Integrative Therapies for Erectile Dysfunction

By Luke Fortney, MD. Dr. Fortney is Assistant Professor, University of Wisconsin-Madison, Department of Family Medicine; he reports no financial relationship to this field of study.

Erectile dysfunction (ED) is the most common sexual problem in men, affecting up to one-third at some point in their lives. It is defined as the inability to achieve or maintain a sufficient erection for satisfactory sex. The prevalence of ED increases with age1 and is associated with poor cardiovascular health, psychosocial factors, hormonal disorders, recreational drug abuse, and adverse effects from prescribed medications. Anatomic, traumatic, or infectious causes are less commonly involved.2

Normally, an erection is stimulated by a combination of neurovascular, hormonal, psychological, and situational factors beginning with sexual interest and desire. Through parasympathetic activation, endothelial cells are directly activated to produce nitric oxide (NO), which relaxes endothelial smooth muscle and engorges the corpus cavernosum with arterial blood while venous return is simultaneously restricted.3

An integrative approach views the presentation of ED as an opportunity to improve health and reverse the progression of cardiovascular disease, which is the main risk factor for ED. As such, the evaluation and treatment of ED should be sensible, safe, and start with lifestyle. The World Health Organization and American Urological Association recommend using the five-item International Index of Erectile Function Questionnaire (IIEF-5) to assess the patient's concerns and symptoms, and as a precursor to determining treatment options and expectations.4 An integrative approach should begin by identifying those contributing factors that interfere with the body's optimal functioning and natural healing processes. Several classes of medications and substance abuse — particularly alcohol, tobacco, and marijuana — are common culprits.5 Blood pressure, BMI, and weight/abdominal girth measurements are quick but sensitive tools that assess and monitor cardiovascular health.

Lifestyle Modification

There is a strong association between chronic diseases of lifestyle and ED, and it is essential that treatment emphasize weight loss, healthy nutrition, and regular exercise.2,5 Research shows that men with ED are at significant risk for cardiovascular disease.6-11 One study found that ED symptoms present on average 3 years earlier than symptoms of coronary artery disease.10 Conversely, adequate blood pressure control is associated with a lower prevalence of ED, particularly in older patients.11 Similarly, metabolic syndrome seems to play an important role in the etiopathogenesis of ED.6 For men diagnosed with diabetes mellitus, ED prevalence is as high as 89%.12,13 Further, both obesity and smoking nearly double the risk of ED,1,12,14 and alcoholism is a well-known contributor to ED symptoms.15 Identifying ED presents the opportunity to use an integrative medicine approach that strongly emphasizes healthy lifestyle and mind-body modifications.12,16 One study found that men who seek treatment for ED may prefer alternatives such as lifestyle changes to pharmaceutical intervention.17 Even though there is no validated exercise or nutrition regimen that specifically treats ED, exercise and nutrition should be tailored to each patient's specific needs without being extreme, heavily restrictive, or overwhelming. Other lifestyle recommendations include regular dental care, such as flossing, which may be beneficial for prevention of cardiovascular disease and ED.18 In addition, prolonged (more than 3 hours weekly) or frequent bike riding may inhibit neurovascular flow to the perineum, thereby negatively influencing ED. In these patients, a trial of rest, change in exercise routine, or cycling adaptations — such as a split seat or recumbent posture — can be tried.

For those men lacking organic etiology of ED as determined through medical evaluation, psycho-social-spiritual interventions should be pursued skillfully. It is important to recognize that sexual desire, arousal, and climax are mediated through complex psychoneurological mechanisms. Triggers and causes of ED symptoms can include anxiety, depression, PTSD, excessive worry and guilt, sex abuse history, relationship strain, performance anxiety, postsurgical adjustment disorder, and many other general stresses.19-23 Although psychological interventions are recognized as a SORT (Strength of Recommendation Taxonomy) category B for ED, there is insufficient evidence to specifically recommend art therapy, hypnosis, aromatherapy, meditation, or guided imagery.19 However, appropriate methods that enhance the relaxation response and encourage self-reflection should be adapted individually and encouraged as needed.16,22

Pharmaceutical Treatments

Targeted pharmaceutical options begin with phosphodiesterase (PDE5) inhibitors such as sildenafil, vardenafil, and tadalafil, which are widely recognized as SORT category A first-line treatment options for ED.24 Even though PDE5 inhibitors are generally safe, effective, and well tolerated,25 approximately one-third of men do not respond to them. Prescriptions should include warnings about prolonged and painful erections, worsening or development of Peyronie's symptoms, and other drug interaction precautions. It also must be clarified that these agents are not considered effective for improving libido.26 However, PDE5 activity is testosterone dependent — research data show that testosterone supplementation in hypogonadism (prevalence 5%-15%) is superior to placebo in improving erections, sexual function, and libido.27-29 Testosterone supplementation with either compounded bioidentical testosterone or pharmaceutical brands should be used cautiously and monitored regularly by a physician. Further escalation of treatment for unique or refractory cases may rely on the self-administered prostaglandin E1 agent alprostadil.

