Erectile Dysfunction
Erectile
dysfunction, sometimes called "impotence," is
the repeated inability to get or keep an
erection firm enough for sexual intercourse. The
word "impotence" may also be used to describe
other problems that interfere with sexual
intercourse and reproduction, such as lack of
sexual desire and problems with ejaculation or
orgasm. Using the term erectile dysfunction
makes it clear that those other problems are not
involved.
Erectile
dysfunction, or ED, can be a total inability to
achieve erection, an inconsistent ability to do
so, or a tendency to sustain only brief
erections. These variations make defining ED and
estimating its incidence difficult. Estimates
range from 15 million to 30 million, depending
on the definition used. According to the
National Ambulatory Medical Care Survey (NAMCS),
for every 1,000 men in the United States, 7.7
physician office visits were made for ED in
1985. By 1999, that rate had nearly tripled to
22.3. The increase happened gradually,
presumably as treatments such as vacuum devices
and inject able drugs became more widely
available and discussing erectile function
became accepted. Perhaps the most publicized
advance was the introduction of the oral drug
sildenafil citrate (Viagra) in March 1998. NAMCS
data on new drugs show an estimated 2.6 million
mentions of Viagra at physician office visits in
1999, and one-third of those mentions occurred
during visits for a diagnosis other than ED.
In older men, ED usually has a
physical cause, such as disease, injury, or side
effects of drugs. Any disorder that causes
injury to the nerves or impairs blood flow in
the penis has the potential to cause ED.
Incidence increases with age: About 5 percent of
40-year-old men and between 15 and 25 percent of
65-year-old men experience ED. But it is not an
inevitable part of aging.
Definition
Erectile
dysfunction (ED) is the inability of a man to
maintain a firm erection long enough to have
sex. Although erectile dysfunction is more
common in older men, this common problem can
occur at any age. Having trouble maintaining an
erection from time to time isn't necessarily a
cause for concern. But if the problem is
ongoing, it can cause stress and relationship
problems and affect self-esteem.
Formerly called
impotence, erectile dysfunction was once a taboo
subject. It was considered a psychological issue
or a natural consequence of growing older. These
attitudes have changed in recent years. It's now
known that erectile dysfunction is more often
caused by physical problems than by
psychological ones, and that many men have
normal erections into their 80s.
Although it
can be embarrassing to talk with your doctor
about sexual issues, seeking help for erectile
dysfunction can be worth the effort. Erectile
dysfunction treatments ranging from medications
to surgery can help restore sexual function for
most men. Sometimes erectile dysfunction is
caused by an underlying condition such as heart
disease. So it's important to take erectile
trouble seriously because it can be a sign of a
more serious health problem.
How Does an Erection Occur?
The penis contains
two chambers called the corpora cavernosa, which
run the length of the organ (see figure 1). A
spongy tissue fills the chambers. The corpora
cavernosa are surrounded by a membrane, called
the tunica albuginea. The spongy tissue contains
smooth muscles, fibrous tissues, spaces, veins,
and arteries. The urethra, which is the channel
for urine and ejaculate, runs along the
underside of the corpora cavernosa and is
surrounded by the corpus spongiosum.
Erection begins with sensory or
mental stimulation, or both. Impulses from the
brain and local nerves cause the muscles of the
corpora cavernosa to relax, allowing blood to
flow in and fill the spaces. The blood creates
pressure in the corpora cavernosa, making the
penis expand. The tunica albuginea helps trap
the blood in the corpora cavernosa, thereby
sustaining erection. When muscles in the penis
contract to stop the inflow of blood and open
outflow channels, erection is reversed.
Causes
Male sexual arousal is a complex
process involving the brain, hormones, emotions,
nerves, muscles and blood vessels. If something
affects any of these systems or the delicate
balance among them erectile dysfunction can
result.
Anatomy of an
Erection
The penis contains
two cylindrical, sponge-like structures (corpus
cavernosum) that run along its length, parallel
to the tube that carries semen and urine
(urethra).
When a man becomes
sexually aroused, nerve impulses cause the blood
flow to the cylinders to increase several times
the normal amount. This sudden influx of blood
expands the sponge-like structures and produces
an erection by straightening and stiffening the
penis.
Continued sexual arousal
maintains the higher rate of blood flow into the
penis and limits the blood flow out of the
penis, keeping the penis firm. After ejaculation
or when the sexual excitement passes, the excess
blood drains out of the spongy tissue, and the
penis returns to its non erect size and shape.
Physical
Causes of Erectile Dysfunction
At one time, doctors thought
erectile dysfunction was primarily caused by
psychological issues. But this isn't true. While
thoughts and emotions always play a role in
getting an erection, erectile dysfunction is
usually caused by something physical, such as a
chronic health problem or the side effects of a
medication. Sometimes a combination of things
causes erectile dysfunction.
Common Causes
of Erectile Dysfunction Include:
Other causes of
erectile dysfunction include:
-
Certain
prescription medications
-
Tobacco use
-
Alcoholism and
other forms of drug abuse
-
Treatments for
prostate cancer
-
Parkinson's
disease
-
Multiple
sclerosis
-
Hormonal
disorders such as low testosterone (hypogonadism)
-
Peyronie's
disease
-
Surgeries or
injuries that affect the pelvic area or
spinal cord
In some cases,
erectile dysfunction is one of the first signs
of an underlying medical problem.
