Erectile Dysfunction (ED)
Erectile dysfunction (ED) is the inability of a man to maintain a firm erection long enough to have sex. Although erectile dysfunction is more common in older men, this common problem can occur at any age. Having trouble maintaining an erection from time to time isn’t necessarily a cause for concern. But if the problem is ongoing, it can cause stress and relationship problems and affect self-esteem.
Formerly called impotence, erectile dysfunction was once a taboo subject. It was considered a psychological issue or a natural consequence of growing older. These attitudes have changed in recent years. It’s now known that erectile dysfunction is more often caused by physical problems than by psychological ones, and that many men have normal erections into their 80s.
Although it can be embarrassing to talk with your doctor about sexual issues, seeking help for erectile dysfunction can be worth the effort. Erectile dysfunction treatments ranging from medications to surgery can help restore sexual function for most men. Sometimes erectile dysfunction is caused by an underlying condition such as heart disease. So it’s important to take erectile trouble seriously because it can be a sign of a more serious health problem.
Erectile dysfunction is the inability to maintain an erection sufficient for sexual intercourse at least 25 percent of the time.
An occasional inability to maintain an erection happens to most men and is normal. But ongoing erection problems are a sign of erectile dysfunction and should be evaluated. In some cases, erectile dysfunction is the first sign of another underlying health condition that needs treatment.
Male sexual arousal is a complex process involving the brain, hormones, emotions, nerves, muscles and blood vessels. If something affects any of these systems — or the delicate balance among them — erectile dysfunction can result.
Anatomy of an Erection
The penis contains two cylindrical, sponge-like structures (corpus cavernosum) 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 several times the normal amount. This sudden influx of blood expands the sponge-like structures and produces an erection by straightening and stiffening the penis.
Continued sexual arousal maintains the higher rate of blood flow into the penis and limits the blood flow out of the penis, keeping the penis firm. After ejaculation or when the sexual excitement passes, the excess blood drains out of the spongy tissue, and the penis returns to its nonerect size and shape.
Physical Causes of Erectile Dysfunction
At one time, doctors thought erectile dysfunction was primarily caused by psychological issues. But this isn’t true. While thoughts and emotions always play a role in getting an erection, erectile dysfunction is usually caused by something physical, such as a chronic health problem or the side effects of a medication. Sometimes a combination of things causes erectile dysfunction.
Common causes of erectile dysfunction include:
- Heart disease
- Clogged blood vessels (atherosclerosis)
- High blood pressure
- Metabolic syndrome
Other causes of erectile dysfunction include:
- Certain prescription medications
- Tobacco use
- Alcoholism and other forms of drug abuse
- Treatments for prostate cancer
- Parkinson’s disease
- Multiple sclerosis
- Hormonal disorders such as low testosterone (hypogonadism)
- Peyronie’s disease
- Surgeries or injuries that affect the pelvic area or spinal cord
In some cases, erectile dysfunction is one of the first signs of an underlying medical problem.
Psychological Causes of Erectile Dysfunction
The brain plays a key role in triggering the series of physical events that cause an erection, beginning with feelings of sexual excitement. A number of things can interfere with sexual feelings and lead to — or worsen — erectile dysfunction.
These can include:
- Poor communication or conflict with your partner
The physical and psychological causes of erectile dysfunction interact. For instance, a minor physical problem that slows sexual response may cause anxiety about maintaining an erection. The resulting anxiety can worsen erectile dysfunction.
Psychological Counseling and Sex Therapy
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 counselor with experience in treating sexual problems (sex therapist). Even if it is caused by something physical, erectile dysfunction can create stress and relationship tension. Counseling can help, especially when your partner participates.
Dr. Allison Hopkins has spent the last 12 years counseling couples and individuals through relationship issues as well as problems encountered in everyday life.
A variety of options exist for treating erectile dysfunction. They range 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 partner may want to talk with your doctor about how much money you’re willing to spend and your preferences. Treatment for erectile dysfunction can be costly and insurance coverage varies. Because erectile dysfunction can by a sign of a number of underlying health conditions, initial evaluation of the problem is covered by most insurance policies. Medications or other treatments for erectile dysfunction may or may not be covered by your policy — check with your insurance provider to find out. Many policies have a limit on how many pills or injections are covered per month. Standard Medicare prescription drug coverage doesn’t cover medications for erectile dysfunction.
Oral medications available to treat ED include:
- Sildenafil (Viagra)
- Tadalafil (Cialis)
- Vardenafil (Levitra)
All three medications work in much the same way. Chemically known as phosphodiesterase inhibitors, these drugs enhance the effects of nitric oxide, a chemical that relaxes muscles in the penis. This increases the amount of blood flow and allows a natural sequence to occur — an erection in response to sexual stimulation.
These medications don’t automatically produce an erection. Instead they allow an erection to occur after physical and psychological stimulation. Many men experience improvement in erectile function after taking these medications regardless of the cause of their impotence.
These medications share many similarities, but they have differences as well. They vary in dosage, duration of effectiveness and possible side effects. Other distinctions — for example, which drug is best for certain types of men — aren’t yet known. No study has directly compared these three medications.
Not All Men Benefit
Although these medications can help many people, not all men can or should take them to treat erectile dysfunction. You should not take these medications if:
- You take nitrate drugs for angina, such as nitroglycerin (Nitro-Bid, others), isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil)
- You take a blood-thinning (anticoagulant) medication
- You take certain types of alpha blockers for enlarged prostate (benign prostatic hyperplasia) or high blood pressure
Viagra, Levitra or Cialis may not be a good choice for you if:
- You have severe heart disease or heart failure
- You’ve had a stroke
- You have very low blood pressure (hypotension)
- You have uncontrolled high blood pressure (hypertension)
- You have uncontrolled diabetes
Don’t expect these medications to fix your erectile dysfunction immediately. Work with your doctor to find the right treatment and dose for you. Dosages may need adjusting. Or you may need to alter when you take the medication.
Before taking any medication Before taking any medication — including Viagra, Levitra or Cialis —
- Any illnesses or serious health problems you have now or have had in the past
- Any prescription or over-the-counter medications you take (including herbal remedies)
Prostaglandin E (alprostadil)
Two treatments involve using a drug called alprostadil. Alprostadil is a synthetic version of the hormone prostaglandin E. The hormone helps relax muscle tissue in the penis, which enhances the blood flow needed for an erection. There are two ways to use alprostadil:
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 five 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.
Self-Administered Intraurethral Therapy (Muse)
This treatment involves using a disposable applicator to insert a tiny alprostadil suppository, about half the size of a grain of rice, into the tip of your penis. The suppository, placed about two 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 testosterone deficiency, testosterone replacement therapy may be an option.
This treatment involves the use of a hollow tube with a hand-powered or battery-powered pump. The tube is placed over the penis, and then the pump is used to suck out the air. This creates a vacuum that pulls 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. You then remove the vacuum device. The erection typically lasts long enough for a couple to have sex. You remove the tension ring after intercourse.
This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery may also be 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.
From: Mayo Clinic