Erectile dysfunction (ED) is the inability to achieve and sustain an erection firm enough for satisfactory sexual intercourse. Most cases of ED is a symptom of another underlying problem. ED is not considered normal at any age. It may be associated with lack of sexual desire (libido), problem with orgasm (anorgasmia) and ejaculation (premature ejaculation).   

The incidence of ED increases from about 6% in the age group 20-29 years to 50-70% in the age group 40-79 years. Its incidence has been projected to increase globally to over 320 million by the year 2025. Men aged 50-59 years have a 3.6 times higher risk of developing ED as compared to those aged 18-29 years, the risk is even higher (6-7 times) among males older than 70 yr. Age-related hormonal, metabolic and inflammatory as well as increased prevalence of other risk factors for ED in the older population may be responsible for higher incidence of this association. 

India has been dubbed as the impotence capital of the world due to the higher incidence of the life style diseases and probably the largest population of males in the world.  Unfortunately, India is a country where conversations about ED are often a taboo and left unspoken. Women may play a crucial role in ensuring that their partners get timely treatment by visiting the doctor. Surveys have shown that women are becoming more vocal about this issue and encourage their partners to get right treatment at an early stage.

Having trouble of penile erection time to time is not necessarily a cause of concern. However, if ED is an ongoing issue, it can cause stress, affects self-confidence and impairs relationship between sexual partners. ED can also be a sign of underlying health problem and a risk factor for heart disease.

An erection is the result of increased blood flow into the penis. Blood flow is usually stimulated by either sexual thoughts or direct contact with penis. When a man is sexually excited, muscles in the penis relax. This allows for increased blood flow through the penile arteries, filling two chambers inside the penis. As the chambers fill with blood, the penis grows rigid. An erection ends when the muscles contract and the accumulated blood flows out through the penile veins.


Mae West has rightly said “sex is an emotion in motion”.  Male sexual arousal is a complex process that involves the emotions, brain, hormones, nerves, muscles and blood vessels. Stress and psychological problems can cause or worsen the ED. Depression, anxiety, poor communication and relationship problems with partner interfere with the sexual feelings and cause inadequate erection to have successful and satisfactory vaginal penetration.

Physical factors that cause erectile dysfunction are high blood pressure, cardiac diseases, high cholesterol, diabetes, obesity, metabolic diseases, and neurological diseases like stroke, Parkinson’s, and multiple sclerosis. Other causes of ED are smoking, tobacco, chronic alcoholism, drug abuse, sleep disorders, prostate enlargement, prostate cancer, surgery of brain or spinal cord, low testosterone (male hormone) and lack of exercise. It is estimated that about 35% to 75% of men with diabetes will experience at least some degree of erectile dysfunction during their life time.    

Research suggests that avid bikers are more likely to get ED than other athletes. Bicycle seats may put pressure in an area between the anus and scrotum full of arteries and nerves vital to sexual arousal. Excessive viewing of porn is associated with higher incidences of ED.   

There are several medicines that cause erectile dysfunction on long term use. Chronic use of medicines for high blood pressure, diabetes, depression, anxiety, insomnia (loss of sleep), prostate enlargement, seizures (epilepsy), anticancer and hormones are associated with erectile dysfunction.  

Physical causes account for 90 percent of ED cases, with psychological causes much less common.


ED may be a major warning sign of cardiovascular disease. The studies have shown men with ED are at significant risk of getting myocardial infarction (heart attack), stroke or circulatory problems in the legs. ED also causes depression, poor self esteem, lack of confidence and distress in relationship with partners. ED may also cause inability to get partner pregnant.


ED is diagnosed by various clinical examinations and investigations. They include physical examination of penis and testicles for checking sensation, laboratory investigations to screen for diabetes, high cholesterol and hormonal deficiencies, ultrasound to find any issue in blood flow in penis and psychological examination for depression, anxiety etc.      


Patient is advised to routinely check their blood pressure and blood sugar for adequate control. Quit smoking, restrict alcohol, reduce body weight and exercise regularly. It is advisable to get psychological counseling for mental stress, anxiety and depression. Couple counseling is highly recommended if there are issues in relationship with the sexual partner. 