Psychological Causes of
Erectile Dysfunction
The brain plays a
key role in triggering the series of physical
events that cause an erection, beginning with
feelings of sexual excitement. A number of
things can interfere with sexual feelings and
lead to or worsen erectile dysfunction. These
can include:
The physical and
psychological causes of erectile dysfunction
interact. For instance, a minor physical problem
that slows sexual response may cause anxiety
about maintaining an erection. The resulting
anxiety can worsen erectile dysfunction.
Risk Factors
A variety of risk
factors can contribute to erectile dysfunction.
They include:
-
Getting older.
As many as 80 percent of men 75 and older
have erectile dysfunction. Many men begin to
notice changes in sexual function as they
get older. Erections may take longer to
develop, may not be as rigid or may take
more direct touch to the penis to occur. But
erectile dysfunction isn't an inevitable
consequence of normal aging. Erectile
dysfunction often occurs in older men mainly
because they're more likely to have
underlying health conditions or take
medications that interfere with erectile
function.
-
Having a chronic health
condition.
Diseases of the lungs, liver, kidneys,
heart, nerves, arteries or veins can lead to
erectile dysfunction. So can endocrine
system disorders, particularly diabetes. The
accumulation of deposits (plaques) in your
arteries (atherosclerosis) also can prevent
adequate blood from entering your penis. And
in some men, erectile dysfunction may be
caused by low levels of testosterone (male
hypogonadism)
-
Taking certain medications.
A wide range of drugs — including
antidepressants, antihistamines and
medications to treat high blood pressure,
pain and prostate cancer — can cause
erectile dysfunction by interfering with
nerve impulses or blood flow to the penis.
Tranquilizers and sleeping aids also can
pose a problem.
-
Certain
surgeries or injuries. Damage to the
nerves that control erections can cause
erectile dysfunction. This damage can occur
if you injure your pelvic area or spinal
cord. Surgery to treat bladder, rectal or
prostate cancer can increase your risk of
erectile dysfunction.
-
Substance
abuse. Chronic use of alcohol, marijuana
or other drugs often causes erectile
dysfunction and decreased sexual drive.
-
Stress,
anxiety or depression. Other
psychological conditions also contribute to
some cases of erectile dysfunction.
-
Smoking.
Smoking can cause erectile dysfunction
because it restricts blood flow to veins and
arteries. Men who smoke cigarettes are much
more likely to develop erectile dysfunction.
-
Obesity.
Men who are obese are much more likely to
have erectile dysfunction than are men at a
normal weight.
-
Metabolic
syndrome. This syndrome is characterized
by belly fat, unhealthy cholesterol and
triglyceride levels, high blood pressure,
and insulin resistance.
-
Prolonged bicycling.
Over an extended period, pressure from a
bicycle seat has been shown to compress
nerves and blood flow to the penis, leading
to temporary erectile dysfunction and penile
numbness.
Symptoms
Erectile
dysfunction is the inability to maintain an
erection sufficient for sexual intercourse at
least 25 percent of the time.
An occasional inability to
maintain an erection happens to most men and is
normal. But ongoing erection problems are a sign
of erectile dysfunction and should be evaluated.
In some cases, erectile dysfunction is the first
sign of another underlying health condition that
needs treatment.
Prevention
Although most men
experience episodes of erectile dysfunction from
time to time, you can take these steps to
decrease the likelihood of occurrences:
-
Work with your
doctor to manage conditions that can lead to
erectile dysfunction, such as diabetes and
heart disease.
-
Limit or avoid
the use of alcohol.
-
Avoid illegal
drugs such as marijuana.
-
Stop smoking.
-
Exercise
regularly.
-
Reduce stress.
-
Get enough
sleep.
-
Get help for
anxiety or depression.
-
See your doctor for regular
checkups and medical screening tests.
Diagnosis
A medical examination may
indicate neurological, vascular, or hormonal
disease, or Peyronie's disease. History of
illness, smoking, drug use, and hypertension can
be ascertained with a thorough examination of
health history.
Laboratory tests are performed to identify the
underlying cause.
Blood Tests
and Urinalysis
Blood tests can
indicate conditions that may interfere with
normal erectile function. These tests measure
hormone levels, cholesterol, blood sugar, liver
and kidney function, and thyroid function.
Excess prolactin (hyperprolactinemea) can lower
testosterone levels, which can diminish libido.
Both of these levels are measured, as well as
levels of other sex hormones. If they are
persistently low, an endocrinologist (hormone
specialist) should be consulted.
CBC.
Complete blood count (CBC)
of red cells and white cells is used to evaluate
the presence of anemia. A low level of red cells
limits the body's utilization of oxygen and can
lead to fatigue and general malaise. The level
of blood lipids (fats) such as cholesterol and
triglycerides may indicate arteriosclerosis,
which can reduce blood flow to the penis.
Liver and
kidney function tests.
