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Another option for treating erectile dysfunction is intraurethral therapy, or as it’s officially known,
medicated urethral system for erections, or MUSE. The medication used in MUSE is alprostadil, which is also one of the drugs used most widely in penile injection therapy. However, MUSE requires no injections.

A small pellet of the medication is introduced into the end of penis, which is known as the urethra, via an applicator consisting of a thin tube at the end of which is the medication. Once the tube is inserted well within the penis, a button on the applicator can be pressed to release the medicated pellet.

Absorbed through the membrane that lines the inside of the urethra, the alprostadil relaxes the blood
vessels that supply the penis, sharply increasing blood flow. An erection usually develops within 10 minutes after the medication is released. The erection almost always lasts for at least 30 minutes and sometimes for up to an hour.

In the late 20th century before the introduction of Viagra, the first of the new wave of ED medications, men looking for ways to treat their ED symptoms had only a couple of options: penile prostheses and penile injection therapy.

According to Boston University School of Medicine, intracavernosal injections gained popularity in the 1980s as a less cumbersome and awkward alternative to penile implants or prostheses. Even with the availability of the new oral ED medications, injection therapy has “withstood the test of time,” according to BU.

This form of therapy involves the self-injection of a small amount of medication directly into the penis’s corpora cavernosa — twin cylinders of spongelike erectile tissue that fill with blood to make an erection.

Your doctor usually administers the first shots to determine optimal dosing level and then supervises as you self-inject the first few times to be sure you’re doing it correctly. Among the medications used
individually or in combination are alprostadil, papaverine, and phenolamine.

Also known as impotence, erectile dysfunction is the inability to get or keep an erection that is firm enough for sexual intercourse, according to AUA Foundation, the foundation of the American Urological Association. While almost all men have an occasional problem achieving and maintaining an erection, the term is most properly used in reference to a chronic pattern of erection difficulties.

While the incidence of ED increases with age, younger men are not immune from the problem, although ED among the young is often psychological in origin rather than physiological.

The risk of ED is greater among those who suffer from underlying medical conditions, such as cardiovascular disease, high blood pressure, diabetes, and obesity. Because both the heart and penis depend on strong blood flow for optimal function, ED sometimes serves as an early warning sign of more serious health problems. Healthy eating and regular exercise can help prevent ED.

Although a number of herbal remedies have been used for centuries to help support erectile function, most have not been scientifically studied adequately to determine definitively whether they work or not. Among those most widely used, Healthline singles out the following:

Panax ginseng has produced promising evidence of its efficacy in small-scale studies. Although the way in which it works is not fully understood, it’s believed to stimulate the body’s production of nitric oxide.

DHEA (dehydroepiandrosterone) is a hormone that your body naturally produces, although in lesser amounts as you age. Synthetic DHEA, manufactured using wild yam and soy derivatives, has helped some men to overcome ED symptoms.

L-arginine is an amino acid found in high-protein foods and also available as a health supplement. It promotes the production of nitric oxide, which is a key player in the erectile process.

Pinus pinaster, a pine tree native to the Mediterranean basin, yields an active ingredient from its bark that is sold under the brand name Pycnogenol. The supplement has helped some with ED, but it is slow-acting and must be taken for some time before results are seen.

To truly understand ED, it’s helpful to know a little about the mechanics of an erection, which usually begins in the brain with feelings of sexual desire. These feelings trigger the release of nitric oxide, a neurotransmitter that sets in motion a relaxation of muscles and allows increased blood flow to the penis.

Breaking these steps down a bit further, we find that the nitric oxide released by the brain in response to feelings of sexual desire sets in motion a chain of chemical reactions that eventually results in an erection. When the nitric oxide reaches the bundle of nerves and blood vessels surrounding the prostate gland, it prompts the guanylate cyclase enzyme to produce cyclic guanosine monophosphate (cGMP), which controls the expansion and contraction of blood vessels that supply the penis. This release of cGMP temporarily expands the arteries that supply the penis and contracts the blood vessels that carry blood away from the penis. This results in an erection.

Also present in the body is the phosphodiesterase-5 enzyme, which under normal conditions breaks down cGMP after an erection. However, sometimes its presence prematurely interferes with the erection process. PDE5 inhibitors temporarily block the effect of the enzyme, which facilitates erection.

The defining symptom of erectile dysfunction is the inability to get and keep an erection that is strong enough — and long-lasting enough — for sexual intercourse, according to WebMD.com. Apart from having difficulty getting and/or keeping an erection, another symptom of ED is a noticeable decline in sexual desire.

If erectile problems occur only occasionally, the problem is unlikely to be a serious one, and the symptoms may be traceable to stress, fatigue, overindulgence in alcohol, drug abuse, or a bout of performance anxiety.

For men who still experience morning erections and have no difficulty getting an erection during masturbation but have trouble getting and maintaining an erection for sexual activity with a partner, the ED symptoms in all likelihood are psychological in origin.

Typically, the onset of chronic impotence is gradual and persistent. Roughly 85 to 90 percent of chronic impotence is physiological in nature. To overcome the problem, these physical causes must be addressed. ED drugs enable men with chronic impotence to engage in sexual activity but do not cure the underlying physical causes of this disorder.

The most common erectile dysfunction drugs, based on U.S. and worldwide sales data, are the PDE5 inhibitors, all of which work by temporarily blocking the effects of an enzyme known as phosphodiesterase-5. The PDE5 enzyme can impede blood flow to the penis and make it more difficult — or even impossible — to achieve and maintain an erection hard enough for intercourse.

Among the PDE5 inhibitors, the best-selling drug in the United States during 2013 was Viagra, which had sales of nearly $1.2 billion. Viagra (sildenafil citrate) was only slightly ahead of Cialis (vardenafil), which had 2013 sales of $1.09 billion in the United States. Two different formulations of Cialis are available in the United States: Cialis for Daily Use and Cialis for Use as Needed. The latter is effective for up to 36 hours.

While Viagra and Cialis had the lion’s share of the ED market in 2013, other impotence drugs available included Levitra and Staxyn (both tadalafil) and Stendra (avanafil).