Erectile Dysfunction

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Erectile Dysfunction

About Erectile Dysfunction

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Overview

Erectile dysfunction (ED) is a common type of male sexual dysfunction. It is when a man has trouble getting or keeping an erection. ED becomes more common as you get older. But it's not a natural part of aging.

ED is sometimes called impotence, but that word is being used less often so​ that it will not be confused with other, nonmedical meanings of the term.

Some people have trouble speaking with their doctors about sex. But if you have ED, you should tell your doctor. ED can be a sign of health problems. It may mean your blood vessels are clogged. It may mean you have nerve damage from diabetes. If you don't see your doctor, these problems will go untreated.

Your doctor can offer several new treatments for ED. For many men, the answer is as simple as taking a pill. Getting more exercise, losing weight, or stopping smoking may also help.

Common Symptoms

ED is the inability to get or keep an erection firm enough for sexual intercourse. ED can be a total inability to achieve an erection, an inconsistent ability to do so, or a tendency to sustain only brief erections.

What Causes it?

ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED.

Because an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases—such as diabetes, high blood pressure, nerve disease or nerve damage, multiple sclerosis, atherosclerosis, and heart disease—account for the majority of ED cases. Patients should be thoroughly evaluated for these conditions before they begin any form of treatment for ED.

Lifestyle choices that contribute to heart disease and vascular problems also raise the risk of ED. Smoking, drinking alcohol excessively, being overweight, and not exercising are possible causes of ED.

Surgery—especially radical prostate and bladder surgery for cancer—can also injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and the fibrous tissues of the corpora cavernosa.

In addition, ED can be a side effect of many common medicines such as blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine, an ulcer drug.

Psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure can also cause ED. Even when ED has a physical cause, psychological factors may make the condition worse.

Hormonal abnormalities, such as low levels of testosterone, are a less frequent cause of ED.

Am I at Risk?

The National Institutes of Health estimates that ED affects as many as 30 million men in the United States. Incidence increases with age: About 4 percent of men in their 50s and nearly 17 percent of men in their 60s experience a total inability to achieve an erection. The incidence jumps to 47 percent for men older than 75. But ED is not an inevitable part of aging. ED is treatable at any age.

What Medicines are Available?

Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis.

Oral Medications

  • Viagra (sildenafil)
  • Levitra (vardenafil)
  • Cialis (tadalafil)

In March 1998, the U.S. Food and Drug Administration (FDA) approved sildenafil (Viagra), the first pill to treat ED. Since that time, vardenafil hydrochloride (Levitra) and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness.

The recommended dose for Viagra is 50 milligrams (mg), and the doctor may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the doctor 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 the drug. The 5 mg and 2.5 mg doses of Cialis are FDA-approved for daily use.

Injectable Medications

While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. 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 widen blood vessels. The injectable form of alprostadil is marketed as Caverject. These drugs may create unwanted side effects, however, including scarring of the penis and persistent erection, known as priapism. Nitroglycerin ointment, a muscle relaxant, can sometimes enhance an erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra uses a prefilled applicator to deliver the pellet about an inch into the urethra. The pellet form of alprostadil is marketed as MUSE. 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; a warm or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.

Other Drugs

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 belief that an improvement will occur.

Are they Effective?

Oral Medications

Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs 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.

Are they Safe?

Oral Medications

None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin pills for heart problems should not use any of the three drugs because the combination can cause a sudden drop in blood pressure. Also, men should tell their doctor if they take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. The doctor may need to adjust the ED prescription. Taking a PDE inhibitor and an alpha-blocker within 4 hours of each other can cause a sudden drop in blood pressure. A small number of men have experienced vision or hearing loss after taking a PDE inhibitor. Men who experience vision or hearing loss should seek prompt medical attention.

Are there Non-Drug Treatments?

Most doctors suggest that treatments proceed from least to most invasive. Making a few healthy lifestyle changes may solve the problem. Quitting smoking, reducing alcohol consumption, losing excess weight, and increasing physical activity may help some men regain sexual function.

Cutting back on or replacing medicines that could be causing ED is considered next. For example, if a patient thinks a particular blood pressure medicine is causing problems with erection, he should tell his doctor and ask whether he can try a different class of blood pressure medicine.

Psychotherapy

Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety during treatment for ED from physical causes.

Vacuum Devices

Mechanical vacuum devices cause an erection by creating a partial vacuum, which draws blood into the corpora cavernosa, engorging and expanding the penis. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic ring, which is moved from the end of the cylinder to the base of the penis as the cylinder is removed. The elastic ring maintains the erection during intercourse by preventing blood from flowing back into the body. The elastic ring can remain in place up to 30 minutes. The ring should be removed after that time to restore normal circulation and to avoid skin irritation.

Couples may find that using a vacuum device requires some practice or adjustment. An erection achieved with a vacuum device may not feel like an erection achieved naturally. The penis may feel cold or numb and have a purple color. Bruising on the shaft of the penis may occur, but the bruises are usually painless and disappear in a few days. Ejaculation may be weakened because the elastic ring blocks some of the semen from traveling through the urethra, but the pleasure of orgasm is usually not affected.

A vacuum device causes an erection by creating a partial vacuum around the penis, which draws blood into the corpora cavernosa.

Surgery

Surgery usually has one of three goals:

  • to implant a device that can cause the penis to become erect
  • to reconstruct arteries to increase blood flow to the penis
  • to block off veins that allow blood to leak from the penile tissues

Implanted devices, known as prostheses, can restore erection in many men with ED.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid (see Figure 3). Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. The pump causes fluid to flow from a reservoir residing in the lower pelvis to two cylinders residing in the penis. Inflatable implants can expand the length and width of the penis to some degree. They also leave the penis in a more natural state than malleable implants do when not inflated.

Once a man has either a malleable or inflatable implant, he must use the device to have an erection. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have decreased in recent years because of technological advances.

With an inflatable implant, an erection is produced by squeezing a small pump implanted in the scrotum. The cylinders expand to create the erection.

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the groin or fracture of the pelvis. The procedure is usually unsuccessful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure—intentional blockage. Blocking off veins, called ligation, can reduce the leakage of blood that diminishes the rigidity of the penis during an erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

Sources

National Library of Medicine’s Medline Plus. Erectile Dysfunction. Published August 2014.

National Institute of Diabetes and Digestive and Kidney Diseases. Erectile Dysfunction. Published March 2012.

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