The most important thing to remember is that if you have a penis, we can get you an erection. We just need to figure out what works best for you.

If you have the problem of erectile dysfunction (ED) you should know that a recent study estimated that 30 million American men suffer from various degrees of ED ranging from mild to severe. It is clearly an age-related phenomenon since the prevalence of ED increases significantly with age. However, it may occur at any age and Dr. Werner has treated a significant number of men in their teens, twenties and thirties.

Here are a few numbers and facts that might be illuminating to you. By the time men reach the age of 40, 5% of them are completely impotent, never achieving an erection rigid enough for penetration. Approximately 15% of men have significant problems achieving or maintaining an erection.

In 90% of cases involving men older than 35, the causes are primarily physical in nature. In men younger than 35, the causes tend to be primarily psychological in nature. Regardless of age, in every man it is important to evaluate thoroughly what the causes of his ED are in order to manage them maximally and comprehensively. However, even in cases with primarily psychological erectile dysfunction, medical intervention can always manage a man’s ED, and sometimes solve the problem too.

Causes of Erectile Dysfunction

If you have erectile dysfunction or male impotence there are four main causes to look into. A description of each follows:


Blood must be able to move into the penis and stay there to maintain an erection. Arteries are the vehicles that bring blood into the penis. Any process that damages the arteries and increases the likelihood of vascular disease would make a man more likely to have ED. A history of arterial disease (e.g. heart attacks, strokes or peripheral vascular disease) indicates that the penile arteries are also at risk. Anything that would make a man more likely to have a heart attack or stroke will make him more likely to have ED. This includes smoking, diabetes, hypertension, high cholesterol and sub-optimal exercise and diet. In fact, ED usually appears before any of these more severe manifestations of vessel disease. One of the main reasons for this is that the artery to the penis is smaller than the heart or limb arteries, and gets clogged first. The development of ED is often the first sign that a man is at significantly increased risk of heart attacks or stroke.


A man must have an intact neurological system in order for an erection to occur. The most common cause of neurologic ED is diabetes, which usually affects both nerves and blood flow. Other causes include previous surgeries, spinal cord injury, strokes, multiple sclerosis and other systemic neurological disease.


Significant low testosterone and thyroid hormones, or a very high prolactin may cause problems with erections.


ED can often occur for psychological reasons, even when there are minimal or virtually no underlying physical problems. However, many men have a significant psychological response (or secondary reaction) to what is at first, primarily a physical problem. Once a man loses confidence in his erections, his anxiety levels may increase, and at that point, he may develop increasing difficulty achieving and maintaining an erection, and a vicious cycle is created. Our job is to break this cycle.

Evaluating and Diagnosing ED

Your first appointment should last between 45 and 60 minutes. It will include:


The practitioner will take a thorough medical history in order to place your erectile dysfunction within a medical context. He will also take a full sexual history. This may include questions such as:

  • How long have you had the erectile dysfunction?
  • What happens when you try to have intercourse?
  • Do you have decreased rigidity?
  • Do you have difficulty maintaining your erection?
  • At what point do you lose your erection?
  • Do you wake up at any point with an erection?
  • How rigid are the nocturnal erections?
  • What is your sexual interest level (libido) like?
  • Does your penis have a curve, bend, or twist in it when it is rigid?
  • Is your ejaculation normal?
  • Is ejaculation early (premature) or delayed?
  • What is the status of your relationship?
  • How is the relationship going?
  • How is your ED affecting the relationship?


Your practitioner will explain to you how erections work (in terms that you will understand). He will explain why yours may not be working.

Physical Examination

Your practitioner will perform a focused physical examination on your penis and testes. This evaluation does not substitute for a regular (general) physical examination.


Your practitioner will usually measure the threshold for perceiving vibration of your penis (biothesiometry) as well as perform specialized testing to assess the function of your penis. This may include:

  • A Rigi-scan to measure the quantity and quality of your nighttime erections.
  • An ultrasound to measure the blood flow through the penis.

Blood tests are also done to measure hormone, cholesterol, and glucose status.

Once your practitioner has completed your evaluation, he will review ED treatment options with you. He will consider these options in light of the history, physical, and specialized testing that has been performed, and of course what preferences you have stated.

Oral Treatment Options for Erectile Dysfunction

Oral medications include Viagra, Levitra, Cialis, and Stendra, which are all members of the class known as phosphodiesterase 5 inhibitors.

