Erectile Dysfunction

Erectile dysfunction, sometimes called "impotence," is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word "impotence" may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved.

Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult. Estimates range from 15 million to 30 million, depending on the definition used. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. The increase happened gradually, presumably as treatments such as vacuum devices and inject able drugs became more widely available and discussing erectile function became accepted. Perhaps the most publicized advance was the introduction of the oral drug sildenafil citrate (Viagra) in March 1998. NAMCS data on new drugs show an estimated 2.6 million mentions of Viagra at physician office visits in 1999, and one-third of those mentions occurred during visits for a diagnosis other than ED.

In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age: About 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. But it is not an inevitable part of aging.

Definition

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.

How Does an Erection Occur?

The penis contains two chambers called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum. 

Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

Causes

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 non erect 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

  • Diabetes

  • Obesity

  • 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:

  • Depression

  • Anxiety

  • Stress

  • Fatigue

  • 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.

Risk Factors

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

  • Getting older. As many as 80 percent of men 75 and older have erectile dysfunction. Many men begin to notice changes in sexual function as they get older. Erections may take longer to develop, may not be as rigid or may take more direct touch to the penis to occur. But erectile dysfunction isn't an inevitable consequence of normal aging. Erectile dysfunction often occurs in older men mainly because they're more likely to have underlying health conditions or take medications that interfere with erectile function.

  • Having a chronic health condition. Diseases of the lungs, liver, kidneys, heart, nerves, arteries or veins can lead to erectile dysfunction. So can endocrine system disorders, particularly diabetes. The accumulation of deposits (plaques) in your arteries (atherosclerosis) also can prevent adequate blood from entering your penis. And in some men, erectile dysfunction may be caused by low levels of testosterone (male hypogonadism)

  • Taking certain medications. A wide range of drugs — including antidepressants, antihistamines and medications to treat high blood pressure, pain and prostate cancer — can cause erectile dysfunction by interfering with nerve impulses or blood flow to the penis. Tranquilizers and sleeping aids also can pose a problem.

  • Certain surgeries or injuries. Damage to the nerves that control erections can cause erectile dysfunction. This damage can occur if you injure your pelvic area or spinal cord. Surgery to treat bladder, rectal or prostate cancer can increase your risk of erectile dysfunction.

  • Substance abuse. Chronic use of alcohol, marijuana or other drugs often causes erectile dysfunction and decreased sexual drive.

  • Stress, anxiety or depression. Other psychological conditions also contribute to some cases of erectile dysfunction.

  • Smoking. Smoking can cause erectile dysfunction because it restricts blood flow to veins and arteries. Men who smoke cigarettes are much more likely to develop erectile dysfunction.

  • Obesity. Men who are obese are much more likely to have erectile dysfunction than are men at a normal weight.

  • Metabolic syndrome. This syndrome is characterized by belly fat, unhealthy cholesterol and triglyceride levels, high blood pressure, and insulin resistance.

  • Prolonged bicycling. Over an extended period, pressure from a bicycle seat has been shown to compress nerves and blood flow to the penis, leading to temporary erectile dysfunction and penile numbness.

Symptoms

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.

Prevention

Although most men experience episodes of erectile dysfunction from time to time, you can take these steps to decrease the likelihood of occurrences:

  • Work with your doctor to manage conditions that can lead to erectile dysfunction, such as diabetes and heart disease.

  • Limit or avoid the use of alcohol.

  • Avoid illegal drugs such as marijuana.

  • Stop smoking.

  • Exercise regularly.

  • Reduce stress.

  • Get enough sleep.

  • Get help for anxiety or depression.

  • See your doctor for regular checkups and medical screening tests.

Diagnosis

A medical examination may indicate neurological, vascular, or hormonal disease, or Peyronie's disease. History of illness, smoking, drug use, and hypertension can be ascertained with a thorough examination of health history.

Laboratory tests are performed to identify the underlying cause.

Blood Tests and Urinalysis

Blood tests can indicate conditions that may interfere with normal erectile function. These tests measure hormone levels, cholesterol, blood sugar, liver and kidney function, and thyroid function. Excess prolactin (hyperprolactinemea) can lower testosterone levels, which can diminish libido. Both of these levels are measured, as well as levels of other sex hormones. If they are persistently low, an endocrinologist (hormone specialist) should be consulted.

