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Erectile Dysfunction & Treatments

Doesn't it happen to every man as they get older? Erectile dysfunction, or simply "ED", is a poorly treated health condition that affects millions of men. Contrary to popular belief, ED is not something you have to just live with. It is a very treatable condition with many different causes. 

At Black Tie Health, our ED treatment regimen is the most comprehensive program available. Our methods are well-researched and carefully structured to make erectile function the best it can be. 

Facts About Erectile Dysfunction

  • 80% of men with erectile dysfunction are overweight or obese.

  • About 25% of men under 40 have erectile dysfunction.

  • By the age of 40, an estimated 40% of men suffer from ED.

  • By the age of 70, an estimated 70% of men suffer from ED.

  • 35-75% of men with type 2 diabetes will develop erectile dysfunction

  • Men with erectile dysfunction are twice as likely to have a  heart attack.

  • Despite being treatable, only 25% of men with erectile dysfunction receive treatment.

Berlin Fernsehturm
Erectile Dysfunction

You're at the point where you're frustrated. The worst part is that after you had difficulty in the bedroom that one time, you think about it leading up to every potential sexual encounter. That began what seems to be the never-ending cycle of erectile dysfunction. Regardless of what you tried, nothing has seemed to work.

Most men (and some women) try and become detectives in searching for the cause of erectile dysfunction. The truth is rarely is there only one cause. It is usually the result of multiple contributors. As a result, there is no one silver bullet treatment for erectile dysfunction. However, you can maximize improvement by addressing all potential issues.

The Basics of Erectile Function

Erections are a function of blood flow. As long as there is enough blood flowing to the penis, erections are possible. The penis is supplied with blood by the dorsal penile arteries as shown on the diagrams below. There is an artery for the right side of the penis and one for the left side. Once the blood is inside the penis it must remain there. Think of it as filling a balloon with air. If you don't keep the air inside the balloon, it will not remain inflated. Likewise, the penis is naturally designed to keep the blood inside the penis by the tissues putting pressure on the veins. 

The image above is a collection of diagrams of the internal anatomy of the penis . The chambers in the penis that fill with blood are called the corpus cavernosa. There is one on the left side of the penis and one on the right side of the penis. When the corpus cavernosa fill with blood, the penis becomes more rigid and points somewhat upward. These two chambers are filled with blood by the dorsal arteries of the penis.

Once the corpus cavernosa are filled, the blood exits the penis through the dorsal penile veins. Just like the dorsal arteries, there is a vein on the left side and a vein on the right side. The veins are depicted in blue on the diagram. As long as the blood leaves the penis at a slower rate than blood enters the penis, the penis will remain erect.

Diagnosing Erectile Dysfunction

Erectile dysfunction is typically a clinical diagnosis based on history alone. However there are a few testing methods that doctors use to determine the severity of ED. The most common one is a written questionnaire about symptoms known as the International Index of Erectile Dysfunction, or the IIEF. This tool is used primarily by physicians and scientists conducting research on erectile dysfunction. The survey is long and extensive and as a result is considered the "gold standard" for grading the severity of ED.

More commonly used is the Sexual Health Inventory for Men, or the SHIM. The SHIM survey is another research-validated tool used to measure the severity of erectile dysfunction. Clinicians tend to use this survey more frequently in the office because it is shorter and faster than the IIEF. The SHIM survey consists of 5 questions  to determine the severity of ED to be mild, mild to moderate, moderate, or severe.

Sexual Health Inventory for Men (SHIM) Survey

One test that some physicians use to determine the severity and/or the cause of erectile dysfunction is called a doppler ultrasound. The ultrasound is used to determine the rate of blood flow into the penis while in an erect state. A normal result suggests that the cause of ED is unlikely to be vascular, but instead caused by some other factor such as in psychogenic ED or neurogenic ED. One drawback to performing the doppler ultrasound procedure is that it requires the penis to be in an erect state. To induce an erection, physicians typically inject a medication directly into the penis to perform the ultrasound study.



