Erectile dysfunction (ED) is defined as the inability to maintain a firm erection long enough to have sex. The problem, also called male impotence, is less common in younger men and increases in prevalence with age. Up to 80 percent of men aged 75 and older experience some degree of ED. It is estimated that 30 million men in the U.S. have problems with ED. Occasional inability to maintain an erection is normal and treatment should be sought only if the problem becomes persistent.
Male Sexual Response
For an erection to occur, a combination of physical and psychological events must occur. The brain, hormones, nerves, muscles and blood vessels are all involved. Smooth muscle in the penis must relax to allow increased blood flow causing the penis to become firm. There is constriction of venous outflow in order to maintain the erection.
In the past, erectile problems were thought to be purely psychological, but it is now known that physical factors play the predominant role.
Causes and Risk Factors
ED can be caused by chronic health problems, injury, medications and other drugs, behavorial and psychological issues.
Some of these factors include:
- Heart disease
- High blood pressure
- Diabetes
- Obesity
- Trauma
- Low levels of testosterone
- Medications (e.g., some blood pressure medications, antidepressants, pain medications, tranquilizers, sleep aids and prostate cancer medications)
- Tobacco use (restricts blood flow to veins and arteries)
- Alcohol overuse
- Illicit drug abuse
- Depression
- Anxiety
- Stress
- Fatigue
- Relationship problems
Evaluation and Treatment
Erectile dysfunction may be an indicator of other undiagnosed illnesses such as heart disease and diabetes.
It is important to inform your primary health care provider when ED problems are persistent. Many men are reluctant to speak about sexual issues, but a direct and open approach should be taken.
Initial evaluation includes a history of the problem, physical examination and blood tests to check for abnormalities such as a low testosterone level and high blood glucose.
Further specialized testing can be done if the situation warrants and may include the following:
- Ultrasound to look for anatomical abnormalities
- Neurological exam for proper nerve function
- X-rays after injection of dye into penile blood vessels to look for blockages
- Nocturnal tumescence test to determine if erections occur over-night
Treatments
There are three prescription medications used for the treatment of erectile dysfunction.
- Viagra (sildenafil)
- Cialis (tadalafil)
- Levitra (vardenafil)
These medications all work in a similar fashion by relaxing penile smooth muscle; allowing increased blood flow to the penis. The erection occurs only after physical and psychological stimulation. No study has directly compared these medications to determine if one is better than the others for specific types of patients.
These male enhancement drugs should not be taken if you are also taking nitrates (e.g., Nitro-Bid, Imdur and Isordil), blood thinners and alpha blockers for enlarged prostate or high blood pressure (e.g., Flomax, Hytrin and Cardura).
Health conditions that preclude use of these oral medications include severe heart disease or heart failure, stroke within the last six months, very low blood pressure, uncontrolled high blood pressure, uncontrolled diabetes, sickle cell anemia and leukemia.
ED treatment medicatons may not be covered by health insurance and usually cost between $10.00 and $20.00 per pill.
Other types of medicatons can be injected directly into the penis or inserted down the urethra or opening of the penis. They also work by relaxing smooth muscle; allowing increased blood flow.
A small number of men with low levels of testosterone benefit from hormone replacement.
Additional forms of treatment include penis vacuum pumps, penile implants and vascular surgery for blood vessel blockage. These treatments are usually employed if medications are ineffective or cannot be utilized.
Psychological counseling is helpful if there are problems with depression, anxiety or stress. Relationship counseling can help if necessary.
Prevention
Prevention includes management of health problems that may lead to erectile dysfunction. Illnesses such as diabetes, heart disease and hypertension should be diagnosed and treated. Regular exercise, adequate sleep, limited use of alcohol and no smoking are all helpful. Regular visits to the doctor for checkups and medical screening tests are expecially important.
Further Resources
American Urological Association
