Erectile dysfunction affects the lives of 20 million to 30 million American men and their partners. The term erectile dysfunction covers a range of disorders, including curvature of the penis during erection (Peyronie's disease), prolonged painful erection not associated with sexual desire (priapism) and premature ejaculation. But typically, it's defined as the inability to obtain an adequate erection for satisfactory sexual activity.
Although erectile dysfunction is more common in men over age 65, it can occur at any age. Still, it's important to realize that an occasional episode of erectile dysfunction happens to most men and is perfectly normal. In fact, in most cases it's nothing to worry about. As men age, it's also normal for them to experience changes in erectile function. Erections may take longer to develop, may not be as rigid or may require more direct stimulation to be achieved. Men may also notice that orgasms are less intense, the volume of ejaculations is reduced and recovery time increases between erections.
When erectile dysfunction proves to be a pattern or a persistent problem, however, it can harm a man's self-image as well as his sexual life. It can also be a sign of a physical or emotional problem that requires treatment.
Erectile dysfunction, formerly called impotence, was once a taboo subject. But attitudes are changing. More men are seeking help for the problem, and doctors are gaining a better understanding of what causes erectile dysfunction and are finding new and better ways to treat it.
Patterns of erectile dysfunction include:
Occasional inability to obtain a full erection
Inability to maintain an erection
Total inability to achieve an erection
Although it's normal to experience erectile dysfunction on occasion, see your
doctor if it lasts longer than 2 months or is recurring.
The penis contains two cylindrical, spongelike structures that run along its length, parallel to the tube that carries semen and urine (urethra). When a man becomes sexually aroused, nerve impulses cause the blood flow to the cylinders to increase about seven times the normal amount. This sudden influx of blood expands the spongelike structures and produces an erection by straightening and stiffening the penis. Continued sexual arousal or excitation maintains the higher rate of blood flow, keeping the erection firm. After ejaculation or when the sexual excitation passes, the excess blood drains out of the spongy tissue, and the penis returns to its nonerect size and shape.
Three steps take place to produce and sustain an erection:
Arousal. The first step is sexual arousal, which men obtain from the senses
of sight, touch, hearing and smell, and from thoughts.
Nervous system response. The brain communicates the sexual excitation to the
body's nervous system, which activates increased blood flow to the penis.
Blood vessel response. A relaxing action occurs in the blood vessels that supply
the penis, allowing more blood to flow into the shafts that produce the erection.
If something affects any of these three factors — arousal, nervous system
response or circulatory system response — or the delicate balance among
them, erectile dysfunction can result.
Nonphysical causes may account for impotence. The most common nonphysical causes are stress, anxiety and fatigue. Impotence is also an occasional side effect of psychological problems such as depression. Negative feelings toward your sexual partner — or expressed by your sexual partner — such as resentment, hostility or lack of interest also can be a factor in erectile dysfunction.
Still, the cause of erectile dysfunction isn't always psychological. Physical causes account for many cases of erectile dysfunction. These causes include diabetic neuropathy, cardiovascular disorders affecting the blood supply to the pelvis, prescription medications, operations for cancer of the prostate, fractures that injure the spinal cord, multiple sclerosis, hormonal disorders, and alcoholism and other forms of drug abuse. In fact, erectile dysfunction may be one of the first signs of an underlying medical problem.
The physical and nonphysical causes of erectile dysfunction commonly interact. For instance, a minor physical problem that slows sexual response may cause anxiety about attaining an erection. Then the anxiety can worsen your erectile dysfunction.
A wide variety of physical and emotional risk factors can contribute to erectile dysfunction. They include:
Physical diseases and disorders. Chronic diseases of the lungs, liver, kidneys,
heart, nerves, arteries or veins can lead to impotence. So can endocrine system
disorders, particularly diabetes. The accumulation of deposits (plaques) in
your arteries (atherosclerosis) also can prevent adequate blood from entering
the penis. And in some men, erectile dysfunction may be caused by low levels
of the hormone testosterone (male hypogonadism).
Surgery or trauma. Erectile dysfunction may result from an injury to the pelvic
area or spinal cord. Surgery to treat bladder, rectal or prostate cancer also
can result in erectile dysfunction. Prolonged bicycle riding can cause a temporary
problem.
Medications. A wide range of drugs — including antidepressants, antihistamines
and medications to treat high blood pressure, pain and prostate cancer —
can cause erectile dysfunction by interfering with nerve impulses or blood flow
to the penis. Tranquilizers and sleeping aids also may pose a problem.
