Erectile dysfunction (ED) is a condition in which a man has difficulty getting or maintaining an erection. It can be caused by physical or emotional problems. Physical problems include heart disease, diabetes, obesity, and high blood pressure. Emotional problems include stress, anxiety, and depression.
If you are experiencing ED symptoms, see your doctor right away for diagnosis and treatment options. Treatment may include lifestyle changes such as quitting smoking or losing weight; medications such as phosphodiesterase type 5 inhibitors (such as sildenafil [Viagra], tadalafil [Cialis], vardenafil [Levitra]) or penile injections; surgery to correct blockages in the veins that drain the penis; or a penile implant.
What is Impotence (Erectile Dysfunction)
Erectile dysfunction (ED) is an inability to achieve or maintain a bony enough erection for sexual intercourse. A man is considered to have ED if he routinely has difficulty getting or keeping a firm enough erection to be able to have sex, or if this interferes with other sexual activities.
Erectile dysfunction (ED) is a prevalent condition among men aged >40 years, the prevalence increasing dramatically as the aging population increases, as well as with other co-morbidities. Erectile dysfunction, a persistent failure to achieve or keep a penile erection that is adequate for sexual intercourse, affects millions of men in various degrees. Recent epidemiologic studies indicate that about 10% of men aged 40-70 years are severely or completely erectile dysfunction, defined as a total failure to attain or maintain an erection sufficient for sexual function.
The most common causes of Erectile Dysfunction
There are many potential causes of erectile dysfunction (ED), and it is important to identify the cause in order to receive appropriate treatment.
Erectile problems can result from physical problems related to:
- Vascular (blood vessel) disease – vascular disease occurs when there is damage to the blood vessels, which can impede blood flow and lead to problems with getting or maintaining an erection.
- Nerve damage.
When the nerves that control erections are damaged, it can be difficult or impossible to get and maintain an erection. This may be due to injury, surgery, or a health condition such as diabetes. Nerve damage can also be caused by lifestyle factors such as smoking and obesity. For example, if a man is obese, changes in blood flow may impact his ability to keep an erection, a physical reason. Being overweight, not exercising enough, and smoking can work against the good blood flow that is critical for an erection. Erectile dysfunction caused by diabetes is not always a fully reversible issue, but you can certainly make it much better, or less likely, to occur, by following your doctors’ recommendations for controlling your blood sugar. Over the long-term, bad diabetes management may lead to increased damage to your nerves and blood circulation, which controls the blood flow to your penis.
- Hormonal problems.
Hormones are important for sexual function in both men and women. Testosterone is the most important hormone for men when it comes to sex, and low levels of testosterone can lead to problems getting or maintaining an erection. Other hormones that play a role in sexual function include estrogen and progesterone in women, and dopamine and serotonin in both men and women. If any of these hormones are out of balance, it can lead to difficulties with sex drive or erections.
If the ED is caused by a physical cause, it is likely that you will still have normal sexual desire, except when the cause is a hormonal issue.
- Psychological factors such as stress, anxiety, or depression can also cause erection problems. When a man is feeling anxious or stressed, it can interfere with his ability to get and maintain an erection. Depression can also cause problems with erections. Men who are depressed may not feel interested in sex, and they may lose their desire for physical intimacy.
- Medications can interfere with blood flow to the penis and cause difficulty getting or maintaining an erection. Blood pressure medications, anti-anxiety and antidepressant medications, eye drops for glaucoma, and chemotherapy for cancer are some of the many medications that may contribute to ED. While many prescription drugs can treat an illness or disease, while doing so, they may impact the males’ hormones, nerves, or blood circulation, leading to erectile dysfunction or increasing his risk for ED. These drugs do not just affect, and often suppress, the central nervous system, they may cause severe blood vessel damage, leading to a permanent ED.
If you are taking any medication and experiencing erection problems, it is important to talk to your doctor about possible alternatives. There may be other medications that can help you without causing this side effect.
Erectile Dysfunction Symptoms
Erectile dysfunction (ED) is an inability to get or maintain an erection that is stable enough for you to engage in sexual intercourse. A man is considered to have ED if he routinely has difficulty getting or keeping a firm enough erection to be able to have sex, or if this interferes with other sexual activities.
Failing to get an erection over 50% of the time usually means that something is wrong, and that treatment is needed. The failure to obtain an erection less than 20 % of the time is not uncommon, and usually does not require treatment. If an erection is still occurring spontaneously at night or in the morning, it is possible that psychological issues are at play.
