What is erectile dysfunction (ED)?
Erectile dysfunction (or ED), also called male impotence, is described as a consistent inability to achieve and maintain an erection sufficient for mutually satisfactory sexual intercourse with his partner. By itself, ED is not a disease but more of a signal that something else may be a problem. Erectile dysfunction is a common condition, affecting more than half of men ages 40 to 70.
Sexual dysfunction can sometimes be caused by disorders such as diabetes, high blood pressure, vascular disease, heart disease, nervous system disorders, and depression as well as an unwanted side effect from some medications. Male sexual dysfunction may be the symptom of such disorders that brings them to the doctor's office in the first place.
Sexual health and function are important in determining a man's quality of life. As Americans age, disorders such as erectile dysfunction (ED) are becoming increasingly apparent. Because this subject is discussed widely in the media, men and women of all ages are seeking guidance in an effort to improve their relationships and experience satisfying sex lives.
The successful treatment of ED has been shown to improve sexual intimacy and satisfaction, improve sexual aspects of quality of life as well as overall quality of life, and relieve symptoms of depression.
How does a man achieve an erection?
For a man to have an erection, a complex process takes place within his body.
- Erection involves the central nervous system, peripheral nervous system, hormones, psychological and stress-related factors, local problems with the penis itself as well as blood flow or circulation. The penile portion of the process leading to erections represents only a single component of a very complex cascade of events.
- Erections occur in response to touch, smell, and visual stimuli that trigger pathways in the brain. Information travels from the brain to the nerve centers at the base of the spine, where primary nerve fibers connect to the penis and regulate blood flow during erection and afterward.
- Sexual stimulation causes the release of chemicals from the nerve endings in the penis that trigger a series of events that ultimately cause muscle relaxation in the erection bodies of the penis. The smooth muscle in the erection bodies controls the flow of blood into the penis. When the smooth muscle relaxes, the blood flow dramatically increases causing the erection bodies to become full and rigid, resulting in an erection. Venous channels normally draining blood are compressed and close off as the erection bodies enlarge.
- Detumescence (when the penis is no longer in a state of erection) results when muscle-relaxing chemicals are no longer released. Ejaculation causes the smooth muscle tissue of the erection bodies in the penis to regain muscle tone, which allows the blood drainage channels to open. As the extra blood drains from the erection bodies, the erection loses rigidity and the penis returns to its original flaccid state.
ED occurs when this process does not progress normally. Arousal and erections are physical and mental activities, so it is important to remember that the sexual partner plays an integral role. Effective management of erection problems and erectile dysfunction is often more successful if the sexual partner is involved with the evaluation and treatment.
Is impotence the same as erectile dysfunction?
Yes, the terms mean the same.
Premature ejaculation is often confused with erectile dysfunction. Premature ejaculation is a condition in which the entire process of arousal, erection, ejaculation, and climax occur very rapidly, often in just a few minutes or even seconds, leaving both the sexual partner and the one experiencing premature ejaculation unsatisfied. Premature ejaculation may accompany an erection problem such as ED but is generally treated differently.
Erection problems will usually produce a significant psychological and emotional reaction in most men. This is often described as a pattern of anxiety and stress that can further interfere with normal sexual function. This "performance anxiety" needs to be recognized and addressed by your doctor.
What causes erectile dysfunction?
Currently, virtually any man who wishes to have an erection can obtain it, regardless of the underlying cause of his problem. Many reasonable treatment options exist. Your first step is to find a well-trained, experienced, and compassionate doctor who is willing to take the time to understand you and fully examine you to discover the cause and discuss the treatments available to you.
Your doctor will want to rule out any other causes for your concern such as high blood pressure, prostate cancer, vascular disease, and diabetes.
By seeing your doctor, you may very well be saving your life if the doctor detects – and treats – a life-threatening illness. Often, you can restore your sexual health by treating a condition such as high blood pressure with diet and exercise or controlling your diabetes.
