NewYork-Presbyterian. The University Hospital of Columbia and Cornell.

Erectile Dysfunction / Impotence

What is erectile dysfunction (ED)?

Impotence, or erectile dysfunction, is the inability to achieve an erection, and/or dissatisfaction with the size, rigidity, and/or duration of erections. Erectile dysfunction affects millions of men.

Although in the past it was commonly believed to be due to psychological problems, it is now known that 80 to 90 percent of impotence is caused by physical problems, usually related to the blood supply of the penis. Many advances have occurred in both diagnosis and treatment of erectile dysfunction.

What are the risk factors for erectile dysfunction?

According to the National Institutes of Health, erectile dysfunction is also a symptom in many disorders and diseases.

Direct risk factors for erectile dysfunction may include the following:

• prostate problems
• type 2 diabetes
• hypogonadism in association with a number of endocrinologic conditions
• hypertension (high blood pressure)
• vascular disease and vascular surgery
• high levels of blood cholesterol
• low levels of HDL (high-density lipoprotein)
• drugs
• neurogenic disorders
• Peyronie's disease (distortion or curvature of the penis)
• priapism (inflammation of the penis)
• depression
• alcohol ingestion
• lack of sexual knowledge
• poor sexual techniques
• inadequate interpersonal relationships
• many chronic diseases, especially renal failure and dialysis
• smoking, which accentuates the effects of other risk factors such as vascular disease or hypertension

Age appears to be a strong indirect risk factor in that it is associated with increased likelihood of direct risk factors, some of which are listed above.

It is estimated that nearly 5 percent of men become impotent by the age of 40, and 15 to 25 percent by the age of 65. Accurate risk factor identification and characterization are essential for prevention or treatment of erectile dysfunction.

What are the different types (and causes) of ED?

The following are some of the different types and possible causes of impotence:

• premature ejaculation (PE)
  Premature ejaculation is the inability to maintain an erection long enough for mutual satisfaction. Premature ejaculation is divided into primary and secondary forms:
  • primary premature ejaculation
    Primary premature ejaculation is a learned behavior that begins when a male first become sexually active. Like any learned behaviors, it can be unlearned. This form of primary PE is psychogenic (as opposed to organic or physical) impotence. (Congenital venous leak is a subset of primary PE and is caused by a congenital venous leak in which the venous drainage system in the penis does not shut down properly.)
  • secondary premature ejaculation
    Secondary premature ejaculation occurs when, after years of normal ejaculation, the duration of intercourse grows progressively shorter. Secondary PE is due to physical causes, usually involving the penile arteries, veins, or both.
• performance anxiety
  Performance anxiety is a form of psychogenic impotence -usually caused by stress or anxiety.
• depression
  Depression is another cause of psychogenic impotence. Some antidepressant medications cause erectile failure.
• organic impotence
  Organic impotence involves the penile arteries, veins, or both, and is the most common cause of impotence, especially in older men. When the problem is arterial, it is usually caused by arteriosclerosis, or hardening of the arteries, although trauma to the arteries may be the cause. The controllable risk factors for arteriosclerosis - being overweight, lack of exercise, high cholesterol, high blood pressure, and cigarette smoking - can cause erectile failure often before progressing to affect the heart. Many experts believe that when veins are the cause, a venous leak or "cavernosal failure" is the most common vascular problem.
• diabetes
  Impotence is common in persons with diabetes. There are 5 million adult men in the US with diabetes, and it is estimated that half are impotent and the other half will become impotent in time. The process involves premature and unusually severe hardening of the arteries. Peripheral neuropathy, with involvement of the nerves controlling erections, is commonly seen in persons with diabetes.
• neurologic causes
  There are many neurological (nerve problems) causes of impotence. Diabetes, chronic alcoholism, multiple sclerosis, heavy metal poisoning, spinal cord and nerve injuries, and nerve damage from pelvic operations can cause erectile dysfunction.
• drug-induced impotence
  A great variety of prescription drugs, such as blood pressure medications, anti-anxiety and antidepressant medications, glaucoma eye drops, and cancer chemotherapy agents are just some of the many medications associated with impotence.
• hormone-induced impotence
  Hormonal abnormalities such as increased prolactin (a hormone produced by the anterior pituitary gland), steroid abuse by body-builders, too much or too little thyroid hormone, and hormones administered for prostate cancer may cause impotence. Rarely is low testosterone responsible for impotence.

