Since many patients fail to seek medical attention and many physicians do not ask about sexual health, the exact true prevalence of erectile dysfunction in the US is difficult to ascertain.

From the best available data, it is estimated that between 40 and 70 years of age, 52% of men have erectile dysfunction.

This translated to between 30 and 50 million men in the US and globally the figure is 150 million with erectile dysfunction.

At age 40, 40% on men are affected with ED, while at age 70, greater than 70% report erectile dysfunction.

By the year 2025, the worldwide prevalence of ED is predicted to be 322 million.

What is Erectile Dysfunction?

The definition of ED is defined as the failure to achieve or maintain a rigid penile erection suitable for sexual intercourse. This problem should be present for greater than 6 months. The term erectile dysfunction was formerly termed impotence.


ED can be a symptom of a wide range of underlying pathologies. ED is considered a cardiovascular risk factor. Any disease process that affects the penile arteries, nerves, smooth muscle tissue, corporal endothelium or tunica albuginea can cause erectile dysfunction.

This condition is closely related to cardiovascular disease, diabetes mellitus, hyperlipidemia, and hypertension.

Although the organic diseases are the primary cause of erectile dysfunction, primary psychological issues, particularly in younger men, can be the cause or at least be a secondary etiology.

Other causes of erectile dysfunction include neurological diseases, hormonal diseases, traumatic, hyperlipidemia, stroke, sleep apnea, glaucoma, multiple sclerosis, depression, prostatic diseases, radiation treatments and post-surgical procedures.

A variety of medications can cause ED. Well know are the antidepressants, antihypertensives, antipsychotics, pain medications such as opioids and recreation drugs.

Cardiovascular Disease

Cardiovascular Disease is a significant risk factor for ED. At least 50% or more of patients with known catheterization proven heart disease have ED. Part of the reason is the coronary arteries and the penile arteries are similar in size and develop atherosclerotic problems similarly. The cavernosal arteries are smaller and can develop blockages earlier resulting in vasculogenic ED years before the development of clinical coronary vascular disease. Both cardiovascular and ED involve endothelial dysfunction.

ED often precedes coronary artery disease, myocardial infarctions and strokes by 5-10 years. Younger men with ED have up to a 50-fold increase in cardiovascular disease in later life.

In a meta- analysis of 14 studies, totaling over 90,000 patients, men with ED had 44% more cardiovascular events, 62% more heart attacks, 39% more strokes, and 25% more deaths compared to those who did not have ED.

The risk factor associated with ED is equivalent to that of smoking.

Prescription Drugs

25% of all the cases of erectile dysfunction is thought to be due to prescription drugs. Of the 12 most commonly prescribed drugs in the US, 8 have been associated with ED.

  • Most all antidepressants especially serotonin reuptake inhibitors
  • Cimetidine
  • Ketoconazole
  • Spironolactone
  • Almost all antihypertensives including thiazide diuretics
  • Finasteride and Dutasteride accounted for 46% of ED reports
  • Simvastatin and Atorvastatin (cholesterol medications)

Riding a Bike?

The role of bike riding in ED is controversial. The seat can place considerable pressure directly on the perineal nerves and the pudendal cavernosal arteries which suggests it could be a potential problem causing ED. In a 2020 meta- analysis of 3330 cyclists compared to 1524 non cyclists as controls, there was a significant increased risk found in the cyclists.


The critical process in an erection is the relaxation of the intracavernosal smooth muscle. This process permits increased blood flow into the corpora cavernosa, which fills and compresses the emissary veins and reducing the venous outflow. Signals travel through the parasympathetic nervous system to the S2-4 sacral plexus then to the penis via the carvernosal nerves. Nitric oxide is released in the nerve terminals initiating the erectile process while nitric oxide from endothelial cells acts to maintain it.

Nitric oxide stimulates the production of cyclic GMP. Cyclic GMP opens potassium channels and closes calcium channels. Low calcium results and this increases arterial blood flow.

The overall process results in a rigid erection with minimal blood flow into or out of the penis. When the cyclic GMP degrades, the smooth muscle contracts again and the process is reversed.

Therefore, this entire process is a complex series, dependent on blood flow and nerve function.


Initial treatment of ED is reviewing the general health status and initiating lifestyle modifications where necessary.

  • Increase physical activity
  • Nutritional changes where necessary
  • Stop alcohol abuse, smoking and other drugs
  • Control other diseases such as diabetes, hypertension and cholesterol
  • Weight loss where necessary
  • Phycological counseling
  • Review prescription drugs and change if indicated

L-arginine supplements have been proven to increase nitric oxide in the body. This supplement is the substrate for producing nitric oxide synthase which is the enzyme that produces nitric oxide.

