Erectile Dysfunction (ED)#

ED is when a person has ongoing trouble getting or keeping an erection firm enough for sexual activity. Erections rely on blood vessels, nerves, and hormones all working together, so a problem in any of those systems can affect erections.

Occasional difficulty (after a stressful day, alcohol, fatigue) is normal. ED becomes a clinical concern when the difficulty is consistent or recurring over several weeks or months.

ED is widespread and the chance of having it goes up with age. Roughly:

• About 40% of men in their 40s have some degree of ED.
• The proportion rises by roughly 10% each additional decade.
• More severe ED is less common in younger men and more common in older men.

It is not rare, and it is not something to feel alone about.

ED is usually grouped into three categories that overlap in practice:

• Vascular (blood-vessel) causes - reduced blood flow into the penis. This is the most common cause and is linked to heart-disease risk factors: high blood pressure, high cholesterol, diabetes, smoking, obesity, and inactivity.
• Nerve-related causes - injury or disease affecting nerves to the pelvis (pelvic surgery, prostate surgery, pelvic radiation, multiple sclerosis, spinal-cord injury, long-standing diabetes).
• Hormonal causes - low testosterone, thyroid disorders, raised prolactin.
• Medication-induced - some blood-pressure medications, antidepressants (especially SSRIs), antihistamines, opioids, and certain other prescriptions can contribute.
• Psychogenic causes - stress, anxiety (especially performance anxiety), depression, relationship issues. Often present alongside a physical cause.
• Structural causes - Peyronie's disease (scar tissue in the penis), prior pelvic trauma.

Most men with ED have a mix of contributing factors rather than a single cause.

Yes - and this matters. The blood vessels in the penis are smaller than the arteries supplying the heart. They can show problems with blood flow before larger vessels do. Studies suggest that new or worsening ED can precede a heart event by 3 to 5 years in some men.

That's why our intake includes basic cardiovascular questions before any prescription is issued. New ED in a man with risk factors (high blood pressure, diabetes, family history of early heart disease, smoking) is a reason to check in with a clinician about overall cardiovascular health, not just the erection symptom.

Yes. ED can affect mood, confidence, and relationships. Treating ED often improves more than just sexual function - many patients describe improved overall wellbeing once erections are reliable again. Involving a partner in the conversation, when possible, generally improves outcomes.

TeleTest is a good fit if you:

• Have ongoing trouble with erections (more than a few weeks).
• Are otherwise reasonably healthy.
• Are open to a brief cardiovascular review and, if needed, basic bloodwork.
• Want oral prescription medication for ED.

You'll be better served by in-person care if:

• You have chest pain or shortness of breath with exertion or sex - this needs in-person cardiac assessment first.
• You have active or unstable heart disease (recent heart attack, unstable angina, recent stroke, severe heart-rhythm problems).
• You regularly use nitrate medications (e.g., for chest pain) - oral ED medication is unsafe with these.
• You have a known structural issue (Peyronie's disease, hard plaques in the penis) that hasn't been assessed.
• You're interested in injectable, intra-urethral, or implant treatments - those need an in-person specialist (you would arrange this through your family doctor or a local in-person clinician).
• You have symptoms suggesting low testosterone that need a full hormonal workup - we can do bloodwork, but complex hormonal management is best handled by an in-person specialist arranged through your family doctor.

TeleTest can prescribe oral medication from the PDE5-inhibitor class. This is the first-line, evidence-based treatment for most men with ED. It works by relaxing the smooth muscle and blood vessels in the penis, allowing blood to flow in when there is sexual stimulation.

A few important points:

• The medication does not cause an erection on its own. Sexual stimulation is still needed - it just makes the response more reliable.
• There are multiple medications in this class with different timing and duration profiles. The clinician will discuss which suits your pattern (occasional use vs. daily low-dose use, short-acting vs. long-acting).
• It typically takes a few attempts at the correct dose and timing to know how well a medication works for you.

TeleTest does NOT prescribe:

• Injectable ED medications (intracavernosal injections).
• Intra-urethral pellets.
• Vacuum erection devices (these are available without a prescription).
• Penile implants (surgical).
• Low-intensity shockwave therapy (Li-SWT).

If first-line oral medication doesn't work, you would seek a local in-person urologist (typically arranged through your family doctor) for second-line options.

These medications work by blocking an enzyme (phosphodiesterase type 5, PDE5) that normally breaks down a molecule called cGMP. By keeping cGMP levels higher in the penis, the smooth muscle stays relaxed and blood flows in more readily during sexual stimulation.

Without sexual stimulation, the medication has little to no effect.

