Erectile Dysfunction in Men: The Workup, the Treatments, the Honest Conversation

Most men I see for ED have been carrying it quietly for two or three years before they bring it up. The shame, the assumption that "this is just aging," the not wanting to make a thing of it. None of that is necessary. ED is common. ED is treatable. And ED is often the body telling you something about your cardiovascular health that you would want to know early. Lets walk through whats happening, what actually helps, and how to decide on the right path for your situation.

How an erection actually works

A useful frame, because the treatments make more sense once the mechanism is clear. An erection is a vascular event coordinated by the nervous system. Arousal triggers nerves in the pelvis to release nitric oxide, which signals the smooth muscle in the penile arteries to relax. The arteries open, blood floods in, and the veins compress against the surrounding tissue to keep the blood in place. Sustained erection requires:

1. Working nerves (so the signal gets through)
2. Working arteries and endothelium (so the relaxation happens and blood flows in)
3. Working venous trapping (so blood doesnt leak right back out)
4. Adequate hormonal signaling (testosterone supports the whole cycle)
5. A nervous system not in fight-or-flight mode (anxiety is a potent vasoconstrictor)

ED can come from a problem in any one of those layers, and often it is a few layered together.

The cardiovascular warning angle

The arteries that supply the penis are small (roughly 1 to 2 mm wide). The arteries that supply the heart are larger (3 to 4 mm). Plaque builds up in the small pipes first. Which means ED is often the earliest visible sign that the cardiovascular system has started to age faster than the rest of you. We cover this in detail on the Erectile Dysfunction and Cardiovascular Risk page; the short version is that organic ED in your 40s is a strong predictor of heart events in your 50s, and treating ED without checking the heart is a missed opportunity. This is also why we do not just prescribe a PDE5 inhibitor and send you home. The pill helps the symptom; the underlying biology still needs attention.

The morning erection question

The single most useful clinical question we ask about ED is "do you still wake up with erections, even occasionally?"

• Yes, regularly. The hardware works. The driver is more likely psychological, relational, situational, or hormonal modulation rather than fixed vascular disease.
• Sometimes. Mixed picture. Worth a full workup.
• No, almost never anymore. Suggests organic ED. The vascular, neurogenic, or hormonal cause needs to be characterized.

This single question often saves a lot of unnecessary anxiety and points the workup in the right direction.

A simple way to describe the severity

"Its not great" only gets us so far. Theres a validated five-point scale (the Erection Hardness Score) that gives us a shared vocabulary:

• 0 - no enlargement
• 1 - larger, but not hard
• 2 - hard, but not hard enough to penetrate
• 3 - hard enough to penetrate, but not fully rigid
• 4 - fully hard and rigid

Most men land at a 2 or 3 and want to get back to a 4. Its also a useful clue about cause. If youre a solid 4 on your own or overnight but a 2 with a partner, that gap points more toward a psychological or situational driver than a plumbing problem.

The workup

Most men get a prescription on the first visit without anyone running labs. We run labs.

• Total and free testosterone, SHBG, estradiol. Drawn between 7 and 10 am, fasting. Repeat once before confirming low T, because the day-to-day variation is real.
• LH and FSH if testosterone is low, to clarify primary (testicular) versus secondary (pituitary) causes.
• Prolactin if testosterone is low, libido is markedly down, or there are headaches or vision changes that could point to a pituitary issue.
• HbA1c and fasting insulin. Diabetes and insulin resistance are major drivers of vascular ED.
• Lipid panel with ApoB. Standard cholesterol screening plus the particle count that more directly reflects cardiovascular risk.
• TSH. Both directions of thyroid dysfunction can affect libido and erectile function.
• CBC and CMP as a general screen.
• Vitamin D, ferritin when the broader picture suggests they matter.

If the morning erection answer is "almost never," vascular risk factors are present, or family history is concerning, we also discuss:

• Coronary artery calcium (CAC) score as a low-radiation screen for plaque burden.
• Carotid intima-media thickness or coronary CTA when the picture warrants it.

For some men, the ED conversation becomes the entry point to actually catching cardiovascular disease while it is still preventable.

The FDA-approved medications

The four PDE5 inhibitors all work through the same mechanism (they amplify the nitric oxide signaling pathway), and each has a slightly different profile.

Sildenafil (Viagra)

The original. Dose range 25 to 100 mg, taken 30 to 60 minutes before sexual activity. Half-life roughly 4 hours, so the window is about 4 to 6 hours. Best on an empty or light-meal stomach; a heavy fatty meal delays absorption. Inexpensive as a generic.

