Erectile Dysfunction

Impotence

Definition

An erection problem is the inability to get or maintain an erection that is firm enough for a man to have intercourse. You may be unable to get an erection at all, or you may lose the erection during intercourse before you are ready. If the condition persists, the medical term is erectile dysfunction.

Considerations

Erection problems are common in adult men. In fact, almost all men experience occasional difficulty getting or maintaining an erection. In many cases, it is a temporary condition that will go away with little or no treatment. In other cases, it can be an ongoing problem that can damage a man's self esteem and harm his relationship with his partner, and thus requires treatment.

If you have difficulty having or keeping an erection more than 25% of the time, it is considered a problem.

In the past, erection problems were thought to be "all in the man's mind." Men often were given unhelpful advice such as "don't worry" or "just relax and it will take care of itself." Today, doctors believe that when the problem is not temporary or does not go away on its own, physical factors are often the cause.

One way to know if the cause is physical or psychologic is to determine if you are having nighttime erections. Normally, men have 3 to 5 erections per night, each lasting up to 30 minutes. Your doctor can explain a test to find out if you are having the normal number of nighttime erections.

What Is Erectile Dysfunction

• Erectile dysfunction is defined as the inability to achieve and/or sustain an erection for satisfactory sexual performance.
• Erectile dysfunction is the most common sexual disorder in men.
• Degrees of erectile dysfunction:
  • Mild……….successful erection 7-8 out of 10 attempts
  • Moderate….successful erection 4-6 out of 10 attempts
  • Severe…….successful erection 0-3 out of 10 attempts
• Men experiencing erectile dysfunction often report increasing anxiety, loss of self-esteem, lack of self-confidence, tension and difficulty in the relationship with their partner.

What causes erectile dysfunction?

Many different conditions can lead to ED. Most of the causes of ED are health problems requiring treatment to help prevent more serious complications than ED:

• High blood pressure and high cholesterol can injure the arteries that supply blood to the penis.
• Diabetes injures blood vessels and the nerves that control erections.
• Alcohol and drug abuse can cause ED by damaging blood vessels and deadening the nerves that control erections.
• Some prescription drugs such as some antidepressants or some high blood pressure medicines can cause ED. Your doctor may be able to change your drug treatment. Never stop taking a prescribed drug without talking to your doctor.
• Unhealthy habits like smoking, overeating, and avoiding exercise can also contribute to ED.
• Anything that's bad for your heart is also bad for your sexual health.
• An injury to the spinal cord can cause ED by interfering with nerve signals.
• Treatments for prostate cancer, including radiation and prostate removal, can damage the nerves that control erections.
• Diseases that affect the nerves, like multiple sclerosis, can also lead to erection problems.
• A small number of ED cases result from a reduced level of the male hormone testosterone.
• Doctors used to believe that most cases of ED resulted from mental or emotional problems. We now know that most ED has a physical cause. But depression and worry or anxiety can still cause ED. And ED from physical causes can lead to depression and worry, making physical ED worse.
• A person should not assume that ED is part of the normal process of aging. There is quite likely an underlying cause.

Is erectile dysfunction just a part of old age?

Erectile dysfunction doesn't have to be a part of getting older. It's true that as you get older, you may need more stimulation (such as stroking and touching) to get an erection. You might also need more time between erections. But older men should still be able to get an erection and enjoy sex.

Sings and symptoms

Although erectile dysfunction is a common problem, many patients are reluctant to discuss it. Certainly some patients who present with issues relating to depression or anxiety disorders may in fact have a significant problem with erectile dysfunction. Additionally patients who are poorly compliant with medication prescribed for hypertension may well be having significant erectile dysfunction. The best way to elicit whether the problem is present is to ask questions about sexual function as a routine part of examinations.

Some health questionnaires help screen for and evaluate erectile dysfunction. These questionnaires may help in the primary care setting. It is important, however, to recognize that abbreviated questionnaires may not evaluate specific areas of the sexual cycle such as sexual desire, ejaculation and orgasm. Nonetheless, they can be quite useful in helping patients discuss the problem and in signaling the need for an evaluation.

The diagnosis of ED

Many men feel embarrassed when they first discuss the issue with their doctor or practice nurse. But, particularly since the launch of the drug sildenafil (Viagra), awareness and understanding from health professionals is high and the consultation will almost certainly be less embarrassing than feared.

The doctor will ask about your general health and about your erections. This will include whether or not you wake up with an erection in the morning and the strength of the erection compared with the past. The doctor will ask about any medicines you are on, and about any changes in your life that may be having an influence on your sexual health.

Your doctor may also want to talk with you and your partner together about any physical or psychological factors that may be contributing to the problem. For example, around the menopause, women may experience pain or discomfort during intercourse. When the man has a faltering erection this may lead to further discomfort for both partners.

A physical examination includes taking the blood pressure and checking the pulses in the legs - an indicator of how healthy the circulation is. The penis and scrotum will be examined. The doctor may request blood tests to look for medical problems, such as anaemia, diabetes, high cholesterol or hormone abnormalities, that might be a contributory factor.

More specialised tests to assess blood flow and the way the nerves are working can be done in specialist hospital clinics.

