DEAR DR. ROACH: I have erectile dysfunction (ED). I am 71, and this has been an issue for over a year. But it seems to be getting worse. I have used sildenafil and Cialis with no effect. I also received testosterone injections for over a year. I have used Trimix and Quadmix, which worked initially to a certain extent, but now it doesn’t work at all. I have read about shockwave therapy and penile implants. Are these my options at this point? Any suggestions?

My primary care physician is no help. He suggested a penis pump that works until you pull the penis out of the pump. Then it goes flaccid. — R.T.

ANSWER: ED is common among men in their 70s, but you have a case that hasn’t responded to the two most common treatments — oral medications and injection medicines. In addition, it sounds like you might have testosterone deficiency, and despite treatment, nothing is working. I would just be sure that your doctor has checked your testosterone level during these treatments. Many men have low levels despite treatment or never even get their levels checked.

At this point, you should be dealing with a urologist who has expertise in sexual function, but you are quite right that penile pumps and implants are two of the options you have now. (I do not recommend shockwave treatment as there are not clear data supporting its use.)

Vacuum-assisted erectile devices work by using a vacuum to draw blood into the penis. Once the penis is erect, an elastic restraining ring must be applied to the base of the penis to keep the blood in and the penis erect. The effectiveness of a vacuum-assisted erectile device is about 70%, but satisfaction rates are about 50% or less in most studies.

Penile implants offer the highest patient and partner satisfaction rates. (Large studies show 75% to 98% satisfaction rates for patients and 88% for partners.) I can’t emphasize strongly enough how important it is to find a urologist who performs many of these procedures. I also want to say that the sooner the procedure is done, the better the outcome as the penis will develop fibrosis if there are no erections for a long period.

DEAR DR. ROACH: I am an 80-year-old woman whose blood pressure is normally around 135/65 mmHg. For several years now, I have one doctor who uses wrist monitors. When they take my blood pressure, it comes out around 113/65 mmHg. I keep telling them that something isn’t right, but they pay no attention.

I have a small wrist (5 and 1/2 inches). Do you think this could be causing the low reading? Just curious. Thank you. — B.R.

ANSWER: Wrist monitors are not as accurate with blood pressure compared to the gold standard of measuring the pressure from inside the artery. They aren’t as reliable as arm cuffs in giving you the same result each time (even if the blood pressure is the same), so I’ve never seen a physician’s office use one.

The artery is smaller and further away from the heart, so the wrist monitor must be placed at the exact height of the heart, which can lead to inaccuracies. A new automated arm cuff, especially those designed for clinical use, is very accurate and reliable, so I wouldn’t take the readings from your wrist too seriously.

I hope the doctor who is managing your blood pressure is using an up-to-date arm cuff or checking your levels manually with the proper technique.