How do they work?

All four of these medications have the same mechanism of action. When a man is sexually aroused, a messenger chemical (nitric oxide) is released, which causes a cascade of biochemical reactions: the blood vessels and tissues of the penis relax and dilate, allowing blood to rush in and an erection to occur. These oral medications block the enzyme PDE5, which reverses this process. Thus, the same stimuli give a man a better erection.

Who cannot take them?

Please note that all of these drugs are contraindicated for men who are:

  • Currently using nitrates or have Retinitis Pigmentosis

These oral medications also should be not be taken by men with a predisposition to potentially hazardous cardiovascular events. These conditions include:

  • Unstable angina
  • Congestive heart failure
  • Taking multiple antihypertensive drugs
  • MI, heart attack, CVA (stroke), or life threatening arrhythmia within the last six months.
  • Hypotension, decreased blood pressure (BP <90/50) or hypertension, increased blood pressure (BP>170/110)
  • Patients on alpha blocks for high blood pressure or prostrate problems should not take Levitra or Cialis

The overall rule of thumb is that if your health makes sexual activity dangerous, you should not take the medications.

How do I maximize their use?

It is important to understand how these medications are absorbed and broken down (pharmacokinetics) in order to get the best results from them. We have created a chart to help summarize this information.


  • Viagra (Sildenafil)
    • The maximum dosage of Viagra is 100mg. It is often the strongest medication available, and best produces the desired result. However, it must be taken on an empty stomach if all of it is to get absorbed. And, it therefore often has the most side effects.
    • It peaks in the blood stream in about one hour. Half is gone at 4 hours and most is out of your system by 8 hours. Thus, it is important to have sexual activity when it is close to its peak levels in your blood stream, which is usually between one and three hours after taking it.
    • Side effects include: Headache, flushing, nasal congestion, temporary abnormal vision, heartburn and blood shot eyes.
  • Cialis
    • The maximum dosage is 20mg. It is the longest acting medication, and this is the main reason why it is the most popular.
    • It peaks in the blood stream about 2 to 4 hours after it is taken. Half is gone by 18 hours and the rest by 36 hours. Thus, it is often called “the weekend drug.” However, it is important to remember that there is less and less in the blood stream after 4 hours, so it is almost never as powerful at 24 hours as it is at 12 hours (for example).
    • Because it remains in the bloodstream for a long time, if a lower dosage is taken daily, there will always be some in your system. Thus, for men who have only modest ED, a daily 2.5mg – 5mg Cialis may be enough for them always to be able to get and maintain a good erection. The daily Cialis is also approved for urination symptoms from an enlarged prostate. Thus, sometimes (with a lot of effort) your specialist can get it paid for by insurance companies for men who have both ED and urination symptoms.
    • Side effects include: Headache, flushing, nasal congestion, heartburn, blood shot eyes, and back or leg cramps. Whatever side affects you do experience, may last longer, because it stays in your system longer.
  • Levitra
    • The maximum does is 20mg. It peaks in the blood stream at about one hour. Half is gone by 4 hours and almost all of it is gone by 8 hours.
    • It is available under the brand name of Staxyn, which is placed under the tongue (sublingually).
    • Side effects include: Headache, flushing, nasal congestion, upset stomach or back pain.
  • Stendra
    • The maximum dose is 200mg. It is the most rapidly effective oral ED drug. (PDE 5 inhibitor)
    • It may give effective results after 15 minutes. Half is gone at 4 hours and the rest by 8 hours.
    • Side effects include: Headache, flushing, nasal congestion, upset stomach or back pain.

We often prescribe more than one PDE 5 inhibitor for our patients. Sometimes they need it to be the absolute strongest it can be. Sometimes the flexibility of a longer acting drug is needed. Sometimes, you just need it quickly!

Though it is not FDA approved to be used this way, we have many men who use a daily 5 mg Cialis, and then use half maximum dosage of another oral medication as needed.

Oral medications work for 70% of men. For many of these men, it is truly a wonder drug, giving them excellent, predictable, and long-lasting penile erections. Oral medications have revolutionized the treatment of ED by bringing the issue into the open and giving many men hope.

However, for 30% of patients, the oral medications fail. For these men, the oral medications do not work well, do not work at all, or is not recommended from a medical point of view. These men are often more unhappy than before they sought treatment since they are convinced that they are alone and that there is no help for them.

