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Frequently Asked Questions About Erectile Dysfunction

What is erectile dysfunction (ED)?

Erectile dysfunction is the persistent and consistent failure to achieve and maintain an erection adequate for sexual needs.  It is a common condition affecting 33 million American men.  An occasional failure to achieve an erection happens to most men at some time during their lives.  However, when it happens too frequently, it becomes a problem that can affect a man’s masculinity, can erode his confidence, and even his performance and productivity in the workplace.  The good news is that nearly every man with ED can be helped and cured of this common medical problem.

How does an erection occur?

An erection is similar to filling a tire using an air compressor. In order to fill a tire, you need to have the air compressor plugged in to the wall socket with electric current. The air compressor must be turned on and air must flow through the tube (perhaps consider the word “hose”) FIGURE 1 to the tire without obstruction or leakage.  The same principles of filling a tire with air hold true for a man’s erection.  The erection starts in the brain which sends a message via nerves in the spinal cord to open the blood vessels that allow blood to flow into the penis.  When the flow of blood IN to the penis is greater than the blood that flows out, an erection will occur.  Failure of any components from the brain to the penis will result in erectile dysfunction. 

What are the causes of ED?

ED can be broadly divided into two categories, psychological and physical.(FIGURE 2) In men over the age of 50, an injury to the nerves (Figure 3)and conditions affecting the blood vessels (figure 4) are the most common causes. (reverse the order and place conditions affecting the blood vessels first as this is much more common than nerve injuries)  Modern medical testing techniques have identified many physical causes including: vascular disease, Peyroine’s disease, Arteriosclerosis or hardening and narrowing of the blood vessels that supply the penis, a venous leak, testosterone deficiency, increased levels of cholesterol, hypertension, high blood pressure, too much or too little thyroid hormone, elevated prolactin levels,  and chronic or long-standing liver and kidney disease. Physical trauma such as a pelvic fracture or surgery of the bladder, colon, or prostate gland can also cause ED. Numerous medications can be a culprit as well. The most common contributors include blood pressure medications, heart medications, antidepressants, tranquilizers, pain medications, and sedatives. Non-prescription drugs including nicotine from cigarette smoking, cocaine, marijuana or excessive alcohol consumption can cause ED. Obesity is also associated with ED and it is likely due to the increased incidence of diabetes in obese men.

In younger men, especially under the age of 40, psychological causes tend to prevail. In fact, less than 10% of all men, who suffer from ED, can look to psychological causes due to depression or emotional trauma.  A common situation in young men is referred to as performance anxiety.  This situation occurs when a man is anxious about his ability to perform. If this situation persists, the erectile failure creates even more anxiety, producing repeated erectile dysfunction. Bottom line: You are not alone.  ED is a common problem affecting millions of American men.  ED is not something you need to live with as a consequence of getting older or suffering an injury. If you are healthy and interested in engaging in sexual intimacy you can be helped.

How is the cause of ED determined?

Your doctor will begin by taking a careful history and asking some routine questions such as: How long have you had ED? What other disease or conditions do you have?  What prescription and over the counter medications or supplements, do you take?  What treatments have you tried in the past?  A physical examination will follow which includes taking your blood pressure, an examination of the penis, testicles and rectal exam to evaluate your prostate gland, evaluation of the nerve supply to the lower extremities and a palpation of the blood vessels in the legs and feet. You will probably be sent for a urinalysis and blood tests to measure testosterone, cholesterol, and blood sugar levels as well as liver, kidney, and thyroid function tests.  Depending on the results of these preliminary blood tests, your Doctor may request additional tests or procedures. These tests may include a penile color duplex ultrasound, which is used to evaluate the blood flow to the penis.  The duplex Doppler study is usually accompanied by an injection of medication into the penis in order to stimulate the blood flow to the penis.  Normally, these injections create an erection that lasts about 20 minutes and allows the doctor to see if the blood vessels respond appropriately to the medication. In some cases, a nocturnal penile tumescence test is ordered to differentiate psychological causes from physical causes.  This test is based on the fact that normal men have 3-5 involuntary nighttime erections that can be measured by placing a band loosely around the penis and attaching it to a monitoring device.  The presence of normal nighttime erections will register on the monitor as an increase in girth indicating that the nerves and blood supply to the penis are intact and that the problem is not a physical one but more likely due to psychological causes. 

How is ED treated?