How is ED diagnosed?

Diagnostic procedures for ED may include the following:

• patient medical/sexual history - may reveal conditions or diseases that lead to impotence and helps distinguish among problems with erection, ejaculation, orgasm, or sexual desire.
• physical examination - to look for evidence of systemic problems, such as the following:
  • A problem in the nervous system may be involved if the penis does not respond as expected to certain touching.
  • Secondary sex characteristics, such as hair pattern, can point to hormonal problems, which involve the endocrine system.
  • Circulatory problems could be indicated by an aneurysm.
  • Unusual characteristics of the penis itself could suggest the basis of the impotence.
• laboratory tests - to help diagnose impotence include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. When low sexual desire is a symptom, measurement of testosterone in the blood can yield information about problems with the endocrine system.
• psychosocial examination - to help reveal psychological factors. The sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.

Treatment for ED:

Specific treatment for erectile dysfunction will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the disease
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

Some of the treatments available for ED include the following:

• sildenafil citrate (Viagra™)
  Viagra™ is a medication made by Pfizer Pharmaceuticals, and is the first approved non-surgical treatment for erectile dysfunction that does not have to be either injected or inserted directly into the penis to achieve and maintain erection. It was approved by the US Food and Drug Administration (FDA) for prescription sale at the end of March, 1998.
  
  Viagra™ does not directly cause penile erection, but affects the response to sexual stimulation. The FDA recommends that men follow these general precautions before taking Viagra™:
  • If you are taking medications that contain nitrates, such as nitroglycerin, you should not use Viagra™. The two taken together can lower blood pressure too much.
  • Viagra™ should not be used by women or children.
  • Have a complete medical history and physical examination to determine your cause of erectile dysfunction.
  • Men with medical conditions that may cause a sustained erection such as sickle cell anemia, leukemia or multiple myeloma, or a man who has an abnormally shaped penis may not be able to take Viagra™.
  • Tell your physician about all the medications you are taking - including over-the-counter ones - because there are medications known to interact with Viagra™.
  • Viagra™'s use in combination with other ED treatments has not been studied, therefore, its use in combination with other treatments is not recommended.
• hormone replacement therapy
  Testosterone replacement therapy may improve energy, mood, and bone density, increase muscle mass and weight, and heighten sexual interest in older men who may have deficient levels of testosterone. Testosterone supplementation is not recommended for men who have normal testosterone levels for their age group due to the risk of prostate enlargement and other side effects. Testosterone replacement therapy is available in an oral form and as a skin patch.
• penile implants
  There are three types of implants used to treat ED, including the following:
  
  
  • hydraulic pump - a pump and two cylinders are placed within the erection chambers of the penis which causes an erection by releasing a saline solution; it can also remove the solution to deflate the penis.
  • prosthesis - two semi-rigid but bendable rods are placed within the erection chambers of the penis which allows manipulation into an erect or non-erect position.
  • interlocking soft plastic blocks - these are placed within the erection chambers of the penis and can be inflated or deflated using a cable that passes through them.

Infection is the most common cause of penile implant failure and is treatable with antibiotics. In some cases, the infected implant must be replaced by a new implant. Implants are usually not considered until other methods of treatment have been tried.