Eroxon is a gel and the only OTC product with a FDA recommendation for treating ED. This gel when applied to the penis, provides a rapid cooling and stimulates the nerves resulting with smooth muscle relaxation. This enhances blood flow to the corpora promoting erectile function.

Oral Phosphodiesterase 5 Inhibitors, such as Viagra and Cialis, (sildenafil and tadalafil) are usually the first line of oral medications given for ED. They work by decreasing the degradation of cyclic GMP. This action increases the relaxation of the cavernosal smooth muscle and intracavernosal arterial blood flow.

Side effects are common. About 40% or more have headache, indigestion, nasal stuffiness and visual changes. These meds can cause significant low blood pressure when taken with alpha blockers and other antihypertensives. Tachyphylaxis is common with prolonged use. That means, higher doses are needed to get the same results until these drugs no longer produce an erection.

Testosterone supplementation is used for proven hypogonadism with low libido. Testosterone is not a primary treatment for ED.

Vacuum Devices can be used to cause a negative pressure around the penis and subsequently engorges the corpus with blood. An elastic band is then placed around the penis to maintain the erection.

Intraurethral and intracavernosal Prostaglandin E1- these are delivered as a urethral suppository or an injection into the penis. These stimulate smooth muscle relaxation, vasodilation and erections. Side effects include urethral burning from the suppositories and pain, bleeding, priapism, bruising and scarring formation at the injection site with using the injection route.

Penile Surgery where a prosthesis is placed inside the corpus. There are two types, inflatable and malleable. Complications from these devices include erosion, infection, leakage and mechanical failure.

Shock Wave Therapy has been used in various medical fields for years to treat different conditions. It was initially used to remove blockages from kidney stones. The waves were directed at the stones and they were decimated. The second application of shock waves was in coronary artery disease where arterial blockages were removed with shockwave treatment.

Today, shockwaves are used in a multitude of medical applications including musculoskeletal and soft tissue injuries, tendinopathies, osteoarthritis and aesthetics. Numerous studies have emerged showing promising results in the treatment of vascular origin erectile dysfunction.

Shockwaves promote blood flow and stimulate the release of vascular growth factors that induce angiogenesis such as vascular endothelial growth factor. Also, shockwaves increase and improve the microcirculation, nerve regeneration, and remodel erectile tissue with an increase in the muscle-collagen ratio and the reduction of inflammatory processes and cellular responses to stress in the microenvironment.

In an umbrella review of five systemic meta-analysis, that encompassed 56 total studies with a patient population of 3908 patients with ED, it was concluded that shock waves enhanced erectile function in patients with ED regardless of the severity of the dysfunction. The findings indicated that shock waves were effective in enhancing penile hardness at erection and subsequently enhancing the quality of life for men suffering from this condition.

Furthermore, there was a significant increase from baseline values in the hemodynamic function of the penis following treatment application. These results suggested a hemodynamically increased function in patients with vasculogenic erectile dysfunction.

What is LIPUS Therapy?

Lipus Therapy is acronym for Low Intensity Pulsed Ultrasound Therapy. This therapy is from a device which produces low energy ultrasound waves in individual bursts. These waves can be directed into localized damaged body tissues stimulating and enhancing the regeneration of the damaged tissue. In the case of erectile dysfunction, this Lipus treatment promotes vascular repair by increasing blood flow and nerve repair.

This treatment can be used in other tissues and musculoskeletal applications such as plantar fasciitis, shoulder and joint tendinopathies. This is a painless, noninvasive method to improve the quality of many conditions.

Shockwaves have been proven to modulate the vascular status, stimulate angiogenesis and neurogenesis, decrease pro-inflammatory mediators and reduce pain. In erectile dysfunction, shockwaves provide a noninvasive, drug free option to many suffering from this problem. However, the shockwave devise was initially only available to large medical centers or clinics. Cost was also out of reach of many.

As with many pieces of equipment, from computers to calculators and now low intensity shockwave devices, the cost is now affordable and available for home personal use.

Juventix Regenerative Medical, in collaboration with Fluent, are proud to offer the personal, handheld Fluent EDX device. This device is easy to use and LIPUS treatments can be performed in the comfort and privacy of your own home. Once out of reach economically, the EDX is the lowest cost shockwave device available in the US. Multiple studies confirm the efficacy of the treatments with the EDX for erectile dysfunction. This device has three application settings, therefore the shockwaves can be applied to a myriad of other musculoskeletal problems, so not just for the treatment of ED.


Regenerative Regards,

Dr. Robert McGrath



Am J Mens Health 2019 Mar-Apr;13(2):1557988319846749 PMID 31027441

J Coll Physicians Sur Pak 2022 Sep;32(9):1181-1186 PMID 36089717

J Pers Med 2024 Feb:14(2):177 PMID 38392610

Sex Med 2022 Oct;10(5):100543 PMID 35843193

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