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Resource Description: 
This site is written and reviewed by urology experts in partnership with the American Urological Association Foundation. It includes an extensive section on sexual function and fertility.
MHN is a non-profit educational organization. Primary goals are to save men's lives by reducing the premature mortality of men and boys and to increase the physical and mental health of men so that they can live fuller and happier lives.
This site provides comprehensive information about a broad range of urologic conditions, including ED.
The National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) is an information dissemination service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health (NIH), one of eight health agencies of the Public Health Service, which is under the U.S. Department of Health and Human Services. NKUDIC was established in 1987 to increase knowledge and understanding about diseases of the kidneys and urologic system.
The American Diabetes Association is the nation's leading nonprofit health organization providing diabetes research, information and advocacy.
Information on this site can help you increase your understanding of arteriosclerosis, its underlying causes and its relationship to ED.
Episode number: 
304
Almost all men experience occasional difficulty getting or maintaining an erection at some time in their lives.  Usually, it's temporary and goes away with little or no treatment.  However, if the experience becomes persistent, the problem is considered to be erectile dysfunction(ED).  

If you suffer from ED, you're not alone. Data from the 2001-2002 National Health and Nutrition Examinational Survey (NHANES) suggests that almost 20 percent of adult men suffer from ED.  The incidence of ED increases with age, with chronic ED affecting as many as 50 percent of men between the ages of 40 and 70.

Does that mean that ED is a natural part of aging?  Researchers and physicians respond with a resounding "no".  They estimate that 70 percent of ED cases can be traced to a physical cause and another 20 percent to stress, anxiety and depression.  The prevalence of physical problems that can cause ED -- disorders with blood vessels, nerves or hormones -- tend to increase with age and are often lifestyle related.  ED can also occur as a side effect of some medications.

Since ED has been widely discussed in the media in the last decade, more men have stepped up and sought help.  But, even with a dramatic increase in doctor visits related to ED, it is still one of the most commonly under treated medical disorders in the world.  Some men are so reluctant to discuss the subject that they resign themselves and their partners to living without sex.  Others try to treat themselves with over-the-counter or over-the-internet remedies.  Both approaches are unfortunate and, sometimes, dangerous.   

Why?  Because: 

  • ED can be a warning that your body isn't working properly. For example, it might be the first sign that leads your doctor to suspect you have heart disease.
  • Many effective treatments are now available, which means that there's a high probability that your ED can be treated successfully.
  • Some unscientific remedies can actually be harmful.
 

Quick Facts

  • Erectile dysfunction is a more medically specific term for impotence.

  • ED affects almost 20 percent of adult men.  The incidence of ED increases with age, with chronic ED affecting as many as 50 percent of men between the ages of 40 and 70.  That's as many as 30 million men in the U.S. alone.  However, ED is not an unavoidable consequence of aging. ED is not considered normal at any age.

  • ED can affect different men to different degrees.  Failure to achieve an erection less than 20% of the time is not unusual and treatment is rarely needed.

  • Men affected by ED may experience performance anxiety, depression, stress, low self-esteem and relationship conflicts. And these can combine to compound the problem.

  • Stress, anxiety and depression are leading causes of temporary ED. 

  • ED usually has a physical cause, often associated with smoking, alcohol abuse, trauma, and underlying medical conditions such as diabetes or vascular disease. It can also be a side effect of certain medications.
    • Overweight men are more likely to have ED
    • Tobacco, alcohol and recreational drugs can all damage a man's blood vessels and/or restrict blood flow to the penis, causing ED
    • Atherosclerosis alone accounts for 50% to 60% of ED cases in men 60 and older. Between 35% and 50% of men with diabetes have ED.

  • Many men don't seek help from a doctor, deciding instead to either live with ED or treat themselves with a variety of unproven over-the-counter or over-the-internet treatments.

  • It is important to have a physician determine the cause of ED so the appropriate treatment can be prescribed.