In rare cases, a man may always have had EDs, and he may have never had erections. Many men indeed do have periodic inability to get an erection, which may happen due to several reasons, such as drinking too much alcohol, stress, relational problems, or being exceptionally tired. Problems getting or maintaining an erection may also be a sign of underlying medical conditions that require treatment, as well as a risk factor for heart disease. For example, a small physical condition that is slowing down your sexual response may be contributing to your concern over keeping an erection.
For example, if a man is obese, changes in blood flow may impact his ability to keep an erection, a physical reason. Symptoms may also include difficulty maintaining an erection for a sufficient period of time to consummate intercourse, or inability to ejaculate. It may also mean that you are unhappy with the size or firmness of an erection, or with the length of time that your erections last.
How is ED diagnosed
There are a few different ways that doctors can diagnose erectile dysfunction.
One way is to ask the patient a series of questions about their symptoms and sexual health history. The most used instrument is the International Index of Erectile Function, a 15-item questionnaire that has been validated in many populations and is considered the gold standard for evaluating patients for ED This questionnaire can help doctors determine if someone has erectile dysfunction and how severe it may be.
Another way to diagnose ED is with a physical examination. The doctor will check for signs of damage or disease in the penis and surrounding tissues. They may also test for nerve function in the area.
A final way to diagnose ED is with lab tests:
- Blood tests can help rule out other causes of erection problems, such as low testosterone or high blood sugar levels. If the health care provider needs to examine blood flow in the penis more, he or she is more likely to order an ultrasound, which may also include injecting a drug (intracavernosal, meaning in the penis) (such as Prostaglandin E1 or Trimix, a mix of papaverine, phentolamine, and prostaglandins).
- Urine tests can also help identify potential causes, such as infection or blocked urine flow from an enlarged prostate gland. Urine testing involves using a stick-like device (a transducer) held above a blood vessel supplying your penis. Urine tests are sometimes done along with an injection of medicine in the penis to stimulate blood flow and induce an erection. This test is performed both when the penis is erect (usually caused by the injection of the medication stimulating an erection) and when it is soft. This may involve a close inspection of your penis and testicles, as well as checking for sensation in the nerves.
In some cases, more than one method might be necessary to get an accurate diagnosis due on how complex someone’s individual case might be.
Erectile Dysfunction Expected Duration
There is no one definitive answer to how long ED lasts. In general, however, it is a chronic condition that can be managed but not cured. For some people, ED may last only a short time, while for others it may be a lifelong challenge. What matters most is how you manage your condition and work to keep yourself healthy and sexually active. With the help of your doctor or other healthcare professionals, you can develop a treatment plan that works for you and helps you maintain an active and satisfying sex life.
Erectile Dysfunction (Impotence) Treatment
There are many methods of treating erectile dysfunction, and each man should discuss the options with his doctor to find the best treatment for him. The most common treatments are:
Oral ED medications
The most popular is a class of drugs called phosphodiesterase type 5 (PDE5) inhibitors. These drugs work by increasing blood flow to the penis, making it easier to get and keep an erection.
PDE 5 inhibitors have become the first-line therapy for ED, as recommended by the American Urological Association (AUA) and the European Association of Urology.
The four oral PDE 5 inhibitors commercially available in the United States are:
Sildenafil, sold under the brand name Viagra, among others, is a drug used for treating erectile dysfunction and pulmonary arterial hypertension. Sildenafil is also used to treat a type of blood pressure that affects the hearts and lung arteries, called pulmonary arterial hypertension.Sildenafil has also been shown to help treat women experiencing female sexual arousal disorders (FSAD). Compared with a placebo, or no treatment at all, sildenafil helps to improve ED, and the side effects are usually mild.Do not take sildenafil if you are also using a nitrate medication to treat chest pain or heart problems, including nitroglycerin, isosorbide dinitrate, isosorbide mononitrate, and certain recreational drugs, such as poppers. Using Sildenafil at the same time as an A 1 blocker (typically prescribed to treat high blood pressure or for urologic conditions, such as benign prostatic hypertrophy) can cause you to have lower blood pressure, but the effect does not happen if the two are taken at least 4 hours apart. Sickle – cell (blood disease) anemia – Sildenafil should be used cautiously in these patients, because problems with penile – longer erections can occur
Taken as directed, sildenafil is used to treat ED in short-term settings, as well as PAH for longer – term treatment.