Penile Injection Treatment for Erectile Dysfunction

What if you can’t take one of the available oral medications or if the medications aren’t working the way you’d like? One of the options available for the treatment of ED is the self-injection of medication into the penis. This often sounds scary to the patient and not particularly appealing but once a patient understands the reality of his treatment, he is willing to consider this widely used and effective treatment technique.

Most men would tell you that the injection doesn’t hurt. They describe it as either painless or as if they have been flicked with a rubber band. The injection is extremely quick and uses a very fine needle (usually a 29 or 30 gauge). And since the side of the penis doesn’t have many pain receptors, there is little sensation.

It works like this. The medication goes into the penis with a device that’s similar to the ones used by diabetics. A disposable syringe, with a very fine needle, is placed on the injector. The device is placed against the side of the penis, and you press a button. A spring pushes a very thin needle into the penis and, at the same time, pushes the medication into the penis.

  • Medications
    • The three most common medications used for injections are prostaglandin E1, papaverine, and phentolamine. All three act by relaxing the smooth muscles and causing the arteries to dilate. This activates the trapping mechanism. Prostaglandin E1 received FDA approval in 1996 for ED treatment. It is currently marketed and available in prescription plans under two brand names, Caverject Impulse and Edex. However, all three are available in different combinations and strengths.
    • Each medication has different characteristics:
      • Prostaglandin E1 or Alprostadil
        • Prostaglandin E1 is a powder that is mixed with a fluid prior to use. This is due to the fact that it is stable as a powder at room temperature, but not as a liquid. Prostaglandin E1 can cause some temporary short-lived aching in the penis. Although it is not medically concerning, it can be uncomfortable. Discomfort is experienced by approximately 20% of patients and is most common in patients who have neurological erectile dysfunction such as diabetes or post-radical prostatectomy.
      • Papaverine and Phentolamine
        • Papaverine is a smooth muscle relaxant, which acts directly on the blood vessel walls to relax and thus dilate, as well as activating the trapping mechanism. It is usually mixed with phentolamine which is an alpha-blocker which causes smooth muscle relaxation through a different mechanism.
        • The papaverine and phentolamine come in a liquid, do not need to be refrigerated, and have the no aching associated with them. Bimix and Trimix
    • Usually, one of three formulations is used:
      1. Prostalandin E1 (stable as a powder, but needs to be refrigerated as a liquid.)
      2. Bimix: is a combination of Papaverine and Phentolamine. It comes as a liquid only, but does not need to be refrigerated. This makes it very convenient for men who travel, or don’t want to store their medication in a shared refrigerator. It also never causes any aching.
      3. Trimix: is a combination of Papaverine, Phentolamine, and ProstaglandinE1. Because it contains PGE1 it needs to be refrigerated and can cause aching in some patients. However, it is often stronger than an equivalent dosage of Bimix (papaverine and phentolamine alone), and thus is often used.
  • How do I learn to do the injections and how do I figure out the dosage?
    • Learning how to use the injections, though intimidating, is actually quite straight-forward. It is important that your practitioner schedules you for several visits, both to teach you how to do the injections comfortably, and to figure out the right dosage.
    • At MAZE, this usually takes three visits. At the first visit you receive your first injection, to introduce you to them, and to see how you respond. Based on your experience, you can decide whether to continue with them, and we can begin to figure out the dosage. Prostalandin E1 is usually used, because it is the least likely to cause a man to have a prolonged erection (priapism). If you get aching you are usually switched to Bimix, which does not cause aching. Even if the PGE1 does not cause aching, if is not strong enough, you will likely be switched to Trimix.
    • At your second visit, you will receive a second injection (the dosage of which is based on your response to your first injection). You will also be supplied with the auto injector, and taught how to use it. You will be strongly encouraged to practice it (empty-no syringe) at home.
    • On your third visit, you will give yourself an injection, under our observation, and hopefully we will have figured out the right dosage and medication, based on your responses to the previous two injections. You are then usually sent home with five preloaded syringes, sometimes of increasing dosages to use at home.