Causes of ED

Causes of Erectile Dysfunction


If you've seen the latest commercial for cholesterol medications, you know that cholesterol plaque builds on the inside of the wall of the arteries. Well, this happens in all of the arteries in the body, not just the ones in the heart. Cholesterol plaque can build up on the inside of the arteries that supply the penis, causing reduced blood flow to the penis. When this happens, men begin to experience erectile dysfunction. 

There are several other causes for erectile dysfunction, however up to 80% of erectile dysfunction is caused by decreased blood flow to the penis. Other causes include nerve issues, mental health issues, hormone problems, scar tissue, and medications.

How Hormone Levels Can Cause Erectile Dysfunction

Testosterone, the male hormone, is responsible for the development of male sexual characteristics. For example, muscle mass, body fat percentage, body hair, and bone density are affected by testosterone levels in the male body. The fact is, after the age of 35 years old, most men begin to have decreasing testosterone levels

Low testosterone can contribute to issues with erectile dysfunction. Without an adequate amount of testosterone in the body,  men are likely to be unable to perform sexually. In addition, testosterone has significant effects on libido (sex drive) and overall feeling of virility. 

In the past 20 years, there has been a huge increase in the number of men who ask to check their testosterone levels. Unfortunately, the results from the lab don't always tell the whole story. Many times, lab values are standardized to the average young man, hence your doctor may have told you that your testosterone levels are just fine. A diagnosis (or lack of one) should always consider a holistic approach to the patient and consider clinical signs and symptoms of a problem. If you're not sure about how much your erections are being effected by your hormone levels, get a second opinion by a licensed physician.

How Overall Health Affects Erectile Dysfunction

Generally speaking, men who are in better physical health overall are less likely to experience erectile dysfunction. In a study conducted on military veterans, they found that those men who exercised frequently had better sexual function.


Other studies have also shown that simply losing weight can have a remarkable effect on  erectile function. The physiologic basis for weight loss could be possibly attributed to how body composition affects hormone levels. Aromatase, an enzyme that converts testosterone to estrogen, is known to be increased in men with obesity. As a result, men with higher levels of body fat will likely convert the testosterone their body creates into estrogen - a feminizing hormone.

Of course, harmful activities such as smoking cigarettes, excess alcohol consumption, and illicit drug use do nothing to improve sexual performance. In fact,  there are obvious negative implications on erection quality. For example, smoking contains nicotine, which causes the blood vessels to become smaller in diameter. The blood vessels that supply the penis with blood become too narrow to deliver enough blood and oxygen to the penis for an erection to become possible. In addition, tobacco smoke contains tons of carcinogens and other chemicals that cause injury to the walls of the blood vessels.

The pelvic floor muscles of the penis that are responsible for penile rigidity

How Penile Rigidity Affects Erectile Dysfunction

For some guys, the penis fills with blood, but isn't quite rigid enough for penetration. This may be for a few different reasons. The first is that it is possible that the penis isn't getting enough blood flow (see above). Another could be muscle weakness. Penile rigidity is in part due to the ability to flex the pelvic floor muscles.

The image above is a diagram of the pelvic floor muscles in men. These muscles are the only muscles involved in normal erectile function. The ischiocavernosus muscle and the bulbocavernosus muscles are composed of skeletal muscle fibers, which means like the other muscles in the body, they can grow (hypertrophy) or shrink (atrophy) and become stronger or weaker.

One solution for weak pelvic floor muscles is - you guessed it - exercise. We're not talking about hitting weights at the gym. However, we are talking about exercises specifically for the pelvic floor muscles. These exercises are known as "kegel exercises". Although many believe these exercises to only be helpful for women after childbirth, kegel exercises can have a remarkable impact on penile rigidity.

The Impact of Medications on Erectile Dysfunction

Many men with erectile dysfunction are taking medications that are only making matters worse. Although unlikely that medications are the sole cause, it's possible.