Drugs for ED:

The drugs for ED produce an erection sufficient to start sexual intercourse in about 70% of otherwise healthy men. In addition to Viagra (sildenafil), other ED drugs are include Cialis (tadalafil),  Levitra (vardenafil) and Stendra (avanafil). These drugs improve blood supply to the penis. In combination with sexual stimulation, the drugs can produce an erection sufficient to initiate and complete intercourse. There is also a fast-dissolving form (oral disintegrating tablet) of Levitra called Staxyn, that is put under the tongue. Cialis, is approved for use daily in a dose of 2.5 or 5 milligrams. This helps to produce erections on demand and may also help relieve urinary problems, like difficulty starting urination, that result from an enlarged prostate.

How well do ED pills work?

Results vary quite a bit from one individual to another. A man with nerves or arteries damaged by prostate surgery, diabetes, or cardiovascular disease will not respond as strongly to ED drugs. There are some men in whom none of these drugs work.

How quickly do ED pills work?

The drugs start working between 15 to 60 minutes after oral intake. Viagra and Levitra are advised to be taken  empty stomach for faster and quick absorption. Food alters the absorption of Viagra and Levitra and affect the response.  Cialis and Stendra do not interact with food and can be taken after meals. The onset time determines how soon a person engages in intercourse. Stendra and daily-use Cialis are closest to being an “on demand” erectile drug; using the others requires more planning.

How to use ED pills properly?

Most of the persons complain of poor or lack of efficacy of these drugs. It is mainly due to incorrect use of drugs. The biggest misconception is that these drugs are an on/off switch for erections.  But the drugs don’t work well without sexual stimulation. Person need to be with his partner and have foreplay. Any distraction or thoughts for bills, work or family will interfere with erection and affect response of these drugs. Remember sex starts in the dinning room and ends in bed room.       

How long do ED pills last?

The durations of action range from four hours to more than a day. Each dose should be sufficient to provide a full cycle of intercourse, from erection to climax. To have sex more than once a day, Cialis is the best choice.

What are the side effects of ED pills?

The most common side effects of ED drugs are headache, flushing, stomach upset, nasal congestion, vision problems, diarrhea, dizziness, and rash. If a man has an erection that lasts four hours or more needs to get to a hospital to prevent permanent damage to penis.

None of the ED drugs is safe to take with cardiac drugs called nitrates because it could cause a dangerous drop in blood pressure. It is recommended to take them at least four hours apart from ED drugs.

ED drugs: How soon they start working and how long they last?
sildenafil (Viagra)30-60 minutes4-5 hours
tadalafil (Cialis)30-45 minutes24-36 hours
tadalafil (Cialis) dailycontinuouscontinuous
vardenafil (Levitra)30-60 minutes4-5 hours
avanafil (Stendra)15-30 minutes6-12 hours

Other Treatment:

Alprostadil self-injection: A fine needle is used to inject alprostadil at the base or side of the penis. Sometime this contains a mixture of two or three medicines called bimix or trimix respectively.

Alprostadil intraurethral therapy:   It involves placing a tiny alprostadil suppository inside penis in the penile urethra. The erection usually starts within 10 minutes and lasts between 30 and 60 minutes

Testosterone replacement: Replacement therapy is recommended for patients with lower level of testosterone that otherwise complicates treatment with ED drugs.

Penis pumps and penile implants: If medicines are ineffective or inappropriate for a person, doctor may advise for penis pump (vacuum erection device) or penile implants. Penile implant surgery is  usually not recommended until other methods have been tried and failed.   Some men believe certain alternative medicines taken by mouth can help them get and maintain an erection. However, not all “natural “medicines or supplements are safe. Combinations of certain prescribed and alternative medicines could cause major health problems. To help ensure coordinated and safe care, discuss your use of alternative medicines, including use of vitamin and mineral supplements, with a doctor. Also, never buy a medicine for erectile dysfunction without consultation with your doctor. Don’t book online products for erectile dysfunction without talking to the doctor.