Coping with ED:

Erectile dysfunction can cause strain on a couple. Many times, men will avoid sexual situations due to their emotional pain associated with ED, causing their partner to feel rejected or inadequate. It is important to communicate openly with your partner. Some couples consider seeking treatment for ED together, while other men prefer to seek treatment without their partner's knowledge. A lack of communication is the primary barrier for seeking treatment, and can prolong the suffering. The loss of erectile capacity can have a profound effect on a man. The good news is that ED can usually be treated safely and effectively.

Impotence and heart disease:

Feeling embarrassed about being impotent may prevent many men from seeking the medical attention they need, which can delay diagnosis and treatment for more serious underlying conditions, according to new research. Impotence itself is often related to an underlying disease, such as heart disease, diabetes mellitus, thyroid problems, or other medical conditions.

According to the researchers, since impotence can be a forewarning symptom of progressive coronary disease, physicians should be more direct when questioning patients about their health. By asking patients more directly about their sexual function, through conversation or a questionnaire during a check-up, physicians may be able to detect more serious health conditions sooner.

In an editorial published in a recent issue of the American Journal of Cardiology, two researchers assert that physicians should ask their male patients routinely if they are experiencing impotence, since many men fail to report the condition. Citing the study of 500 men who were seen by their urologist for problems other than impotence, approximately 44 percent failed to tell their urologist they were experiencing impotence. Seventy-four percent of those who failed to inform their urologist of their impotence said they were too embarrassed.

Although many men may attribute impotence to aging, impotence may actually be an early sign of a progressive heart disease, according to the American Heart Association. In addition, impotence may also be a sign of hypertension, diabetes, or other disorders.

Although many men are embarrassed by their condition, impotence is a common condition among the male population, and also a highly treatable one. With treatment, most men can resume an active sex life. In addition, reporting the condition promptly to a physician may aid in the early diagnosis of a more serious disease, according to the researchers.

Active lifestyle may lower man's risk of sexual inability:

Researchers are finding that, when it comes to sexual ability, exercise can make a difference. The study, published in the journal Urology, is one of a few that connects a sedentary lifestyle with impotence, demonstrating once again the health benefits of exercise.

In the study, researchers wanted to determine whether lifestyle had an effect on a man's sexual ability, particularly on middle-aged men - those between the ages of 40 and 70 years of age. The study's authors analyzed the data from nearly 600 men who had participated in the Massachusetts Male Aging Study.

At the study's initial stage, the researchers analyzed the lifestyle habits and health of the participating men. At this time, none of the men had been diagnosed with erectile dysfunction, heart disease, or diabetes.

Eight years later, the researchers evaluated the same men, analyzing any changes with their lifestyle, in comparison to any problems with erectile dysfunction. It was found that half of the men who smoked had now quit and that half of the heavy drinkers - those drinking more than three alcoholic drinks a day - had reduced their alcohol intake.

Eighteen percent of the men who were then considered obese had lost weight, and slightly over half of the men once considered sedentary were now consistently exercising and burning at least 200 calories a day through physical activity. It was also found that 17 percent of the men suffered from erectile dysfunction.

What made an impact in regards to sexual dysfunction?

The researchers found that the higher number of those suffering from sexual dysfunction were the men who had been obese at the study's initial stages. The researchers also found that the men with the sedentary lifestyle at the study's follow-up had a higher incidence of erectile dysfunction, regardless of their activity level when the study initially started eight years ago.

In terms of smoking and heavy drinking, no connection leading to an increased risk of erectile dysfunction was found, making it obvious to the researchers that weight and physical activity played stronger roles when it comes to impotence.

The researchers also discovered that the greatest risk of impotence was among the middle-aged men who had remained sedentary throughout the eight years of the study, as well as those who had gained weight.

When it comes to improving sexual ability, the good news is that exercise can make a difference no matter what age you start. The study indicates the risk of sexual inability is lowered with moderate, consistent exercise. But do not overdo it. The researchers also pointed out that the study participants doing the most intense exercise had a higher level of impotence than the men who moderately exercised.