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"Man survives earthquakes and all the tortures of the soul. But the most tormenting tragedy of all times is the tragedy of the bedroom."

Tolstoy

What is erectile dysfunction (ED)?

Erectile dysfunction is persistent and consistent failure to achieve and maintain an erection adequate for sexual needs for the needs of his partner. 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 most of the time, it becomes a problem that affects a man's masculinity, an erosion of 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 into the wall and have an electric current flow to the air compressor. The air compressor has to be turned on and the air compressor has to take air from the environment and make it flow through the tube from the air compressor to the tire. The tubing has to be open or patent without obstruction or kinds in the tubing, which could impede the airflow. The tube has to be attached to the nipple on the tire and the tire must be a closed system without any holes that could allow the air to escape.

The same principles of filling a tire hold true for a man's erection. The erection starts in the brain and sends a message via nerves in the spinal cord to open the blood vessels that allow blood to flow into the penis. The heart has to be working properly to pump the blood into the blood vessels that supply the penis. When more blood flows into the penis than leaves the penis through the veins, an erection will occur. Failure of any components from the brain to the end organ, the penis, will result in erectile dysfunction.

What are the causes of ED?

ED can broadly be divided into causes psychological and physical. In the past most ED was thought be psychological in nature. Now we have identified many physical causes such as injury to nerves and conditions affecting the blood vessels as the most common causes of ED. For men over the age of 50 years, physical causes are the most common. In younger man, especially under the age of 40 years, psychological causes prevail.

Of the physical causes, vascular disease is the most common. Arteriosclerosis or hardening and narrowing of the blood vessels that supply the penis causes more than 50% of men with ED. Increased levels of cholesterol and hypertension or high blood pressure can also narrow the blood vessels and decrease the blood flow into the penis causing ED. Diabetes affects the nerves and the blood vessels resulting in ED in nearly 50% of men with diabetes. Neurologic causes, which impair the nerves to the penis or affect the brain and spinal cord, include spinal cord injury, multiple sclerosis, Parkinson's disease, stroke, and Alzheimer's disease. Significant pelvic trauma such as a fracture of the pelvis, pelvic surgery such as removal of the entire prostate gland, bladder or colon surgery can result in ED. Radiation therapy to the prostate gland or bladder can result in injuries to the nerves and blood supply, which can impact a man's ability to have an erection. Peyronie's disease that results in the formation of a thick fibrous plaque in the penis that results in curvature of the penis can alter the blood supply and result in ED. Medications are also a culprit as there are hundreds of medications such as blood pressure medications, heart medications, antidepressants, tranquilizers, pain medications, and sedatives just to name a few. Although the male hormone produced in the testicles, testosterone is primarily responsible for the libido or sex drive, deficiencies of testosterone can affect a man's erection. Venous leak is a condition that results in blood leaving the penis as fast as it enters via the arteries and usually associated with failure to maintain the erection once it has been achieved. Miscellaneous causes include smoking, which affects the blood vessels, use of illicit drugs such as cocaine and marijuana are also factors that can impede an erection, as well as chronic or long-standing liver and kidney disease. Excessive alcohol consumption can impact a man's erection. (Shakespeare made mention of this in Macbeth: "alcohol provokes, and unprovokes; it provokes the desire, but it takes away the performance...") Other hormonal causes include too much or too little thyroid hormone and an elevation of prolactin levels, which can decrease the testosterone level. Finally obesity is also associated with increased incidence of ED possibly because of the association of obesity with diabetes, hypertension, and high cholesterol levels which are all co-morbid conditions associated with ED.

Psychological causes, which only causes ED in 10% of men who suffer from ED, can occur with depression, recent emotional trauma such as loss of a partner, divorce, stress in the work place or job loss. Psychological causes can also occur with deterioration in the relationship between a man and his partner or if there are problems and distractions with other family members. A common situation in young men is referred to as performance anxiety. This situation occurs when a young man is anxious about his ability to perform especially with a new partner and has ED, which becomes a cyclical event as the erectile failure creates more anxiety producing, repeated ED on each subsequent desire to be sexually intimate.

Bottom line: ED is a common problem affecting millions of American men. You are not alone. Although ED is more common in middle age and older men, it is not a consequence of aging. Older men who are healthy, have an available partner, and interested in engaging in sexual intimacy can be helped.

How is ED diagnosed?

Your doctor will begin by taking a careful history. He may ask: How long have you had ED? What other disease or conditions do you have? What medications, including over the counter medications or supplements, do you take? What treatments have you tried in the past?

Next is a physical examination, which includes taking your blood pressure, an examination of the penis, testicles and rectal exam to evaluate your prostate gland. The physical examination also includes an 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 a few blood tests which include a testosterone level, cholesterol level, blood sugar, liver, kidney and thyroid function tests. If the testosterone level is decreased, a prolactin level, and other blood tests associated with testosterone secretion may be obtained. The urine examination is for protein and glucose (sugar), which can indicate kidney disease or diabetes respectively. 
 


Additional tests may also 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 a drug or drugs 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.

A nocturnal penile tumescence test is only occasional 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 measure with band placed loosely around the penis and attached to a monitoring device. If a man obtains an erection =there will be a subsequent increase in girth of the penis which is recorded on the monitor. The presence of normal nighttime erections indicates that the nerve 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?

First, the good news - nearly everyone with ED can be helped. There are many treatment options available to all men who suffer from ED. You just have to find one that meets your situation and that you are comfortable with. The best patients are those who are aware of the options and then, with the help of their doctor, select a treatment works best for them. Most men start with the least invasive treatment options first and then proceed to additional treatments if the less invasive treatments are not effective.