Impotence- Rock Hard Facts and Solutions When Viagra Doesn't Work

First, the good news.  Nearly everyone with ED can be helped through many treatment options available.  Understand your options and work with your Doctor to find one that is right for you. Perhaps the easiest and least expensive treatment is life style modification.  If you are a smoker, you should quit, if you are overweight you should lose the excess weight and begin an exercise program, if you have high cholesterol levels, you should modify your diet accordingly, and don’t use alcohol to excess. For men who use medications with the side effects of ED or a decrease in libido or sex drive, speak with your Doctor who may decrease the dosage of the medication or change to another class of drugs. If your ED does not respond to these simple lifestyle changes, your Doctor may prescribe one of several oral medications on the market today.  These oral medications are taken 30-60 minutes before engaging in sexual intimacy and will result in an increase in the blood supply to the penis through genital stimulation.  These oral medications can remain effective from 4 hours to as long as 36 hours depending on the brand. These oral medications should only be taken once a day. You should not use any of these oral medication if they are not prescribed specifically for you and under the supervision of a Doctor who is aware of your complete medical history, has an accurate list of medications you take, and has determined that it is safe for you to engage in sexual activity.

If oral ED drugs are not effective, the second line treatment includes self-injections, urethral suppositories or a vacuum erection device that may be helpful in regaining your erections.

An injection of one of these drugs or the insertion of a suppository in the urethra 10-15 minutes before engaging in sexual intimacy will work to dilate the blood vessels to the penis causing an erection without genital stimulation lasting 30 to 45 minutes. These drugs are delivered via self injection through a very small needle and with little or no pain. The two side effects are small amount of black and blue discoloration of the penis and priapism. The discoloration will go away on its own in just a few days, but priapism, which is a prolonged erection lasting several hours, is much more serious. Although it is not a very common complication, you will need to return to your doctor or go to the emergency room if your erection last more than 3-4 hours and is associated with pain and discomfort.  The priapism can be relieved by an injection of medication that causes the blood vessels to constrict and the erection will subside. A vacuum erection device is another option for men who have not had success using oral medications. The vacuum device is a tube where the penis is inserted. Air is then removed creating negative pressure around the penis.  Blood will flow into the penis that is trapped in place by an elastic or plastic band placed at the base and then the tube is removed.  The man using a vacuum device will have an erection that is usually adequate for penetration. 

If all this fails, third line treatment consists of surgical options which indlude reconstruction of the blood supply to the penis, tying the abnormal veins in the penis, or the insertion of a penile prosthesis. Surgery to reconstruct or bypass the blockage of the blood vessels is usually limited to younger men who have had trauma to the blood vessels to penis such as a pelvic fracture that disrupts the blood supply.  The blood supply can be rerouted from larger blood vessels to the smaller blood vessels in the penis and is very similar to the coronary artery bypass operation done for coronary artery disease. Surgery to ligate or tie off the abnormal veins in the penis is performed to correct venous leakage which causes ED by allowing blood to leave the penis as fast as it is pumped in, making it difficult or impossible to maintain the erection.  This procedure is not commonly done because the long-term effectiveness of the venous ligation procedure is not successful. A penile prosthesis is the surgical insertion of device through a very small, two-inch incision, which allows a man to create an erection whenever he wants and the erection will last as long as he wishes.  The most popular is the inflatable penile prosthesis, which was developed in 1973.  There have been over 300,000 devices implanted worldwide over the past 30 years and 25,000 (Tony, I will obtain this number) devices inserted annually in the United States.  The inflatable prosthesis consists of two cylinders, which are inserted into the penis, a small pump inserted into the scrotum, and a reservoir of a harmless salt solution place behind the muscles of the abdomen.  When the man desires to have an erection, he squeezes the pump and fluid is moved from the reservoir behind the muscle of the abdomen into the cylinders in the penis allowing the penis to increase in girth and length.  When he desires for the penis to become soft, the man squeezes a release valve located on the pump and the fluid return to the reservoir and the penis becomes flaccid.  The entire device is completely concealed and cannot be detected even under the closest scrutiny. The complications of the inflatable prosthesis, although rare, include bleeding, infection and failure.  The device is successful in 98% of patients and seldom has to be repaired or replaced.  The procedure is done on an out patient basis in a hospital or a surgical center.  Most men are discharged within a few hours and can begin using their prosthesis within 4 weeks after the procedure. Most insurance companies, including Medicare, pay for the procedure. Another surgical option is a malleable implant consisting of two semi-rigid rods, which are surgically inserted through a small incision into the penis.  The penis can be placed into position for intercourse or pushed down to conceal it in clothing. 

What treatment is available for psychogenic ED?

For men with psychogenic ED, counseling may alleviate the problem.  Often times the man and his partner will attend counseling sessions especially if there is discord in the relationship. Psychotherapy with a counselor can be very effective for men who have performance anxiety as a cause of their ED. Men with psychogenic ED can also be aided with oral medications, the use of which are temporary and discontinued once the man gains confidence and control of his erections.

Summary:

Erectile dysfunction is a common condition affecting millions of American men.  The diagnosis is easily made.  Nearly every man with this problem can be helped.  Call your urologist today for an evaluation and treatment.

Resources:

National Kidney and Urologic Diseases Information Clearinghouse

National Institute of Diabetes and Digestive and Kidney Diseases 

American Urological Association

American Diabetes Association

American Association of Sex Educators, Counselors, and Therapists (www.aasect.org)