Blood pressure medications are common culprits. Blood pressure medications tend to be a double-edged sword when it comes to erectile function. If a man's blood pressure is high, the arteries of the entire body are more narrow. Narrower blood vessels allow less blood to flow through. This includes the penile vessels. Therefore, high blood pressure decreases blood flow to the penis. Hence, high blood pressure can directly cause erectile dysfunction by limiting the amount of blood supplied to the penis. 

High blood pressure, or hypertension, is a key risk factor for heart disease. So many physicians prescribe medications such as beta-blockers or calcium channel blockers to decrease the strain on the heart. These drugs are great for managing blood pressure and reducing the risk for heart attacks. However, these classes of drugs are well-known to contribute to erectile dysfunction.

Blood pressure medications are the only ones that have a negative impact on erections. Some other medications that contribute to erectile dysfunction include stimulant medications for ADHD, many drugs prescribed for depression, anxiety, and other mental health issues, chemotherapy drugs, and some medications used to treat acid reflux or heart burn.



Treatment of Erectile Dysfunction

Treatment of erectile dysfunction over the last several decades has focused on the blood vessels. The first drugs approved by the FDA for erectile dysfunction (for example, Viagra) worked by dilating the blood vessels, which allows more blood into the penis. As outlined above, erectile function relies on blood flow.

Methods to Treat Erectile Dysfunction

The standard of care for erectile dysfunction in today's healthcare environment is to prescribe medication. To be fair, prescription medication revolutionized sexual health in the world for older men and women. Before the little blue pill was invented, erectile dysfunction was dismissed and considered just something that comes with age.


Sildenafil (trade name "Viagra") and other erectile dysfunction medications work by dilating the blood vessels that supply the penis with blood. More blood flow = more erections. This is the reason that large doses of these medications cause side effects such as headaches and low blood pressure. Unfortunately, the human body adapts to the medication, requiring larger doses to maintain the same effect. For many patients, either the maximum dose no longer is effective or the side effects become too strong to tolerate.

Nowadays, standard of care consists of prescription medications, lifestyle changes, and testosterone replacement. If those options don't work, the only other option most urologists may offer is a surgical implant of a penile prosthesis. The surgery is permanent and frequently involves complications.

Ultimately, you can choose to go that route, or you can choose to do things a little different. Schedule your appointment to learn about new options to help you get back to the bedroom.

What are the FDA-approved treatments for erectile dysfunction?

Currently, there are only a handful of FDA approved medications for ED. Medications approved by the FDA for erectile dysfunction include:

  • Viagra (sildenafil)

  • Cialis (tadalafil)

  • Levitra (vardenafil)

  • Stendra (avanafil)

  • Muse/Caverject (alprostadil)

Currently, four of the five medications approved by the FDA for erectile dysfunction below to a class of drugs know as phosphodiesterase-5 (PDE-5) inhibitors.

New and Alternative Treatments Available for Erectile Dysfunction

If you've made it through the information above, you're well on your way to finding a solution. Whether you're a man or woman looking to improve things in the bedroom, you've come to the right place. We provide treatment programs designed to target erectile dysfunction from every angle.

Some of the alternative treatment options we offer include:

*Not available at all locations.

What is acoustic soundwave therapy?

Acoustice soundwave therapy (ASW), also known as Extracorporeal Shockwave Therapy (ECWST), was made popular by the inventor of the Gainswave Device. The Gainswave device was one of the first ECWST devices marketed specifically for erectile dysfunction. The technology, however, is decades old. Lithotripsy (breaking up kidney stones) using ECWST became commonplace in the 1980's. ECSWT uses high-intensity acoustic pulse to create a shockwave. When applied to the skin, the shockwave moves through the tissue beneath the skin. The impact on this tissue depends on the frequency of the pulse, the pressure of the shockwave produced, and the depth of penetration targeted.

What about supplements? Are there any supplements that I can take to improve my erectile function?