    • Some men need more practice and coaching, and we will work with you for as long as it takes to get you comfortable with the technique.
  • How good will my erection be?
    • Our goal is to get you a rock-hard erection, lasting virtually as long as you want (up to two hours), which is basically better than you were when you were 18! If you have a problem with your trapping mechanism, this may not be possible, but is what most of our patients achieve. We are successful in getting about 90% of our patients, many of who have failed pills and injections at other centers, great erections.
  • If I have already failed injections somewhere else, can you help me?
    • It is extraordinarily frustrating for us how poorly penile self-injections are managed by “shot clinics” and non-specialists. Rarely is a man taught the right technique. An auto-injector which pushes the needle through the skin and then delivers the medication is almost never used. Also, many practitioners are so worried about the patient having a prolonged erection, the patient is under-dosed, leaves poorly trained, with the wrong equipment, and, as a result, likely to have poor erections.We would estimate, conservatively, that 80% of men, who have failed injections at other practices, are successful at ours.
  • What are the possible complications of penile self-injections?
    • There are two potential complications, but they are rare if patients are taught how to inject properly, and follow the dosages prescribed. 
    • The first is a prolonged erection, or “priapism.”  When you have a rigid erection, you are trapping the blood in your penis.  This causes pressure, which makes your penis hard, but also acts like a tourniquet around your penile arteries, shutting off the flow.  This prevents fresh blood from coming into the penis.  When your erection goes down, the arteries then can bring fresh blood into your penis.  If the erection remains rigid for too long, you are not getting fresh blood into your penis, and you can get permanent damage.  It is not clear how long this damage takes to happen, but we ask patients to call us if their erections last more than four hours.  However, it is our job to figure out the right dosage for you, and your job not to abuse it, so this is extremely rare.  If it happens, it can be taken care of in the office, almost always, unless you have waited too long.
    • The second potential complication is developing scar tissue of the lining of the penis.  This is also uncommon, particularly if you are taught the right technique.  It is important that you vary the site in the penis, and that you compress the site for five minutes after the injection, to prevent bleeding on the inside, which then causes scar tissue.  This is, of course, part of what we teach you.
  • How long have penile injections been around?
    • Penile injections were developed in 1983 and were the second method developed for the treatment of erectile dysfunction.  They thus predated the pills, by more than a decade.  Viagra was the first pill and was approved March 29, 1998.
  • How do I maintain spontaneity while using the injections?
    • Our experience with injectable medication tells us that many men are successfully treated this way. Their erections are often much stronger and more reliable than those from the oral medications. With foreplay and the medication, the individual gets a good, strong erection. In some ways, the injection is a more spontaneous solution for treating ED since it can be used right before a sexual encounter.
    • Also, in our experience people vastly prefer excellent sex to spontaneous sex.  If you go back and think about your life, there are very few periods where sex is totally spontaneous.  Working around parents and siblings, roommates, and then children (the ultimate “sex-killers”) means that you have typically put more planning into having sex than you think.
  • Will my body get used to the injections to the point where they stop working?
    • There are certain drugs that the body routinely builds up a tolerance to, requiring more and more to achieve the same effects.  This is called “tachyphylaxis.”  Fortunately, this does not happen to this injection.  In fact we often see that when men start using the injections their own erections improve.  This is probably a combination of physical changes to the penis, which is both stretched and getting more oxygen, and more confidence.  However, just as the rest of our body is aging, so is our penis, and if you use the injections over a long period of time, you may need more as time goes on, because your penis is getting older too.  However, the vast majority of men are able to use the injections for their whole sexual life (which hope is their entire life.)
    • We ask our men to use the dosage they need to get good, rigid, long lasting erections.  This leads to more improvement in the penis, and of course better sex.
Vacuum Erection Device (VED)

