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Erectile dysfunction

Definition

Erectile dysfunction (impotence) occurs when a man can no longer get or keep an erection firm enough for sexual intercourse. Having erection trouble from time to time isn't necessarily a cause for concern. But if erectile dysfunction is an ongoing problem, it may cause stress, cause relationship problems or affect your self-confidence.

Even though it may seem awkward to talk with your doctor about erectile dysfunction, go in for an evaluation. Problems getting or keeping an erection can be a sign of a health condition that needs treatment, such as heart disease or poorly controlled diabetes. Treating an underlying problem may be enough to reverse your erectile dysfunction.

If treating an underlying condition doesn't help your erectile dysfunction, medications or other direct treatments may work.

Erect penis

Illustration of erect penis
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The penis contains two cylindrical, sponge-like structures (corpus cavernosum). When a male becomes sexually aroused, nerve impulses increase blood flow to both cylinders. This sudden influx of blood ...

Symptoms

Erectile dysfunction symptoms may include persistent:

  • Trouble getting an erection
  • Trouble keeping an erection
  • Reduced sexual desire

When to see a doctor
A family doctor is a good place to start when you have erectile problems. See your doctor if:

  • Erectile or other sexual problems are an issue for you or your partner
  • You have diabetes, heart disease or another known health problem that may be linked to erectile dysfunction
  • You have other symptoms along with erectile dysfunction that may not seem related

Causes

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 problems can cause or worsen erectile dysfunction. Sometimes a combination of physical and psychological issues causes erectile dysfunction. For instance, a minor physical problem that slows your sexual response may cause anxiety about maintaining an erection. The resulting anxiety can lead to or worsen erectile dysfunction.

Physical causes of erectile dysfunction
In most cases, erectile dysfunction is caused by something physical. Common causes include:

  • Heart disease
  • Clogged blood vessels (atherosclerosis)
  • High cholesterol
  • High blood pressure
  • Diabetes
  • Obesity
  • Metabolic syndrome, a condition involving increased blood pressure, high insulin levels, body fat around the waist and high cholesterol
  • Parkinson's disease
  • Multiple sclerosis
  • Low testosterone
  • Peyronie's disease, development of scar tissue inside the penis
  • Certain prescription medications
  • Tobacco use
  • Alcoholism and other forms of substance abuse
  • Treatments for prostate cancer or enlarged prostate
  • Surgeries or injuries that affect the pelvic area or spinal cord

Psychological causes of erectile dysfunction
The brain plays a key role in triggering the series of physical events that cause an erection, starting with feelings of sexual excitement. A number of things can interfere with sexual feelings and cause or worsen erectile dysfunction. These include:

  • Depression, anxiety or other mental health conditions
  • Stress
  • Relationship problems due to stress, poor communication or other concerns

Risk factors

As you get older, erections may take longer to develop and may not be as firm. You may need more direct touch to your penis to get and keep an erection. This isn't a direct consequence of getting older. Usually it's a result of underlying health problems or taking medications, which is more common as men age.

A variety of risk factors can contribute to erectile dysfunction. They include:

  • Medical conditions, particularly diabetes or heart problems.
  • Using tobacco, which restricts blood flow to veins and arteries. Over time tobacco use can cause chronic health problems that lead to erectile dysfunction.
  • Being overweight, especially if you're very overweight (obese).
  • Certain medical treatments, such as prostate surgery or radiation treatment for cancer.
  • Injuries, particularly if they damage the nerves that control erections.
  • Medications, including antidepressants, antihistamines and medications to treat high blood pressure, pain or prostate cancer.
  • Psychological conditions, such as stress, anxiety or depression.
  • Drug and alcohol use, especially if you're a long-term drug user or heavy drinker.
  • Prolonged bicycling, which may compress nerves and affect blood flow to the penis, can lead to temporary erectile dysfunction.

Complications

Complications resulting from erectile dysfunction can include:

  • An unsatisfactory sex life
  • Stress or anxiety
  • Embarrassment or low self-esteem
  • Marital or relationship problems
  • The inability to get your partner pregnant

Preparing for your appointment

You're likely to start by seeing your family doctor or a general practitioner. Depending on your particular health concerns, you may go directly to a specialist such as a doctor who specializes in male genital problems (urologist) or a doctor who specializes in the hormonal systems (endocrinologist).

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready, and what to expect from your doctor.

What you can do
Take these steps to prepare for your appointment:

  • Ask what you need to do ahead of time. At the time you make the appointment, be sure to ask if there's anything you need to do in advance. For example, your doctor may ask you not to eat before having a blood test.
  • Write down any symptoms you've had, including any that may seem unrelated to erectile dysfunction.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, vitamins, herbal remedies and supplements you take.
  • Take your wife or partner along, if possible. Your partner can help you remember something that you missed or forgot during doctor's appointments.
  • Write down questions to ask your doctor.

