Ask the Pharmacist – Men’s Sexual Wellness – Erectile Dysfunction (ED) Edition

January 3, 2024

By: Damian Thrasher

Erectile dysfunction (ED) is the most common form of sexual dysfunction in men, with increased risk between the ages of 40 and 70. It is estimated that at least 30 million men in the United States are dealing with the frustrating experiences of ED.  

Damian Thrasher, PharmD, is Belmar’s clinical expert for ED therapies. Below, Damian answers some of the most common questions about erectile dysfunction and related therapies.  

Q: Is ED a common sign of aging? 

A: Erectile dysfunction can be a consequence of aging.
As we get older, our hormone levels begin to drop. For many men, testosterone levels drop roughly 1% each year after age 30. This can lead to lower libido and a decrease in nitric oxide (N.O.) production, which is needed for an erection.  

Q: How does ED relate to other health conditions? 

A: Many conditions can be connected to ED.
Diabetes, high blood pressure, depression, high cholesterol, and cardiovascular disease are the major players that contribute to erectile dysfunction. These conditions affect blood flow, N.O. production, and nerve signaling necessary to stimulate an erection.  

To address ED, your provider should also evaluate your risk for these other health conditions. Improving the underlying causes that relate to erectile dysfunction, may also help restore sexual function. If you are considered healthy and ED is your only complaint, it’s a sign for your provider to dig a little deeper into your medical screening for cardiovascular issues. ED can be a precursor to cardiovascular events down the road.  

Q: How do I know if I have ED or it’s something else? 

A: ED is the inability to create or maintain an erection for sexual penetration.
It’s not uncommon for men to experience this situation once or twice and nothing comes of it. However, if it continues to occur regularly, there may be an issue worth looking into. Anxiety can also play a huge role in ED. Thinking about erectile dysfunction can manifest itself as ED (psychogenic ED). Look for patterns during intimacy to recognize if this reflects your own experiences and discuss them with your doctor. 

Q: Is testosterone all I need to address ED? 

A: Low testosterone may only play a small role in ED.
Testosterone is connected to a person’s desire for sexual activity (libido), which in turn triggers dopamine and oxytocin release from the brain to increase N.O. for an erection.
In most cases there are other underlying causes for ED. As we get older, disease states are often the primary culprit for ED, with decreased testosterone being just one contributing factor.  

Q: What medication options are available for ED? 

A: There are several different medication options to address erectile dysfunction.
You’ve most likely heard of commercially available oral pills like sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). Compounded forms of these medications as oral or sublingual tablets can be custom made for your individual needs. We offer injectable erectile dysfunction medications, too.  

Q: What is the difference between injectable ED medications and others?  

A: Intracavernosal injections (ICI) are considered second-line therapy.
Injections are typically used when oral medications are not effective. Depending on the type of erectile dysfunction and the presumed cause, your provider can determine if either ICI or oral medications would be a better fit. This decision is based on your medical history and your provider’s expertise. There are conditions where oral medications may not work, and ICIs are the drug of choice. For the creation of an erection, oral medications often need neurologic stimulation to work, but ICIs do not. 

Q: I’ve been diagnosed with ED. How do I know which injectable medication is right for me? 

A: If you and your provider have determined that injectable medications are the way to go, trimix is the gold standard.
This combination of three ingredients can give you the ability to use a lower volume of medication at decreased concentrations. This may allow for fewer side effects and less time spent injecting into the penis.  

Alprostadil (PGE1) is the driving force behind trimix, however, pain is a potential side effect associated with this ingredient. If the discomfort is limiting activity, bimix would be the next option – it’s a combination of ingredients without the Alprostadil. Ultimately, the medication and concentration would be determined by your physician. They understand the degree of erectile dysfunction and your disease states contributing to the issue. See this page for more clinical information about our therapeutic options.

Q: How do I know if I’m doing the injection correctly? How should it feel? Should I feel pain?  

A: Intracavernosal injections should feel like you are injecting into warm butter.
There should be no resistance during an injection. You may feel a little pressure from the needle, but the injection itself should be painless. Any resistance from the injection will most likely be from a vein or scar tissue. Avoiding those areas is key to a smooth, painless injection.  

Q: What should I do if my erection isn’t going away? 

A: Priapism is an erection lasting more than 4 hours.
An erection lasting that long is considered an emergency! Before you reach the 4-hour mark, over-the-counter Sudafed (generic name phenylephrine) or a cold shower may help retract it. Additionally, your provider may prescribe a phenylephrine injection to help bring down the erection before the 4-hour time limit.  

The time to be concerned about priapism is also patient-specific. If the duration of your erections is fairly consistent, anything beyond that timeframe should raise a red flag. (e.g., If an erection normally lasts 45 minutes to an hour, an episode lasting 2 hours could be cause for concern.) 

Q: My ED medication has always worked for me, but the last time it didn’t. Should I be concerned? 

A: It’s expected that ED medications may not work from time to time.
Your mental state may be preventing the drugs from working. External stimuli play a major role in triggering the neuropathic driving force needed to cause an erection. The worsening of existing disease states could also be contributing. If your usual medication stops working for you altogether, it may be time to talk to your doctor and explore other options.