A viable alternative to obtain an erection is the VED.  It is a cylinder that goes over the whole penis.  A vacuum is then created in it, by pumping out the air.  This pulls blood into the penis giving you an erection.  A band is then placed around the base of the penis to hold the blood in.

There are many different brands of VED.  Some of them have a battery operated pump and some are manually pumped.  It is important that you get a medical one, which has a built in pop-off valve, so that you do not injure the penis by applying too much pressure.  It is also important that you not leave the band around the base of the penis for too long, so that you can get fresh blood into the penis.

Advantages of the VED

The advantages of the VED are that if it works for you, it is a one time purchase, usually covered by your insurance.  It does not take very long to apply.  There are no medications, with potential side effects, taken.

Disadvantages of the VED

Many men do not like the way it feels.  Some find the band uncomfortable. For some men it is hard for the scrotal contents not to be sucked into the cylinder, causing discomfort.  (Some VED’s come with a piece to try to prevent this.)  Also, even if the penis beyond the band is rigid, the part of the penis under the skin and attached to your pubic bone is not, and thus you may get some hinging of the penis.

Most importantly, many men do not really get a truly rigid erection. 


MUSE is alprostadil put into a pellet form.  The pellet is placed by the manufacturer in a disposable applicator.  Prior to initiating sex, the man urinates, and then places the applicator about one inch into the tip of the penis (the urethra.)  The pellet is then pushed out of the applicator and into the urethra.  The man then compresses the penis so the pellet of alprostadil cannot come out. 

Advantages of MUSE

Some men like this method, as it acts quickly, and may be effective for them.  It is paid for by some insurance companies, although it assumes you are willing to put something in your penis.

Disadvantages of MUSE

Many, if not most, men do not get a very good erection from MUSE.  Most men do not like the idea, or the reality of putting something into the tip of their penis.  Many men get burning from the medication in the urethra.  Since the medicine is not delivered directly into the erection chambers, much of it leaks out into the general circulation, and causing drops in some men’s blood pressure.  (Fortunately, this is quite rare.)  In our practice, though we offer it to every patient, few patients have tried it, and even fewer stick with it.

Penile Prosthesis (Penile Implant)

The first treatment, and one still frequently used for ED, is placement of a penile implant. The technique involves placing cylinders in the two erection chambers of the penis.  When they are inflated or bent upwards, they allow a man to have a rigid penis.  Originally, they consisted of bendable rods, put into the erection chambers.  However, they have developed significantly since that time.

Today most prosthesis are inflatable.  They consist of a closed system filled with saline. There is a reservoir that holds most of the fluid when you don’t want to be erected.  It is hidden under your abdominal muscles or, more rarely, in your scrotum.  There is a pump placed  in your scrotum, which you can feel and manipulate through the scrotal skin painlessly.  When you want an erection, you literally pump the fluid from the hidden reservoir to the cylinders in the erection chambers, giving you an erection.  Your orgasm and sensation will be the same.  When you no longer need/desire the erection, you press a valve on the pump, and then squeeze the penis, gently, and transfer the fluid out of the penile cylinders and back into the reservoir.

The surgery, when done by an expert with a lot of experience, is quite short.  It is done in the hospital, and most physicians keep their patients in the hospital overnight, though the trend is starting to discharge them home the day of the surgery.  All of the pieces can be placed through one small incision, which is either in the scrotum, or right above the pubic bone, in the middle.  None of the pieces are sticking out.  (Otherwise, besides being embarrassing, they would get infected.)

Advantages of a Penile Prosthesis

The implant is well hidden.  It is quick to pump up, offering spontaneity.  The erection is quite good for most men, though some complain of shortening of the penis.  Sensation is not changed, and a man can still get the same stimulation he got from relations when he got his erections by other means (either naturally or medically.)

Disadvantages of a Penile Prosthesis

Getting the prosthesis involves an operation.  It is successful for most men.  However the most common complications are infections and malfunctions.  Because the prosthesis is a “foreign body” if it gets infected, it is virtually impossible to treat, without removing and replacing the prosthesis.  A goopy layer of bacteria and its by-products surrounds the prosthesis and prevent antibiotics from getting in.  A small percentage of implants malfunction over the years and need to be replaced.

Who should get a Penile Prosthesis?

In our mind, men should at least try all of the other non-surgical methods before getting a penile prosthesis.  In medicine, we usually start from least invasive and move to more invasive options, as necessary, when deciding on treatment, and ED is no exception to that rule.

Herbal Alternatives for Treating ED

For many years, Yohimbe, which is found in Rubaceae and related trees, was considered an impotence remedy. The efficacy of Yohimbe has been debated for a number of years. Many studies have concluded that it is no better than a placebo. Others have concluded that it does improve erections, though modestly. It is still occasionally used for men with very mild erectile dysfunction, especially when a lack of desire and psychological factors are major issues.

A multitude of multivitamins or herbal supplements are marketed for erectile dysfunction. At the moment, there are no reliable studies that prove the efficacy of any of these medications. The supplement combinations are not regulated by the FDA, and there are those that may be not only ineffective, but also harmful. Some include hormones, which remain controversial when used by patients with normal hormone levels, and are possibly dangerous.

Herbal supplements must be viewed with a fair amount of caution and skepticism until there is evidence that they are safe and effective, and that the medications actually contain what the bottle says they do.


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