Your time with your doctor is limited. Prepare a list of questions to get the most out of your appointment. For erectile dysfunction, some basic questions to ask your doctor include:

  • What is most likely causing my erection problems?
  • Other than the most likely cause, what are other possible causes?
  • What kinds of tests do I need?
  • Is my erectile dysfunction most likely temporary or chronic?
  • What's the best treatment?
  • What are the alternatives to the primary approach that you're suggesting?
  • I have these other health conditions. How can I best manage them together?
  • Are there any restrictions that I need to follow?
  • Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask additional questions during your appointment.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • What other health problems or chronic conditions do you have?
  • Have you had any other sexual problems?
  • Have you had any changes in sexual desire?
  • Do you get erections during masturbation, with a partner or while you sleep?
  • Are there any problems in your relationship with your sexual partner?
  • Does your partner have any sexual problems?
  • Are you anxious, depressed or under stress?
  • Have you ever been diagnosed with a mental health condition? If so, do you currently take any medications or get psychological counseling (psychotherapy) for it?
  • When did you first begin noticing sexual problems?
  • Do your erectile problems occur only sometimes, often or all of the time?
  • What medications do you take, including any herbal remedies or supplements?
  • Do you drink? If so, how much?
  • Do you use any illegal drugs?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

Tests and diagnosis

For many men, a physical exam and answering questions (medical history) are all that's needed before a doctor is ready to recommend a treatment. If your doctor suspects that underlying problems may be involved, or you have chronic health problems, you may need further tests or you may need to see a specialist.

Tests for underlying problems may include:

  • Physical exam. This may include careful examination of your penis and testicles and checking your nerves for feeling.
  • Blood tests. A sample of your blood may be sent to a lab to check for signs of heart disease, diabetes, low testosterone levels and other health problems.
  • Urine tests (urinalysis). Like blood tests, urine tests are used to look for signs of diabetes and other underlying health conditions.
  • Ultrasound. This test can check blood flow to your penis. It involves using a wand-like device (transducer) held over the blood vessels that supply the penis. It creates a video image to let your doctor see if you have blood flow problems. This test is sometimes done in combination with an injection of medications into the penis to determine if blood flow increases normally.
  • Overnight erection test. Most men have erections during sleep without remembering them. This simple test involves wrapping special tape around your penis before you go to bed. If the tape is separated in the morning, your penis was erect at some time during the night. This indicates the cause of your erectile dysfunction is most likely psychological and not physical.
  • Psychological exam. Your doctor may ask you questions to screen for depression and other possible psychological causes of erectile dysfunction.

Treatments and drugs

The first thing your doctor will do is to make sure you're getting the right treatment for any health problems that could be causing or worsening your erectile dysfunction.

A variety of options exist for treating erectile dysfunction. The cause and severity of your condition, and underlying health problems, are important factors in your doctor's recommending the best treatment or treatments for you. Your doctor can explain the risks and benefits of each treatment and will consider your preferences. Your partner's preferences also may play a role in treatment choices.

Oral medications
Oral medications are a successful erectile dysfunction treatment for many men. They include:

  • Sildenafil (Viagra)
  • Tadalafil (Cialis)
  • Vardenafil (Levitra, Staxyn)

All three medications work in much the same way. These drugs enhance the effects of nitric oxide, a natural chemical your body produces that relaxes muscles in the penis. This increases blood flow and allows you to get an erection in response to sexual stimulation. These medications vary in dosage, how long they work and their side effects. Your doctor will take into account your particular situation to determine which medication may work best.

Possible side effects include flushing, nasal congestion, headache, visual changes and stomach upset.

These medications may not fix your erectile dysfunction immediately. You may need to work with your doctor to find the right medication and dose for you.

Before taking any prescription erectile dysfunction medication (including over-the-counter supplements or herbal remedies), get your doctor's OK. Although these medications can help many people, not all men should take them to treat erectile dysfunction. These medications may not work or may be dangerous for you if you:

  • Take nitrate drugs commonly prescribed for chest pain (angina) such as nitroglycerin (Nitro-Bid, Nitro-Dur, Nitrostat, others), isosorbide mononitrate (Imdur, Monoket) and isosorbide dinitrate (Dilatrate, Isordil)
  • Take a blood-thinning (anticoagulant) medication, alpha blockers for enlarged prostate (benign prostatic hyperplasia) or high blood pressure medications
  • Have heart disease or heart failure
  • Have had a stroke
  • Have very low blood pressure (hypotension) or uncontrolled high blood pressure (hypertension)
  • Have uncontrolled diabetes

Other medications
Other medications for erectile dysfunction include:

  • Alprostadil self-injection. With this method, you use a fine needle to inject alprostadil (Caverject Impulse, Edex) into the base or side of your penis. In some cases, medications generally used for other conditions are used for penile injections on their own or in combination. Examples include papaverine, alprostadil and phentolamine. Each injection generally produces an erection that lasts about an hour. Because the needle used is very fine, pain from the injection site is usually minor. Side effects can include bleeding from the injection, prolonged erection and formation of fibrous tissue at the injection site.
  • Alprostadil penis suppository. Alprostadil intraurethral (Muse) therapy involves placing a tiny alprostadil suppository inside your penis in the penile urethra. You use a special applicator to insert the suppository into your penile urethra. The erection usually starts within 10 minutes and lasts between 30 and 60 minutes. Side effects can include pain, minor bleeding in the urethra, and formation of fibrous tissue inside your penis.
  • Testosterone replacement. Some men have erectile dysfunction caused by low levels of the hormone testosterone, and may need testosterone replacement therapy.

