Erectile Dysfunction

Erectile dysfunction (ED), sometimes called impotence, is the persistent or recurring inability to achieve or maintain an erection that is firm enough and lasts long enough for satisfying sexual activity.

ED does not always mean you cannot get an erection. You may still get hard but notice that erections are softer, take longer, require more stimulation, disappear during sex, or are less reliable. Fewer or weaker morning erections and increasing reliance on Viagra® (sildenafil), Cialis® (tadalafil), Trimix, BiMix or QuadMix can also signal that erectile function is changing.

ED can be an early sign of cardiovascular or metabolic disease. The arteries supplying the penis are smaller than the arteries supplying the heart, so plaque buildup and reduced blood flow may affect erections before more obvious symptoms appear elsewhere. [5,6] Erectile dysfunction should not simply be accepted as aging or treated as only a bedroom problem.

ED can show up in several ways, including:

• Erections that are less hard or full than they used to be
• Taking longer to get hard or needing more stimulation
• Losing an erection during sex or when changing positions
• Erections that do not last as long
• Fewer or weaker morning or spontaneous erections
• ED medications or injections working less reliably than before

At Bawa Medical in Boca Raton, Dr. Kanwal Bawa evaluates the factors that can affect erectile function and creates a plan around the individual man rather than treating every case the same way.

Erectile dysfunction often has more than one cause. The most important question is not simply how to create an erection for a few hours—it is why your erectile function is changing in the first place.

Poor Blood Flow, Plaque, and Blocked Arteries

Reduced blood flow from vascular disease is the most common cause of physical erectile dysfunction and is known as vascular or vasculogenic ED. [4] Atherosclerosis, plaque and cholesterol can narrow the arteries supplying the penis, making erections softer, slower to develop, harder to maintain or increasingly dependent on medication.

Because erectile changes can appear before more obvious cardiovascular symptoms, new or worsening ED deserves medical attention rather than another temporary workaround.

Low Testosterone

Low testosterone can contribute to weaker erections, reduced sex drive, fatigue, low energy and fewer spontaneous erections. [7] Testosterone is not the main cause of every case of ED but it can definitely contribute to it, so Dr. Bawa evaluates symptoms, total and free testosterone, other relevant laboratory results, medical history and overall health together.

Diabetes and Metabolic Health

Diabetes can damage both the blood vessels and nerves required for healthy erections. It can also accelerate plaque buildup and interfere with nitric oxide signaling and circulation.

Excess weight, insulin resistance, high blood pressure, high cholesterol, sleep apnea and inactivity can further affect erectile function. Metabolic health therefore matters when the goal is not just a temporary erection, but better long-term function.

Medications, Nerves, Stress, Sleep, and Lifestyle

Certain antidepressants, blood pressure medications, opioids, prostate medications and other prescriptions can contribute to ED. Prostate or pelvic surgery, radiation, neurological disease, spinal injury, Peyronie’s disease and nerve damage may also affect erectile function.

Stress, performance anxiety, depression, poor sleep, smoking, vaping, excessive alcohol use and inactivity can add another layer. Physical and emotional factors frequently overlap, which is why a complete evaluation matters.

Dr. Bawa feels strongly about addressing why a man is suffering from ED instead of simply putting a Band-Aid over the problem and hoping it goes away. If the underlying vascular, hormonal, metabolic, neurological or tissue-related problem continues, erectile function can continue to worsen.

The Bawa Method is designed to improve function in the short term while also addressing the factors affecting long-term sexual health and SexSpan®.

Depending on your needs, treatment may include:

• BawaWave®
• BawaRF®
• BawaShot®
• Testosterone and Hormone Optimization
• DSF.me® Supplements
• Medical Weight Loss

Start with a private virtual or in-office consultation with Dr. Bawa. She will evaluate what is contributing to your ED and create a personalized plan designed to improve function now and long term.

Viagra® (sildenafil), Cialis® (tadalafil), Levitra® (vardenafil), Stendra® (avanafil), Trimix, BiMix and QuadMix do not work for every man. When they do work, the response may be partial, inconsistent or temporary.

More importantly, these medications and injections do not remove plaque, restore low testosterone, reverse diabetic nerve damage, or correct any other underlying causes of ED. Sildenafil, tadalafil, vardenafil and avanafil are PDE5 inhibitors that enhance nitric oxide signaling, while penile injections use medications to temporarily increase blood flow and produce an erection.

If the underlying problem continues to progress, the response to pills or injections may become weaker or less reliable. A man may find himself increasing doses, using treatment more often or moving from pills to injections while the reason his natural erectile function is declining remains untreated.