Herbal and Dietary Supplements

In general, supplements are less effective for treating ED when compared to pharmaceutical options.30 Further, in 2007, the FDA issued a statement warning consumers to avoid use of impotence supplements.31 Health care providers should counsel patients to avoid e-mail promotions and Internet advertisements for these and other products that falsely claim to enhance male libido and sexual function. Many of these products are contaminated or adulterated and are not considered reliable or safe for use.32,33 Other products may be safe but ineffective.19,30 However, there is some evidence for the judicious use of high-quality dietary supplements that may be considered in appropriate situations.

Yohimbine is likely the most effective supplement for treating ED; however it has significant interactions with medications. There also are safety concerns in patients with cardiovascular disease, mood disorders, and renal/hepatic disease among others. Yohimbine, although effective, should be avoided for most patients.30,34-37 L-arginine in combination with pycnogenol has demonstrated additive effectiveness in treating ED when taken in respective doses of 1000 mg and 40 mg three times a day. Response to this treatment may take up to 12 weeks of consistent daily use, and the combination should be used with caution in patients with gout, asthma, vertigo, and concomitant warfarin use.38-40 Panax ginseng (Asian or Korean) 1000 mg three times a day may be helpful, and there are topical creams available that may also help with premature ejaculation.30,41-43 For men with documented low dehydroepiandrosterone (DHEA) or testosterone levels, DHEA supplementation at 50 mg daily may be helpful in improving ED symptoms. However, treatment response may take up to 24 weeks. Caution should be used in patients with sleep disturbance, bipolar disorder, acne, and gynecomastia. DHEA treatment seems to be more helpful in men who are also diagnosed with hypertension, but less effective in men with diabetes.44,45 Ginkgo biloba has mixed evidence, but 60-120 mg twice a day may be helpful in treating ED due to antidepressant side effects. Ginkgo should be used cautiously with aspirin or warfarin due to potentiating drug interactions.46,47 Propionyl-L-carnitine also has mixed evidence, but may be most helpful in improving sildenafil effectiveness in men who have undergone prostate surgery when taken at 1000 mg twice a day. It also may be an adjunctive option to support sildenafil response in men with diabetes.48,49 Other agents, such as epimedium (horny goat weed), saffron, and pomegranate, are considered safe but evidence is lacking for efficacy in ED treatment.50-54


Other treatment and adjunctive integrative approaches include vacuum erection/constriction devices (VED/VCDs). For those men who are comfortable, motivated, and open-minded to this approach, VED/VCDs have shown promise in postsurgical, structural (Peyronie's), and prostate cancer radiation rehabilitation.55,56 Satisfaction rates for VED/VCD use are higher than 80% when used appropriately, but the device should be avoided in men with severe Peyronie's, sickle cell disease, or other bleeding disorders.57 Patients who elect this treatment option should be counseled by a trained health care worker experienced with VED/VCDs.

Acupuncture and Traditional Chinese Medicine

Evidence is generally lacking for acupuncture to treat ED.58 Further, evidence also is lacking for massage, osteopathic and chiropractic manipulation, yoga, energy medicine, physical therapy, and Alexander technique for the specific treatment of ED.19 However, these and other methods should be adapted individually and encouraged as part of a larger individualized health plan when appropriate.16 Comprehensive treatment plans that encourage greater overall health and self awareness can be facilitated through Ayurveda, traditional Chinese medicine, and naturopathy. However, there is insufficient evidence to recommend specific treatments within these disciplines for ED, and caution should be used to avoid complex, overstated, and costly treatments. Various detoxification programs also should be approached skeptically.


Although ED is not a life-threatening disease, it does portend underlying health risk and should be approached skillfully. An integrative approach sees the patient as an active contributor to the treatment process, and strongly emphasizes both mind and body interventions that take the whole person, including beliefs and preferences, into consideration. Treatment of ED starts with the therapeutic relationship and emphasizes lifestyle changes that more appropriately address the root of the problem in which ED symptoms are only a part. Although pharmaceutical agents are effective, other options should also be considered when appropriate. Caution should be used regarding supplements, particularly those brands that are not verified or third-party tested for quality. Safety and multimedia marketing scams for sex enhancement products continue to be problematic and should be avoided. Finally, maintaining communication with timely follow-up is important to ensure that each patient's concerns are being addressed adequately, noting that ED is a sensitive and often missed diagnosis.


1. Bacon CG, et al. Sexual function in men older than 50 years of age: Results from the health professionals follow-up study. Ann Intern Med 2003;139:161-168.