  • The vast majority of cases of ED can be successfully treated, regardless of cause and regardless of age. A variety of treatment options are available.

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.

  • What is the cause of my erectile dysfunction?
    • Does it stem from an underlying illness?
    • Could any of my medications be causing it or making it worse?
    • If so, can I safely change my medications or their dosages? Never stop yoru medications without your doctors knowledge. This can be dangerous or even deadly.
    • Could stress or other psychological problems be causing the problem?

  • Do I need to have any tests performed to determine or confirm my diagnosis?
    • What tests?
    • Why these tests?

  • What treatment do you recommend?
    • If medication is recommended: 
      • What are the potential side effects or risks? 
      • Will it interact with any of my current medications?

    • If surgery is recommended: 
      • Am I a good candidate for surgery?
      • What procedures are you considering?
      • What is the downside of this surgery?
      • Are there other options I should try first

  • How much improvement should I expect with your recommended treatment plan? 

  • How long will it take for me to experience improvement?

  • Should I consult a specialist?

Key Point 1

Erectile dysfunction is the inability to maintain an erection to completion of intercourse.  Erectile dysfunction is not a normal part of aging.  It may, in fact, mean there is something else going on with your health.

Sexual dysfunction has often been seen as a byproduct of aging, but that outlook is changing as we define what aging really means.  There are people in their 80s who are sexually active and, conversely, there are people of all ages who have erectile dysfunction. Renowned researchers of human sexual response, Masters and Johnson, have stated that the ability to have sex well into old age essentially depends on not stopping. 

What's "average" for older men? 
Keeping in mind that everyone ages differently:

  • Arousal may take longer
  • Erection may be less full
  • The time it takes to reach orgasm may increase
  • Orgasms may be less intense
  • Recovery (the time needed before another erection can be achieved) after orgasm may take longer

Bottom line, ED is not an inevitable consequence of aging.  In fact, medical professionals who study aging have found that many of the common changes we used to believe were unavoidable, including ED, have turned out to be the result of disease.        

What causes ED?
The process of erection is complex and involves the vascular system, the nervous system, the endocrine system and the individual's emotions.  (See Key Point #2 for more information.)  Medical experts estimate that 70 percent of ED cases can be traced to a physical cause and another 20 percent to stress, anxiety and depression.

Physical causes and risk factors
ED is related to basic health, meaning that if you have other health problems, your likelihood of having ED is greater.  Conditions that lead to reduced blood flow to the penis, inability of the penis to retain blood during erection and reduced ability of the nerves to send or receive the proper signals are the most common physical causes. 

Common conditions include:

  • Cardiovascular disorders, such as high blood pressure, blocked arteries, and high cholesterol levels
  • Diabetes
  • Insulin resistance
  • Use of some prescription drugs, such as certain blood pressure and cardiovascular medications, tranquilizers and antidepressants
  • Hormone disorders, such as thyroid disease and hypogonadism
  • Pelvic trauma, surgery, radiation therapy
  • Neurological disease, including Parkinson's, Alzheimer's, and multiple sclerosis
  • Spinal cord injuries
  • Renal
  • Enlarged prostate
  • Disorders of the penis itself, such as Peyronie's disease   

Lifestyle choices that lead to those physical disorders may affect erectile function as well, including.

  • Excessive caffeine
  • Cigarette smoking
  • Alcohol and drug abuse
  • Lack of exercise
  • Obesity

Psychological causes and risk factors
Emotional and psychological issues – including almost any form of stress, worry and anxiety – can be causes of erectile dysfunction.  Though psychological causes of ED are a much smaller percentage of the total, they are equally important and very treatable. 

The consequence of ED

  • Physical causes of ED can be early warning signs of more general and potentially dangerous conditions. 
  • ED may diminish a man's willingness to be intimate and affectionate with his partner, damaging their relationship and hurting the person he most cares about.
  • ED can affect more than your sex life.  It can create mental stress that affects your self-confidence and the way you approach the world.

