Erectile dysfunction (impotence) is the inability to get and keep an erection firm enough for sex.
Having erection trouble from time to time isn’t necessarily a cause for concern. If erectile dysfunction is an ongoing issue, however, it can cause stress, affect your self-confidence and contribute to relationship problems. Problems getting or keeping an erection can also be a sign of an underlying health condition that needs treatment and a risk factor for heart disease.
If you’re concerned about erectile dysfunction, talk to your doctor — even if you’re embarrassed. Sometimes, treating an underlying condition is enough to reverse erectile dysfunction. In other cases, medications or other direct treatments might be needed.
What Is Erectile Dysfunction (ED)?
Erectile dysfunction (ED) happens when a man has ongoing problems getting and keeping an erection. Without treatment, the ED can make sex difficult. The problem is reported by 1 in 5 men, and that number gets bigger with age.
Male sexual arousal is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. Erectile dysfunction can result from a problem with any of these. Likewise, stress and mental health concerns can cause or worsen erectile dysfunction.
Sometimes a combination of physical and psychological issues causes erectile dysfunction. For instance, a minor physical condition that slows your sexual response might cause anxiety about maintaining an erection. The resulting anxiety can lead to or worsen erectile dysfunction.
It is always worth consulting a physician about persistent erection problems, as it could be caused by a serious medical condition.
Whether the cause is simple or serious, a proper diagnosis can help to address any underlying medical issues and help resolve sexual difficulties.
The following list summarizes many of the most common physical or organic causes of ED:
- heart diseaseand narrowing of blood vessels
- hormonal disorders including thyroid conditions and testosteronedeficiency
- structural or anatomical disorder of the penis, such as Peyronie disease
- smoking, alcoholism, and substance abuse, including cocaine use
- treatments for prostate disease
- surgical complications
- injuries in the pelvic area or spinal cord
- radiation therapyto the pelvic region
Atherosclerosis is a common cause of blood flow problems. Atherosclerosis causes a narrowing or clogging of arteries in the penis, preventing the necessary blood flow to the penis to produce an erection.
Numerous prescription medications can also cause ED, including those below. Anyone taking prescription medications should consult their doctor before stopping or changing their medications
- drugs to control high blood pressure
- heart medications such as digoxin
- some diuretics
- drugs that act on the central nervous system, including some sleeping pills and amphetamines
- antidepressants, including monoamine oxidase inhibitors (MAOIs), selective serotoninreuptake inhibitors (SSRIs), and tricyclic antidepressants
- opioid painkillers
- some cancerdrugs, including chemotherapeutic agents
- prostate treatment drugs
- hormone drugs
- the peptic ulcermedication cimetidine
- Physical causes account for 90 percentof ED cases, with psychological causes much less common.
What are the symptoms of ED?
You may have erectile dysfunction if you regularly have:
- trouble getting an erection
- difficulty maintaining an erection during sexual activities
- reduced interest in sex
Other sexual disorders related to ED include:
- premature ejaculation
- delayed ejaculation
- anorgasmia, which is the inability to achieve orgasm after ample stimulation
You should talk to your doctor if you have any of these symptoms, especially if they’ve lasted for two or more months. Your doctor can determine if your sexual disorder is caused by an underlying condition that requires treatment.
Treatment for Erectile Dysfunction
How can I treat erectile dysfunction?
You can work with a health care professional to treat an underlying cause of your erectile dysfunction (ED). Choosing an ED treatment is a personal decision. However, you also may benefit from talking with your partner about which treatment is best for you as a couple.
Go to counselling:
Talk with your doctor about going to a counselor if psychological or emotional issues are affecting your ED. A counselor can teach you how to lower your anxiety or stress related to sex. Your counselor may suggest that you bring your partner to counseling sessions to learn how to support you. As you work on relieving your anxiety or stress, a doctor can focus on treating the physical causes of ED.
- It is possible to buy treatment over the internet for ED. However, caution is advised.
The United States (U.S.) Food and Drug Administration (FDA) has a consumer safety guide about this, including a recommendation to check that the online pharmacy:
- is located in the U.S. and licensed
- has a licensed pharmacist to answer questions.
- requires a prescription.
- offers direct contact with a person who can discuss any problems.
You can check whether the pharmacy is licensed using this list of Verified Internet Pharmacy Practice Sites (VIPPS).
The FDA also offers tips for spotting the dangers of an unsafe website, including watching out for the following clues:
- There is no way to contact the website by phone.
- Prices are dramatically lower than those offered by legal online pharmacies.
- Prescription drugs are offered without requiring a prescription – which is illegal.
- Personal information is not protected.
The FDA adds that these illegal sites may send drugs of unknown quality and origin, even sending the wrong drug or a dangerous product.
Discuss alternative medicines:
Some men say certain alternative medicines taken by mouth can help them get and maintain an erection. However, not all “natural” medicines or supplements are safe. Combinations of certain prescribed and alternative medicines could cause major health problems. To help ensure coordinated and safe care, discuss your use of alternative medicines, including use of vitamin and mineral supplements, with a health care professional. Also, never order a medicine online without talking with your doctor.
Prescribe medicines you take by mouth:
A health care professional may prescribe you an oral medicine, or medicine you take by mouth, such as one of the following, to help you get and maintain an erection:
- vardenafil(Levitra, Staxyn)
All of these medicines work by relaxing smooth muscles and increasing blood flow in the penis during sexual stimulation. You should not take any of these medicines to treat ED if you are taking nitrates to treat a heart condition. Nitrates widen and relax your blood vessels. The combination can lead to a sudden drop in blood pressure, which may cause you to become faint or dizzy, or fall, leading to possible injuries.