PDE5 inhibitors can cause headache, flushing, indigestion, congestion, dizziness, visual changes, back or muscle pain and blood-pressure changes, and they cannot be used safely with nitrate medications. These at-home penile injections can cause pain, bruising, fibrosis or scar tissue, curvature and priapism. [9–11]

Dr. Bawa does not view a temporary medication-assisted response as the same thing as treating erectile dysfunction. The Bawa Method focuses on improving how you function now while also addressing the reasons your function is changing over time.

1. Kessler A, Sollie S, Challacombe B, Briggs K, Van Hemelrijck M. “The Global Prevalence of Erectile Dysfunction: A Review.” BJU International. 2019;124(4):587–599. doi:10.1111/bju.14813.

2. Leslie SW, Sooriyamoorthy T. “Erectile Dysfunction.” StatPearls. Treasure Island, FL: StatPearls Publishing. Updated January 9, 2024.

3. Mark KP, Arenella K, Girard A, Herbenick D, Fu J, Coleman E. “Erectile Dysfunction Prevalence in the United States: Report From the 2021 National Survey of Sexual Wellbeing.” The Journal of Sexual Medicine. 2024;21(4):296–303. doi:10.1093/jsxmed/qdae008.

4. Yafi FA, Jenkins L, Albersen M, et al. “Erectile Dysfunction.” Nature Reviews Disease Primers. 2016;2:16003. doi:10.1038/nrdp.2016.3.

5. Montorsi P, Ravagnani PM, Galli S, et al. “The Artery Size Hypothesis: A Macrovascular Link Between Erectile Dysfunction and Coronary Artery Disease.” American Journal of Cardiology. 2005;96(12B):19M–23M. doi:10.1016/j.amjcard.2005.07.006.

6. Kloner RA, et al. “The Princeton IV Consensus Recommendations for the Management of Erectile Dysfunction and Cardiovascular Disease.” Mayo Clinic Proceedings. 2024;99(9):1500–1517. doi:10.1016/j.mayocp.2024.06.002.

7. Bhasin S, Brito JP, Cunningham GR, et al. “Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline.” Journal of Clinical Endocrinology & Metabolism. 2018;103(5):1715–1744. doi:10.1210/jc.2018-00229.

8. Corona G, et al. “Anti-Hypertensive Medications and Erectile Dysfunction: Focus on β-Blockers.” Endocrine. 2024. doi:10.1007/s12020-024-04020-x.

9. Bobo WE, Melchiode Z, Pavuluri H, Bobo AG, Hellstrom WJG. “Current Status of Intracavernosal Injection Therapy in Erectile Dysfunction.” Expert Opinion on Pharmacotherapy. 2023;24(8):925–933. doi:10.1080/14656566.2023.2204189.

10. Chew KK, Stuckey BGA, Earle CM, Dhaliwal SS, Keogh EJ. “Penile Fibrosis in Intracavernosal Prostaglandin E1 Injection Therapy for Erectile Dysfunction.” International Journal of Impotence Research. 1997;9(4):225–229.

11. Biebel MG, Gross MS, Munarriz R. “Review of Ischemic and Non-Ischemic Priapism.” Current Urology Reports. 2022;23:143–153.

12. Whelan G, Brown J. “Pornography Addiction: An Exploration of the Association Between Use, Perceived Addiction, Erectile Dysfunction, Premature Ejaculation, and Sexual Satisfaction in Males Aged 18–44 Years.” The Journal of Sexual Medicine. 2021;18(9):1582–1591.

13. Chung E, Bettocchi C, Egydio P, et al. “The International Penile Prosthesis Implant Consensus Forum: Clinical Recommendations and Surgical Principles on the Inflatable 3-Piece Penile Prosthesis Implant.” Nature Reviews Urology. 2022;19:534–546. doi:10.1038/s41585-022-00607-z.

14. Erol İ, Yıldız A, Karamık K, et al. “Electrophysiological Evaluation of Alterations in Penile Sensation Due to Penile Prosthesis Implantation in Patients With Erectile Dysfunction.” Asian Journal of Urology. 2023;10(4):541–545.

15. Pizzol D, Smith L, Fontana L, Caruso MG, Bertoldo A, Demurtas J, McDermott D, Garolla A, Grabovac I, Veronese N. “Associations Between Body Mass Index, Waist Circumference and Erectile Dysfunction: A Systematic Review and Meta-Analysis.” Reviews in Endocrine and Metabolic Disorders. 2020;21(4):657–666. doi:10.1007/s11154-020-09541-0.