Yes. The clinician will discuss the trade-offs:

• Shorter-acting options taken on demand, 30-60 minutes before sex. Effect typically lasts a few hours.
• Longer-acting options that can be taken on demand or as a low daily dose. With daily use, the medication is in your system continuously, so you don't have to plan around timing.

Choice depends on the pattern of your sexual activity, comfort with planning, and any side-effect considerations.

Don't take it if:

• You take nitrate medications (e.g., nitroglycerin for chest pain, isosorbide mononitrate or dinitrate) regularly or occasionally. The combination can cause dangerously low blood pressure.
• You take certain alpha-blockers for blood pressure or prostate symptoms - the combination needs caution and dose adjustment.
• You've had a recent heart attack, stroke, or severe heart-rhythm problem.
• You have uncontrolled high or low blood pressure at rest.
• You have severe liver disease.
• You're allergic to the medication or any of its components.

A few rarer conditions (certain inherited eye conditions, severe vision loss in one eye that came on suddenly) also rule out this class - the clinician will screen for these in the intake.

Most men tolerate this class well. Common, usually mild side effects:

• Headache - the most common side effect; usually mild.
• Facial flushing (warm, red face).
• Stuffy or runny nose.
• Mild indigestion or back pain (more common with the longer-acting option).
• Brief blue tint to vision (rare, usually with one specific medication in the class).

Serious but rare side effects to know about:

• Erection lasting more than 4 hours (priapism) - this is a medical emergency. Go to an emergency department.
• Sudden vision loss or hearing loss - stop the medication and seek urgent care.

Sex is mild-to-moderate physical exertion. For most men, an erection itself isn't a cardiac strain, but the sexual activity that follows is. We need to confirm your heart can handle that level of exertion safely before adding a medication that increases blood flow.

We also screen because the medication can interact dangerously with nitrate medications (used for chest pain). A man taking nitrates for angina should not be on this class of ED medication.

We ask about:

• Chest pain, especially with exertion or sex.
• Shortness of breath climbing stairs or doing moderate activity.
• Recent heart attack, stroke, or hospitalization for heart problems.
• Heart-rhythm problems.
• High blood pressure and how well controlled it is.
• All current medications (so we can check for nitrate use and interactions).
• Family history of early heart disease.

If anything in your answers suggests undiagnosed or unstable cardiovascular disease, the clinician may recommend a check-in with your family doctor or a brief in-person assessment before starting ED medication. This is a safety step, not a refusal.

The clinician may recommend basic bloodwork, especially if you have risk factors or symptoms suggesting an underlying cause:

• Blood glucose / HbA1c - to screen for diabetes, a common contributor to ED.
• Lipid profile (cholesterol panel) - to assess cardiovascular risk.
• Morning total testosterone - if there are symptoms suggesting low testosterone (low libido, fatigue, reduced muscle mass) or if first-line ED medication doesn't work.
• TSH - if thyroid issues are suspected.

Testosterone is best measured on a fasting morning sample (between 7-10 AM, before eating). Testosterone levels fluctuate through the day and are highest in the morning.

The lifestyle changes that help ED are the same ones that help heart and vascular health - which makes sense because the underlying biology overlaps.

• Exercise. Regular aerobic activity (30+ minutes most days) and strength training improve vascular function and erections.
• Weight management. Excess body fat lowers testosterone and increases vascular risk. Even modest weight loss helps.
• Stop smoking. Smoking damages small blood vessels - including those in the penis - and is a major contributor to ED.
• Limit alcohol. Heavy or regular alcohol use depresses the nervous system and can contribute to ED. Cannabis can have similar effects.
• Sleep. Poor sleep and untreated sleep apnea lower testosterone and worsen ED. Get screened for sleep apnea if you snore heavily, wake unrefreshed, or have witnessed pauses in breathing.
• Manage stress and mental health. Anxiety, depression, and relationship strain all affect erections. Therapy or counselling can help, on its own or alongside medication.
• Mediterranean-style eating. Whole foods, vegetables, healthy fats, less ultra-processed food - shown to support vascular health and erectile function.

These supplements are theoretically interesting because they're precursors to nitric oxide, the molecule that triggers blood flow in the penis. Some small studies have shown modest effects, but the evidence is not strong enough to recommend them as a primary treatment.

If you'd like to try them, mention them in your consultation so the clinician can check for interactions. They are generally well-tolerated but should not replace evidence-based treatment if your ED is significant.

Yes, especially when there's a psychological component (performance anxiety, depression, relationship issues, history of sexual trauma). Sex therapy and couples counselling can be very effective and pair well with medication. Many patients find that medication helps break a cycle of anxiety, and counselling helps prevent the cycle from coming back when medication is stopped.

Vacuum devices (sometimes called "penis pumps") are FDA- and Health Canada-cleared and available without prescription. They draw blood into the penis using suction, and a constriction band at the base maintains the erection.