Vardenafil, also known by its brand name, Levitra, is a prescription drug used to treat men’s erectile dysfunction (impotence) and pulmonary arterial hypertension (PAH). Vardenafil is a potent, selective inhibitor of the specific cGMP-specific phosphodiesterase type 5 (PDE5), responsible for reducing cGMP in the corpus cavernosum.This means that, with vardenafil in place, regular sexual stimulation leads to increased levels of cGMP in the corpus cavernosum, resulting in better erections. In a natural environment, i.e., under sexual stimulation, vardenafil repairs impaired erection by increasing blood flow to the penis. In addition to its indications for erectile dysfunction, Vardenafil can be effective for treating premature ejaculation, where it can greatly extend the time between penetration and ejaculation.
Tadalafil (Cialis) is a phosphodiesterase type 5 inhibitor that is approved by the Food and Drug Administration (FDA) to treat erectile dysfunction (ED), signs and symptoms of benign prostatic hyperplasia (BPH), and both ED and BPH signs and symptoms (ED+BPH).If you are taking Tadalafil to treat erectile dysfunction, you are likely to be started off with a medium dose of Tadalafil by your GP, increasing or decreasing the dosage depending on how well you respond to the drug. If you must take nitrates, take them at least 48 hours after the last dose of tadalafil.If you are already taking medicines to treat BPH, your healthcare provider can tell you to stop taking other medicines for at least one day before starting treatment with tadalafil. If you take too much tadalafil, or take Tadalafil along with other PDE5 inhibitors, the chances of having a negative effect are higher.If you do not get an erection after taking tadalafil, or it does not last long enough to allow you to have sex, talk with your doctor about this — do not take more pills than your doctor has told you.When using Tadalafil to treat ED, your ability to have sex can improve up to 36 hours after taking the pills.Tadalafil is also used for both men and women to treat symptoms of pulmonary arterial hypertension, which can make it easier for you to exercise.
Avanafil (Stendra) was approved for treatment of erectile dysfunction by the U.S. Food and Drug Administration on April 27, 2012
Stendra is only available in branded form, called Stendra, rather than in generic form, like avanafil, to help avoid any confusion with the first-generation ED drugs.You may have more side effects when taking Avanafil if you are also taking medicines called nitrates to help with chest pain, medicines that help control high blood pressure, some medicines to help treat HIV, are older, or have liver or kidney disease.Avanafil should not be combined with other PDE5 inhibitors used to treat impotence, such as vardenafil or sildenafil. Avanafil also increases the blood pressure-lowering effects of certain alpha-blocking drugs, such as terazosin (Hytrin), which are used mostly to treat high blood pressure or prostate enlargement.
The side effects of an ED drug usually happen as the medication is active in the body, though it is possible for ED drug side effects to continue a little longer than the medication itself. The most common side effects of oral ED medications are stomach upset, nose congestion, flushing, headache, and temporary vision impairment. For most men who struggle to maintain a firm enough erection to engage in sexual activity (ED), oral medications work well and produce little side effects. Oral ED medications do not intensify sexual desire or produce sexual stimulation; they work by increasing blood flow to the penis when sex is in progress.
Because the oral drugs are all equally effective, the American College of Physicians suggests choosing according to your preferences, including cost, ease of use, how long a drug’s effects last, and side effects.
Brief ED drugs comparison table
If it is believed that erectile dysfunction (ED) is a psychological condition, then if your GP believes that this would be helpful, he or she might recommend that you see a sex therapist. A sex therapist can help to identify the situational, relationship, and psychological causes of your ED, and may direct you to a health care provider if necessary. In sessions with the sex therapist, you will work individually or together to address any psychological barriers, improve your sexual communications, and learn lifelong skills for the bedroom. Sometimes, during sex therapy, therapists will discover the issue is bigger than sex-specific issues, and the treatment plan shifts into more conventional couple’s therapy.
A penis pump, also known as a vacuum-constriction device or an ED pump, is a cylindrical device used to get and keep an erection by drawing blood to the penis by using suction. A penis pump sometimes provides an effective erectile dysfunction treatment, which allows men to keep an erection long enough to participate in sexual intercourse.
Generally, the firmness at the base of your penis is lower in erections achieved through the use of a vacuum device, so you are more likely to experience twisting or movements that you do not usually experience.
