What Is Erectile Dysfunction?

Erectile dysfunction (ED) is typically used to describe the repeated inability to attain and maintain an erection for sexual intercourse.

This condition is also commonly known as impotence. Impotence, however, may refer to other problems that interfere with sexual intercourse. These include a 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.

It is normal for men to experience changes in erectile function, such as taking longer to achieve an erection. When the problem becomes persistent, it can be a sign of a physical or emotional problem. ED can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections.

The problem is more common in men older than 65, but it can occur at any age. The National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) says 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.

In older men, ED usually has a physical cause, such as disease, injury, surgery, or side effects of drugs. Medications that can cause ED include blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and illegal drugs. A condition or disease that causes injury to the nerves, or impairs blood flow in the penis also could cause ED.

Three phases

ED results from a problem in any of three phases needed to produce an erection. The first phase is sexual arousal. This is followed by the nervous system response that increases blood flow to the penis. The final phase is a relaxation of the blood vessels of the penis that allows more blood to flow into the penis to cause an erection. A problem in any of these three phases can cause impotence.

Testosterone is important to the erection process. Levels of this hormone begin decreasing in men after age 40. Also, some research suggests that when the penis is flaccid for long periods of time, scar tissue forms in cells. This can interfere with the penis' ability to expand when filled with blood.

According to Marian Dunn, Ph.D., a psychiatrist and human sexuality expert in Brooklyn, the average couple currently seeking help for the man's dysfunction has not had intercourse for two to five years.

For years, doctors thought the primary cause of ED was psychological. Today most doctors and researchers think that 80 percent of cases are physical.

In some psychological cases, the trigger may be anger at a spouse, guilt over normal but "unfaithful" sexual interest in another person, or stress and burnout at work, says Mack Lipkin, M.D., a primary care specialist in New York City.

Treating the problem

The first step in treating ED is to find out what is causing the dysfunction. Talk with your primary health care provider or urologist. For some men, lifestyle changes may help. These changes may include quitting smoking, losing excess weight, or increasing physical activity.

ED may be caused by vascular disease; neurological problems, which can be a consequence of diabetes; prostate and treatment of prostate disease; medications; hormonal disorders; psychological disorders; and substance abuse.

If the cause is a side effect of a prescription medication, your doctor may be able to substitute another drug.

Men having difficulties with their romantic partner may need to seek therapy for solutions.

It's important that you share with your sexual partner what you are going through. Talk about how you want to approach fixing it, including options and treatments.

"Both the patient and his sexual partner should be reassured that erectile dysfunction is common and usually no indication of a permanent or irreversible loss of sexual function or desire," says Gerald D. Brock, M.D., a urological surgeon in London, Ontario. "Open communication is important and should be maintained throughout the diagnosis and treatment process, which is often more successful if couples work together as a team."

Medications

In recent years, drugs have been prescribed along with counseling. Examples of these drugs are Viagra and Levitra. These drugs improve response to sexual stimulation, but they do not automatically trigger an erection. They are not aphrodisiacs, so they have no effect on sexual desire. They physically relax the blood vessels of the penis, allowing it to fill with blood and to stay erect long enough for intercourse.

These drugs should not be used more than once a day. They can cause side effects and interact with other medications. They shouldn't be used by men who have heart disease and are taking nitrates.

Injection therapy

Men whose ED comes from diabetes or radical prostate surgery have more success with injection therapy. In injection therapy, medication is given with a fine needle directly into the side of the penis. An erection usually occurs within five to 20 minutes and lasts for 30 to 60 minutes.

Success rates for injection therapy range from 60 to 80 percent. The main side effects are bruising, moderate pain, and scarring. This therapy can be expensive.

A similar method involves tiny pellets that a man can insert into the urethra at the head of the penis before sex. The pellets dissolve and are absorbed by surrounding tissue, dilating arteries, allowing blood to flow. This method causes an erection within eight to 10 minutes and lasts 30 to 60 minutes.

Devices

Devices to help achieve and keep erections range from bands to vacuum tubes and surgical implants.

For men who can get erections but not keep them, a penile band—a ring-like device—can be fastened around the base of the erect penis to keep blood from escaping.

Vacuum pumps are perhaps the most non-invasive devices on the market. A man lubricates his penis and puts it into an air-tight plastic cylinder attached to a hand-held pump. Air is pumped out of the cylinder, and the vacuum increases blood flow to the penis. Once an erection occurs, the man removes the cylinder and places a band around the base of the erect penis. The pumps work for 80 to 90 percent of men and can be used as often as desired. Some men experience pain, bruising, or difficulty ejaculating when a using pump.

Penile implants date to the 1930s. They are inserted into the penis as permanently stiff rods or as inflatable cylinders that become erect when filled with a saline solution that is pumped from a reservoir implanted in either the abdomen or the scrotum.

Vascular surgery

Two types of operations improve erections, but each is recommended only for unusual situations. One involves tying off blood vessels that allow blood to leak out of an erect penis. The other entails bypassing blocked arteries to let more blood into the penis.

Bypass operations are reserved mainly for patients with blood-flow problems caused by injuries such as pelvic fractures.

Hormone therapy

Testosterone supplements are only for men with abnormally low levels of testosterone. The supplements may increase libido and ability to have an erection. They come in three forms: pills, intramuscular injections, and skin patches. They are most effective when given as intramuscular injections or through a skin patch.

Several new medications for erectile dysfunction have been developed and await approval by the FDA.

For men who cannot solve their problems with the above solutions or who have psychological issues, the International Impotence Association recommends that they, and their partners, if willing, get counseling from a qualified psychotherapist.

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