They are a reasonable option for men who can't take or don't respond to oral medication. Effectiveness varies. They are not prescribed by TeleTest - you can buy one directly from a pharmacy or medical-supply retailer.

Li-SWT is offered at some clinics in Canada but is not approved by Health Canada or the US FDA for ED. The research is mixed - some small studies suggest benefit, but larger, higher-quality trials have not consistently confirmed it. Costs can be substantial and are out of pocket.

If you're considering Li-SWT, that's a conversation for a urologist who offers it and can explain the realistic expectations for your situation.

It varies by medication and by person:

• Shorter-acting options typically take effect 30-60 minutes after taking the pill and last a few hours.
• Longer-acting options can start working in 30-60 minutes and last up to 24-36 hours, with the effect tapering over that window.

The medication does not work without sexual stimulation. You may need to try a dose 4-6 times at the right timing to know how well it works for you.

It depends on the specific medication. Some are absorbed slower if taken with a heavy fatty meal. The clinician will give you guidance for the one you're prescribed.

Heavy alcohol intake before sex can blunt the medication's effect (and depress sexual response generally). Light or moderate alcohol is usually fine.

Not necessarily. For some men, ED is reversible with lifestyle changes (weight loss, stopping smoking, treating sleep apnea, better-controlled diabetes). Some men use ED medication only for occasional intercourse and don't need a daily prescription. Others use it long-term.

Treating the underlying cause - rather than just the symptom - usually gives the best long-term outcome.

A few steps before concluding it isn't working:

• Check the timing. Was the medication taken on a full stomach? Heavy meal? Wrong time relative to sex?
• Check the dose. The starting dose isn't always the dose that works. The clinician can adjust.
• Try sexual stimulation again. The medication needs stimulation to take effect.
• Try 4-6 times at the optimised dose and timing before concluding it doesn't work.

If it still doesn't work, the clinician can review your situation and discuss:

• Switching to a different medication within the class.
• Daily low-dose use vs. on-demand.
• Workup for underlying causes (testosterone, vascular assessment, sleep apnea screening).
• Seeking a local in-person urologist (through your family doctor) for second-line options (injectable medications, vacuum device, implant).

Usually yes, as long as the blood pressure is reasonably controlled. The clinician will check that you're not on nitrate medications and that any alpha-blocker dose is appropriate. Mention all blood-pressure medications in your intake.

Generally yes. There are no major interactions between this medication class and common antidepressants. In fact, ED caused or worsened by SSRI antidepressants is a common reason men start this medication, and the combination is generally safe.

If you're on an unusual antidepressant or mood stabilizer, mention it - the clinician will check.

A few important interactions:

• "Poppers" (amyl nitrite, inhaled nitrites) - do not combine with oral PDE5-inhibitor medication. The interaction can cause dangerously low blood pressure.
• Alcohol - moderate use is usually fine; heavy use blunts the medication's effect and the body's sexual response.
• Cannabis - generally safe but can suppress sexual response in some users.
• Cocaine, MDMA, methamphetamine - combinations carry cardiovascular risks beyond what the medication itself contributes. Mention any regular substance use to the clinician.

Honesty in your intake matters more than worrying about judgment - the clinician needs to know to keep you safe.

Coverage varies. Some private drug plans cover ED medication; many do not, treating it as a "lifestyle" medication. Generic options are substantially cheaper than brand names. Provincial health plans generally don't cover ED medication.

If your insurance requires a drug-authorization form, TeleTest can complete it. Select the ED authorization form panel from the Notes, Forms & Referral category, pay for the paperwork, and attach the form to your consultation.

Not directly. Injectable, intra-urethral, and implant treatments need in-person assessment with a urologist. If your ED hasn't responded to oral medication, you would seek a local in-person urologist (typically arranged through your family doctor). TeleTest can do supporting bloodwork (hormones, vascular risk markers) before that visit.

Performance anxiety is a very common cause of ED, especially in younger men with no other risk factors. Medication can help break the anxiety cycle by providing a few successful experiences and rebuilding confidence. Many men find they need the medication less over time, or only situationally.

If anxiety is the dominant driver, therapy or sex counselling alongside (or instead of) medication often works best long term. A clinician can discuss both options.

You pay:

• The TeleTest consultation fee for the assessment and prescription. This is not covered by provincial health plans.
• The medication at your pharmacy. Generic options are substantially less expensive than brand names. Costs vary by pharmacy - independents and warehouse pharmacies (e.g., Costco) are usually lower-cost.

Some private drug plans cover ED medication; many do not. Ask your pharmacist what your plan covers before filling a prescription.

Provincial drug plans generally do not cover ED medication. Some private plans do. Generic options keep out-of-pocket cost reasonable for most patients.