“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
* Obesity
* Tobacco Smoking
* Diabetes
* 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:
* Stroke
* Spinal cord or back injury
* Multiple sclerosis
* Dementia
* Pelvic trauma
* Prostate surgery (even with nerve-sparing surgeries it
can take up to 24 months to regain normal sexual function)
* Priapism
* Nervous system tumor
* Epilepsy
* Diabetic neuropathy
Vascular causes include:
* Arteriovenous fistula
* Diabetes
* Atherosclerosis
* Congenital anomaly
Hormonal causes include:
* Low testosterone (The patient can achieve an erection
but it will not always be turgid enough for vaginal penetration.)
* Hyperprolactinemia
* Hyperthyroidism
* Hypothyroidism
* Cushing's disease
* Addison's disease
Pharmacological causes include:
* Antidepressants (mainly SSRIs)
* Spironolactone
* Sympathetic blockers (clonidine, guanethidine, or
methyldopa)
* Thiazide diuretics
* Ketoconazole
* Cimetidine
Penile dysfunction causes include:
* Peyronie's disease
Psychological causes include:
* Stress
* Depression
* Negative emotions associated with sex
* Loss of feeling toward the other person
* Stress
* 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
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.
Psychological
Treatments
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.
Transurethral
therapy
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.
Intracavernous
injection
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.
Prosthesis
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.
Future methods
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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