Yes - there are a few supplements that are known to have a positive impact on erectile function. However, beware of the supplements sold in stores that claim to be "natural viagra". The FDA has done numerous investigations on those types of supplements and determined that many of them contain drugs similar to Viagra or Cialis. The real problem is that some of the drugs contained in those "natural viagra" pills are more prone to side effects and could have potentially serious negative effects on your ability in the future.

We maintain a list of supplements for which there is clinical evidence of effectiveness. We also maintain a list of specific manufacturers and products that have a proven track record of quality, follow the FDA recommendation for good manufacturing practices, and the products must be evaluated by a 3rd party auditor. 

ED Treatments

In 2015, the FDA found more than 300 products sold over-the-counter as supplements, herbal, or all natural medication alternatives for sexual performance could be a danger to your health. The products contained hidden drug ingredients, untested chemicals, and unknown contaminants.

Off-label Treatments for Erectile Dysfunction

Off-label treatments for erectile dysfunction typically include medications that are FDA approved for one medication, but the medications are prescribed for a different purpose. Some off-label treatments are available to be administered in different ways than the original drug approved by the FDA. Some off-label treatments include:

  • Injectable medications such as Trimix or Quadmix

  • Peptide therapy

  • Botulinum toxin (such as Botox)

  • Apomorphine

  • Combination drugs containing PDE5 inhibitors

Trimix and Quadmix Injections for Erectile Dysfunction

Trimix and Quadmix are injectable medications used to induce an erection immediately prior to sexual intercourse. Unlike PDE5 inhibitor drugs, such as Viagra or Cialis, Trimix and Quadmix are primarily local acting medications. This means that Trimix and Quadmix work primarily in the penis and minimize the possibility of side effects. Also, Trimix and Quadmix work in a slightly different way to the oral medications, which can make them much more effective at treating erectile dysfunction.

Trimix is a combination of medications, including phentolamine, papaverine, and alprostadil. Phentolamine acts by blocking alpha-1 receptors thereby dilating the blood vessels of the penis. Papaverine is an opioid derivative that works in a similar way to PDE5 inhibitors. Alprostadil is a prostaglandin analog that also works by dilating the blood vessels in the penis. When combined, these medications produce a potent medication with a huge chance of effectiveness. 

Quadmix is a combination of the medications in Trimix combined with a medication called atropine. Atropine is a anticholinergic medication used to treat conditions such as pesticide poisoning and slow heart rate. Quadmix, when dosed appropriately and combined with Trimix, is a medication that is all but guaranteed to produce an erection.

The biggest benefit of Trimix and Quadmix is how they are administered. These medications are injected directly into the penis, which magnifies their impact on the penile blood vessels. Also, the dosages of the individual medications is so low that any side effects are extremely rare. 

Peptide Therapy as Treatment for Erectile Dysfunction

Peptides have become an area of increased focus in recent years. PT-141, also known as bremelanotide, is a peptide hormone that has become a potential game-changer for erectile dysfunction treatment. In 2019, the FDA approved PT-141 under the brand name Vyleesi. However, Vyleesi was approved for female sexual dysfunction, not erectile dysfunction.

The good news is that, even though PT-141 was approved by the FDA for female sexual dysfunction, it can be used legally to treat erectile dysfunction in men with a prescription. On the contrary, PDE-5 inhibitors like Viagra and Cialis are not equally effective in men and women. The reason for the ability of PT-141 to effect men and women in a similar way is the mechanism of action for the drug.

The way PT-141 works is through melanocortin receptors, specifically the melanocortin-4 receptor. These receptors have been found to effect weight, libido, skin complexion, and mood. As a result, one of the side effects of PT-141 is a tan complexion, which is explained by the drug's distant origins.


The first drug in the melanocortin family of peptides was Melanotan-1, which was used as a sunless tanning agent. Melanotan-2 is also a peptide medications used for sunless tanning and libido enhancement. It is in the same family of medications as Melanotan-1 and PT-141 - they all work on melanocortin receptors. There seems to be a reliable trend across all melanocortin drugs, tan skin and more sex.