Substance abuse. Chronic use of alcohol, marijuana or other drugs often causes
erectile dysfunction and decreased sexual drive. Excessive tobacco use also
can damage penile arteries.
Stress, anxiety or depression. Psychological causes account for about 10 percent
to 15 percent of erectile dysfunction cases.
If erectile dysfunction lasts longer than 2 months or is a recurring problem, see your doctor for a physical exam or for a referral to a doctor who specializes in erectile problems. Your own doctor or a specialist can help you determine the underlying cause or causes of erectile dysfunction and then help you find the right type of treatment.
Although you might view erectile dysfunction as a personal or embarrassing problem, it's important to seek treatment, especially if a physical cause might be to blame. In many cases, erectile dysfunction can be successfully treated. Also, see your doctor if the therapy or medication prescribed to treat erectile dysfunction isn't working for you. Don't try to combine medications or therapies on your own or deviate from prescribed doses.
If you go to your doctor because of a problem with erectile dysfunction, he or she will want to ask questions about how or when the problem developed, the medications you take and any physical conditions you may have. Your doctor will also want to discuss recent physical or emotional changes.
If your doctor suspects that physical causes are involved, he or she will likely want to take blood tests to check your level of male hormones and for other potential medical problems, such as diabetes. Your doctor may also want to try eliminating or replacing certain prescription drugs you're taking one at a time to see whether any are responsible for erectile dysfunction.
More specialized tests may include:
Ultrasonography. This test can determine the adequacy of arterial circulation
in your genital organs. Ultrasonography involves using a wandlike device (transducer)
held over the blood vessels that supply the penis. The transducer emits sound
waves that pass through body tissues and reflect back, producing an image to
let your doctor see if your blood flow is impaired. The test often is done before
and after injection of medication to see if there's an improvement in blood
flow.
Neurologic evaluation. Your doctor usually assesses possible nerve damage by
conducting a physical examination to test for normal touch sensation in your
genital area.
Cavernosometry and cavernosography. Cavernosometry is a test that measures penile
vascular pressure. Cavernosography involves injecting a dye into your blood
vessels to permit your doctor to view any possible abnormalities in blood flow
into and out of your penis.
If your doctor suspects that mainly nonphysical causes are to blame, he or she
may ask whether you obtain erections during masturbation, with a partner or
while you sleep. Most men experience many erections, without remembering them,
during sleep. A simple test that involves wrapping a special perforated tape
around your penis before going to sleep can confirm whether you have nocturnal
erections. If the tape is separated in the morning, your penis was erect at
some time during the night. Tests of this type confirm nonphysical causes.
A wide variety of options exist for treating erectile dysfunction. They include everything from medications and simple mechanical devices to surgery and psychological counseling. The cause and severity of your condition are important factors in determining the best treatment or combination of treatments for you. You and your doctor may also want to consider how much money you're willing to spend and the personal preferences of you and your partner. If erectile dysfunction is the result of a medical condition, the cost of treatment may be covered by insurance.
Sildenafil (Viagra)
Sildenafil (Viagra) was approved by the Food and Drug Administration (FDA) in
1998 and became the first oral medication for erectile dysfunction on the market.
Since then, doctors have written millions of prescriptions for the blue, diamond-shaped
tablets. Drugs for treating ED can be taken orally, injected directly into the
penis, or inserted into the urethra at the tip of the penis. In March 1998,
the Food and Drug Administration (FDA) approved Viagra, the first pill to treat
ED. In August 2003, the FDA gave approval to a second oral medicine, vardenafil
hydrochloride (Levitra). Additional oral medicines are being tested for safety
and effectiveness.
Taken an hour before sexual activity, Viagra and Levitra work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.
While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for Levitra is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. Lower doses of 5 mg and 2.5 mg are available for patients who take other medicines or have conditions that may decrease the body's ability to use Levitra.
Neither Viagra nor Levitra should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also, Levitra should not be taken with any of the drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure.
Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs--including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone--are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur.
Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.
A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.
Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.
Prostaglandin E (alprostadil)
Alternatives to sildenafil exist. Two treatments involve using a drug called
alprostadil (al-PROS-tuh-dil). Alprostadil is a synthetic version of the hormone
prostaglandin E. The hormone helps relax smooth muscle tissue in the penis,
which enhances the blood flow needed for an erection. There are two ways to
use alprostadil:
Needle-injection therapy. With this method, you use a fine needle to inject
alprostadil (Caverject, Edex) into the base or side of your penis. This generally
produces an erection in 5 to 20 minutes that lasts about an hour. Because the
injection goes directly into the spongy cylinders that fill with blood, alprostadil
is an effective treatment for many men. And because the needle used is so fine,
pain from the injection site is usually minor. Other side effects may include
bleeding from the injection, prolonged erection and formation of fibrous tissue
at the injection site. The cost per injection can be expensive. Injecting a
mixture of alprostadil and other prescribed drugs may be a less expensive and
more effective option. These other drugs may include papaverine and phentolamine
(Regitine).
