Erectile Dysfunction (ED)

Erectile dysfunction, or ED, is the most common sex problem that men report to their doctor. It affects as many as 30 million men.

What is Erectile Dysfunction

During sexual arousal, nerves release chemicals that increase blood flow into the penis. Blood flows into two erection chambers in the penis, made of spongy muscle tissue (the corpus cavernosum). The corpus cavernosum chambers are not hollow.

During erection, the spongy tissues relax and trap blood. The blood pressure in the chambers makes the penis firm, causing an erection. When a man has an orgasm, a second set of nerve signals reach the penis and cause the muscular tissues in the penis to contract and blood is released back into a man’s circulation and the erection comes down.

When you are not sexually aroused, the penis is soft and limp. Men may notice that the size of the penis varies with warmth, cold or worry; this is normal and reflects the balance of blood coming into and leaving the penis.

How Erections Work

During sexual arousal, nerves release chemicals that increase blood flow into the penis. Blood flows into two erection chambers in the penis, made of spongy muscle tissue (the corpus cavernosum). The corpus cavernosum chambers are not hollow.

During erection, the spongy tissues relax and trap blood. The blood pressure in the chambers makes the penis firm, causing an erection. When a man has an orgasm, a second set of nerve signals reach the penis and cause the muscular tissues in the penis to contract and blood is released back into a man’s circulation and the erection comes down.

When you are not sexually aroused, the penis is soft and limp. Men may notice that the size of the penis varies with warmth, cold or worry; this is normal and reflects the balance of blood coming into and leaving the penis.

Symptoms

With Erectile Dysfunction (ED), it is hard to get or keep an erection that is firm enough for sex. When ED becomes a routine and bothersome problem, your primary care provider or a Urologist can help.

ED may be a major warning sign of cardiovascular disease indicating blockages are building in a man’s vascular system. Some studies have shown men with ED are at significant risk of getting a heart attack, stroke or circulatory problems in the legs. ED also causes:

    • Low self-esteem
    • Depression
    • Distress for the man and his partner

If ED is affecting a man’s well-being or his relationships, it should be treated. Treatment aims to fix or enhance erectile function, help circulatory health and help the quality of a man’s life.

Causes

ED can result from health problems, emotional issues, or from both.

Some known risk factors are:

    • Being over age 50
    • Having high blood sugar (Diabetes)
    • Having high blood pressure
    • Having cardiovascular disease
    • Having high cholesterol
    • Smoking
    • Using drugs or drinking too much alcohol
    • Being obese
    • Lacking exercise

Even though ED becomes more common as men age, growing old is not always going to cause ED. Some men stay sexually functional into their 80s. ED can be an early sign of a more serious health problem. Finding and treating the reason for ED is a vital first step.

For some men with ED, specialized testing may be needed to guide treatment or re-assess you after a treatment fails.

    • Blood work to check Testosterone and other male hormones
    • Blood work to measure blood sugar (Diabetes)
    • Ultrasonography (penile Doppler) to check blood flow
    • A shot into the penis with a vascular stimulant to cause an erection
    • Pelvic x-rays like arteriography, MRI or CT scanning are rarely needed to check ED unless there is history of trauma or cancer

Treatment

The treatment for ED starts with taking care of your heart and vascular health. Your doctor may point out ‘risk factors’ that can be changed or improved.

You may be asked to change certain food habits, stop smoking, increase workouts or stop using drugs or alcohol. You may be offered alternatives to the drugs you take. (Never stop or change prescription drugs without first talking to your health care provider.)

Your health care provider may also suggest treating emotional problems. These could stem from relationship conflicts, life’s stressors, depression or anxiety from past problems with ED (performance anxiety).

The treatments below are available to treat ED directly.

Non-invasive treatments are often tried first. Most of the best-known treatments for ED work well and are safe. Still, it helps to ask your health care provider about side effects that could result from each option:

  • Oral drugs or pills known as phosphodiesterase type-5 inhibitors are most often prescribed in the U.S. for ED (Viagra, Cialis, Levitra, Stendra)
  • Testosterone Therapy (when low testosterone is detected in blood testing)
  • Penile Injections (ICI, intracavernosal Alprostadil)
  • Intraurethral medication (IU, Alprostadil)
  • Vacuum Erection Devices
  • Penile Implants
  • Surgery to bypass penile artery damage for some younger men with a history of severe pelvic trauma. Penile vascular surgery is not recommended for older men with hardened arteries.

Drugs known as PDE type-5 inhibitors increase penile blood flow. These are the only oral agents approved in the U.S. by the Food and Drug Administration for the treatment of ED.

  • Viagra ® (sildenafil citrate)
  • Levitra ® (vardenafil HCl)
  • Cialis ® (tadalafil)
  • Stendra ® (avanafil)

For best results, men with ED take these pills about an hour or two before having sex. The drugs require normal nerve function to the penis. PDE5 inhibitors improve on normal erectile responses helping blood flow into the penis. Use these drugs as directed. About 7 out of 10 men do well and have better erections. Response rates are lower for Diabetics and cancer patients.

If you are taking nitrates for your heart, you SHOULD NOT take any PDE5 inhibitors. Always speak with your health care provider before using a PDE5 inhibitor to learn how it might affect your health.

Most often, the side effects of PDE5 inhibitors are mild and often last just a short time. The most common side effects are:

  • Headache
  • Stuffy nose
  • Facial flushing
  • Muscle aches
  • Indigestion

In rare cases, the drug Viagra ® can cause blue-green shading to vision that lasts for a short time. In rare cases, the drug Cialis ® can cause or increase back pain or aching muscles in the back. In most cases, the side effects are linked to PDE5 inhibitor effects on other tissues in the body, meaning they are working to increase blood flow to your penis and at the same time impacting other vascular tissues in your body. These are not ‘allergic reactions’.

In those rare cases where a low sex drive and low blood levels of Testosterone are at fault for ED, Testosterone Therapy may fix normal erections or help when combined with ED drugs (PDE type 5 inhibitors).

A vacuum erection device is a plastic tube that slips over the penis, making a seal with the skin of the body. A pump at the other end of the tube makes a low-pressure vacuum around the erectile tissue, which results in an erection. An elastic ring is then slipped onto the base of the penis. This holds the blood in the penis (and keeps it hard) for up to 30 minutes. With proper training, 75 out of 100 men can get a working erection using a vacuum erection device.

If oral drugs don’t work, the drug Alprostadil is approved for use in men with ED. This drug comes in two forms, based on how it is to be used: intracavernosal injection (called “ICI”) or through the urethra (called “IU therapy”).

Several restorative or regenerative treatments are under investigation for the future treatment of ED:

  • Extracorporeal shock wave therapy (ESWT) – low-intensity shock waves that aim to fix the erectile tissues and help restore natural erections.

These are not currently approved by the FDA for ED management.

Patients who are interested should discuss the risks and benefits (informed consent) of each, as well as costs. Most therapies not approved by the FDA are not covered by government or private insurance benefits.

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