“You think I can't get it up anymore, maybe? Lemme tell you, you eat enough garlic and it stands up every time.”
― Alberto Vitale
What is erectile dysfunction?
Erectile dysfunction (ED) is a medical term that describes the inability to achieve and or maintain an erect penis adequate for sexual function. This condition is one of the most common sexual problems for men and increases with age. It is estimated between 15 to 30 million American men suffer from ED, although not all men are equally distressed by the problem.
Most men have difficulty with erections from time to time, yet in some men, it is a regular and more severe problem. It can cause low self-esteem, performance anxiety, depression and stress. ED may affect the quality of a marriage or intimate relationships. However, there are many safe and effective ED treatments available.
Prevalence of erectile dysfunction varies according to the patient's age. About 18% of men from 50 to 59 years of age will suffer from erectile dysfunction and 37% of those aged 70 to 75 years will, too.
How erection occurs?
Achieving a normal erection is a complex process involving psychological impulses from the brain, adequate levels of the male sex hormone testosterone, a functioning nervous system, and adequate and healthy vascular tissue in the penis.
The simplest way to describe the process of erection is to think of a washing machine. The "on-off" switch (the brain) initiates the process; the wires in the washing machine (the nerves) carry the electrical signal to the pipes (the blood vessels), when an appropriate signal arrives a valve opens to allow water to flow in (the arteries carry blood into the penis) and the drain shuts (the penile veins close). Water flows in and fills the tank (the penis fills with blood and becomes erect) and the wash cycle begins (enjoys sexual activity). At the end of the wash cycle this process reverses, the switch goes to the off position (the brain terminates erection), the valve closes (the arteries markedly decrease blood inflow) and the drain opens draining the wash tank of water (the veins open, blood leaves the penis and erection subsides).
When a man is not sexually aroused, his penis is soft, limp or flaccid. During sexual arousal, nerve messages release chemicals that increase blood flow into the penis. The blood flows into two erection chambers made of spongy tissue (the corpus cavernosum) in the penis. The “smooth muscle” in the erection chambers relaxes, which allows blood to enter and remain in the chambers. The pressure of the blood in the chambers makes the penis firm, producing an erection. After a man has an orgasm, the blood flows out of the chambers and the erection subsides.
There are three types of erections -- those caused by tactile stimulation, those caused by mental stimulation (so called psychogenic erections - occur when a man has sexual thoughts), and those that men experience while sleeping (so called nocturnal erections - healthy men of all ages have three or four each night with each erection lasting for 30 minutes). This classification can be important when the cause of erectile dysfunction is yet to be determined.
Risk factors for erectile dysfunction
The risk factors for erectile dysfunction include:
* Age over 50
* Tobacco Smoking
* High blood pressure
* High cholesterol
* Cardiovascular disease
* Medication use
* Obstructive sleep apnea
* Restless leg syndrome
* Systemic sclerosis (scleroderma)
* Peyronie's disease
* Prostate cancer treatment
The latest studies have shown that the majority of men seen in the emergency room for a cardiac event—such a heart attack or stroke—suffered from erectile dysfunction three to five years earlier.
Main causes for erectile dysfunction
ED can result from medical, physical or psychological factors. ED may be caused by a combination of factors that could also include medicine, alcohol or drugs. The physical and medical causes of ED include three basic problems:
* Not enough blood flows into the penis. Many conditions can reduce blood flow into the penis, examples include heart disease, diabetes and smoking.
* The penis cannot store blood during an erection. A man with this problem, called venous leak or cavernosal dysfunction, cannot maintain an erection because blood does not remain trapped in the penis. This condition can occur to any man regardless of age.
* Nerve signals from the brain or spinal cord do not reach the penis. Certain diseases, injury or surgery in the pelvic area can damage nerves in the penis.
Here is a brief classification for the potential causes of erectile dysfunction.
Neurologic causes include:
* Spinal cord or back injury
* Multiple sclerosis
* Pelvic trauma
* Prostate surgery (even with nerve-sparing surgeries it can take up to 24 months to regain normal sexual function)
* Nervous system tumor
* Diabetic neuropathy
Vascular causes include:
* Arteriovenous fistula
* Congenital anomaly
Hormonal causes include:
* Low testosterone (The patient can achieve an erection but it will not always be turgid enough for vaginal penetration.)
* Cushing's disease
* Addison's disease
Pharmacological causes include:
* Antidepressants (mainly SSRIs)
* Sympathetic blockers (clonidine, guanethidine, or methyldopa)
* Thiazide diuretics
Penile dysfunction causes include:
* Peyronie's disease
Psychological causes include:
* Negative emotions associated with sex
* Loss of feeling toward the other person
* Fear of non-performance
Functional causes include:
* Bicycling irritating the nerves and tissue of the penis
Main symptoms of erectile dysfunction
Erectile dysfunction will cause the penis to be unable to acquire or maintain a satisfactory erection. It is important to specify to the doctor the rapidity of onset, the presence of nocturnal erections, and the quality of the erection if it can be attained but not maintained. The quality of an erection can be judged according to the rigidity and the functionality (Is the penis erect enough to allow for vaginal penetration?).