Also talk to your health care professional if you are taking alpha-blockers to treat prostate enlargement. The combination of alpha-blockers and ED medicines also could cause a sudden drop in blood pressure.
A health care professional may prescribe testosterone if you have low levels of this hormone in your blood. Although taking testosterone may help your ED, it is often unhelpful if your ED is caused by circulatory or nerve problems. Taking testosterone also may lead to side effects, including a high red blood cell count and problems urinating.
Testosterone treatment also has not been proven to help ED associated with age-related or late-onset hypogonadism . Do not take testosterone therapy that hasn’t been prescribed by your doctor. Testosterone therapy can affect how your other medicines work and can cause serious side effects.
Role of the endothelium in ED:
The role of the endothelium in ED has been noted for a number of years and the overlapping of ED and other conditions, especially coronary heart disease, CVD, affecting endothelial function/dysfunction, is clearly present. The endothelial cell is now known to affect vascular tone and impact the process of atherosclerosis, and impacting ED, CVD and peripheral vascular disease.
The role of the endothelium in erectile function became clearer with the observation that the phosphodiesterase type 5 (PDE5) inhibitor, sildenafil, enhanced erectile function. Erection occurs with the release of nitric oxide (NO) from the vascular endothelial cells.The reduction in endothelial cell production of NO results in the negative impact on the smooth muscles in the corporal bodies and results in less relaxation of the smooth muscle cells with decrease in blood supply and resulting ED. A similar phenomenon is well known to impact the coronary arterial system resulting in CVD.
It is important to understand that ED is frequently, if not usually, directly related to endothelial dysfunction, and that the release of NO by the vasculature of the penile arteries is directly related to the function of intact, healthy endothelium. In the face of endothelial dysfunction, the process of erection fails to occur in a normal fashion.
Testosterone and erectile function:
Among the phenomena in the ageing man are a decrease in erectile function and testosterone levels. Add to these, increased risk for CVD, muscle wasting, decrease in bone density and libido, with all of these factors having an interplay with testosterone metabolism.Androgens play a key role in maintaining erectile function through four main mechanisms. Androgen deprivation has been shown to result in impairment of NO synthase release, altered PDE5 expression and activity, impaired cavernosal nerve function, and contribution to veno-occlusive disease in the penis. The role of testosterone replacement therapy (TRT) as a potential to improve erectile function in the man with ED remains an issue for patient and physicians who are comfortable treating androgen deficiency which include primary care physicians and specialists. Androgens are known to have a significant impact on the function of the smooth musculature within the corpus spongiosum.
The observation that TRT enhances the efficacy of PDE5 inhibitors in hypogonadal men taking these therapies with suboptimal response to the PDE5 inhibitors alone has been reported. In addition, investigators have demonstrated that TRT in hypogonadal men can improve erectile function even without the benefit of PDE5 inhibitors In addition, guidelines for managing ED in hypogonadal men by the European Association of Urology recommend controlling the man to a eugonadal state prior to initiation of PDE5 inhibitor therapy.Testosterone measurement consists of a serum specimen which should be ideally obtained in the morning because of the normal diurnal variation of testosterone which is at its peak in the morning. Since TRT is relatively safe, and men can potentially see an improvement in erectile function, it seems prudent to consider this issue when presented with a patient suffering from ED.
- Vacuum erection devices are a mechanical way of producing an erection for men who do not want or cannot use drug treatments, or find they are not working.
- The penis is made rigid by the use of a vacuum pump sealed around it that draws up blood. This is prevented from then leaving the penis by the use of an accompanying band.
- The lack of spontaneity with the use of vacuum devices means that many men find other treatments for ED preferable.
What non-surgical treatments are there for erectile dysfunction (ED)?
Education and communication:
Education about sex, sexual behaviors, and sexual responses may help a man overcome his anxieties about sexual dysfunction.
- Talking honestly with your partner about your needs and concerns may also help to overcome many barriers to a healthy sex life.
- Medications such as sildenafil (Viagra), vardenafil (Levitra), or tadalafil (Cialis) may help improve sexual function in men by increasing blood flow to the penis. Men who are on medicines that contain nitrates such as nitroglycerine should not take oral ED medications. The combination of nitrates and these specific medications can cause low blood pressure (hypotension).The most common side effects of these medications are indigestion, nasal congestion, flushing, headaches, and a temporary visual disturbance.
Diagnostic Evaluation of Erectile Dysfunction
The penis consists of two parallel cylinders of erectile tissue, the corpora cavernosa, and a smaller, single ventrally placed cylinder, the corpus spongiosum, which surrounds the urethra and distally forms the glans penis (Figure 1). The corpora cavernosa are composed of a mesh-work of interconnected cavernosal spaces lined by vascular endothelium. They share an incomplete septum that allows them to function as a single unit. 3 Blood flow is provided primarily by the cavernosal branches of the internal pudendal artery. Each branch divides into numerous terminal branches that open directly into the cavernous spaces. Venous drainage of the erectile bodies occurs via postcavernous venules that coalesce to form large emissary veins that pierce the tunica albuginea before draining into the deep dorsal vein.
Autonomic and somatic nerves innervate the penis. Parasympathetic nerve fibers originate from sacral segments of the spinal cord, while sympathetic nerves originate from lower thoracic and upper lumbar segments.3 Somatic sensory and motor fibers enter and leave the sacral cord and innervate the penis and the perineum via the pudendal nerve.