PT-141 is thought to work by binding to the melanocortin receptors in the brain. This likely explains the reason why PT-141 works to improve erectile function in men and improve libido in women. In addition, PT-141 doesn't appear to have the significant effect on blood pressure as PDE-5 inhibitors, which may make it a preferable treatment option for some men with heart or blood pressure issues.

Off-label Treatments
Vacuum Assisted Erectile Devices (AKA "Penis Pumps")

Vacuum assisted erectile devices are more commonly known as penis pumps. Penis pumps work by using negative pressure (vacuum) to force blood into the penis. As stated earlier, erections are a result of more blood entering the penis than is leaving the penis at a given moment. So if a restricting device is placed at the base of the penis while using a vacuum device, an erection rigid enough for sexual intercourse could be maintained.

To prevent injury to the penis and scrotum, vacuum devices should be appropriately sized. Men should purchase a pump that is barely larger than the girth of the penis when erect. This is to minimize risk of the scrotum entering the pump, which can cause extreme amounts of pain.

When using a vacuum device, it is also important to be aware of the negative pressure created by the pump. Ideally, a pump should be fitted with a gauge that indicates the amount of pressure in the tube. Pressures greater than 5 inHg can cause injury to the penis and should be avoided.

There are penis pumps that are approved by the FDA, but coverage of penis pumps by insurance companies is uncommon. 



Recent Men's Health Articles

Research on Treatments for Erectile Dysfunction

Anastasiadis E, Ahmed R, Khoja AK, Yap T. Erectile dysfunction: Is platelet-rich plasma the new frontier for treatment in patients with erectile dysfunction? A review of the existing evidence. Front Reprod Health. 2022 Aug 16;4:944765. doi: 10.3389/frph.2022.944765. PMID: 36303622; PMCID: PMC9580815.

Khodamoradi K, Dullea A, Golan R, Molina M, Arora H, Masterson TA, Ramasamy R. Platelet Rich Plasma (PRP) Growth Factor Concentration Varies in Men With Erectile Dysfunction. J Sex Med. 2022 Sep;19(9):1488-1493. doi: 10.1016/j.jsxm.2022.06.003. Epub 2022 Jul 9. PMID: 35817715.

Shadiack AM, Sharma SD, Earle DC, Spana C, Hallam TJ. Melanocortins in the treatment of male and female sexual dysfunction. Curr Top Med Chem. 2007;7(11):1137-44. doi: 10.2174/156802607780906681. PMID: 17584134.

Sighinolfi MC, Eissa A, Bellorofonte C, Mofferdin A, Eldeeb M, Assumma S, Panio E, Calcagnile T, Stroppa D, Bozzini G, Gaia G, Terzoni S, Sangalli M, Micali S, Rocco B. Low-intensity Extracorporeal Shockwave Therapy for the Management of Postprostatectomy Erectile Dysfunction: A Systematic Review of the Literature. Eur Urol Open Sci. 2022 Jul 30;43:45-53. doi: 10.1016/j.euros.2022.07.003. PMID: 35928730; PMCID: PMC9344341.

Siregar S, Novesar AR, Mustafa A. Application of Stem Cell in Human Erectile Dysfunction - A Systematic Review. Res Rep Urol. 2022 Oct 26;14:379-388. doi: 10.2147/RRU.S376556. PMID: 36320568; PMCID: PMC9618244.

Zaghloul AS, El-Nashaar AM, Said SZ, Osman IA, Mostafa T. Assessment of the intracavernosal injection platelet-rich plasma in addition to daily oral tadalafil intake in diabetic patients with erectile dysfunction non-responding to on-demand oral PDE5 inhibitors. Andrologia. 2022 Jul;54(6):e14421. doi: 10.1111/and.14421. Epub 2022 Mar 17. PMID: 35301742.

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