CBC. Complete blood count (CBC) of red cells and white cells is used to evaluate the presence of anemia. A low level of red cells limits the body's utilization of oxygen and can lead to fatigue and general malaise. The level of blood lipids (fats) such as cholesterol and triglycerides may indicate arteriosclerosis, which can reduce blood flow to the penis.

Liver and kidney function tests. Liver and kidney disease can create horomonal imbalances. Blood tests for liver function involves analysis of enzyme and serum creatinine levels, which are indicators of kidney efficiency.

Thyroid function tests. Thyroid hormones regulate metabolism and the production of sex hormones; a deficiency may contribute to impotence.

Urinalysis. Urine is analyzed for protein (albumin), sugar (glucose), and hormone (testosterone) levels that may indicate diabetes mellitus, kidney dysfunction, and testosterone deficiency.

Erectile Function Tests

Tests that assess erectile function examine the blood vessels, nerves, muscles, and other tissues of the penis and pelvic region.

Duplex ultrasound. Duplex ultrasound is used to evaluate blood flow, venous leak, signs of artherosclerosis, and scarring or calcification of erectile tissue. Erection is induced by injecting prostaglandin, a hormone-like stimulator produced in the body. Ultrasound is then used to see vascular dilation and measure penile blood pressure (which may also be measured with a special cuff). Measurements are compared to those taken when the penis is flaccid.

Prostate examination. An enlarged prostate, which can be detected with a digital rectal examination (DRE), can interfere with blood flow and nerve impulses in the penis.

Penile nerve function. Tests such as the bulbocavernosus reflex test are used to determine if there is sufficient nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger inserted past the anus. Specific nerve tests are used in patients with suspected nerve damage as a result of diabetes or nerve disease.

 Nocturnal penile tumescence (NPT). It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). These erections occur about every 90 minutes and last for about 30 minutes. Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge.

Snap gauge. Involves wrapping three plastic bands of varying strength around the penis. Erectile function is assessed according to which bands break. Strain gauge involves placing special elastic bands at the base and tip of the penis. These bands stretch during erection and register changes in circumference.

Penile biothesiometry. This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glands and shaft of the penis. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence.

Vasoactive injection. When injected into the penis, certain solutions cause erection by dilating blood vessels in erectile tissue. Normally, these injections produce an erection lasting about 20 minutes. During this procedure, penile pressure is measured and x-rays may be taken of the penile blood vessels using a special dye (contrast agent).

Effects

Whether the cause of impotence is physiological or psychological, both the patient and his partner often experience a range of intense feelings and emotions. Any of these feelings can lead to a sense of hopelessness and lower self-esteem.

Of course, feelings of sexual insecurity can reinforce any performance anxiety a man experiences and create a vicious cycle of repeated failures and increasingly negative feelings.

The first step to overcoming these feelings is to acknowledge the problem and communicate honestly and openly with each other.

Self Esteem

Because sexual performance is often a big part of a man's self-esteem, experiencing erectile dysfunction (ED) can be devastating not only to a man's sex life, but to his entire sense of being. Men with ED can become uncertain of themselves and avoid intimate situations with their partners; this only increases the pressure and anxiety associated with a condition which is often treatable.

In addition, erectile dysfunction can cause men to feel inadequate in their roles. Men who are suffering from ED tend to isolate themselves from their relationships and withdraw from their partners.

The psychological effects of ED can invade every aspect of a man's life, from his relationship with his partner, to his interactions on a social level, to his job performance. Therefore, it is important for a man who is suffering from ED to feel as comfortable as possible discussing his condition with his partner, and with his physician, in order to discover the treatment strategy which can best help overcome this condition.

Partners

Erectile dysfunction can be embarrassing to discuss not only with a health care provider but with also with a partner. It often causes men to withdraw from those who care about them, which puts a serious strain on relationships.

Partners of men with ED feel that initiating a discussion regarding the situation will cause embarrassment and humiliation. They also may develop a sense of inadequacy, thinking the cause of ED is their fault and that they are no longer physically attractive to their partner.

In most cases, ED is a result of physical causes (although it can easily be made worse by psychological factors), and can often be treated. However, silence, embarrassment, and feelings of inadequacy and humiliation only lead to further withdrawal on the part of both partners, increasing the distance and tension within the relationship. The anxiety which results can easily make a case of ED worse, leading to a vicious circle of failure and anxiety about failure.

Both partners and men with ED need to try to remember that ED is most often a treatable physical condition. The first step to treatment, however, is trust and a willingness on the part of both partners to discuss the situation with each other, and with a physician.

Treatment

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