No one needs to passively accept the loss of sexual function because they think it's normal.  With the help of your primary care physician or urologist, you can deal with the causes of ED with lifestyle changes, medical treatment for underlying disorders, ED-specific treatment and/or counseling.

    

Key Point 2

Erectile dysfunction can be a symptom of an underlying problem in the physiological chain.  With your doctor, you have to figure out where the problem is occurring. 

The process of erection is complex and involves the vascular system, the nervous system, the endocrine system and an individual's emotions. 

When a man is sexually aroused the brain sends messages along the nerves to the vascular system. The messages tell the vascular system to increase the amount of blood flowing into the penis. Inside the penis are two chambers filled with spongy erectile tissue. This tissue fills with blood causing the penis to expand. At the same time, fibrous elastic sheathes around the erectile tissue tighten, so the blood can't leave the penis and the erection continues. After ejaculation or when sexual stimulation ends, the sheathes loosen, the blood leaves the penis, and the penis returns to its non-erect state. A problem with any one of these functions can result in ED. 

So, ED can be a symptom of many issues.  (See Key Point #1 for more information.)  That being the case, your doctor will want to do a thorough exam.

Elements of a medical exam for ED
A complete medical exam for ED may include some or all of the following:

  • Medical history, including your general physical and emotional state, your lifestyle and questions about any prescribed or illicit drugs you're currently taking that might cause ED
  • Sexual history
    • How often do you have relations with your partner?
    • How important is sex to you and your partner?
    • Do you have difficulty obtaining and/or maintaining an erection?
    • How long have you been unable to obtain and/or sustain an erection?
  • Physical exam
    • Are testicles normal in size?
    • Does the prostate appear to be enlarged?
    • Are hair patterns normal? (to evaluate potential problems with testosterone levels)
    • Is the thyroid enlarged?
    • Is blood pressure elevated?
    • Does the body mass index suggest the risk of diabetes?
    • Is there sensation in all extremities?
  • Laboratory tests, such as routine blood and urine tests that can check your level of male hormones, cholesterol, blood sugar, and liver, kidney and thyroid function.
  • Cardiac work-up including and EKG and echocardiogram. ED can be the first indicator of coronary artery and valve disease.
  • Erectile function tests to evaluate blood flow into and out of the penis and measure the blood pressure in it (normally and during erection) and evaluate the sensitivity and nerve function of the penis. Among the most common are:
    • Ultrasound to evaluate blood flow, venous leak, signs of arteriosclerosis and scarring or calcification of erectile tissue.
    • Penile nerve function to determine if there is sufficient nerve sensation in the penis. 
    • Nocturnal penile tumescence (NPT) tests to measure the number and strength of the erections you have during sleep.
    • Vasoactive injection to measure pressure in penile blood vessels.

The importance of a proper diagnosis
Some patients are unwilling to undergo a long evaluation and testing process to obtain a better understanding of their sexual problem.  However, proper diagnosis is the key to beneficial treatment.  That's because:

  • Many of ED's causes are physical and can be successfully treated; however, if they're not treated they may lead to other problems.
  • Self-treatment with over-the-counter or over-the-internet remedies is usually ineffective and can even be dangerous.
  • New, highly touted prescription medications for ED may or may not work, depending on the underlying cause of the problem.  If a patient's health is optimized, the drugs may not be needed – or, if needed, they may be more effective.
    

Key Point 3

If you are suffering from erectile dysfunction, there is help available.  There are good treatments but you have to make sure the treatment is appropriate for the problem.  

With more potential remedies on the market than ever, erectile dysfunction is a highly treatable problem in all age groups. However, before any ED-specific therapy is attempted, underlying causes should be diagnosed and treated.  (See Key Point #1 and Key Point #2 for more information.) 

