Impotence (erectile dysfunction)

What is erectile dysfunction?

Impotence means that a man's penis doesn't get hard enough to have sexual intercourse. The man cannot get or maintain an erection. The medical term is erectile dysfunction (ED).

ED is not the same as premature ejaculation.

The major causes of ED include:

• Vascular (blood vessel) disease — Erections happen when blood collects in the shaft of the penis. Vascular disease can limit the amount of blood flowing to or staying in the penis. Both can result in problems with erections. Vascular disease is the most common medical cause of impotence.
• Nerve damage — Nerves must be working normally for a man to get and keep an erection. Nerves can be damaged by diabetes, multiple sclerosis, prostate surgery, or damage to the spinal cord.
• Psychological factors — Psychological issues such as depression, anxiety, guilt, or fear can sometimes cause sexual problems. At one time, these factors were thought to be the major cause of impotence. Doctors now know that physical factors cause impotence in most men with the problem. However, embarrassment or "performance anxiety" can make a physical problem worse.
• Medications — Many medications cause problems with sexual function. These include drugs for high blood pressure, depression, heart disease, and prostate cancer.
• Hormonal problems — Abnormal levels of certain hormones can interfere with erections and sex drive. Hormonal problems, such as a low testosterone level, are an uncommon cause of impotence.

Symptoms of erectile dysfunction

A man with impotence has either a problem getting an erection or difficulty maintaining one. This usually interferes with sexual activity.

Impotence can happen suddenly or gradually. Some men slowly lose the firmness of their erections or how long the erections last.

In other men, especially those whose impotence is largely caused by psychological factors, the problem may occur unpredictably. It can improve at any time.

Men with impotence may continue to have normal orgasm and ejaculation without a full erection.

Diagnosing erectile dysfunction

Your doctor will ask you about your medical history. He or she will want to learn if any medical conditions might be causing the impotence. These may include vascular, neurological, and hormonal disorders.

Vascular disorders affect the entire body. Many men who have impotence because of vascular disease also have a history of heart disease, stroke, or poor circulation in their legs.

Neurological problems can contribute to impotence in men with a history of diabetes and spinal cord injury. They also can cause symptoms in other parts of the body.

In men with abnormal hormone levels, a reduced sex drive often accompanies impotence.

Your doctor will review the medications you take. These include over-the-counter products and herbal remedies.

Your doctor will ask about your sex life. He or she will ask about the quality of your sexual relationships.

Your doctor will examine you to look for evidence of medical problems. This will include an examination of your penis and testes. Your blood may be tested for blood sugar, cholesterol, and levels of certain hormones.

Occasionally, a doctor may order additional tests. One such test is a nocturnal penile tumescence study. This is a way to determine how often you get erections while you sleep.

Another test that may be done is a Doppler ultrasound of the blood vessels in the penis. This test measures how well the blood is flowing in your penis.

Your doctor may not be able to give you a specific reason why you have impotence. But many of the treatments work well no matter what caused the problem. So extensive testing may not be necessary.

Expected duration of erectile dysfunction

How long your impotence lasts depends upon what causes it and how quickly your treatment starts to work. Impotence is treatable in all age groups.

Preventing erectile dysfunction

You can decrease your risk of developing erectile dysfunction by making lifestyle choices that help keep your blood vessels healthy and help prevent type 2 diabetes.

The following steps may help:

• Eat a healthy diet and exercise daily.
• Avoid cigarette smoking.
• Maintain normal blood pressure.
• Maintain normal cholesterol levels.

Because certain medications have been associated with impotence, ask your doctor about possible side before you start a new prescription.

Treating erectile dysfunction

There are many effective treatments for impotence. The most popular is a class of drugs called phosphodiesterase type 5 (PDE5) inhibitors. These include sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), and avanafil (Stendra). These drugs are taken in pill form. They work in most men. But they are less effective in men with neurological causes of impotence.

The PDE5 drugs are generally safe. But always review the risks with your doctor. PDE5 drugs can interact with other medications and cause dangerously low blood pressure. For example, you should not take PDE5 drugs if you use nitroglycerin or other nitrate medications.

The most worrisome side effects are sudden onset of vision or hearing loss. This occurs very rarely but requires immediate medical attention. PDE5 drugs can cause other side effects, such as flushing and headache.

If PDE5 drugs don't work or cannot be used because of potential side effects, your doctor can recommend other therapies. The drug alprostadil (Caverject, Edex, Muse) allows blood to flow more freely in the penis, leading to an erection. The drug can be injected with a tiny needle into your penis. Or, a small pellet (suppository) can be inserted into the opening of the penis. Suppositories and injections are effective in the majority of men.

Taking extra testosterone will not improve ED. For men who have abnormally low levels of the hormone, testosterone replacement may enhance sexual desire.

Psychological therapy can be effective in men whose impotence is caused primarily by psychological factors. This might include counseling, behavioral therapy, or couples' therapy.

Men who do not benefit from medical or psychological treatment often have success with mechanical or prosthetic devices. External products, known as vacuum erection devices, are safe and highly effective. But many men and their partners find them unappealing.

Another option is a surgically placed penile implant. Only a small number of men with impotence choose this option.

Vascular (blood vessel) surgery sometimes is recommended for young, healthy men who develop impotence after trauma to the groin.

When to call a professional

Speak to your doctor if you have trouble getting or keeping an erection over three months or more.

Impotence caused by psychological factors may get better on its own. But treatment is needed if the problem is caused by a physical factor.

Prognosis

In general, the outlook for most men with erectile dysfunction is positive.

Additional info

American Urological Association
https://www.urologyhealth.org/