2. Montague DK, et al. Chapter 1: The management of erectile dysfunction: An AUA update. J Urol 2005;174:230-239.

3. Kim NN. Vascular physiology of erectile function. In: Kirby R, et al, eds. Textbook of Erectile Dysfunction. 2nd ed. New York: Informa Healthcare USA; 2009: 35-41.

4. Rosen RC, et al. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. Int J Impot Res 1999;11:319-326.

5. McVary KT. Clinical practice. Erectile dysfunction. N Engl J Med 2007;357:2472-2481.

6. Aktas BK, et al. Impact of metabolic syndrome on erectile dysfunction and lower urinary tract symptoms in benign prostatic hyperplasia patients. Aging Male 2010;14:48-52.

7. Kostis JB, et al. Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference). Am J Cardiol 2005;96:313-321.

8. Thompson IM, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA 2005;294: 2996-3002.

9. Chew KK, et al. Erectile dysfunction as a predictor for subsequent atherosclerotic cardiovascular events: Findings from a linked-data study. J Sex Med 2010;7:192-202.

10. Inman BA, et al. A population-based longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clin Proc 2009;84:108-113.

11. Cordero A, et al. Erectile dysfunction may improve by blood pressure control in patients with high-risk hypertension. Postgrad Med 2010;122:51-56.

12. Holden CA, et al. Windows of opportunity: A holistic approach to men's health. MJA 2010;192:708-711.

13. el-Rufaie OE, et al. Sexual dysfunction among type II diabetic men: A controlled study. J Psychosom Res 1997;43:605-612.

14. Johannes CB, et al. Incidence of erectile dysfunction in men 40 to 69 years old: Longitudinal results from Massachusetts male aging study. J Urol 2000;163:460-463.

15. Dissiz M, Oskay UY. Evaluation of sexual functions in Turkish alcohol-dependent males. J Sex Med 2010;doi: 10.1111/j.1743-6109.2010.02091.

16. Fortney L, et al. Introduction to integrative primary care: The health-oriented clinic. Prim Care 2010;37:1-12.

17. Wentzell E, Salmeron J. You'll "get viagraed:" Mexican men's preference for alternative erectile dysfunction treatment. Soc Sci Med 2009;68:1759-1765.

18. Zadik Y, et al. Erectile dysfunction might be associated with chronic periodontal disease: Two ends of the cardiovascular spectrum. J Sex Med 2009;6:1111-1116.

19. Impotence and related conditions. Levels of scientific evidence for specific therapies. Natural Standard: The Authority on Integrative Medicine. Available at: Accessed March 22, 2011.

20. Smith JF, et al. Sexual function and depressive symptoms among male North American medical students. J Sex Med 2010;7:3909-3917.

21. Shabsigh R, et al. Lack of awareness of erectile dysfunction in many men with risk factors for erectile dysfunction. BMC Urol 2010;10:10-18.

22. Melnik T, et al. Psychosocial interventions for erectile dysfunction. Cochrane Database Syst Rev 2007;18(3):CD004825.

23. Spark RF, et al. Impotence is not always psychogenic. Newer insights into hypothalamic-pituitary-gonadal dysfunction. JAMA 1980;243:750-755.

24. Carson CC, Lue TF. Phosphodiesterase type 5 inhibitors for erectile dysfunction. BJU Int 2005;96:257-280.

25. Rendell MS, et al. Sildenafil Diabetes Study Group. Sildenafil for treatment of erectile dysfunction in men with diabetes: A randomized controlled trial. JAMA 1999;281:421-426.

26. Goldstein I, et al. Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998;338:1397-1404.

27. Salom MG, Jabaloyas JM. Testosterone deficit syndrome and erectile dysfunction. Arch Esp Urol 2010;63: 663-670.

28. Shabsigh R, et al. Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone. J Urol 2004;172:658-663.

29. Jain P, et al. Testosterone supplementation for erectile dysfunction: Results of a meta-analysis. J Urol 2000;164:371-375.

30. Shamloul R. Natural aphrodisiacs. J Sex Med 2010;7: 39-49.

31. U.S. Food and Drug Administration (FDA). FDA Warns Consumers Not to Use Super Shangai, Strong Testis, Shangai Ultra, Shangai Ultra X, Lady Shangai, and Shangai Regular (also known as Shangai Chaojimengnan). Available at: Accessed March 22, 2011.

32. Cortes-Gonzalez JR, et al. The use of Butea superba (Roxb.) compared to sildenafil for treating erectile dysfunction. BJU Int 2009;105:225-228.

33. Montorsi F, et al. Effect of yohimbine-trazodone on psychogenic impotence: A randomized, double-blind, placebo-controlled study. Urol 1994;44:732-736.

