two other options available. The first is an intraurethral suppository, a small medicated pellet that is inserted directly into the urethra through the head of the penis to increase blood flow. There are also injectable medications, which are self-administered with a needle directly into the blood vessels of the penis. Like the suppository, it’s more of a local treatment, so it reduces full-body side effects like the headaches or heartburn that some of the oral medications can cause. It also increases the risk of priapism (abnormally prolonged erection) more so than other treatments. Like oral medication, these treatments are used as needed. Vacuum erection devices are also an option and used most often in combination with other treatments. The device goes directly over the penis, activating a vacuum that pulls the air out and causes the blood to rush to the penis, causing an erection. Like the other available treatments, you should have a prescription for use of these devices, rather than buying an over-the-counter pump that doesn’t have a pressure regulator. Surgery If all other treatments have been exhausted, your doctor may recommend surgery. This involves an inflatable or malleable penile prosthesis that is implanted along with a manual pump. The surgery is permanent; once the prosthesis is implanted, you won’t be able to achieve a natural erection ever again. Typically this treatment is for older men with diabetes or high blood pressure, or men who have had radical prostatectomy for prostate cancer and haven’t had any success with other treatments. However, some of my patients insist surgery is the best way to go because it’s instant and doesn’t have the same side effects that some of the other medications can have. Although we recommend trying more conservative and less invasive treatments first, many patients are very happy with the surgery.