Liver and kidney disease can
create horomonal imbalances. Blood tests for
liver function involves analysis of enzyme and
serum creatinine levels, which are indicators of
kidney efficiency.
Thyroid
function tests.
Thyroid hormones regulate metabolism and the
production of sex hormones; a deficiency may
contribute to impotence.
Urinalysis.
Urine is analyzed for protein (albumin), sugar
(glucose), and hormone (testosterone) levels
that may indicate diabetes mellitus, kidney
dysfunction, and testosterone deficiency.
Erectile
Function Tests
Tests that assess
erectile function examine the blood vessels,
nerves, muscles, and other tissues of the penis
and pelvic region.
Duplex
ultrasound. Duplex
ultrasound is used to evaluate blood flow,
venous leak, signs of artherosclerosis, and
scarring or calcification of erectile tissue.
Erection is induced by injecting prostaglandin,
a hormone-like stimulator produced in the body.
Ultrasound is then used to see vascular dilation
and measure penile blood pressure (which may
also be measured with a special cuff).
Measurements are compared to those taken when
the penis is flaccid.
Prostate
examination. An
enlarged prostate, which can be detected with a
digital rectal examination (DRE), can interfere
with blood flow and nerve impulses in the penis.
Penile
nerve function. Tests
such as the bulbocavernosus reflex test are used
to determine if there is sufficient nerve
sensation in the penis. The physician squeezes
the glans (head) of the penis, which immediately
causes the anus to contract if nerve function is
normal. A physician measures the latency between
squeeze and contraction by observing the anal
sphincter or by feeling it with a gloved finger
inserted past the anus. Specific nerve tests are
used in patients with suspected nerve damage as
a result of diabetes or nerve disease.
Nocturnal
penile tumescence (NPT).
It is normal for a man to have
five to six erections during sleep, especially
during rapid eye movement (REM). These erections
occur about every 90 minutes and last for about
30 minutes. Their absence may indicate a problem
with nerve function or blood supply in the
penis. There are two methods for measuring
changes in penile rigidity and circumference
during nocturnal erection: snap gauge and strain
gauge.
Snap
gauge. Involves
wrapping three plastic bands of varying strength
around the penis. Erectile function is assessed
according to which bands break. Strain gauge
involves placing special elastic bands at the
base and tip of the penis. These bands stretch
during erection and register changes in
circumference.
Penile
biothesiometry. This
test uses electromagnetic vibration to evaluate
sensitivity and nerve function in the glands and
shaft of the penis. A decreased perception of
vibration may indicate nerve damage in the
pelvic area, which can lead to impotence.
Vasoactive injection.
When injected into the penis,
certain solutions cause erection by dilating
blood vessels in erectile tissue. Normally,
these injections produce an erection lasting
about 20 minutes. During this procedure, penile
pressure is measured and x-rays may be taken of
the penile blood vessels using a special dye
(contrast agent).
Effects
Whether the cause
of impotence is physiological or psychological,
both the patient and his partner often
experience a range of intense feelings and
emotions. Any of these feelings can lead to a
sense of hopelessness and lower self-esteem.
Of course,
feelings of sexual insecurity can reinforce any
performance anxiety a man experiences and create
a vicious cycle of repeated failures and
increasingly negative feelings.
The first step to overcoming
these feelings is to acknowledge the problem and
communicate honestly and openly with each other.
Self Esteem
Because sexual
performance is often a big part of a man's
self-esteem, experiencing erectile dysfunction
(ED) can be devastating not only to a man's sex
life, but to his entire sense of being. Men with
ED can become uncertain of themselves and avoid
intimate situations with their partners; this
only increases the pressure and anxiety
associated with a condition which is often
treatable.
In addition, erectile dysfunction
can cause men to feel inadequate in their roles.
Men who are suffering from ED tend to isolate
themselves from their relationships and withdraw
from their partners.
The psychological effects of ED
can invade every aspect of a man's life, from
his relationship with his partner, to his
interactions on a social level, to his job
performance. Therefore, it is important for a
man who is suffering from ED to feel as
comfortable as possible discussing his condition
with his partner, and with his physician, in
order to discover the treatment strategy which
can best help overcome this condition.
Partners
Erectile
dysfunction can be embarrassing to discuss not
only with a health care provider but with also
with a partner. It often causes men to withdraw
from those who care about them, which puts a
serious strain on relationships.
Partners of men
with ED feel that initiating a discussion
regarding the situation will cause embarrassment
and humiliation. They also may develop a sense
of inadequacy, thinking the cause of ED is their
fault and that they are no longer physically
attractive to their partner.
In most cases, ED
is a result of physical causes (although it can
easily be made worse by psychological factors),
and can often be treated. However, silence,
embarrassment, and feelings of inadequacy and
humiliation only lead to further withdrawal on
the part of both partners, increasing the
distance and tension within the relationship.
The anxiety which results can easily make a case
of ED worse, leading to a vicious circle of
failure and anxiety about failure.
Both partners and men with ED
need to try to remember that ED is most often a
treatable physical condition. The first step to
treatment, however, is trust and a willingness
on the part of both partners to discuss the
situation with each other, and with a physician.
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