Not long ago, "erection" wasn’t spoken in public. Now, thanks to erectile dysfunction drug marketing, it shouts out to you from the radio and TV, in magazines and on the Internet.

But how can you decide when to get help and learn what the best treatment option is for you?

Hossein Mirheydar, M.D., a urologist with Sutter Medical Foundation in Santa Rosa, sees many men with this condition. “Erectile dysfunction affects one in five American men, which means that we have 30 million American men with impotence,” he says. “We need to spread the word about all the treatment options available, including penile implants, which have a 97 percent satisfaction rate.”

Although the introduction of Viagra in 1998 started the discussion about erectile dysfunction with patients, even now, Dr. Mirheydar sees many patients who do not know about treatment options or have misconceptions about erectile dysfunction. Here are the facts.

Erectile Function is Variable

Erectile function changes over time. You should expect some "erectile dysfunction" – or loss of firmness of the penis – as you age. Among men aged 40 to 70, at least half will experience changes in their erections.

Stress, lack of sleep, anxiety and overall health status all contribute to sexual health, Dr. Mirheydar explains. Occasional failure to achieve an erection is normal. However, you shouldn’t wait to talk to your doctor about it if it begins to impact your relationships and quality of life, or if you notice a sudden change in your energy, libido and mood.

Low testosterone or other male hormone (androgen) changes can be a concern, especially if you’ve gone through cancer treatment, have taken long-acting opioids for pain for several years, or used illicit steroids, Dr. Mirheydar says.

ED as a Warning

Erectile dysfunction can also be an important warning sign of serious health problems. An erection occurs when blood flows into the penis, so problems with an erection can mean problems with blood flow, overall.

"The diameter of the common penile artery is only 3 mm while the diameter of the coronary artery is 4 to 5 mm, so the first place where the hardening and blocking of the arteries will stop blood flow is not in the heart but in the penis," he says. "Erectile dysfunction can be like a warning for heart attack."

Dr. Mirheydar has all his patients in their early 40s and 50s who present with erectile dysfunction get a cardiac stress test from a cardiologist. Many are found to be at risk for a heart attack and stroke and are started on life-saving medications and prescribed lifestyle changes.

He also typically has younger patients tested for diabetes and finds that many are either pre-diabetic or diabetic already. "It is really incumbent on urologists to be the advocates for men because we tend to see them earlier than other physicians in our networks of care," he says.

Help is Available

Dr. Mirheydar says there are many treatment options available beyond the heavily advertised oral medications such as Viagra (sildenafil) and Cialis (tadalafil). These include vacuum erection devices, penile suppositories like Muse (alprostadil) and injections that can increase blood flow to the penis. 

In addition, one option men tend to overlook is a penile implant. Dr. Mirheydar is specially trained in penile implant surgery and has published research examining long-term outcomes for such surgeries.

"The satisfaction rate with penile implants is very high because six weeks after surgery, they have a very natural feeling erection that lasts as long as they want," he says. "They are some of the happiest patients I treat."

Modern penile implants are reliable and typically last 10 years or more before any type of revision surgery is necessary, Dr. Mirheydar notes. His study in the Journal of Sexual Medicine found that among 5,000 men over 15 years of follow up, 85 percent did not need any type of revision surgery.

"It is great that we have drugs and injections today, but we shouldn’t forget about the fact that we have a safe, reliable procedure as well," he says.

Quality of Life Matters

In our society, sexual health is often seen as less important than other aspects of health and well-being. Yet, it’s important, says Dr. Mirheydar.

"If men wait too long to get treatment, they will notice a significant drop off in penile length and girth to the point that they are less inclined to even have intercourse," he says. "If you are not getting erections, it will be harder and harder to have a happy outcome."

Consider Your Partner

Finally, when thinking about erectile dysfunction, remember that it is about you and your partner.

"Implants, pumps and medications can be helpful, but they don’t increase sexual desire, enhance libido or fix relationships," he says. "I always ask about relationships before I put in a penile implant to make sure the patient is in a healthy relationship.  If the relationship is not doing well and the patient is looking to this procedure to fix the relationship, I will not do the implant."

In addition, Dr. Mirheydar says more and more urologists are moving into treating both partners. If a patient is married, he will typically have the wife come in as part of the counseling so that she can actively support the recovery. She may also possibly be evaluated if she is of an age where conditions such as vaginal dryness and pain with intercourse might be a risk.

"A successful treatment outcome comes with a successful partner outcome," he says. "If a penile implant will give a 65-year-old man a 25-year-old man’s erection, I can’t forget about his 60-year-old wife. I am a big proponent of vaginal estrogen creams and vaginal testosterone creams for women because a good treatment outcome is more than the ability to have an erection. It is a happy couple with a healthy sexual relationship."