Erectile dysfunction with sudden onset and no previous history of sexual dysfunction suggests a psychogenic cause, unless there was a previous surgery or a genital trauma. The loss of nocturnal erections will suggest a neurologic or vascular cause. Finally, when an erection is not sustained, its loss may be due to an underlying psychological cause or vascular problem. Talk to your doctor if you have noticed any problems with your erectile function.
Complications resulting from erectile dysfunction can include:
* An unsatisfactory sex life
* Stress or anxiety
* Embarrassment or low self-esteem
* Relationship problems
* The inability to get your partner pregnant
How erectile dysfunction diagnosed?
ED is diagnosed by an urologist or another medical professional and for most patients; the diagnosis will require a simple medical history, physical examination and a few routine blood tests.
Medical History exam requires health care providers to ask about you, and your ED experience. The doctor will also want to know if you have any other conditions that might affect your ED, such as any endocrine problems or depression. They may ask questions about your sexual history and performance, which may be very personal but necessary to understand the root cause of the problem. The important thing to remember is not to be embarrassed while speaking with your physician and to be very open to allow for the best treatment options for you. Other questions the physician is likely to ask are the following:
* Your current sexual function
* When you started noticing changes
* Any past medical or sexual problems
* Surgery or injury to the pelvic area
* Current and past medication usage
* Lifestyle and personal habits (i.e. smoking, drinking, use of illicit drugs, etc.)
* Relationship with current and past partners
Physical Examinations means the doctor will check your overall health and physical condition. They will look for signs of problems with your circulatory, nervous and endocrine system. This includes checking your blood pressure, penis and testicles and you may need to have a rectal exam to check the prostate. These tests are not painful and may provide valuable information about the cause of ED. Most patients do not require extensive testing before beginning treatment.
The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment like oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied, then further steps may be taken. In general, as more invasive treatment options are chosen, testing may become more complex.
Treatment options for erectile dysfunction
Nowadays, there are many options for men who suffer from erectile dysfunction. Before suggesting pharmacological help, the doctor may suggest a change in lifestyle habits. Since many causes of erectile dysfunction are disorders in which lifestyle changes will have a positive effect, addressing these issues can be helpful. Therefore, regular exercise, a healthy diet, smoking cessation, and limiting alcohol consumption can all have an impact on erectile function. Lifestyle changes can also include the use of a more genitalia-friendly bicycle seat.
Smoking is a very effective way of spoiling efficient blood circulation, which is why heavy smokers experience fewer erections than non-smokers do. Any way you can improve blood circulation will strengthen your erections (as well as providing you with other obvious overall health benefits). Exercise, diet, and relaxation will all improve the flow of blood around your body. As will certain foods. For example, taking Ginkgo biloba for several months seems to have a hugely beneficial effect for many men. Eating garlic regularly may well have a similar effect (although taking it in tablet form may enable you to actually get close enough to use your erection!).
Pelvic floor exercises are often recommended for women after giving birth as a useful way of strengthening their pelvic floor muscles. However, there is evidence to show that men may benefit from these exercises as well. These exercises may help with erectile dysfunction and other male reproductive problems. To do these exercises, sit or lie down on the floor and try to relax your pelvic muscles. The pelvic muscles include those around your urethra, anus and abdomen. Draw these muscles in and tighten them, holding for a count of 5. Then relax. You should have a sensation of these muscles relaxing and ‘letting go’. Squeeze these muscles, rest for 10 seconds then relax. Do eight to ten squeezes. Then follow this by five quick squeezes, one after another. Repeat this routine, four or five times in a day.
Nonsurgical treatments for erectile dysfunction
There are many nonsurgical treatments available for erectile dysfunction.
Stress is a major cause of erectile problems that is often overlooked. If a male is experiencing considerable pressure at work, facing relationship difficulties, or undergoing myriad other hardships, he may have difficulty obtaining an erection. This can be true for a variety of different reasons. In sexual situations, he may be distracted by pressing life issues rather than being fully immersed in the joys of sex and all the great ways to make it optimally exciting. These factors can prevent a male from experiencing the sexual stimulation required to produce a firm, long-lasting erection. High levels of stress can also affect a man in physiological ways by decreasing blood flow to the penis. A harmful domino effect can take place when erectile dysfunction is caused by stress; if a man is already stressed and has trouble obtaining or maintaining an erection with his partner or by himself, feelings of frustration can lead to even more stress, thus creating a negative feedback loop. This new stress factor is called “performance anxiety.” Most males experience occasional erectile difficulties, and it is important to avoid feeling frustrated or stressed when issues do arise. By reducing the feelings of performance anxiety, a man is more likely to overcome the erectile issues he may be experiencing. It is important to breathe deeply, relax, and solve one problem at a time.