Self-administered intraurethral therapy. This method's trade name is Medicated
Urethral System for Erection (Muse). It involves using a disposable applicator
to insert a tiny suppository, about half the size of a grain of rice, into the
tip of your penis. The suppository, placed about 2 inches into your urethra,
is absorbed by erectile tissue in your penis, increasing the blood flow that
causes an erection. Although needles aren't involved, you may still find this
method painful or uncomfortable. Side effects may include pain, minor bleeding
in the urethra, dizziness and formation of fibrous tissue.
Hormone replacement therapy
For the small number of men who have a testosterone deficiency, testosterone
replacement therapy may be recommended.
Vacuum devices
This treatment involves the use of an external vacuum and one or more rubber
bands (tension rings). To begin you place a hollow plastic tube, available by
prescription, over your penis. You then use a hand pump to create a vacuum in
the tube and pull blood into the penis. Once you achieve an adequate erection,
you slip a tension ring around the base of your penis to maintain the erection.
The vacuum device is then removed. The erection typically lasts long enough
for a couple to have adequate sexual relations.
Vascular surgery
This treatment is usually reserved for men whose blood flow has been blocked
by an injury to the penis or pelvic area. Surgery is also used to correct erectile
dysfunction caused by vascular blockages. The goal of this treatment is to correct
a blockage of blood flow to the penis so that erections can occur naturally.
But the long-term success of this surgery is unclear.
Penile implants
This treatment involves surgically placing a device into the two sides of the
penis, allowing erection to occur as often and for as long as desired. These
implants consist of an inflatable device or semirigid rods made from silicone
or polyurethane. This treatment is often expensive and is usually not recommended
until other methods have been considered or tried first. As with any surgery,
there is a small risk of complications such as infection.
Psychological counseling
If stress, anxiety or depression is the cause of your erectile dysfunction,
your doctor may suggest that you, or you and your partner, visit a psychologist
or psychiatrist with experience in treating sexual problems.
Although most men will experience episodes of erectile dysfunction from time to time, you can take these steps to decrease the likelihood of occurrences:
Limit or avoid the use of alcohol and other similar drugs
Stop smoking
Exercise regularly
Reduce stress
Get enough sleep
Deal with anxiety or depression
See your doctor for regular checkups and medical screening tests
Whether erectile dysfunction is caused by physical or psychological factors or a combination of both, it can become a source of mental and emotional stress for a man — and his partner. If you only experience erectile dysfunction on occasion, try not to assume that you have a permanent problem or to expect it to happen again during your next sexual encounter. One episode of erectile dysfunction should not be seen as a lasting comment on your health, virility or masculinity.
It's also important for a man who experiences occasional or persistent erectile dysfunction to remember his sexual partner. Your partner may see your inability to have an erection as a sign of diminished sexual desire. Your reassurance that this is not the case can be helpful in this situation.
To appropriately treat erectile dysfunction and strengthen your relationship with your partner, try to communicate openly and honestly about your condition. Couples may also want to seek counseling to confront any concerns they may have about erectile dysfunction and to learn how to discuss their feelings. Couples should try to maintain this communication throughout the diagnosis and treatment process. In fact, treatment is often more successful if couples work together as a team.
Drugs for treating ED can be taken orally, injected directly into the penis,
or inserted into the urethra at the tip of the penis. In March 1998, the Food
and Drug Administration (FDA) approved Viagra, the first pill to treat ED. In
August 2003, the FDA gave approval to a second oral medicine, vardenafil hydrochloride
(Levitra). Additional oral medicines are being tested for safety and effectiveness.
Taken an hour before sexual activity, Viagra and Levitra work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.
While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for Levitra is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. Lower doses of 5 mg and 2.5 mg are available for patients who take other medicines or have conditions that may decrease the body's ability to use Levitra.
Neither Viagra nor Levitra should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also, Levitra should not be taken with any of the drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure.
Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs--including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone--are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur.
Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.
A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.
Research on drugs for treating ED is expanding rapidly. Patients should ask
their doctor about the latest advances.( www.cure-ed.org
)