For some men, erectile dysfunction develops with age or may be related to depression or another psychological cause. In these cases, psychological counseling with you and your sexual partner may be successful.
Medications can cause ED, especially drugs you might take to control blood pressure or depression (antidepressants) (see Impotence/Erectile Dysfunction for a list of medications that may cause ED). Anti-ulcer drugs can be a cause, as can alcohol or drug abuse. ED is a side effect. Talk with your doctor about medications that might not cause this side effect. Do not just stop taking your prescribed medication.
Other causes include damage to the erection bodies in the penis; diabetes; various hormonal disorders; blood flow problems; psychological factors, such as depression; and surgical complications from abdominal, pelvic, or back surgery.
Erectile Dysfunction (ED) Causes and Treatment
How is erectile dysfunction treated?
Treatment options include sexual counseling, medications, external vacuum devices, hormonal therapy, penile injections, or intraurethral suppositories (see Impotence/Erectile Dysfunction for treatment options). In highly selected cases under the supervision of a urology specialist in ED, combination therapy using several of these methods together can be used. If none of these therapies is satisfactory, penile implants through surgery can be considered.
Illustration of two rigid cylinders placed into the penis. Illustration of two balloon cylinders placed into the penis.
Most patients start with Viagra and other similar drugs. No one could miss all of the consumer advertising for drugs to aid in ED. You see advertising for these drugs in magazines and on TV. Certainly there are plenty of jokes about Viagra and similar drugs, but ED is not funny if you are experiencing it.
How do drugs like Viagra work?
Viagra (sildenafil citrate), a prescription medication for the treatment of erectile dysfunction, is the first pill available that's been proven to improve erections in most men with impotence.
Since its introduction in March 1998, no other therapy for ED has achieved such wide public recognition. Viagra doesn't improve erections in normal men, only in those with difficulty in achieving or maintaining erections sufficient for sexual intercourse due to a true medical problem. It is not an aphrodisiac (sexual stimulant) and will not increase sexual desire. Unlike other treatments for erectile dysfunction, Viagra requires sexual stimulation to function. Without this stimulation, Viagra won't have any effect.
Viagra works by blocking an enzyme found mainly in the penis that breaks down chemicals produced during sexual stimulation that normally produce erections. Viagra allows these chemicals of arousal to survive longer and improves erectile function. That is also why sexual stimulation is necessary for Viagra to work.
In general, Viagra works successfully in about 65-70% of all impotent men.
Viagra works best if taken about 30 to 60 minutes before sexual activity. Only 1 tablet should be taken per day. It should be taken on an empty stomach. Increasing the dosage of Viagra beyond the recommended amounts will not improve the response and will only result in greater side effects.
Several drugs very similar to Viagra have recently been approved by the FDA. These drugs, called vardenafil (Levitra), Stendra (avanafil) and tadalafil (Cialis), have essentially the same activity and general precautions as Viagra. Levitra may be taken with food where Viagra needs to be taken on an empty stomach. Cialis has a much longer duration of improved erection function (up to 24-36 hours) compared with Viagra and Levitra (up to 4 to 6 hours). Cialis in daily dosage now has FDA approval for treatment of patients with benign prostatic hyperplasia and erectile dysfunction for clinical situations where treatment of both conditions has been shown to be of medical necessity. Stendra is effective when taken with or without food, and it works within 15 minures. Moderate consumption of alcoholic beverages is possible with Stendra.
Do ED drugs have side effects?
The most common side effect of Viagra and similar drug use is headache, affecting about 16% of users. A drop in blood pressure, transient dizziness, and facial flushing (red face) are reported in 10%. Indigestion occurs in 7% and nasal congestion in 4%. Between 3% and 11% of users report some visual problems while on Viagra. This visual disturbance is described as either blurred vision, increased light sensitivity, persistence of a bluish tinge, or temporary loss of the ability to distinguish between blue and green.
