If any types of reversible causes are identified in the assessment, these should be treated initially. Typical reversible causes include hormonal imbalance (eg low testosterone), medication-induced erectile dysfunction and psychogenic erectile dysfunction. Modifiable risk factors, such as diabetes, hypertension, smoking and dyslipidaemia, should be optimised as well. Lifestyle modifications, risk factor optimisation, pharmacological and psychological treatments are not mutually exclusive, and patients are often better served by an integrative approach. For example, combining psychological treatment with a phosphodiesterase type 5 (PDE5) inhibitor may optimise the treatment response in patients with psychogenic erectile dysfunction.9
These external devices create a vacuum to induce an erection. This is then maintained by a thick rubber band placed tightly at the root of the penis. They have a modest role in the treatment of men in whom intracavernosal injection therapy is contraindicated (e.g. bleeding diatheses), is unacceptable or fails. These devices have modest efficacy and are suitable mainly for men with psychogenic or partial organic impotence. Their efficacy and acceptability are limited in men with severe neurovascular impotence. Apart from occasional penile bruising, they are generally safe if the duration of each use is limited. Compared with penile implants or long-term intracavernosal injections, their cost is low.
Untreated ED is associated with a reduced quality of life and an increased risk of psychological complaints, including stress, depression and low self-esteem. A man’s erectile function affects his partner’s sexual functioning, and is a common cause of relationship breakdown.In addition, ED is a risk factor for many chronic health conditions, some of which are life-threatening. These include cardiovascular disease, diabetes and metabolic syndrome, dyslipidaemia, high blood pressure, and endocrine disorders. Doctors commonly check for these conditions when assessing erectile dysfunction and, if necessary, treat them. Men who do not visit a doctor miss the opportunity to have their overall health checked.

These drugs only work when you’re aroused – medical treatments for erectile dysfunction will only treat your physical ability to get and keep an erection sufficient for sex. They also only work if you are sexually aroused in the first place. This means that taking a drug like Sildenafil won’t lead to an erection on its own – you need to combine ED treatment with sexual arousal.
None of the ED drugs is safe to take with cardiac drugs called nitrates because it could cause a dangerous drop in blood pressure. Drugs that many men take for urinary symptoms, called alpha blockers, can also lower blood pressure, so take them at least four hours apart from ED drugs. Your doctor may start you on a smaller dose of the ED drug if you already take an alpha blocker, or may recommend the alpha blocker tamsulosin (Flomax), which affects blood pressure less.
Doses of the active ingredient contained in counterfeits vary, from not containing any active ingredient, to containing up to twice the dose of the medicine they are supposed to mimic. Only 10% of counterfeit ED drugs tested in the European Union contained an amount of active ingredient that was within 10% of the quantity contained in the original product. However, containing the same amount of the active ingredient does not mean the counterfeit medicine is exactly the same. If the drug has been stored incorrectly, is past the use by date, or uses active ingredients from a different source, the way the drug is absorbed by the body may differ from the original.
You may find that using a vacuum device requires some practice or adjustment. Using the device may make your penis feel cold or numb and have a purple color. You also may have bruising on your penis. However, the bruises are most often painless and disappear in a few days. Vacuum devices may weaken ejaculation but, in most cases, the devices do not affect the pleasure of climax, or orgasm.
With the pumps, erections last until the user hits the deflate button, which Kohler says “doesn’t happen” accidentally. He adds that pump prostheses “are locker-room proof: Nobody can see that you have one.” (Obviously, this is not the case with the always-on malleable rod option.) Implanted pumps are reliable, experts say, with more than 90 percent of the devices working for 12 to 15 years. 

Choosing the treatment that is best for you comes down to preference and efficacy. Montague cites a study that surveyed three groups of men, all of whom were successfully using an ED treatment. One group was on oral medications, one was using injections and a third had surgically implanted pumps. The most satisfied users were those with the implanted prostheses.
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In addition, when research has shown a nutrient such as zinc or niacin to improve sexual function, it's usually in people who are deficient in it. So, before you stock up on over-the-counter nutritional supplements for ED, speak with your doctor. He can test you for deficiencies and steer you toward the most effective and safest way to treat your erectile dysfunction. 
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Erythrocytosis has been noted in men on TRT, and should be monitored every 6–12 months depending upon the patients’ response to changes in haematocrit levels. For mild elevations, the dosage of testosterone can be decreased or the interval of using the medication can be increased. With the haematocrit greater than 50%, decisions to temporarily discontinue the medication or periodic phlebotomy may be indicated.38
ED medicines provide a lucrative industry for drug counterfeiters. The medications are expensive, enabling counterfeit manufacturers to make large profits, particularly if they fix manufacturing costs by leaving out the expensive active ingredients contained in the genuine medication. Even counterfeit drugs that do contain the active ingredients provide lucrative profits of up to 2000%. Their sale is estimated to be 10 times more profitable than heroin.

Another potential new treatment consists of penile low-intensity shock wave lithotripsy. This consists of 1500 shocks twice a week for 3–6 weeks. The purpose is to stimulate neovascularisation to the corporal bodies with improvement in penile blood flow and endothelial function. The use of low-intensity shock wave lithotripsy may convert PDE5 inhibitor non-responders to responders.47
Dr Kenny du Toit is a urologist practicing in Rondebosch, Cape Town. He is also consultant at Tygerberg hospital, where he is a senior lecturer at Stellenbosch University. He is a member of the South African Urological Association, Colleges of Medicine South Africa and Société Internationale d’Urologie. Board registered with both the HPCSA (Health professions council of South Africa) and GMC (General medical council UK). He has a keen interest in oncology, kidney stones and erectile dysfunction.http://www.dutoiturology.co.za
Among the phenomena in the ageing man are a decrease in erectile function and testosterone levels. Add to these, increased risk for CVD, muscle wasting, decrease in bone density and libido, with all of these factors having an interplay with testosterone metabolism.33 Androgens play a key role in maintaining erectile function through four main mechanisms. Androgen deprivation has been shown to result in impairment of NO synthase release, altered PDE5 expression and activity, impaired cavernosal nerve function, and contribution to veno-occlusive disease in the penis.34 The role of testosterone replacement therapy (TRT) as a potential to improve erectile function in the man with ED remains an issue for patient and physicians who are comfortable treating androgen deficiency which include primary care physicians and specialists. Androgens are known to have a significant impact on the function of the smooth musculature within the corpus spongiosum.35

Erectile dysfunction can have organic or psychological causes. Often, an organic problem can be complicated by psychological factors. The cause can usually be found by history and examination, but testosterone, luteinising hormone and prolactin should be measured. Non-drug treatments are suitable for some patients, while prostaglandin E1 is the most appropriate drug for intracavernosal injection.
Erectile dysfunction (ED) is one of the most common conditions affecting middle-aged and older men. Nearly every primary care physician, internist and geriatrician will be called upon to manage this condition or to make referrals to urologists, endocrinologists and cardiologists who will assist in the treatment of ED. This article will briefly discuss the diagnosis and management of ED. In addition, emerging concepts in ED management will be discussed, such as the use of testosterone to treat ED, the role of the endothelium in men with ED and treating the partner of the man with ED. Finally, future potential therapies for ED will be discussed.

Psychotherapy and counselling can help if one of the underlying causes of erectile dysfunction is psychological. Counselling can also benefit a man who has lost sexual confidence, even though his erectile dysfunction is caused by physical factors. It may be provided by your doctor, a psychologist or a psychiatrist. Your partner may also be involved.