Penis pumps, surgery and implants
Medications may not work or may not be a good choice for you. If this is the case, your doctor may recommend a different treatment. Other treatments include:

  • Penis pumps. A penis pump (vacuum erection device) is a hollow tube with a hand-powered or battery-powered pump. The tube is placed over your penis, and then the pump is used to suck out the air inside the tube. This creates a vacuum that pulls blood into your penis. Once you get an erection, you slip a tension ring around the base of your penis to hold in the blood and keep it firm. 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. Bruising of the penis is a possible side effect, and ejaculation may not be as forceful. If a penis pump is a good treatment choice for you, your doctor may recommend or prescribe a specific model. That way you can be sure it suits your needs and that it's made by a reputable manufacturer. Penis pumps available in magazines and sex ads may not be safe or effective.
  • Penile implants. This treatment involves surgically placing devices into the two sides of the penis. These implants consist of either inflatable or semirigid rods. The inflatable devices allow you to control when and how long you have an erection. The semirigid rods keep the penis firm but bendable. This treatment is usually not recommended until other methods have been tried first. As with any surgery, there is a risk of complications such as infection.
  • Blood vessel surgery. In rare cases, leaking or obstructed blood vessels can cause erectile dysfunction and surgery is necessary to repair them.

Psychological counseling
If your erectile dysfunction is caused by stress, anxiety or depression, your doctor may suggest that you, or you and your partner, visit a psychologist or counselor. Even if it is caused by something physical, erectile dysfunction can create stress and relationship tension.

Battery-powered penis pump for erectile dysfunction

Illustration of a battery-powered penis pump
Enlarge Image
A penis pump is used to draw blood into the penis to create an erection. You then place a rubber ring around the base of the penis to maintain the erection. ...

Lifestyle and home remedies

For many men, erectile dysfunction is caused or worsened by lifestyle choices. Here are some things you can do that may help:

  • If you smoke, quit. If you have trouble quitting, get help. Try nicotine replacement (such as gum or lozenges), available over-the-counter, or ask your doctor about prescription medication that can help you quit.
  • Lose weight. Being overweight can cause or worsen erectile dysfunction.
  • Get regular exercise. This can help with underlying problems that play a part in erectile dysfunction in a number of ways, including reducing stress, helping you lose weight and increasing blood flow.
  • Get treatment for alcohol or drug problems. Drinking too much or taking certain illegal drugs can worsen erectile dysfunction directly or by causing long-term health problems.
  • Work through relationship issues. Improve communication with your partner and consider couples or marriage counseling if you're having trouble working through problems on your own.

Alternative medicine

Several alternative treatments are used to treat erectile dysfunction, but more studies are needed to see whether they are safe or effective. Alternative treatments used for erectile dysfunction include:

  • Korean red ginseng (Panax ginseng)
  • Dehydroepiandrosterone (DHEA), a hormone that's a building block for testosterone
  • L-arginine
  • Acupuncture

While some of these supplements appear to be relatively safe, others are more risky and can interact with medications or cause other problems. Before using any supplement, OK it with your doctor to make sure it's safe for you especially if you have chronic health problems.

Herbal viagra
Some alternative products that claim to work for erectile dysfunction can be dangerous. The Food and Drug Administration (FDA) has issued warnings about several types of "herbal viagra" because they contain potentially harmful drugs not listed on the label. Some of these drugs can interact with prescription drugs and cause dangerously low blood pressure. These products are especially dangerous for men who take nitrates.

Coping and support

Whether the cause is physical, psychological or a combination of both, erectile dysfunction can become a source of mental and emotional stress for you and your partner. Here are some things you can do:

  • Don't assume you have a long-term problem. Don't view occasional erection problems as a reflection on your health or masculinity, and don't automatically expect to have erection trouble again during your next sexual encounter. This can cause anxiety, which may make erectile dysfunction worse.
  • Involve your sexual partner. Your partner may see your inability to have an erection as a sign of diminished sexual interest. Your reassurance that this is not the case can help. Communicate openly and honestly about your condition. Treatment is often more successful when a man involves his partner.
  • Don't ignore stress, anxiety or mental health problems. Talk to your doctor, or see a mental health provider to address these issues.

Prevention

The best way to prevent erectile dysfunction is to make healthy lifestyle choices and to manage any existing health problems you have. Here are some things you can do:

  • Work with your doctor to manage diabetes, heart disease or other chronic health problems.
  • See your doctor for regular checkups and medical screening tests.
  • Stop smoking, limit or avoid alcohol, and don't use street drugs.
  • Exercise regularly.
  • Take steps to reduce stress.
  • Get help for anxiety or depression.
Updated: 2/10/2012

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