34. O'Mathùna DP. "Herbal viagra" should be shunned. Altern Med Alert 2010;13:85-89.

35. Carey MP, Johnson BT. Effectiveness of yohimbine in the treatment of erectile disorder: Four meta-analytic integrations. Arch Sex Behav 1996;25:341-360.

36. Ashton AK. Yohimbine in the treatment of male erectile dysfunction. Am J Psychiatr 1994;151:1397.

37. Ernst E, Pittler MH. Yohimbine for erectile dysfunction: A systematic review and meta-analysis of randomized clinical trials. J Urol 1998;159:433-436.

38. Ledda A, et al. Investigation of a complex plant extract (Prelox) for mild to moderate erectile dysfunction in a randomized, double-blind, placebo-controlled, parallel-arm study. BJU Int 2010;106:1030-1033.

39. Stanislavov R, Nikolova V. Treatment of erectile dysfunction with pycnogenol and L-arginine. J Sex Marital Ther 2003;29:207-213.

40. Durackova Z, et al. Lipid metabolism and erectile function improvement by Pycnogenol, extract from the bark of Pinus pinaster in patients suffering from erectile dysfunction — a pilot study. Nutr Res 2003;23:1189-1198.

41. Kim TH, et al. Effects of tissue-cultured mountain ginseng (Panax ginseng CA Meyer) extract on male patients with erectile dysfunction. Asian J Androl 2009;11:356-361.

42. Choi HK, et al. Clinical study of SS-cream in patients with lifelong premature ejaculation. Urol 2000;55: 257-261.

43. Hong B, et al. A double-blind crossover study evaluating the efficacy of Korean red ginseng in patients with erectile dysfunction: A preliminary report. J Urol 2002;168:2070-2073.

44. Reiter WJ, et al. Dehydroepiandrosterone (DHEA) in the treatment of erectile dysfunction: A prospective, double-blind, randomized, placebo-controlled study. Urol 1999;53:590-595.

45. Reiter WJ, et al. Dehydroepiandrosterone in the treatment of erectile dysfunction in patients with different organic etiologies. Urol Res 2001;29:278-81.

46. Wheatley D. Triple-blind, placebo-controlled trial of Ginkgo biloba in sexual dysfunction due to antidepressant drugs. Hum Psychopharmacol 2004;19:545-548.

47. Kang BJ, et al. A placebo-controlled, double-blind trial of Ginkgo biloba for antidepressant-induced sexual dysfunction. Hum Psychopharmacol 2002;17:279-284.

48. Gentile V, et al. Preliminary observations on the use of propionyl-L-carnitine in combination with sildenafil in patients with erectile dysfunction and diabetes. Curr Med Res Opin 2004;20:1377-1384.

49. Cavallini G, et al. Acetyl-L-carnitine plus propionyl-L-carnitine improve efficacy of sildenafil in treatment of erectile dysfunction after bilateral nerve-sparing radical retropubic prostatectomy. Urol Nov 2005;66:1080-1085.

50. Qinna N, et al. A new herbal combination, Etana, for enhancing erectile function: An efficacy and safety study in animals. Int J Impot Res 2009;21:315-320.

51. Dell'Agli M, et al. Potent inhibition of human phosphodiesterase-5 by icariin derivatives. J Nat Prod 2008;71:1513-1517.

52. Shamsa A, et al. Evaluation of Crocus sativus L. (saffron) on male erectile dysfunction: A pilot study. Phytomedicine 2009;16:690-693.

53. Safarinejad MR, et al. An open-label, randomized, fixed-dose, crossover study comparing efficacy and safety of sildenafil citrate and saffron (Crocus sativus Linn.) for treating erectile dysfunction in men naïve to treatment. Int J Impot Res 2010;22:240-250.

54. Forest CP, et al. Efficacy and safety of pomegranate juice on improvement of erectile dysfunction in male patients with mild to moderate erectile dysfunction: A randomized, placebo-controlled, double-blind, crossover study. Int J Impot Res 2007;19:564-567.

55. Bosshardt BJ, et al. Objective measurement of effectiveness, therapeutic success and dynamic mechanisms of the vacuum erection device. Br J Urol 1995;75:786-791.

56. Pahlajani G, et al. Vacuum erection devices revisited: Its emerging role in the treatment of erectile dysfunction and early penile rehabilitation following prostate cancer therapy. J Sex Med 2010;doi:10.1111/j.1743-6109.2010.018841.x.

57. Baltaci S, et al. Treating erectile dysfunction with a vacuum tumescence device: A retrospective analysis of acceptance and satisfaction. Br J Urol 1995;76:757-760.

58. Lee MS, et al. Acupuncture for treating erectile dysfunction: A systematic review. BJU Int 2009;104:366-370.