Erectile Dysfunction

Erectile dysfunction (ED), or impotence, is the inability to get or keep an erection (hard penis) for enough time to have satisfactory sex. To maintain an erection, blood must be able to flow into and stay in the penis until orgasm. Men commonly have problems with their erections once in a while. But if ED occurs frequently, medical therapy may be helpful. About 30 million men in the United States have ED. It can happen at any age, but is more common in men older than 65. ED is treatable at any age. ED can be a symptom of early blood vessel disease in other locations in the body.

Diagnosis of ED is based on a man’s history of problems with erections; medications, illnesses, or injuries that could cause ED; and any recent physical or emotional changes. The evaluation typically includes a physical exam, urinalysis, and a measurement of early morning testosterone levels. The doctor may also order blood tests for luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin fasting blood glucose (sugar) and lipids (blood fats such as cholesterol). To obtain more information about the patient’s general and endocrine (hormonal) function, the doctor may also test for liver, kidney, and thyroid disorders.

Causes of erectile dysfunction
Any physical condition that interferes with sexual desire (libido), blood flow, or nerve signals to the penis can cause ED. The most common causes are conditions that affect blood vessels and blood flow in the penis, such as hardening of the arteries (atherosclerosis) that is linked to diabetes, obesity, smoking, high blood pressure, and high cholesterol—risk factors for heart disease and stroke. Medications (antidepressants, sleeping pills or tranquilizers, and drugs to treat high blood pressure, pain, or prostate cancer), alcohol, tobacco, and illegal drugs commonly cause ED.

Other common causes for ED include:

• Brain diseases (such as stroke)
• Damage to the nerves that deliver signals from the brain and spinal cord to the penis due to diabetes, multiple sclerosis, spinal cord injuries, pelvic or prostate surgery, radiation therapy, or pelvic or bicycle seat pressure trauma
• Hormone imbalances such as low testosterone, high prolactin, and abnormal thyroid hormone levels
• Chronic kidney and liver disease (which affect blood vessels, nerves, and hormone levels)
• Rarely, scarring of the penis that causes a severe curving (Peyronie’s disease) and interferes with normal erections

Treatment of erectile dysfunction
The treatment of ED depends on the cause and seriousness of the condition. For some men, adopting a healthier lifestyle, such as quitting smoking, exercising regularly, eating a healthy diet, reducing stress, and/or limiting alcohol, may be all that is needed to remedy the problem. But for those who require more intensive treatment, options include:

• Oral medication. Three effective drugs are available—sildenafil, vardenafil, and talafadil. All three work by increasing blood flow to the penis during sexual stimulation.
  
  
• Penile therapies. Medications that can be injected into the penis or inserted into the urethra (the tube that carries urine and semen outside the body) to increase blood flow. These may work when oral medication does not.
  
  
• Testosterone replacement therapy. In men with low testosterone levels, testosterone can be replaced through injections, skin patches, gels, or tablets placed between the cheek and gums. (See the section on Treatment of male hypogonadism/androgen deficiency.)
  
  
• Combination medical therapy. Some men who don’t respond well to any one of the first three therapies alone may have a better response with a combination of oral medication plus penile therapy and/or, if blood testosterone levels are low, testosterone replacement therapy.
  
  
• Vacuum device. This is an external plastic cylinder and vacuum pump that pulls blood into the penis and then uses a ring around the base of the penis to prevent blood from flowing out of the penis back into the body.
  
  
• Surgery. Penile implants (rigid or inflatable types) are used for the rare patient who doesn’t respond well to other therapies. Implants are expensive, can lead to infections, and may not work in the long term. Surgery is rarely used to correct a blockage of penile blood flow; the best candidates are young men with limited blockage.
  
  
• Psychological counseling. If a relationship or an emotional problem is causing ED, a sex therapist may be needed.