Perhaps the easiest and least expensive treatment is life style modification. Men who are smokers will find that there will be improvement in their erections when they stop using cigarettes. Men who are overweight will notice an improvement in their ability to engage in sexual intimacy by losing weight and beginning a physical exercise program. For men with high cholesterol levels, dietary modification may decrease the cholesterol levels and improve the blood supply to the penis resulting in better erections. Also, excessive use of alcohol can negatively impact a man's erection and decreasing the alcohol consumption will significantly improve a man's sexual function.

For men who use medications with the side effects of ED or a decrease in libido or sex drive can speak to their doctor abut the adverse side effects. The doctor may then decrease the dosage of the medication or change to another class of drugs that do not have the adverse side effect of ED or a decrease in sex drive or interest. For example, there are anti-depressants that have the side effect of ED, which can be changed to another medication, such as Wilburton, which is much less likely to cause ED and be effective for treating the depression.

Oral medication, such as Viagra, Levitra, and Cialis, are available for treating ED. These medications are taken 30-60 minutes before engaging in sexual intimacy and will result in an increase in the blood supply to the penis when there is accompanying genital stimulation. Viagra and Levitra work for 4-6 hours and Cialis remains effective for up to 36 hours. There is a low dose of Cialis, the 5mg tablet, which can be taken on a daily basis that is helpful for men who "want to be ready when the moment is right!" All three oral medications should only be used once a day. These medications are not to be used at the same time as alpha-blockers like Flomax and Uroxatrol. It is best that the alpha-blocker be separated form the use of the oral medication for ED by four hours. All three ED oral medications are contraindicated in men using nitroglycerin, a drug used to treat heart problems. Nitroglycerin and the ED oral medications can cause a precipitous drop in blood pressure that can have serious negative consequences. If a man can walk up two flights of stairs without chest pain or shortness of breath, then he can safely engage in sexual intimacy. So if you have a prescription for nitroglycerin and carry a small vial of the pill in your pocket but haven't used it for months or years, check with your doctor and he may recommend that you don't need the nitroglycerin and that it is safe to use one of the oral medications for ED.

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

Self-injections consist of a drug, alprostadil, or a combination of alprostadil and other drugs which cause a dilation of the blood vessels to the penis causing an erection when it is injected through a very small needle by the man into his penis 10-15 minutes before engaging in sexual intimacy. The erection does not require genital stimulation and the erections usually lasts 30-45 minutes. There is minimal pain associated with the injection. The side effects are occasional black and blue discoloration of the penis which is temporary and goes away in a few days and the more problematic priapism which is a prolonged erection lasting several hours. Priapism is not a very common complication, however, men will need to return to their doctor or go to the emergency room if their erection last more than 3-4 hours and is associated with pain and discomfort. The priapism can be relieved by injection medication that causes the blood vessels to constrict and the erection will subside.

Alprostadil is also available as a tiny rice-sized pellet that can be inserted into the end of the penis into the urethra or tube that transports urine from the bladder to the outside of the body. There is minor irritation of the urethra causing a small spot of blood that is temporary and will subside after one or two urinations.

A vacuum erection device is another option for men who have tried the oral medications, which are not successful in creating an erection adequate for penetration. The vacuum device is a tube where the penis is inserted and then air is removed from the cylinder creating a slight negative pressure around the penis. Now blood will flow into the penis that is trapped in place by an elastic or plastic band placed at the base of the penis and then the cylinder is removed. The man will have an erection that is usually adequate for penetration.

Surgical options consist of a reconstruction of the blood supply to the penis, tying the abnormal veins in the penis, or the insertion of a penile prosthesis. These are third line treatment options and should be entertained if the other options are not successful.

Surgery to reconstruct or bypass the blockage of the blood vessels is usually limited to younger men who have had trauma to the penis such as a pelvic fraction that disrupts the blood supply to the penis. The blood supply can be rerouted from larger blood vessels to the smaller blood vessels in the penis very similar to the coronary artery bypass operation done for coronary artery disease.

Surgery to ligate the abnormal veins in the penis is performed for a problem of venous leakage where blood leaves the penis as fast as it is pumped into the penis thus 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 1972. There have been over 500,000 devices implanted world wide and 15,000 devices inserted annually in the United States. The inflatable prosthesis consists to 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. Men with the prosthesis can comfortably shower and change clothes in the men's locker room without anyone being able to suspect that prosthesis is in place. The complications of the inflatable prosthesis include bleeding, infection and failure. Rarely is bleeding or infection a problem. The device is successful in 98% of patients and seldom has to be repaired or replaced. The patient and the partner have nearly 100% satisfaction with the device. The procedure is done in the hospital or one-day stay surgical center. Most men are discharged within a few hours after the procedure or after they are able to urinate. Most men can begin using their prosthesis within 4 weeks after the procedure. Most insurance companies, including Medicare, pay for the procedure.

A malleable implant consists to two semi-rigid rods, which are surgically inserted through a small incision into the penis. The man can place the penis into the position for intercourse or push it down to conceal the penis in his underwear.

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 between the man and his partner. Psychotherapy with a counselor is often very effective for men who have performance anxiety as a cause of their ED. Often times men with psychogenic ED can be aided with oral medications which are used temporarily until the man gains confidence and control of his erections and then he can discontinue the use of the medications.

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. Today, no one needs to suffer the "tragedy of the bedroom". Call your doctor 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)