The little blue pill is only one way to get back to passionate pursuits.

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When the action isn’t happening below the belt, guys are surprisingly hesitant to seek help: Only one-quarter of men diagnosed with erectile dysfunction (ED) actually seek treatment for the problem, according to a study published in the October issue of The Journal of Sexual Medicine.

That means 75 percent of guys with ED aren’t taking anything for their performance issues — and this was no small study: More than 6 million men with erectile trouble were included. “We were kind of shocked,” said study author Dr. Kevin McVary, chair of the division of urology at the Southern Illinois University School of Medicine. “There’s no question that we have effective treatments — there are pills, pellets, shots, and there’s surgery. And they are nearly 100 percent effective in total.”

Among one-quarter of men who did seek treatment, phosphodiesterase type 5 inhibitors (PDE5i were overwhelmingly the preferred option: Three-quarters took the pills — that is, Viagra (sildenafil), Cialis (tadalafil), or Levitra (vardenafil) — which are largely considered the first line of treatment for ED.

Other options, such as injections or vacuum devices, were grossly underused. “A guy may think, ‘OK, I’ll take a pill, but I won’t take anything more than that,’” McVary told Yahoo Health. And even then, they may not stick with it: “Only 50 percent of guys that are diagnosed will [accept] a prescription,” he said. “Of that 50 percent, only 50 percent will ever fill it. And of those, only 50 percent will ever refill it. So there is much attrition every step of the way.”

That doesn’t explain the lack of treatment entirely, though. Some men may simply not respond to PDE5 inhibitors, and they don’t bother trying the other available treatments — if they even know about them. “A lot of primary-care physicians don’t want to go there at all — they don’t even want to talk about ED,” acknowledged McVary. For some patients, though, talking through options is a necessary step, since degradation of the smooth muscle cells in the penis can prevent drugs like Viagra from doing their job. “Things like diabetes, high cholesterol, and hypertension affect those muscles,” he said. “They die, and they ain’t coming back.”

Before you assume the worst, though, make sure you’ve given the pills a chance — guys who swear by PDE5 inhibitors often had to take the meds five or six times before they noticed a change, said McVary. And make sure you don’t pop your pill after downing a giant-size steak, since fatty foods can affect the absorption of Viagra and Levitra, said Dr. Darius Paduch, an associate professor of urology and reproductive medicine at Weill Cornell Medical College. “Foods with high fat content can decrease the absorption of Viagra by 50 percent, so if you take 100 milligrams, you actually are going to get 50 milligrams. That may not be enough.”

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And realize that stimulation — even just the mental kind — is still necessary to wake up your penis. “You have to have sexual thoughts. If you’re sitting there reading the Chicago Tribune, you’re not going to have an erection,” noted McVary.

Still not rising to the occasion? It may be time to try one of these second-line treatments:

Prostaglandin E1 injections

A shot to the penis may sound like the last thing any man would attempt—but prostaglandin E1 injections, or alprostadil, are actually effective in about 90 percent of men with ED, said McVary. “Once they see that it works, most men won’t go back to a pill,” he added. What’s the draw? The shots work much faster than the pills — you can expect to be erect within 10 to 15 minutes, whereas pills take can take an hour or two to kick in. “You can be more spontaneous with the needle,” he said.

The mechanism is similar to that of PDE5 inhibitors, said McVary, but with one big difference: They don’t require any help from your brain. “You don’t have to do the fantasy thing. You can read the Tribune if you want,” he said. Shots may be an especially appealing option to younger guys with lots of stress, which can prevent the pills from working. “After a couple times, they gain confidence, and they usually don’t need to use it anymore,” said Paduch.

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