Tadalafil (Cialis)

Distinct in two ways. First, the half-life is much longer (about 17.5 hours), giving a 24 to 36 hour window of effectiveness from a single dose. Second, it can be taken as a low daily dose (2.5 to 5 mg) for continuous effect, which many men prefer because it removes the timing question entirely and produces more spontaneous erections. The daily-dose strategy also has a side benefit for benign prostatic hyperplasia (BPH) symptoms, which is why some urologists prescribe it for men with both. Food does not affect absorption.

Vardenafil (Levitra)

Similar profile to sildenafil with a slightly different side-effect distribution. Half-life around 4 to 5 hours. Less commonly prescribed today because the generic landscape has favored sildenafil and tadalafil.

Avanafil (Stendra)

Faster onset (about 15 to 30 minutes) and a more selective receptor profile. Useful for men who get nasal congestion or visual side effects from sildenafil or tadalafil. Currently the most expensive of the four. Heres how the four compare at a glance:

Medication	Onset	Peak effect	Window	Food effect
Sildenafil	30-60 min	~60 min	4-6 hours	High-fat meal delays and blunts it
Tadalafil	30-60 min	~2 hours	24-36 hours	Not affected
Vardenafil	~30 min	~1 hour	4-6 hours	High-fat meal can blunt it
Avanafil	15-30 min	~45 min	4-6 hours	Minimal

One thing worth saying out loud: none of these create an erection by themselves. They turn up the volume on your bodys normal response to arousal, so you still need the stimulation. And if the first attempt disappoints, that isnt always a failed dose. It often takes a couple of real-world tries to find the right drug, dose, and timing. In our practice, the most common starting protocols are sildenafil 50 mg as-needed or tadalafil 5 mg daily. We adjust based on response, side effects, and timing preferences. All four are FDA-approved, all four are prescribed through licensed US pharmacies, and the cost has come down dramatically with generics.

The one hard rule: never with nitrates

This matters more than anything else on the page. PDE5 inhibitors and nitrate medications (nitroglycerin, isosorbide, and the "poppers" sold recreationally) both lower blood pressure, and together they can drop it catastrophically. If you take nitrates for chest pain in any form, PDE5 inhibitors are off the table, full stop. Tell whoever prescribes your ED medication about every heart medication you take. Two other symptoms are emergencies rather than wait-and-see: an erection lasting more than 4 hours (priapism, which can permanently damage the tissue) and any sudden loss of vision or hearing. Either one means stop the medication and get to an ER. These are rare, but they are the reasons this should run through a real clinician rather than a checkout cart.

Is it safe for my heart?

Sex is exercise, so this is a fair question to ask out loud. For most men with stable, well-managed cardiovascular health, PDE5 inhibitors are safe. A useful rule of thumb from the cardiology consensus guidelines: if you can climb two flights of stairs or walk briskly for a few minutes without chest pain or severe breathlessness, your heart can generally handle both sex and these medications. Controlled blood pressure, a stent or bypass done more than a few months ago and cleared by your cardiologist, and mild stable heart disease all sit in the green zone. The slow-down zone is where we get cardiology involved first: a heart attack in the last few months, chest pain that comes on with exertion, uncontrolled blood pressure, advanced heart failure, or a serious arrhythmia. None of that means ED goes untreated forever. It means we treat the heart first and bring the ED treatment in alongside it. And the nitrate rule above is absolute no matter where you land.

When PDE5 alone is not enough

Roughly 70% of men respond well to a PDE5 inhibitor. For the rest, the next steps depend on what the workup showed.

Optimize what's optimizable first

• Testosterone replacement if labs confirmed low T with appropriate clinical context. TRT alone does not usually fix vascular ED, but it improves libido and the response to PDE5 inhibitors.
• Sleep apnea treatment when the apnea picture fits. Untreated OSA suppresses testosterone and impairs vascular function.
• Blood pressure and lipid management. Treating the underlying vascular disease improves the substrate for everything else.
• Diabetes management. Tightening glycemic control improves vascular function over months to years.

Intracavernosal injection therapy

Self-injection of alprostadil (or a tri-mix combination) directly into the corpus cavernosum. Effective in the vast majority of men, including those who fail PDE5 inhibitors. Requires a comfortable conversation, careful titration, and dose calibration in a urology office; we coordinate the referral.