When to seek medical advice

It's normal to experience erectile dysfunction on occasion. But if erectile dysfunction lasts longer than two months or is a recurring problem, see your doctor for a physical exam or for a referral to a doctor who specializes in erectile problems. Your own doctor or a specialist can help you determine the underlying cause or causes of erectile dysfunction and then help you find the right type of treatment.

Although you might view erectile dysfunction as a personal or embarrassing problem, it's important to seek treatment. In many cases, erectile dysfunction can be successfully treated. Also, see your doctor if the therapy or medication prescribed to treat erectile dysfunction isn't working for you. Don't try to combine medications or therapies on your own or deviate from prescribed doses.

How is erectile dysfunction treated?

How erectile dysfunction is treated depends on what is causing it. After your doctor checks you for medical problems and medicines that might cause erectile dysfunction, he or she may have you try a medicine to help with erectile dysfunction. Some of these medicines are injected into your penis. Other medicines are taken by mouth. Not everyone can use these medicines. Your doctor will help you decide if you can try them.

Psychotherapy

Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED from physical causes is being treated.

Drug Therapy

Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved Viagra, the first pill to treat ED. Since that time, vardenafil hydrochloride (Levitra) and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness.

Viagra, Levitra, and Cialis (Difference between Viagra, Cialis, Levitra) all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.

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While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection as injections do. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for either Levitra or Cialis is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug. Levitra is also available in a 2.5 mg dose.

None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also, tell your doctor if you take any drugs called alpha-blockers, which are used to treat prostate enlargement or high blood pressure. Your doctor may need to adjust your ED prescription. Taking a PDE inhibitor and an alpha-blocker at the same time (within 4 hours) can cause a sudden drop in blood pressure.

Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs-including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone-are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur.

Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Vacuum devices

This treatment involves the use of an external vacuum and one or more rubber bands (tension rings). To begin you place a hollow plastic tube, available by prescription, over your penis. You then use a hand pump to create a vacuum in the tube and pull blood into the penis. Once you achieve an adequate erection, you slip a tension ring around the base of your penis to maintain the erection. You then remove the vacuum device. The erection typically lasts long enough for a couple to have adequate sexual relations. You remove the tension ring after intercourse.

Withdrawal of Offending Medication

It is extremely important to take a complete drug history particularly with regard to antihypertensive medications and drugs used for cardiovascular disease, anxiety, depression or psychosis in any patient complaining of erectile dysfunction. Antihypertensive drugs, such as diuretics and beta-blockers, may be associated with erectile dysfunction and perhaps can be discontinued or switched to alternative drugs such as angiotensin converting enzyme inhibitors or calcium channel blockers (diltiazem, nifedipine, amlodipine) which may cause less of a problem. The newer angiotensin II receptor antagonists may also cause less of a problem but more long-term data will be needed to confirm this.

Of the drugs used for depression, tricyclic antidepressants may be associated with erectile problems and other drugs hopefully can be substituted to prevent this complication. Of those currently available it would appear that bupropion, nefazodone and trazadone may be helpful in this regard. The selective serotonin reuptake inhibitors (such as fluoxetine, sertraline, paroxetine, and citalopram) may also cause difficulties with erectile dysfunction, but perhaps more commonly have other significant sexual side effects which include decreased libido and anorgasmia.

Clinical experience in switching medication has overall been rather disappointing and improvement does not seem to occur very often. Nonetheless, it is important to try to discontinue possible offending medications before moving on to more invasive options. Oral therapy has also basically changed the way in which discontinuing medications may work as well, and has improved the approach. An example of this is a patient who may develop erectile dysfunction on a thiazide diuretic. The drug may be withdrawn but also a trial of oral therapy can be initiated during the observation period while the patient is waiting to see if any spontaneous improvement in erectile function occurs after drug withdrawal. Alternatively if diuretic therapy is effective, well tolerated and controlling the blood pressure, oral therapy can be used to deal with the sexual side effect on an ongoing basis which is frequently what is done.

If a trial of oral therapy and withdrawal of offending medications proves to be ineffective in restoring erectile function, it is probably appropriate for most primary care practitioners to consider referral to a specialist for additional evaluation and discussion of alternative treatment options such as intracavernous injection therapy, vacuum constriction devices, intraurethral therapy or possible surgery.

Prevention

Although most men experience episodes of erectile dysfunction from time to time, you can take these steps to decrease the likelihood of occurrences:

• Limit or avoid the use of alcohol and other similar drugs.
• Stop smoking.
• Exercise regularly.
• Reduce stress.
• Get enough sleep.
• Deal with anxiety or depression.
• See your doctor for regular checkups and medical screening tests.

Points to Remember

• Erectile dysfunction (ED) is the repeated inability to get or keep an erection firm enough for sexual intercourse.
• ED affects 15 to 30 million American men.
• ED usually has a physical cause.
• ED is treatable at all ages.
• Treatments include psychotherapy, drug therapy, vacuum devices, and surgery.

PATIENT INFORMATION ABOUT ERECTILE DYSFUNCTION (ED)

• Erectile Dysfunction
• Considerations
• What Is Erectile Dysfunction
• What causes erectile dysfunction?
• Is erectile dysfunction just a part of old age?
• Sings and symptoms
• The diagnosis of ED
• When to seek medical advice
• How is erectile dysfunction treated?
• Psychotherapy
• Drug Therapy
• Vacuum devices
• Withdrawal of Offending Medication
• Prevention
• Points to Remember

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