Cautions: Viagra, Levitra, and Cialis are absolutely not to be taken by men with heart conditions who are taking nitrates such as nitroglycerine or isosorbide (Isordil, Ismo, Imdur). Certain street drugs such as "poppers" also can cause serious problems if taken with Viagra, Levitra, or Cialis. Ecstasy is a street drug that may increase sexual desire but interferes with performance. This has prompted some men to combine ecstasy with Viagra, Levitra, or Cialis. This mixture (a combination sometimes called "sextasy") can improve erection ability but also causes severe headache and priapism. (Priapism is an abnormally prolonged erection that becomes extremely painful and may result in permanent damage to the erection mechanism.) There are also potentially dangerous effects to your heart from mixing Viagra and similar medications with various other street drugs.
What are penile implants?
Two types of devices are available, a semirigid and a multi-component inflatable system.
With the semirigid device, two matching cylinders are implanted into the penis. These devices provide enough rigidity for penetration and rarely break. The major drawbacks are the cosmetic appearance of the penis, the need for a surgery, and the destruction of the natural erectile mechanism when the device is implanted.
The inflatable devices consist of two cylinders inserted into the penis, a pump placed in the scrotum to inflate the cylinders, and a reservoir that is contained either within the cylinders or in a separate reservoir placed beneath the tissue of the lower abdomen. The inflatable prosthesis generally remains functional for 7 to 10 years before a replacement may be necessary.
Isn't surgery a rather drastic measure?
In the past, the placement of prosthetic devices within the penis was the only effective therapy for men with certain types of erectile dysfunction. Now, this is the last option considered when all other treatments are unacceptable or unsuccessful. Nevertheless, surgery remains a reliable form of therapy (see Impotence/Erectile Dysfunction for surgical options). Once a surgical implant has been done, the normal structure of the penis is permanently altered, which means that the surgery is not reversible.
What if I feel embarrassed to talk about this?
This is a delicate topic, and your doctor should be sensitive and caring to make you comfortable about sharing these intimate details of your private life. Schedule enough time with your doctor to conduct a full interview and physical examination. The first step in the medical management of erectile dysfunction is taking a thorough sexual, medical, and psychosocial history.
- Your doctor will ask if you have difficulty obtaining an erection, if the erection is suitable for penetration, if the erection can be maintained until the partner has achieved orgasm, if ejaculation occurs, and if both partners have sexual satisfaction.
- The doctor will want to know all medications you have taken during the past year, including all vitamins and other dietary supplements.
- Tell the doctor about your tobacco use, alcohol intake, and caffeine intake, as well as any illicit drug use.
- Your doctor will be looking for indications of depression. You will be asked about libido (sexual desire), problems and tension in your sexual relationship, insomnia, lethargy, moodiness, nervousness, anxiety, and unusual stress from work or at home.
- You will be asked about your relationship with your sexual partner. Does your partner know you are seeking help for this problem? If so, does your partner approve? Is this a major issue between you? Is your partner willing to participate with you in the treatment process?
Your doctor will want your candid answers to questions like these so you can discuss the best treatment for you.
A physical examination is necessary. The doctor will pay particular attention to the genitals and nervous, vascular, and urinary systems. Your blood pressure will be checked because several studies have demonstrated a connection between high blood pressure and erectile dysfunction.
The physical examination will confirm information you gave the doctor in your medical history and may help reveal unsuspected disorders such as diabetes, vascular disease, penile plaques (scar tissue or firm lumps under the skin of the penis), testicular problems, low male hormone production, injury, or disease to the nerves of the penis and various prostate disorders.
You can achieve a satisfactory erection and sexual health, and working with your doctor or a specialist (urologist) is the best way to get help.
Medically reviewed by Michael Wolff, MD; American Board of Urology
Edward David Kim, MD, FACS, et al. "Erectile Dysfunction." Medscape. 16 Sep 2013.