Vacuum erection devices

A mechanical pump that pulls blood into the penis, paired with a constriction ring to keep it there. Non-pharmacologic, low-cost after the initial device purchase, useful as a primary tool or as an adjunct.

Penile implant surgery

The definitive option for men with severe organic ED who have failed medical management. A urology specialty procedure. Outcomes are generally good and satisfaction is high in well-selected patients. We refer to urology when this is the right next step.

What we do not prescribe

A few categories you may see online that we do not provide:

• Compounded "research-grade" peptides marketed for ED (PT-141 / bremelanotide for men, melanotan, kisspeptin). Bremelanotide has a narrow FDA-approved indication in premenopausal women only; it is not approved for ED in men. State medical boards prohibit physician prescribing of non-FDA-approved peptides regardless of how a clinic frames them.
• "Compounded sildenafil/tadalafil troches" and proprietary blends sold by DTC platforms outside the licensed-US-pharmacy framework. The FDA-approved generic medications are inexpensive, reliable, and dispensed through your local pharmacy on a normal prescription.
• Stem cell, PRP, or shockwave clinic offerings for ED. The evidence is mixed to weak, the costs are very high, and the regulatory environment is loose. We discuss the data honestly when patients ask and we do not push them as a first move.

The psychological and relational layer

ED is rarely 100% physical or 100% psychological. Even when the original driver is vascular, anxiety builds on top of the physical issue and creates a feedback loop. A few practical principles:

• Anxiety-driven ED often presents with intact morning erections, normal labs, and a clear situational pattern (worse with new partner, better in established relationship). PDE5 inhibitors can break the anxiety cycle by removing the variable while the underlying confidence rebuilds.
• Relationship strain changes erectile function in ways that medicine cannot fully address. We acknowledge it directly when its part of the picture.
• Pornography and arousal calibration. Many younger men present with situational ED tied to a mismatch between the intensity of internet pornography use and partnered sexual experience. We discuss it without moralizing and offer practical adjustments.
• Therapy referral. When the psychological layer is dominant, sex therapy or general therapy is the right tool. We coordinate.

The lifestyle layer

The same levers that drive cardiovascular health drive erectile function. Improving any of them tends to improve the other.

• Sleep. Untreated sleep apnea is one of the most under-recognized causes of low testosterone and vascular ED. We screen and treat directly when its present.
• Aerobic and resistance training. Improves endothelial function, reduces insulin resistance, supports testosterone. Three to four sessions a week of mixed cardio and strength is a meaningful intervention on its own.
• Alcohol. Acute alcohol impairs erections (the "whiskey dick" effect is real and biological). Chronic heavy use reduces testosterone and worsens vascular function. We dont moralize about it; we look at the numbers.
• Smoking and vaping. Strongly associated with vascular ED through endothelial dysfunction. Worth stopping for many reasons; this is one.
• Body composition. Higher visceral fat increases aromatization of testosterone to estradiol, worsening the hormonal picture. Improving body composition often improves ED measurably.

Guidance from the clinic

"Most men show up for ED already convinced its just aging. Two-thirds of the time, theres a treatable driver underneath, and the conversation about ED becomes the conversation about cardiovascular health, sleep, and the things you actually have leverage on for the next 20 or 30 years."

Actionable Steps in Philly

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Scientific References

1. Goldstein I, et al. "Oral Sildenafil in the Treatment of Erectile Dysfunction." N Engl J Med. 1998.
2. Porst H, et al. "Efficacy and Tolerability of Tadalafil Once Daily in Men with Erectile Dysfunction." Eur Urol. 2006.
3. Inman BA, et al. "A Population-Based, Longitudinal Study of Erectile Dysfunction and Future Coronary Artery Disease." Mayo Clin Proc. 2009.
4. Vlachopoulos C, et al. "Prediction of Cardiovascular Events and All-Cause Mortality with Erectile Dysfunction: A Systematic Review and Meta-Analysis." Circ Cardiovasc Qual Outcomes. 2013.
5. Hatzimouratidis K, et al. "Pharmacotherapy for Erectile Dysfunction: Recommendations from the Fourth International Consultation for Sexual Medicine (ICSM 2015)." J Sex Med. 2016.

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Related at Fishtown Medicine

• Low Libido in Men - the testosterone, sleep, and metabolic workup for low desire
• Premature Ejaculation - the clinical and behavioral approaches that actually help
• Performance Anxiety - the cycle of anxiety and physical response, and how to break it