A penis pump is a perfect choice for men who may be experiencing ED due to a physical factor, like diabetes, or a nerve injury from a spinal cord injury or treatment of prostate cancer, or as a result of a psychological factor, including performance anxiety. For instance, using a penis pump can help to regain the ability to have natural erections following prostate surgery or radiation treatment for prostate cancer. Using a penis pump does not cure erectile dysfunction, but it can build up a strong enough erection to allow for sex.
Testosterone therapy involves taking supplemental doses of testosterone in order to increase levels in the body. For men with ED, this can help improve blood flow and sexual function. Studies have shown that testosterone therapy can be successful in treating up to 80% of cases of male ED.
However, there are some risks associated with testosterone therapy. These include increased risk of heart attack and stroke, as well as potential side effects like hair loss and acne. It is important to weigh these risks against the benefits before deciding if testosterone therapy is right for you.
If you decide to try testosterone therapy, it is important to work with a doctor who can monitor your health closely and help you manage any potential risks involved.
If four PDE5 inhibitors do not work for you, penile injections of phentolamine, papaverine, and alprostadil are considered the second-line treatments for ED, with alprostadil being most often used. The idea of putting a needle in your penis might seem scary, but many ED patients have found the treatment works.
In penile injection therapy, medication (the drug alprostadil which allows blood to flow more freely in the penis, leading to an erection. is administered directly to the inside of your penis, via a ridiculously small insulin-style needle. The drug is not injected beneath the skin, but rather it needs to be injected into the inner part of the penis, which is filled with blood when erect. With injections, a thin needle is used to insert different medications into the base or sides of your penis.
It is especially important that you choose the right place on the penis for injection to avoid injections into the nerves or blood vessels. To prevent injury to the tissues of your penis, always switch sides of your penis whenever injecting medicine (right side, then left side).
Incorrect injections, and any scarring that follows, may cause curved and lumpy peniles, which is why it is essential to receive appropriate training before starting this treatment. When men are interested in penile injection therapy, a urologist performs a trial injection first in office to make sure that there are no adverse effects on the patient.
Alprostadil may also be administered intraurethrally (into the urethra) by insertion of the pellet into the urethral meatus and allow the medication to absorb into the corpora cavernosa. Intraurethral alprostadil is a useful agent for men who do not wish to self-inject, or for men for whom oral medications have failed. Intraurethral alprostadil is delivered via Medicated Erection System (MUSE)–a disposable pellet of alprostadil suspended in polyethylene glycol administered using an applicator.
If other strategies are not effective, or if anatomical causes for Erectile Dysfunction exist, the physician may suggest surgery. It is an option for patients who cannot tolerate oral or injectable, or intraurethral, treatments for ED. Although it might appear that penile revascularization would be a sensible treatment, this is a choice in a small proportion of men with erectile dysfunction that fit a specific criterion. Because vascular penile surgery is not recommended for older men who have failed treatment with an oral PDE5 inhibitor, an ICI, or a UI, implants are the next-best thing for these patients.
Your doctor may explain the risks and benefits of each treatment, and he will consider your preferences. You also might benefit from talking to your partner about what treatments are best for you as a couple.
A man experiencing problems with his sexual function may not want to talk with his health care provider, seeing this as a potentially embarrassing issue. Feeling embarrassed by a sexual health issue may keep many men from seeking medical help that is needed, potentially delaying diagnosis and treatment for more serious underlying conditions.
How to prevent Erectile Dysfunction (Impotence)
Erectile dysfunction is a condition that affects many men and can have a negative impact on their quality of life. Fortunately, there are steps that men can take to help prevent erectile dysfunction from occurring.
- One of the most important things that men can do to prevent erectile dysfunction is to maintain a healthy weight. Being overweight or obese increases the risk of developing type 2 diabetes and other health conditions that can lead to ED. In addition, maintaining a healthy weight helps keep blood pressure and cholesterol levels in check, which are also factors that contribute to ED.
- Another key factor in preventing ED is getting regular exercise. Exercise helps improve blood flow throughout the body, including the penis, which helps reduce the risk of developing erectile dysfunction. Exercise also has numerous other health benefits, such as reducing stress levels and improving overall moods.
- A third way for men to help prevent erectile dysfunction is by avoiding smoking and excessive alcohol consumption. Smoking cigarettes damages blood vessels and makes it more difficult for blood to flow properly throughout the body – including to the penis – leading to problems with getting or maintaining an erection. Excessive alcohol consumption can also damage blood vessels as well as interfere with hormone production, both of which are important for normal sexual function.