Treatment for erectile dysfunction depends on its causes and its severity. Treatments may include:

    • Lifestyle modification
    • Alternative medicine and "natural" remedies
    • Vacuum devices
    • Oral medication
    • Suppositories
    • Injection therapy
    • Surgery
    • Psychotherapy

Lifestyle modification
Since what makes us sick can also cause ED, what makes us well can also be a remedy for ED.  Lifestyle modification can both prevent ED and improve sexual function.  Five healthy behaviors characterize a healthy lifestyle -- not smoking, eating a healthy diet, avoiding alcohol (or consuming it only in moderation), getting plenty of physical activity and controlling weight.

Alternative medicine and "natural" remedies
Many alternative remedies are aggressively marketed for ED. However, very few have been studied, most are not regulated so their quality is not controlled, and some can actually be harmful.  Be sure to talk to your doctor before using any alternative remedy.

Alternative remedies that may work include:

  • Dietary supplements. These may be helpful as part of an overall plan to maintain a healthy diet.  Fish oil supplements can be beneficial to blood vessels overall.
  • Herbal supplements.  Most have been ineffective when tested in blind studies, but they may be useful for their placebo effect. However, a recent double-blind study appears to show evidence that ginseng is better than placebo and, in one small study, 78% of men who had ED caused by impaired blood flow improved after taking ginkgo.
  • Arginine. This amino acid may help increase circulation.
  • Relaxation techniques.  Relaxation is a requirement for successful sexual function. 

Vacuum devices
The vacuum device is an external penile pump.  A plastic tube is placed over the penis and against the body to form a seal. The hand pump creates a vacuum in the tube that draws blood into the penis and creates an erection.  A rubber ring is then snapped over the base of the penis to help maintain the erection.  Downsides include lack of spontaneity, plus the resulting erection may be somewhat uncomfortable.      

Oral medication
The most popular prescription drugs for erectile dysfunction are selective enzyme inhibitors. They work in about two third of patients by causing the smooth muscles of the penis to relax and allow blood to flow into the erectile tissue. Men with certain conditions shouldn't take selective enzyme inhibitors.  Possible side effects include headache, flushing, indigestion, muscle aches and nasal congestion.  Commonly prescribed selective enzyme inhibitors are:

  • Sildenafil (brand name: Viagra®)
  • Vardenafil HCl (brand name: Levitra®)
  • Tadalafil (brand name: Cialis®)

Only a relatively small number of men have ED because of insufficient levels of sex hormones. However, for those that do, the problem is relatively easy to solve with hormone replacement medicines. Hormone replacement is not without its side effects. Please discuss possible side effects with your doctor.

Suppositories
This treatment involves using an applicator to insert a tiny suppository into the tip of the penis to widen the penile blood vessels.  Tests suggest this method can be more painful and less effective than injection therapy.  

Injection therapy
This therapy involves self-injection directly into the base or side of the penis to dilate blood vessels to produce an erection. The procedure is relatively painless, but possible potential side effects include bleeding from the injection, a burning sensation in the penis, dizziness, heart palpitations, flushing, scarring or fibrous tissue forming at the injection site, and prolonged erection.
 
Surgery
There are several kinds of prosthetic devices that can be implanted in the penis. The two main types are (1) inflatable silicone or plastic tubes and (2) semi-rigid rods (made of metal covered by silicone or polyurethane). Implanting these devices is a surgical procedure requiring anesthesia and possibly an overnight in the hospital, with all the possible side effects of any surgery.  This step is irreversible.
 
For men whose ED is caused by blocked blood supply to the penis because of injury to the penis, pelvic area, or other vascular problems, vascular surgery of the penis may be the solution. These surgeries are not common and they're recommended only for men with very specific conditions.

Psychotherapy
Individuals with ED caused by psychological issues will generally be referred to a mental health professional specializing in sex therapy.  Issues can include:

  • Lack of sexual knowledge
  • Lack of communication between partners
  • A poor relationship between partners
  • Performance anxiety
  • Depression
  • Life stresses
  • Inhibition related to upbringing, religion, and social background

Medline Plus

Medline Description: 

Conduct an off-site search for Erectile Dysfunction information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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