In addition to stress, erectile dysfunction can also result from feelings of shame, guilt, fear, and/or other emotions that have been associated with sex during one’s life. If a male were raised in a strict religious family, he might have learned to believe that sex is a sin, and therefore may feel ashamed at the thought of engaging in any type of sexual activity, including masturbation. Perhaps his parents caught him masturbating one day and punished him for it. Perhaps he had a negative sexual experience with a partner, which left him feeling embarrassed or ashamed. Any negative experiences one may have had in the past could have made sex more stressful or negative experience and thus may be causing erectile difficulties.
The way to combat these negative associations with sex is to change them to positive ones. Realize that masturbation is perfectly healthy and normal and is actually a great way to learn more about yourself and your sexuality. Recondition yourself by thinking about positive thoughts while masturbating. Learn more about the beauty of sex, and how wonderful it can be in the context of a loving and honest relationship. Oftentimes, the best cure for a sexual difficulty is to openly communicate with one’s partner about what one is experiencing so that both people can solve the problem together. Try practicing the technique of sensate focus with your partner. Sensate focus is a therapy technique that is commonly used to treat sexual problems such as female anorgasmia, erectile difficulty, and low sexual desire. In time, you will be able to override the negative thoughts that could be causing ED and become more confident and happy during your sexual experiences.
Oral pharmacological treatment
Speaking about the pharmacological treatment options, the first line of defense is considered a class of medication called phosphodiesterase (PDE-5) inhibitors. This class includes sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis). They will improve the ability to attain and maintain the erection, but sexual stimulation is still required for this medication to work. It should be taken some time before the sexual act is planned, but has a long timeframe of action. Side effects include visual disturbances, flushing, back pain, and muscle pain. Most side effects will abate with time. Usually, there will be no side effects at all. If you are taking nitrates, phosphodiesterase inhibitors are not recommended since both medications taken simultaneously could cause severe hypotension.
Other types of oral medication are available. Apomorphine will enhance penile erection. And there are others. You should ask your doctor for other types of medication if the first one did not work. Other treatment options should also be discussed.
Another type of pharmacological solution is a solution that can be applied in the urethra that manages to improve erection. The erection can be maintained by applying an elastic band at the base of the penis.
Injections at the base of the penis (intracavernous) can help attain and maintain an erection. There are various types of solutions that can be injected -- papaverine, alprostadil, and drug combinations. These injections are considered the most effective treatments for erectile dysfunction. They are also convenient for the patients who do not tolerate the oral therapies.
Side effects include priapism (prolonged and painful erection) and fibrosis (scarring) but they are rare. There are ways to prevent these side effects (especially the prolonged and painful erection). The patient must follow the training and recommendations given at the beginning of this type of therapy. Contraindications for intracavernous injections include sickle cell anemia, schizophrenia, and severe psychiatric disorder.
Vacuum constriction device
This is a plastic cylinder connected to a vacuum-generating source that creates a negative pressure that draws the blood to the penis and makes way for an erection. An elastic band must be placed at the base of the penis to maintain the rigidity. The base of the penis will stay flaccid which might make the genitalia pivot. Side effects include ejaculatory problems, penile pain, and blood pooling because of ruptured blood vessels (ecchymosis or petechiae).
Surgical treatments for erectile dysfunction
There are numerous surgical treatments available for erectile dysfunction.
Penile vascular surgery
Bypass surgery can be performed when there is an isolated artery occlusion disrupting blood flow in the penis. With any surgical procedure, it is necessary to consider the patient's surgical risk. Not all patients will be able to qualify for this type of intervention.
Various types of prosthesis are available -- malleable, mechanical, and inflatable. The patient should discuss the type he would prefer with his physician. The majority of prostheses will need replacement after 10 to 15 years. Surgical complications include infection, mechanical failure, cylinder leaks, perforation, penile shortening, autoinflation, and pain.
There are new and exciting cures already in the works for treating erectile dysfunction. Although Viagra has become quite popular, it has a reputation for reducing spontaneity and has potentially serious side effects for people with heart problems. A new drug called Uprima claims to preserve spontaneity. This drug is placed under the tongue and takes effect in approximately twenty minutes. Another new and exciting treatment currently in development is called “gene therapy.” Still in its preliminary testing, gene therapy offers a treatment for erectile dysfunction that is quick, convenient, and has few side effects. Researchers are hoping to have the treatment administered via injection only once or twice a year. Others hope to effectively create a cream that will produce the same results without the use of hypodermic needles. Some gene therapy methods in development directly target smooth muscle tissue in the penis, while others are designed to increase the production of nitric oxide, which open blood vessels and causes vasocongestion.
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